INTERNSHIP / FELLOWSHIP IN COMMUNITY HEALTH COMMUNITY HEALTH WORKSHOP I FROM 14-16TH APRIL 2004 HELD AT ISI, BANGALORE
Item
- Title
- INTERNSHIP / FELLOWSHIP IN COMMUNITY HEALTH COMMUNITY HEALTH WORKSHOP I FROM 14-16TH APRIL 2004 HELD AT ISI, BANGALORE
- extracted text
-
RF_COM_H_89_SUDHA
PEOPLE’S CHARTER FOR HEALTH
INTRODUCTION
In 1978, at the Alma-Ata Conference, ministers from 134 members countries in
association with WHO and UNICEF declared “Health for All by the Year 2000” selecting
Primary Health Care as the best tool to achieve it.
Unfortunately, that dream never came true. The health status of Third World populations
has not improved. In many cases it has deteriorated further. Currently we are facing a
global health crisis, characterised by growing inequalities within and between countries.
New threats to health are continually emerging. This is compounded by negative forces
of globalisation which prevent the equitable distribution of resources with regard to the
health of people and especially that of the poor.
Within the health sector, failure to implement the principles of primary health care, as
originally conceived in Alma-Ata, has significantly aggravated the global health crisis.
Governments and the international bodies are fully responsible for this failure.
It has now become essential to build up a concerted international effort to put the goals
of Health for All to its rightful place on the development agenda. Genuine, peoplecentred initiatives must therefore be strengthened in order to increase pressure on
decision-makers, governments and the private sector to ensure that the vision of AlmaAta becomes a reality.
Several international organisations and civil society movements, NGOs and women's
groups decided to work together towards this objective. This group together with others
committed to the principles of primary health care and people’s perspectives organised
the “People’s Health Assembly" which took place from 4-8 December 2000 in
Bangladesh, at Savar, on the campus of the Gonoshasthaya Kendra or GK (People's
Health Centre).
1,453 participants from 92 countries came to the Assembly which was the culmination of
eighteen months of preparatory action around the globe. The preparatory process
elicited unprecedented enthusiasm and participation of a broad cross section of people
who have been involved in thousands of village meetings, district level workshops and
national gatherings.
People's Charter for Health (8 Dec 2000)
1
The Plenary Sessions at the Assembly covered five main themes: Health, Life and WellBeing; Inequality, Poverty and Health; Health Care and Health Services; Environment
and Survival; and The Ways Forward.
People from all over the world presented
testimonies of deprivation and service failure as well as those of successful people’s
initiatives and organisations. Over a hundred concurrent sessions made it possible for
participants to share and discuss in greater detail different aspects of the major themes
and give voice to their specific experiences and concerns. The five days event gave
participants the space to express themselves in their own idiom. They put forward the
failures of their respective governments and international organisations and decided to
fight together so that health and equitable development become top priorities in the
policy makers’ agendas at the local, national and international levels.
Having reviewed their problems and difficulties and shared their experiences, they have
formulated and finally endorsed the People's Charter for Health. The Charter from now
on will be the common tool of a worldwide citizen’s movement committed to make the
Alma-Ata dream a reality. We encourage and invite everyone who shares our concerns
and aims to join us by endorsing the Charter.
People's Charter for Health (8 Dec 2000)
2
PEOPLE’S CHARTER FOR HEALTH
PREAMBLE
Health is a social, economic and political issue and above all a fundamental human right.
Inequality, poverty, exploitation, violence and injustice are at the root of ill-health and the
deaths of poor and marginalised people. Health for all means that powerful interests have
to be challenged, that globalisation has to be opposed, and that political and economic
priorities have to be drastically changed.
This Charter builds on perspectives of people whose voices have rarely been heard
before, if at all. It encourages people to develop their own solutions and to hold
accountable local authorities, national governments, international organisations and
corporations.
VISION
Equity, ecologically-sustainable development and peace are at the heart of our vision of a
better world — a world in which a healthy life for all is a reality; a world that respects,
appreciates and celebrates all life and diversity; a world that enables the flowering of
people's talents and abilities to enrich each other; a world in which people's voices guide
the decisions that shape our lives.
There arc more than enough resources to achieve this vision.
THE HEALTH CRISIS
“Illness and death every day anger us. Not because there are people who get sick or
because there are people who die. We are angry because many illnesses and deaths
have their roots in the economic and social policies that are imposed on us. ”
(A voice from Central America)
In recent decades, economic changes world-wide have profoundly affected people’s
health and their access to health care and other social services.
Despite unprecedented levels of wealth in the world, poverty and hunger are increasing.
The gap between rich and poor nations has widened, as have inequalities within
countries, between social classes, between men and women and between young and old.
A large proportion of the world’s population still lacks access to food, education, safe
drinking water, sanitation, shelter, land and its resources, employment and health care
services. Discrimination continues to prevail. It affects both the occurrence of disease and
access to health care.
People's Charter for Health (8 Dec 2000)
3
The planet’s natural resources arc being depleted at an alarming rate. The resulting
degradation of’the environment threatens everyone's health, especially the health of the
poor. There has been an upsurge of new conflicts while weapons of mass destruction still
pose a grave threat.
The world's resources are increasingly concentrated in the hands of a few who strive to
maximise their private profit. Ncoliberal political and economic policies are made by a
small group of powerful governments, and by international institutions such as the World
Bank, the International Monetary Fund and the World Trade Organisation. These
policies, together with the unregulated activities of transnational corporations, have had
severe effects on the lives and livelihoods, health and well-being of people both in the
North and the South.
Public services are not fulfilling people's needs, not least because they have deteriorated
as a result of cuts in governments’ social budgets. Health services have become less
accessible, more unevenly distributed and more inappropriate.
Privatisation threatens to undermine access to health care still further and to compromise
the essential principle of equity. The persistence of preventable ill health, the resurgence
of diseases such as tuberculosis and malaria, and the emergence and spread of new
diseases such as HI V/A1DS are a stark reminder of our world's lack of commitment to
principles of equity and justice.
PRINCIPLES OF THE PEOPLE’S CHARTER FOR HEALTH
The attainment of the highest possible level of health and well-being is a fundamental
human right, regardless of a person's colour, ethnic background, religion, gender, age,
abilities, sexual orientation or class.
- The principles of universal, comprehensive Primary Health Care (PHC), envisioned in
the 1978 Alma-Ata Declaration, should be the basis for formulating policies related to
health. Now more than ever an equitable, participatory and intersectoral approach to
health and health care is needed.
- Governments have a fundamental responsibility to ensure universal access to quality
health care, education and other social services according to people’s needs, not
according to their ability to pay.
- The participation of people and people's organisations is essential to the formulation,
implementation and evaluation of all health and social policies and programmes.
- Health is primarily determined by the political, economic, social and physical
environment and should, along with equity and sustainable development, be a top priority
in local, national and international policy-making.
People's Charter for Health (8 Dec 2000)
4
A CALL FOR ACTION
To combat the global health crisis, we need to take action at all levels - individual,
community, national, regional and global - and in all sectors. The demands presented
below provide a basis for action.
HEALTH AS A HUMAN RIGHT
Health is a reflection of a society's commitment to equity and justice. Health and
human rights should prevail over economic and political concerns.
This Charier calls on people of the world to:
Support all attempts to implement the right to health.
- Demand that governments and international organisations reformulate, implement and
enforce policies and practices which respect the right to health.
Build broad-based popular movements to pressure governments to incorporate health
and human rights into national constitutions and legislation.
- Fight the exploitation of people’s health needs for purposes of profit.
TACKLING THE BROADER DETERMINANTS OF HEALTH
Economic challenges
The economy has a profound influence on people’s health. Economic policies that
prioritise equity, health and social well-being can improve the health of the people as
well as the economy.
Political, financial, agricultural and industrial policies which respond primarily to
capitalist needs, imposed by national governments and international organisations,
alienate people from their lives and livelihoods. The processes of economic
globalisation and liberalisation have increased inequalities between and within
nations.
Many countries of the world and especially the most powerful ones are using their
resources, including economic sanctions and military interventions, to consolidate and
expand their positions, with devastating effects on people’s lives.
This Charter calls on people of the world to:
- Demand radical transformation of the World Trade Organisation and the global trading
system so that it ceases to violate social, environmental, economic and health rights of
people and begins to discriminate positively in favour of countries of the South. In order
to protect public health, such transformation must include intellectual property regimes
such as patents and the Trade Related aspects of Intellectual Property Rights (TRIPS)
agreement.
- Demand the cancellation of Third World debt.
People’s Charter for Health (8 Dec 2000)
5
- Demand radical transformation of the World Bank and International Monetary Fund so
that these institutions reflect and actively promote the rights and interests of developing
countries.
- Demand effective regulation to ensure that TNCs do not have negative effects on
people's health, exploit their workforce, degrade the environment or impinge on national
sovereignty.
- Ensure that governments implement agricultural policies attuned to people's needs and
not to the demands of the market, thereby guaranteeing food security and equitable access
to food.
- Demand that national governments act to protect public health rights in intellectual
property laws.
- Demand the control and taxation of speculative international capital flows.
- Insist that all economic policies be subject to health, equity, gender and environmental
impact assessments and include enforceable regulatory measures to ensure compliance.
- Challenge growth-centred economic theories and replace them with alternatives that
create humane and sustainable societies. Economic theories should recognise
environmental constraints, the fundamental importance of equity and health, and the
contribution of unpaid labour, especially the unrecognised work of women.
Social and political challenges
Comprehensive social policies have positive effects on people’s lives and livelihoods.
Economic globalisation and privatisation have profoundly disrupted communities,
families and cultures. Women are essential to sustaining the social fabric of societies
everywhere, yet their basic needs are often ignored or denied, and their rights and
persons violated.
Public institutions have been undermined and weakened. Many of their responsibilities
have been transferred to the private sector, particularly corporations, or to other
national and international institutions, which are rarely accountable to the people.
Furthermore, the power ofpolitical parties and trade unions has been severely
curtailed, while conservative and fundamentalist forces are on the rise. Participatory
democracy in political organisations and civic structures should thrive. There is an
urgent need to foster and ensure transparency and accountability.
This Charter calls on people of the world to:
- Demand and support the development and implementation of comprehensive social
policies with full participation of people.
- Ensure that all women and all men have equal rights to work, livelihoods, to freedom
of expression, to political participation, to exercise religious choice, to education and to
freedom from violence.
- Pressure governments to introduce and enforce legislation to protect and promote the
physical, mental and spiritual health and human rights of marginalised groups.
People's Charter for Health (8 Dec 2000)
6
- Demand that education and health are placed at the top of the political agenda. This
calls for free and compulsory quality education for all children and adults, particularly
girl children and women, and for quality early childhood education and care.
- Demand that the activities of public institutions, such as child care services, food
distribution systems, and housing provisions, benefit the health of individuals and
communities.
- Condemn and seek the reversal of any policies, which result in the forced displacement
of people from their lands, homes or jobs.
- Oppose fundamentalist forces that threaten the rights and liberties of individuals,
particularly the lives of women, children and minorities.
- Oppose sex tourism and the global traffic of women and children.
Environmental challenges
Water and air pollution, rapid climate change, ozone layer depletion, nuclear energy
and waste, toxic chemicals and pesticides, loss of biodiversity, deforestation and soil
erosion have far-reaching effects on people’s health. The root causes of this
destruction include the unsustainable exploitation of natural resources, the absence of
a long-term holistic vision, the spread of individualistic and profit-maximising
behaviours, and over-consumption by the rich. This destruction must be confronted
and reversed immediately and effectively.
This Charter calls on people of the world to:
- Hold transnational and national corporations, public institutions and the military
accountable for their destructive and hazardous activities that impact on the environment
and people's health.
- Demand that all development projects be evaluated against health and environmental
criteria and that caution and restraint be applied whenever technologies or policies pose
potential threats to health and the environment (the precautionary principle).
- Demand that governments rapidly commit themselves to reductions of greenhouse
gases from their own territories far stricter than those set out in the international climate
change agreement, without resorting to hazardous or inappropriate technologies and
practices.
- Oppose the shifting of hazardous industries and toxic and radioactive waste to poorer
countries and marginalised communities and encourage solutions that minimise waste
production.
- Reduce over-consumption and non-sustainable lifestyles — both in the North and the
South. Pressure wealthy industrialised countries to reduce their consumption and
pollution by 90 per cent.
- Demand measures to ensure occupational health and safety, including worker-centred
monitoring of working conditions.
- Demand measures to prevent accidents and injuries in the workplace, the community
and in homes.
People's Charter for Health (8 Dec 2000)
7
Reject patents on life and oppose bio-piracy of traditional and indigenous knowledge
and resources,
- Develop people-centred, community-based indicators of environmental and social
progress, and to press for the development and adoption of regular audits that measure
environmental degradation and the health status of the population.
War, violence, conflict and natural disasters
violence, c onflict and natural disasters devastate communities and destroy human
dignity. They have a severe impact on the physical and mental health of their members,
especially women and children. Increased arms procurement and an aggressive and
corrupt international arms trade undermine social, political and economic stability and
the allocation of resources to the social sector.
This Charter calls on people of the world to:
- Support campaigns and movements for peace and disarmament.
- Support campaigns against aggression, and the research, production, testing and use of
weapons of mass destruction and other arms, including all types of landmines.
- Support people's initiatives to achieve a just and lasting peace, especially in countries
with experiences of civil war and genocide.
- Condemn the use of child soldiers, and the abuse and rape, torture and killing of women
and children.
- Demand the end of occupation as one of the most destructive tools to human dignity.
. Oppose the militarisation of humanitarian relief interventions.
Demand the radical transformation of the UN Security Council so that it functions
democratically.
- Demand that the United Nations and individual states end all kinds of sanctions used as
an instrument of aggression which can damage the health of civilian populations.
- Encourage independent, people-based initiatives to declare neighbourhoods,
communities and cities areas of peace and zones free of weapons.
- Support actions and campaigns for the prevention and reduction of aggressive and
violent behaviour, especially in men, and the fostering of peaceful coexistence.
- Support actions and campaigns for the prevention of natural disasters and the reduction
of subsequent human suffering.
People's Charter for Health (8 Dec 2000)
8
A PEOPLE-CENTERED HEALTH SECTOR
This Charter calls for the provision of universal and comprehensive primary health
care, irrespective ofpeople’s ability to pay. Health services must be democratic and
accountable with sufficient resources to achieve this.
This Charier calls on people of the world to:
Oppose international and national polieics that privatise health care and turn it into a
commodity.
- Demand that governments promote, nuance and provide comprehensive Primary
I lealth Care as the most effective way of addressing health problems and organising
public health services so as to ensure free and universal access.
- Pressure governments to adopt, implement and enforce national health and drug
policies.
- Demand that governments oppose the privatisation of public health services and ensure
effective regulation of the private medical sector, including charitable and NGO medical
services.
- Demand a radical transformation of the World Health Organization (WHO) so that it
responds to health challenges in a manner which benefits the poor, avoids vertical
approaches, ensures intersectoral work, involves people's organisations in the World
1 lealth Assembly, and ensures independence from corporate interests.
Promote, support and engage in actions that encourage people’s power and control in
decision-making in health at all levels, including patient and consumer rights.
- Support, recognise and promote traditional and holistic healing systems and
practitioners and their integration into Primary Health Care.
Demand changes in the training of health personnel so that they become more problemoriented and practice-based, understand better the impact of global issues in their
communities, and are encouraged to work with and respect the community and its
diversities.
- Demystify medical and health technologies (including medicines) and demand that they
be subordinated to the health needs of the people.
- Demand that research in health, including genetic research and the development of
medicines and reproductive technologies, is carried out in a participatory, needs-based
manner by accountable institutions. It should be people- and public health-oriented,
respecting universal ethical principles.
- Support people’s rights to reproductive and sexual self-determination and oppose all
coercive measures in population and family planning policies. This support includes the
right to the full range of safe and effective methods of fertility regulation.
PEOPLE’S PARTICIPATION FOR A HEALTHY WORLD
Strong people’s organisations and movements are fundamental to more democratic,
transparent and accountable decision-making processes. It is essential that people's
People's Charter for Health (8 Dec 2000)
9
civil, political, economic, social and cultural rights are ensured. While governments
have the primary responsibility for promoting a more equitable approach to health and
human rights, a wide range of civil society groups and movements, and the media have
an important role to play in ensuring people's power and control in policy development
and in the monitoring of its implementation.
This Charter calls on people of the world to:
- Build and strengthen people's organisations to create a basis for analysis and action.
- Promote, support and engage in actions that encourage people’s involvement in
decision-making in public services at all levels.
- Demand that people’s organisations be represented in local, national and international
fora that are relevant to health.
- Support local initiatives towards participatory democracy through the establishment of
people-centred solidarity networks across the world.
The People's Health Assembly and the Charter
The idea of a People's Health Assembly (PHA) has been discussed for more than a
decade. In 1998 a number of organisations launched the PH A process and started to plan
a large international Assembly meeting, held in Bangladesh at the end of 2000. A range
of pre- and post-Assembly activities were initiated including regional workshops, the
collection of people's health-related stories and the drafting of a People's Charterfor
Health.
The present Charter builds upon the views of citizens and people's organisations from
around the world, and was first approved and opened for endorsement at the Assembly
meeting in Savar, Bangladesh, in December 2000.
The Charter is an expression of our common concerns, our vision of a better and healthier
world, and of our calls for radical action. It is a tool for advocacy and a rallying point
around which a global health movement can gather and other networks and coalitions can
be formed.
Join Us - Endorse the Charter
We call upon all individuals and organisations to join this global movement and invite
you to endorse and help implement the People's Charterfor Health.
PH A Secretariat, e-mail:
Website:
Mailing address: mEU
People's Charter for Health (8 Dec 2000)
10
Amendment
After the endorsement of the PCH on December 8, 2000 it was called to the attention of
the drafting group that action points number 1 and 2 under Economic challenges could be
interpreted as supporting the social clause proposed by WTO, which actually serves to
strengthen the WTO and its neoliberal agenda. Given that this countervails the PHA
demands for change of the WTO and the global trading system, the two paragraphs were
merged and amended.
The section on War, Violence, and Conflict has been ammended to include natural
disasters. A new action point, number 5 in this version, was added to demand the end of
occupation. Furthermore, action point number 7, now number 8, was ammended to read
to end ail kinds of sanctions. An additional action point number 11 was added
concerning natural disasters.
People's Charter for Health (8 Dec 2000)
11
People's Charter For Health
I approve the text of the Charter
I wish to Support the Movement
I wish to actively participate in the Movement
(You can tick all the three)
Name:
Organisation:
_____________________________________________
Add ress:
Tel:
Fax:
E-mail:
Date:
Signature:
Please return to:
Dr. Ravi Narayan
Coordinator
PHM Secretariat
CHC Bangalore
# 367 "Srinivasa Nilaya", 1 Block Jakkasandra,
1 Block, Koramangala, Bangalore-560034, India
email: secretariat@phmovement.org
website: www.phmovement.org
Nov. 2003
4
Alma Ata Anniversary
In this Issue
September 1978 was a defining moment in
Alma Ata Anniversary
the struggle of the people, especially the
poor, of the world for health. The health
Why Alma Ata?
decision makers from 131 countries
A-Z of ideas for celebration of the Alma Ata
endorsed the Alma Ata Declaration, a
The Alma Ata anniversary celebrations in
document so much ahead of its time and so
PHM worldwide
radical that the participants expected
Million signature campaign website in new
resistance to its implementation. Resistance
languages of the world
to and subversion of the primary principles
Event
Reports from different regions
of Alma Ata was so widespread that in
Forthcoming events in PHM circles September 2003 as we look back on the
Region-wise
last twenty-five years, the gains have been
limited and the health status of the poor
Enlarging the network
around the world continues to be abysmal.
Report from the Secretariat
In between, another moment, Health for All
2000 came and went without causing any
ripple. There are several reasons why this happened, some of them being: the reduction of
the scope of Primary Health Care through the concept of selective PHC, neo-libera!
economic policies, the debt crisis, trade imbalances and such on the one hand and the
prescription of the IMF and the World Bank in the form of Structural Adjustment Programs, on
the other. Conspicuous in its absence has been political will, either of the implementers or
people themselves around the world. The results are plain to see: vital indicators such as
infant mortality rate, maternal mortality rate, malnutrition levels have deteriorated around the
globe, diseases thought to have been contained or eradicated such as Leishmaniasis,
Leptospirosis, Plague have reappeared. Malaria and Tuberculosis have returned in virtually
untreatable forms, TB killing 500,000 people per year in India alone, HIV-AIDS, Ebola virus
and a host of other newer diseases have appeared on the scene. Just to reiterate the point,
in Alma Ata itself, since rechristened as Almaty, IMR which was 12 per 1000 live births in
1978, is now 60/1000. A sad but apt commentary on the state of public health in the world.
The 25lh Anniversary, therefore, does not call for any celebration but rather calls for a deep
introspection on why things have come to such a pretty pass. It is also the moment when
meaningful efforts to reaffirm the principles and practice of PHC that would make health a
reality for those who need it most need to be started and nurtured. One lesson that has been
recognized is that unless people take charge of their own health, no systems would work.
People’s participation was indeed one of the bedrocks of the Alma Ata Declaration. People’s
Health Movement of which all of us are a part, is one very hopeful step in that direction.
S3
Epj
S3
EE
tzrs
053
PHM and its constituents across the globe will mark this year as the Year of Alma Ata to raise
the consciousness of people and decision makers to the founding principles of Alma Ata and
to re-establish the primacy of PHC in our struggle for equity in health. One hopeful sign is
already on the horizon - Dr. Lee, the new DG of WHO has already started a serious initiative
on primary health care. (PCJ)
Editorial Committee:
Prem John (Editor), premjohn@vsnl.net
Qasem Chowdhury, gksavar@citechco.net; Hani Serag, hserag@yahoo.com
Assisted by Prasanna Saligram; Secretariat@phmovement.org
PHM Secretariat, CHC-Bangalore, # 367, "Srinivasa Nilaya". I Block, Jakkasandra
I main I Block Koramangala, Bangalore-560034, India; tel: + 91-80-5128 0009
fax: +91-80-552 5372 email: secretariat@phmovement.org
website: www.phmovement.org
WHY ALMA ATA ANNIVERSARY?
1.
The Alma Ata Declaration was finalized at the Alma
Ata Conference in September 1978. So September
2003 is actually the 25th anniversary month. For
purposes of our local regional and global reflections,
we could focus on 2003 as the year of the anniversary
reflection.
2.
The coordinates in the post Alma Ata reflections
should include not only what happened to the Primary
Health Care Strategy at the Global and country levels
but also reflect on special initiatives and programme
like Essential Drugs strategy; the code for Marketing
Breast Milk substitutes; the expanded programmes
of immunization and a series of international
initiatives all the way from the GOBI-FFF, safe
motherhood to RBM, TFI, GAVI, MMV, Global fund
for AIDS, TB, Malaria and others.
3.
4.
5.
The Alma Ata Declaration and the Peoples Health
Charter could be used as the framework of analysis.
With the changing visions and roles of international
health agencies like WHO and UNICEF who were
co-sponsors of the Alma Ata meeting; and the
growing development of World Bank as a key health
player; and the effects of neo-liberal economic
policies of liberalization, Globalization and
privatization; and evolving international instruments
of governance like WTO, IPR, GATT etc., The whole
primary health care/community health/peoples health
context has changed drastically and our analysis
must be both historical and contextual. The role of
other actors including NGOs and civil society can
also be discussed.
The changing leadership of WHO and UNICEF over
the years including the change in WHO in 2003 must
be added to the analysis and the opportunity used to
discuss not only international health concerns and
international health programmes- initiatives and
trends but perhaps also significantly the type of
international health leadership we have and what we
need.
With PHA and WSF and similar, visible, international,
solidarity and collectivity, this is also an important
year to reflect on all our own networking, lobbying
and advocacy efforts around the world. Since while
it may be easier in our analysis to focus on WHO/
UNICEF/World Bank and national governments - the
NGO-civil/society and peoples networks will also
have to take the responsibility for not becoming an
adequate countervailing power to this neo-liberal
distortion in the HFA goals. While we too failed the
people, - PHA and PHM at different levels may be
the beginning of a new phase, a new collective
commitment and 2003 must include a critical self
reflection of our own initiatives, campaigns and
perspectives before 2000 AD. We need to build
sustainable mechanisms of functioning so that the
momentum continues and gets more deeply socially
rooted
6.
The biggest challenge for all of us in PHM is to ensure that
the PH Charter does not go the same way as the Alma Ata
declaration - forgotten, distorted, selectivised, verticalised,
commercialized and ignored. PHM was meant to be a global
challenge to this global amnesia. We need to evolve a
different strategy this time and use 2003 as a launching
pad for it. As we celebrate the Alma Ata Anniversary, let us
also celebrate the evolution of the People’s Charter for
Health. Two documents that support the struggle for Health
for All, Now.
The Alma Ata Anniversary Pack
The PHM Secretariat has prepared a pack of materials
that would make it easy for our constituents to mark this
event. This pack consists of several papers such as:
Why Alma Ata Anniversary, Some suggestions for the
celebration, The Declaration of Alma Ata- September
1978, The People’s Charter for Health-December 2004|
The Million Signatures on the Internet to Demand "Health
for All, Now’’.
Some background papers with excellent analysis of the
problem based on available empirical data by well known
thinkers and activists such as David Werner, Debabar
Banerji David Sanders and Prem John are also there.
This compilation done by Unnikrishnan, the media
coordinator of PHM, was released in PHM related
events during October 2003 in the form of a booklet
titled “Health for all Now! Revive Alma Ata!' first in Che
and Espejo Forum in Ecuador followed by Italy,
Canada, Philippines and India.
FOR MORE INFORMATION / MATERIAL
PLEASE VISIT
www.phmovement.org
A-Z of ideas for celebration of the Alma Ata
A.
B.
DISCUSS the Alma Ata Declaration and the People's
Charter for Health
SIGN the million signature campaign for Health for All
Now
C.
TRANSLATE the signature campaign note into your
own language and release a vernacular language
website version
D.
REVIEW the primary health care experience in your
state or country and present it at this meeting
E.
IDENTIFY case studies of primary health care projects
by government or NGO/civil society initiative in your
state or country and invite project leaders to share their
experiences.
F.
RELEASE a press statement or media brief for the
occasion and release it through a press conference
G.
CELEBRA TE your Country's Health Policy if it has been
Primary Health Care oriented or has tried to reach Health
f°r All in your country context.
H. HONOUR Primary Health Care workers in your state or country.
/. ORGANIZE a small exhibition on Alma Ata Declaration
principles and the action points of the People’s Charter for
Health.
J.
ORGANIZE a convention of Primary Health Care workers and
community level PHC volunteers. Listen to their experiences.
Endorse their work.
Coordinating Office
The Coordinates of the new office:
Mailing Address:
People’s Health Movement Secretariat (Global)
CHC, # 367, Jakkasandra 181 Main,
1Bt Block, Koramangala, Bangalore - 560 034, India.
K. WRITE articles in bulletins and journals on the Health for All /
L.
Primary Health Care and People’s Health Movement Themes.
E-Mail contact IDs:
ORGANIZE a street event, a public march; a candle light vigil;
a human chain; a children’s rally; a cycle rally; a walkathon; a
run for health; to express solidarity with the Health for All Now
campaign.
phmsec@touchtelindia.net
secretariat@phmovement.org
M. ORGANIZE street theatre or folk culture events that express
solidarity with the theme through skits and songs and other
forms of cultural expressions [Themes: Explore the distortions
done by the market economy to the Primary Health Care;
celebrate how the people have resisted these distortions or
how they have taken health in their own hands].
ORGANIZE talks in schools on the theme - People’s Health
in People’s Hands. Thereby inspiring the next generation to
the Health for All challenges.
O. ORGANIZE a Radio talk on the theme.
P. ORGANIZE a Television show - an interview or a panel
E-mail pertaining to communications/website should
address:
Comm.phmsec@touchtelindia.net
Telephone numbers are:
+91-80-5128 0009 (Direct line)
+91-80-552 5372 which number is also the fax
Gonoshasthaya Kendra, Savar, Bangladesh will
continue to be in charge of publications, the News
Brief and also the Archives. Dr. Qasem Chowdhury,
the outgoing Coordinator will handle this.
He is at: gksavar@citechco.net
discussion with Primary Health Care activists in your area.
Q.
WRITE a letter from your PHM Circle to the Government of
your country (Health Ministry and other related ministries, i.e.,
women, child, labour, rural development, environment, etc.,
Dr. Prem Chandran John helps edit the Newsbrief.
He is at: premJohn@vsnl.net
R. TRANSLATE the Charter into your own language and release
S.
it at the anniversary celebration.
Enlarging the Network: The validity and strength of
DISTRIBUTE the Charter or translated version actively on
any movement depend on how far and how wide we
are able to spread (not to speak of how soon and
how much in depth). Every new contact, every new
network brings hope and joy. Here are a few new
places where PHM’s foot print has been
implanted:
1. West Africa:
a) A new country contact established
in the Western African region E-mail:
asdebtg@yahoo.fr
b) Sierra Leone
c) Cote D’Ivoire
d) Ghana
this occasion and or present it to key health officials.
T.
ORGANIZE a rewriting of the Charter into a simpler local
language version with examples, drawings and case sheet
and release it I distribute it at the meeting to members of the
community.
'(/^ORGANIZE a public signing of the Charter and the Million
^^Signature Campaign in the town square or town hall or some
central point in the bulletin.
V.
ORGANISE Alma Ata Anniversary meetings in Schools of
medicine, nursing schools, health worker schools and
sensitise the next generation of health professionals to the
Health for All Now campaign.
W. ORGANISE a musical evening or cultural programme. Have
2.
Southern African region: Mauritius .
3.
East and Central Africa : Congo
a few health and development songs to endorse the HFA
campaign.
4.
Europe: Bulgaria
X. LAUNCH a PHM Circle in your institution / local area / state /
5.
South America: Bolivia
6.
India: The states of Jharkhand, Uttaranchal
country - do so as part of the celebration.
Y.
INNOVATE other ideas that are more creative, more
collective, more in solidarity with the theme.
Z.
FINALLY, SEND us a report, copy of invitation, programme,
poster, photographs, video clippings, press releases,
background paper/s, educational materials or any other
handouts about your event (whatever you do for the Alma
Ata Anniversary) - so that we can put it on the PHM exchange
or Website. (RM)
'
'
v
The Million signature campaign launched to demand
Health for All Now! in this Alma Ata Anniversary year is
now available in 2 other international languages
namely Italian and German. Similar efforts can be
undertaken by different countries to translate the
website in their country languages. For further
information and help on this please contact
unni@phmovement.org
w \VAV/\V/<V/(VAV/<V/kVAV/<VAV/vvz
News from the Secretariat
5.
1. The new PHM Global Secretariat in Bangalore,
India inaugurated by Mr. Olle Nordberg and Dr.
Qasem Chowdhury:
Most of you may not be aware that PHM secretariat
(Global) and most of the PHM activities have so far been
running on the pitiful remnants of funds that were raised for
PHA 2000. This is of great concern to all of us. Therefore
the funding group consisting of Andy Rutherford, Prem
John, Ravi Narayan, Olle Nordberg as well as Pamela
Zinkin, Dave McCoy, Alifia Chakera, Mike Rowsen and
Udayakumar met in London on 23rd and 24,h of October
2003 to discuss the strategies for future funding and to
finalise the Proposal.
Mr. Olle Nordberg from Dag Hammerskjold Foundation,
one of the founding networks of the PHM inaugurated
the PHM Global secretariat in Bangalore, India on 19lh
February 2003. Dr. Qasem Chowdhury, the outgoing
coordinator of the PHM Global secretariat was also
present during the time. Besides Dr. Ravi Narayan, the
Coordinator, the secretariat consists of Prasanna
Saligram as the Communications Officer and Srindhi as
Secretariat support staff. The PHM secretariat in
Bangalore is hosted by the Community Health Cell.
Besides electronic communication systems, the
secretariat also houses a lot of resource materials from
various parts of the world and in various
languages
2. Jagdishwar Goburdhan, former Health Minister of
Mauritius visited the Secretariat
Mr. Jagdishwar Goburdhan, former health minister of
Mauritius who was responsible for setting up a peopleresponsive “Community Health Fund” in Mauritius,
spent two days at the Secretariat starting July 4lh
sharing his experiences in the field of Primary Health
Care. Since his visit a new initiative called "Mouvement
Sante Communitaire" (People’s Health Movement) has
taken root there. They are also sending a delegation of 7
people to the International Health Forum, Mumbai, India
preceding the World Social Forum in order to learn the
process of Health Forum so that a similar meeting can
be held in Africa.
3. Meeting in Bangalore of some of the Steering
committee members to finalize the proposal for
PHM
Some of the Steering group members: Zafrullah
Chowdhury, Prem John, K. Balasubramaniam and Mira
Shiva met on July 28lh 2003 to finalize the proposal for
PHM Global activities.
4. A meeting on the Traditional systems of medicine
(TSM)
30 people - activists, academics and practitioners people
involved in Traditional systems of medicine (TSM), met
on 29“' July 2003. The meeting focused on bio-piracy
involving herbal plants as well as the increase in
commercialization of the traditional systems of medicine.
An urgent need to systematically document these
systems of medicine was felt. Also discussed were
WHO’s initiatives in traditional systems, whether they
promote pluralism or hamper it with a new set of
regulations? A small PHM- TSM circle was formed. A
TSM workshop at the World Social Forum highlighting
people's voices in TSM is planned.
6.
Funding group meets in London
Dialogue with WHO in Madrid:
From London Ravi Narayan went to Madrid to
participate in the WHO meeting entitled “Future strategies
for Primary Health Care". This was an opportunity used by
PHM to present people's perspectives as expressed in the
People’s Charter for Health. This opportunity was also
used to present the PHM's concerns on WHO’s
policies.
^])
7.
Planning Strategy
A three-year strategy planning exercise has been initiated
by the Secretariat through a series of communications to
all members of the Steering Group and the Secretariat
support group. The process is ongoing and will be
completed in October 2003.
8.
A communication strategy
A communication strategy is being evolved so that all the
methods presently being used including website; PHM
exchange; news brief; press releases; publications and
email communications are better focused and directed
towards specific objectives to support the growth of the
movement. The strategy evaluation was stimulated by a
thought provoking paper by Andrew Chetley entitled 'PHM
Communication Matters', (chetley.a@healthlink.org.uk &
webmaster@phmovement.org).
9. PHM - Global Website
The baton of the Global web site has been transferred to
Prasanna (PHM Communications Officer) from Nand
Wadhwani (PHM - Cost Rica), who was the website
consultant and manager till recently. We hope all of you
will actively participate in telling us of your activities to help
us update / upload the website actively. As a PHM policy,
we are now suggesting some standardized methods of
communication regarding events and initiatives (A
separate communication follows).
10.
The Global Health Equity Watch project
The PHM / GEGAIWEMOS joint initiative for a Global
Health Equity Watch report has progressed well with a
detailed framework evolved by Dave McCoy, Mike Rowson
and an informal advisory group through e-group discus
sion. This has now been circulated for wider comments.
((David.McCoy@lshtm.ac.uk &
mikerowson@medact.org).
Portugal:
WHO and PHM
After the close interaction at the World Health
Assembly in Geneva, May 2003 when we introduced
PHM to the incoming DG, Dr. Lee Jong-wook, PHM
received a letter from him expressing his desire to
work closely with PHM in the coming years. This is
good news indeed!
News from the Regions
1.
SOUTH AFRICA REGION
A South African Alma Ata Anniversary meeting entitled
‘Twenty Five years after Alma Ata’ was held end of
August 2003 supported by David Sanders and the PHM
Circle <lmartin@uwc.ac.za
2.rEAST AND CENTRAL AFRICA REGION
fcnya
PHM Kenya Circle was launched on 23rd August 2003 at
Mombasa. Participants from Tanzania, Kenya, Uganda,
and Netherlands participated in solidarity.
A post launch seminar was held, attended by 20 participants
from Kenya, Uganda and Tanzania, which chartered the way
forward for PHM Kenya and its collaborators and partners in
health (phmkenya@yahoo.com)
Tanzania
Mwajuma has continued to establish contact with other net
works and the Alma Ata Anniversary pack was mailed to 150
addresses in Africa (masaigana@africaonline.co.tz)
4.
INDIA REGION:
The National Working Group of the Jana Swasthya Abhiyan
(PHM India) met in Bangalore on 26-27"’ July 2003 to plan
for PHM activities and the Alma Ata Anniversary in India.
The discussions included themes such as The Right to
Health Care campaign to be launched by PHM India on 6lh
September 2003 at Mumbai as part of the Anniversary cam
paign; planning the initial framework of the International
Health Forum in Mumbai on 14-15lh January 2004.
cehatpun@vsnl.com
In August 2003, PHM India held a workshop on ‘Hunger
Watch’ in Bhopal.
On 5'h September 2003, a Workshop for activists from 18
states on the ‘‘Right to Health Care" campaign was
organized by PHM India, at Mumbai, as part of the Alma
Ata Anniversary celebration and over 250 people attended
the meeting. On 6lh September 2003, a National Public
Consultation of PHM India with the National Human Rights
Commission was also held. Testimonies from many
states on the ‘Denial of the Right to Health Care’ were
recorded. PHM meetings and workshops have taken place
in several states - Karnataka, Andhra Pradesh, Tamil
Nadu, Maharashtra, Rajasthan.
5.
SOUTH ASIA REGION:
Uganda
Bangladesh
‘Uganda Coalition for Access to Essential Medicine’ was
PHM Bangladesh Circle management committee met on
5,h June 2003 to review the experience of Bangladesh
participants at PHM Geneva, May 2003
(dorpco@bangla.net, afmimam@dhaka.net &
phmbc@dhaka.net).
formed to be a stronger voice for advocate and campaign for
f^ legislation and access to essential medicine.
(^ps@utlonline. co. ug)
3.
MIDDLE EAST/ NORTH AFRICA REGION
Palestine
A regional meeting of PHM contacts was held on October 17"1
in Cyprus. (Jihad@shabaka.net)
Egypt
AHED conducted a one day seminar on 25"' year Alma Ata
Declaration in Egypt at the end of August 2003. The PH Char
ter was distributed / promoted during this meeting
(hserag@yahoo.com).
<•>’
The World Consumer Congress, facilitated by Consumer In
ternational, was held between 17lh to 19,h October 2003, at
Lisbon, Portugal, bala@haiap.org
and <carmelita@ciroap.org>
A National Health Convention on 25 years of Alma Ata
Anniversary was held on 6lh September 2003 at Dhaka
(dorpco@bangla.net, afmimam@dhaka.net &
phmbc@dhaka.net).
Sri Lanka
Prem John ofACHAN/PHM visited Colombo on 29“’ August
to 1s' September 2003 to meet PHM contacts and increase
their involvement in PHM.
(hariprem@eth.net & premJohn@vsnl.net).
SOUTH EAST ASIA REGION:
Cyprus :
6.
A PHM Regional meeting was organized in Aya Napi,
Cyprus, on 17-18'" of October 2003 to make a year plan for
the region. 13 countries were represented. Documents in
Arabic and English are being prepared
<jihad@shabatic.net>
Philippines
Health Action Information Network and Health Link Ex
change Worldwide, UK, organized a 6-day Communication
for Advocacy Training workshop in Manila from July 22-26,
2003 <hain_sj@kalusugan.org>
AZ, .V/ W W W W W <v/ kvav/ <vz <v/ KVZ wz XV-Z <V/ w xvz ozz <VAV/
V/ V/ W M
AZ, AZ. AZJ A
*>:
:<•>: <•> TO TO TO TO TOTO TO TO 7
A forum on 25 years of Primary Health Care was held in
Manila on 12" September 2003
(bdelapaz@uplink.com.ph)
Philippines :
An International Conference on ‘Challenges in Health
work in a Globalized and Terrorized world: Continuing
our Resistance’ was organized in Manila, from 2nd - 10"1
November 2003 by the International League of People’s
Struggles - Adhoc Health Commission, PHM Philippines
and IPHC - Philippines (bdelapaz@uplink.com.ph).
7.
NORTH AMERICAN REGION:
USA
As a follow up of PHM -USA 8- city tour in March 2003 of
Zafrullah, Ravi and Thelma (PHM South Asian leaders) the
coordination ofPHM-USA activities is evolving. Four circles
have been launched - War and Health Circle; Health and
Trade Circle; Environmental Justice Circle; and US Health
Care Access Circle (sarahs@hesperian.org).
A coordinating group has been set up to address different
needs including listserve relations / monitor; website; con
ference coordination; publications; finances and PHM In
ternational relations (sarahs@hespenan.org)
Alma Ata celebrations were organized at the Doctors for
Global Health Annual Meeting at Berkeley - end of July
2003 dghinfo@dghonline.org
Canada :
The Canadian Conference on International Health on the
themes: The Right to Health influencing the Global Agenda
and How Research, Advocacy and Action can shape the
future was held in Ottawa, 26-29,h October 2003. ‘A Right
to Health Care Now Campaign’ from the perspective of
PHM and IPHC was organized by Maria Zunega
<maria@iphcglobal.org>. A workshop on ‘Public Private
Partnerships' was organized by Jose Utrera with WEMOS
and IPHC participation <jose.utrera@wemos.nl>. Another
Workshop on “Liberation Medicine and PHM” was orga
nized by Lanny Smith <vze2x6qm@verizon.net>. Abhay
Shukla from PHM India presented a paper on “Right to
Health Care" campaign cehatpun@vsnl.com
8. CENTRAL AMERICA, MEXICO & CARIBBEAN
REGION
Guatemala
A meeting of PHM activists took place to share
experiences and to plan action strategies from the
region.
Mexico
A workshop on ‘WTO - Food and Nutritional security: A
Global Concern’ was organized by WEMOS for
delegates on 12P September during the 5lh WTO
Ministerial conference at Cancun, 10-14lh September
2003 <trade@wemos.nl>. Many PHM members
including Mira Shiva and Carmelita Canila attended the
Cancun meeting.
Nicaragua
The E-mail list serve called
REDLATINOAMERICANASALUD has been very active
This list serve is moderated by the IPHC office in
Nicaragua and is open to all Spanish language persons
who attended PHA 2000, as well as others who have
subscribed to the first serve.
Apart from the above, this region has a network called
“The Regional Committee for the Promotion of
Community Health" founded in 1975, which is vital to
PHM Mexico, Central America and the Spanish speaking
Caribbean and is fully involved in PHM and its activities.
Efforts are on in most countries for the Million-Signature
campaign. Regular activities are being carried out in the
framework of the 25,h Anniversary of Alma Ata. Activists
are also preparing a response to the PAHO PHC
document.
Ecuador
An International Primary Health Care Forum in Quito was
held, 20-24"' October 2003. It was be preceded by the Che
and Espejo Forum in Cuenca in the week 13-17"1 October
2003 (aquizhpe@yahoo.com).
9.
SOUTH AMERICAN REGION
Brazil
Sr. Ani, PHM Brazil, informs us of the PHM campaign
Hearing the Voices of the Unheard is going on well, of
special significance in a country affected by the
domination of Banks and Multinationals and where the
vast majority of people do not have computers. PHM is
promoting pamphlets explaining the campaign, adding a
slip for signatures and enclosing a copy of the declaration
of Alma Ata. All these are presented in assemblies local and regional meetings as well as individually
among poor communities. Hundreds and thousands of
grass roots folk are signing up.
[Can other countries adopt (adapt) this simple low
cost method to their own cultures and situation?
Write to Sr. Ani for further details
<Acwlepalis@aol. com>],
Bolivia
MAP International, Bolivia, has informed that they are
endorsing and promoting the spirit of the People's
Charter for Health in their educational activities as well as
in the different projects.
<mapbol@supernet.com.bo>
10.
EUROPEAN REGION
UK
Reaching the 4O'h Translation of Charter
A recent list from Pam Zinkin who is coordinating /
tracking translations of the Charter, brings great news.
Finalised and on the website - Arabic, Bangla, Chinese,
Danish, English, Farsi. Finnish, Flemish, French, German,
Greek, Hindi, Indonesian, Italian, Japanese, Kannada,
Malayalam, Ndebele. Nepalese, Philippines, Portuguese,
Russian, Shona, Sinhalese, Spanish, Swahili, Swedish,
Tamil, Urdu, Ukrainian. Promised Cambodian, Tonga,
Lithuanian, Norwegian, Welsh, Thai, Dari, Pastun, Creole,
Vietnamese, Welsh and Bulgarian.
Also available Audio in English and in English with Braille
titles
[If you have done translation into your own language not
in the above list, please let us know immediately to add
to the list. Can we reach the 5O'h Mark by the PHA
anniversary on 8th December 2003?
(pamzinkin@gn.apc.org and gksavar@citecho.net)]
Russia
A ^iterance was held in the Medical Academy of
Postgraduate study in St. Petersburg on Alma Ata - Health
for All is necessary and possible. 300 participants attended
including over 32 social and medical NGOs. The Charter
was published in the Medical Academy Newspaper and a
special Russian edition of Charter distributed to all partici
pants. This was reported widely in the popular press
(simb@comset.net).
The materials of the conference were also used during the
Hearing on the Medical compulsory insurance reformation at
St. Petersburg legislative assembly (simb@comset.net).
Netherlands
The Women's Access to Health Care campaign was launched
Fischer and Andreas Wulf (Germany). This was followed
by a series of smaller meetings in different towns of
Germany, with Zafar Mirza of Pakistan and Thelma
Narayan of India as resource persons.
Switzerland
Dr. Bala and David Woodward represented HAI and PHM
respectively in the Millennium Development Strategy Task
Force on Access to Medicine Workshop at Geneva in June
2003. David presented a paper on ‘Medicine and Phar
maceutical Technology as Public Goods’
(bala@haiap.org and woodwarddavid@hotmail.com).
Bulgaria
An IBFAN linked Bulgarian NGO called NM - Women
and Mothers against Violence which has more than 1600
members and volunteers has offered to translate the
Charter into Bulgarian and spread PHM in their country.
They work on protection of mothers and children’s
health, support of breast feeding, infant feeding and
trade issues <ibfanbg@rtsonline.net>.
Italy
A PHM Italy meeting was held in Bologna, Italy in July
2003 facilitated by AIFO. Dr. Thelma Narayan, PHM
India was a special invitee and resource person in
Health. A discussion with Medical faculty and students
of the University of Bologna was also facilitated by her
and Sunil Deepak of AIFO (sunil.Deepak@aifo.it).
The AIFO biennial conference was held in Rome on 25lh
and 26,h October 2003. A three member PHM team
(Ravi, Maria and Mwajuma) received a Human Rights
Award on behalf of PHM.
by WGNRR in collaboration with a large network of
organizations including PHM on 27 May 2003. In many parts
of
world, there have been local and national launch and
related events <wahc@wgnrr.nl>.
Germany
PHM was invited for a meeting on Genetics Research in
Germany to discus the profound challenges of the new
human genetic technologies and the need for social controls.
The conference was held,October 12-15, in Berlin. It was
organized by the Heinrich Boell Foundation and the Institut
Mensch, Ethik und Wissenschaft (in Berlin), and the Center
for Genetics and Society in California (Dr. Sigrid Graumann graumann@imew.de). PHM was represented by Gilles de
Wildt<gillesdewildt@yahoo.com>.
A Seminar on ‘Public, Private Partnerships - Hand in Hand
with Industry? was organized by BUKO, in Bad Boll, in
Germany, 3SI October - 2nd November 2003. Panelists will
included Zafar Mirza (Pakistan), Thelma Narayan (India),
Jose Utrera (The Netherlands), Judith Richter, Christiane
REJOICE WITH US!
The President of Amici di Raoul Follereau foundation
(AIFO) of Italy, Dr. Enzo Venza, presented the award
to PHM for safeguarding Human Rights at their
Biennial meeting on 25th of October 2003. It was
received by Ravi Narayan from Asia, Maria Hamlin
Zuniga from Latin America and Mwajuma
Masaiganah from Africa. The meaningfully done
Citation reads:
“To the Multitude of excluded people for whom the
People’s Health Movement speaks. To their desire
for life and future. To their intelligence and abilities.
To the new world sprouting from the actions of
grass-roots movements, a world where the
supremacy of people over profit can be re
established”.
Spain
A WHO Global Meeting on Future Strategic Directions for
Primary Health Care’, was organized in Madrid, Spain, 2729:h October 2003. PHM was represented by Ravi Naraya, the
Global Coordinator.
secretariat@phmovement. org
Switzerland
Forum 7 of the Global Forum for Health Research, will be held
in Geneva from 3rd to Th December 2003. PHM participation in
many sessions is evolving. Imartin@uwc.ac.za
12.
CHINA REGION
Our efforts to re-start the process in China have not yet
been very successful. Unnikrishnan will be visiting
China shortly for an Action Aid workshop and will try and
make some contacts with PHA-I participants.
[Suggestions and volunteers to follow up in this
region are welcome]
The Government of South Australia launched a Revitalised
Primary Health Care policy on 12"' September 2003. Fran
Baum and other PHM colleagues were involved. PHM has
sent a congratulatory message. Fran had also requested
PHM friends to send short messages of how they could
support struggles for health in other countries
<fran.baum@flinders. edu.au>
FORTHCOMING EVENTS
Australia :
An International Health Education and Health Promo
tion Conference will take place in Melbourne, Austra
lia, in April 2004. PHM Australian colleagues are
exploring how to organize a PHM event in the Confer
ence. Please contact the Conference authorities after
visiting the web page < 2004.com.au> and request for
nomination for a scholarship if you are keen to attend.
You will need to send your name, address, email,
age, area of interest and whether you would present a
paper. Send this information also, urgently, to Fran
Baum at fran.baum@flinders.edu.au
Macmillan Education, Australia, publisher of secondary
school textbooks in Melbourne had requested permission
from the PHM Secretariat to reproduce a screen shot of the
PHM Website in their forthcoming book - Achieving Health
and Human Development. A print run of 10,000 copies to be
distributed in Australia and New Zealand in November 2003
is planned. School children will be invited to visit the PHM
website and answer a set of questions about what they find
there (Karen Forsythe - <kforsythe@copperleife.com>).
ONWARD TO MUMBAI
India :
The International Health Forum in defense of the
Health of the People is being organized by PHM on
14-15th January 2004 at Mumbai, India. This Forum
will precede the World Social Forum, which will be
held from 16-21st January 2004 at Mumbai. (For
further information see Section B) <ctddsf@vsnl.com>
and <secretariat@phmovement.org>
11.
AUSTRALIA, NEW ZEALAND AND PACIFIC REGION
Australia
If undelivered, please return to:
PHM Secretariat
CHC-Bangalore
# 367 “Srinivasa Nilaya”
Jakkasandra, 1st Main, I Block, Koramangala
Bangalore-560034, India*
Printed Matter
By Air Mail
Printed al Gonomudran Limited, a project or Gonoshasthaya Kendra Trust, P.O. Mirzanagar via Savar Cant., Dhaka 1344, Bangladesh
I
1
[Opinion Survey]
COMMUNITY HEALTH INTERNSHIP CUM FELLOWSHIP
SCHEME
Dear Fellows / Mentors,
Kindly fill up the knowledge / skill I attitudes that
(i)
(ii)
as fellows, you have picked up during your linkage with CMC or
as mentors, you feel you could inculcate in the fellows during their field
posting with your organization / project.
This is an opinion survey which will be collated to produce an update on an earlier
check list prepared at the start of the scheme.
An opinion survey on Attitudes, Skills & Knowledge to be
developed during the Scheme.
Attitudes:
Skills :
Knowledge:
During the internship / fellowship linkage with CHC, we encourage interns / fellows
to do as much reading as possible. As fellows or mentors, please recommend any
book, booklet, journal, document as a ‘must read’ during the period of linkage:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I
Place :
Name & Signature
Date
(Use additional sheets if required)
Ilmrsday
4— x_z Febfuaiy
—-
1997
/ Ax
A
.
A
&T$rr -7
~A
.■ >
A
7777av (~??a <7777
\j
z 57
-'.
Ac?’? -V <?// A/
3
---------------
7n
_
, 3)
■
.
■
C11
//
' , f=77c77
0 5/'-7“ 7/
A 3^/
A
•
TVT&fiVYT a? ?‘777 n
-------------
\v n
-
c
c\
/C/.7777 -7- 37^ z-^-?
5777=77? 3 777? ^ g
'X
\
^7^77?t/ ,
C7T)77 /
737^^7
\!
~
-J
o - XL'
57777=7 ?\ TV77 *
^Tf ~~^7 ? t,
\
\
\pV
.
<= A777P,
, •5/ V7777S77 <^7? ^77 /
c\
Q- c\ __ Q \
- o v
9
777 7^^7 =7J/ ;7^^7=?/ f>7 ^cTFi
3/77^77?,
3 AT?
-A -77^7
C\
Appointments
8
io
12
75,
■
eff7-^^7
b
A
___
\’Y
‘
\
777^7 (77 f7 ,577 77^=7 -5Z5?
e\
•
I
C.P
H
The Mitanin Programme- the context, rationale and policy perspective.
Dr Alok Shukla,
Secretary,Government of Chhattsigarh,
Department of health and family welfare
The context:
Chhattisgarh is a new State carved out of Madhya Pradesh on 1st November 2000. It is
the 9th largest State in the country. It has a population of a little over 2 crores.
Chhattisgarh has 16 districts, 96 tehsils, 146 blocks, and approximately 9,129 village
Panchayats. It has about 19,720 villages, and 54,000 habitations. The State has 9
Municipal Corporations, and 66 other Municipal bodies.
Chhattisgarh has relatively poor health infrastructure. It has only 9 District Hospitals.
Only 114 Blocks out of 146 have Community Health Centers. It has 786 Sectors and
3878 Sections. Large number of posts of doctors, and paramedical personnel are vacant.
Many PHCs in the remote tribal areas do not have doctors.
I
isy. Ci
Chhattisgarh has approximately 34% Scheduled Tribe population, 12% Scheduled Caste
population, and more than 50% Other Backward Classes. People are relatively poor. The
State is rich in natural resources. It has large reserves of coal, and iron ore. It also has a
lot of lime stone and Bauxite. Recently Diamond has been found in Chhattisgarh.
Chhattisgarh has approximately 40% forest cover. The Literacy levels of Chhattisgarh
are quite high. Health Statistics are on the other hand, still poor. Some important figures
from the 2001 Census are given below: -___________ _______________
Chhattisgarh
Indicator
India
2.07
Population
Decadal Growth Rate
Sex Ratio
Literacy Rate
102.70
21.34
18.06
933
65.38
990
65.18
Female Literacy Rate
54.16
52.40
Some other important Health Indicators are given below: -
INDICATOR
Population
HDI
CHHATTISGARH
INDIA
98.13
2.06
45
39
Sex Ratio (1991)
927
985
Crude Birth Rate (SRS 2003)
25.4
26.3
Crude Death Rate (SRS 2003)
8.4
8.8
Total Fertility Rate (1997)
3.3
3.6
IMR (SRS 2003)
66
76
30.2
29.5
Couple Protection Rate by Sterilization %)
Adult Literacy Rate (age 15-34)
Total
56.86
46.62
69.56
43.48
64.13
29.14
16.73
12.21
Scheduled Tribe Population (%) 1991
7.95
32.46
Urban Population (%)1991
Percentage of Married Women in 15-19 age
group (1991)
Proportion of Women in Work Force (1991)
Proportion of Farm Labor in work force
(1991)
Houses with Electrification (%) 1991
25.7
17.4
35.3
22.3
40.99
Male
Female
Scheduled Caste Population (%) 1991
Houses with Safe Drinking Water (%) 1991
Villages connected with mettle roads (%)
1991
41.89
26.1
42.4
62.3
23.06
31.67
36.96
20.84
51.1
Though we have progressed a lot in the field of health, yet we still have a long way to go.
Diseases like diarrhoea, malaria, leprosy, and tuberculosis still present a major health
problem in the State. Measles still causes death of children in the State. Our Infant
Mortality Rate is 76, which is very high in comparison to the developed States of the
country. Many women still die during pregnancy, and labor for want or proper care.
Anaemia, and malnutrition are present in the State on a large scale.
The system of Public Health, which has developed in the last few decades, has been
constrained by an increasing distance between the people, and the health services.
Underlying this is the increasing complexity of the health system itself. The result of this
is that people are not able to benefit fully from these public health services. On the other
hand after being educated in the ultra-modem, mechanized, and urban environment,
doctors are not interested in working in rural areas. As a result of this today there is’a
great shortage of trained doctors, and health workers in rural areas. On the other hand
incompletely educated quacks are taking advantage of the public in these areas. On the
one hand the Health Department feels that people do not take advantage of the services
offered by the Government and on the other hand people feel that Government is not able
to provide even basic health care services to them. The reality lies somewhere in
between, and there is gap both on the supply side as well as on the demand side. Present
policies have instead of empowering people, increased their dependence on the
Government machinery. Our present system is wholly hospital based. In this system,
treatment of diseases has got precedence over prevention of diseases, and programmes of
improvement of Public Health. We must remember that all our policies should be made
keeping communities in focus, as empowerment of people is out ultimate goal.
Health infrastructure is very limited in Chhattisgarh. 10 of our 16 districts do not still
have a functioning district hospital though government sanctions for converting them to a
district hospital have now been accorded to all of them. There are 146 blocks in the State,
yet there are only 114 Community Health Centers. Most hospitals do not have modem
equipments. There are only two medical colleges in the State. Even the hospitals of these
medical colleges do not have adequate modem equipment. Health department gets a very
limited amount of money for medicines. Because our programmes are not focused on the
community, the poor do not get the desired benefit of even these limited resources.
Though programmes are made to benefit the people living below the poverty line, in
reality it is only the middle classes who are able to take advantage of them. The real poor
often times are not able to access government health facilities, and lose both money and
health at the hands of quacks.
Being a new State we have no infrastructure in many fields. There is no drug-testing
laboratory in Chhattisgarh. Medicines can therefore not be tested in the State. Similarly
there is no facility to test food adulteration in the State. There is no institute to train
health workers in the State. A good system to collect health statistics also does not exist
in the State. A good Information, Education, and Communication machinery is need to
ensure community participation in health. It is simply lacking in the State.
Needs of Primary' Health
At present Health Services are focused on cure of diseases. Enough attention is not paid
to promotion of health, and prevention of diseases. Though a big system of Primary
Health, having Sub Health Centers, Primary Health Centers, and Community Health
Centers, has been created, during the last few years, yet this system is not able to work
according to expectations. It is necessary to improve this system. The following needs to
be done for this: 1.
2.
3.
4.
5.
6.
7.
S,
Make a system of Public Health based on the community, in which people should
be able to solve their day-to-day health problems themselves with the help of
local doctors. The help of many Non-govemment organizations existing in the
state and the Private Sector should be taken for this.
In order to empower communities for Public Health it is necessary to develop an
understanding of Public Health among the social workers, and communities, and
develop capacity to solve ordinary health problems at local level. Training of
voluntary workers, and people working in social sectors will have to be organized
for this. This will have to be done on a large scale, and the efforts of voluntary
workers will have to be integrated with governmental efforts.
A good referral system will have to be developed for such decentralization of
Health services, so that people know clearly where they have to go for solution of
problems, which they cannot solve at local levels.
Full assistance of Local Government institutions should be taken for the
decentralization of Health Services. There is a very developed and capable system
of Panchayati Raj institutions and Urban Local Bodies in Chhattisgarh. These
institutions have been given full responsibility for Public Health by law. It is
necessary that these institutions are trained to make their full use in the health
sector, and adequate powers are delegated to them.
While planning for expansion of health services it is necessary to keep in mind the
rights of the disadvantages classes. Many studies have shown that the poor are not
able to take advantage of the schemes, which the government has made for the
poor. Therefore we must ensure during the planning process itself that the benefits
of the scheme go to the target group. New strategies, making use of the private
sector will have to be examined for this.
Our programmes should help innovations, and provide full opportunities to new
ideas.
Training of people working in the government system will also be necessary, so
that they are able to work in partnership with Local Government institutions,
Non-govemment organizations, and Private sector for empowerment of people to
benefit the disadvantaged classes.
There is a big challenge to bring the doctors of Indian Systems of Medicine, and
other systems of Medicine in the mainstream of Public Health. People in villages
often times have great faith on these systems of Medicine. These systems of
4
Medicine have sufficient human resources too. It is necessary to plan for their
maximum development, and maximum use in Public Health.
"Mitanin": The Community Health Worker Scheme
It is a generally accepted fact that improvements in Primary Health can be made only
through the involvement -of communities in the delivery of health services. However
different people mean different things when they talk of community participation. Some
of these different meanings are described below: 1. To some persons the meaning of community participation is wholehearted
acceptance of Government schemes by the people. They feel Government knows
what is best for the people, and therefore makes the policies and programmes,
which are best suited for their good. If people do not benefit from such
programmes it is their own fault, as they do not participate fully in Government
schemes.
2. Some people feel that community participation means demand generation for the
services provided by the Government. If this view is accepted it will mean that
though all services are readily available to the people, they do not make use of
these services, as they do not know what is good for them. Government should
therefore launch Information, Education, and Communication (IEC) programmes,
so that people understand the importance of using the services. According to this
view also the blame rests squarely at the people for not using sendees.
3. Still other people feel that the community can participate in Government
programmes in service delivery as well. These people acknowledge that the
service delivery mechanism of the Government may not be foolproof, and
therefore people may not have access to sendees. They thus feel that Community
can help the Government in service delivery. The concept of depot holders of
simple medicines, and contraceptives is such a concept. Most planners in
Government now realize that the outreach of Government staff is limited. They
also accept that increase in the numbers of Government employees to increase the
outreach to all the habitations is not cost effective. The decision of the Planning
Commission of India to freeze the number of Sub-Health-Centers at the 1991
population level is the result of such realization and a very real resource crunch.
Still these people do not really accept the ability of communities to plan and work
for their own good. They do not believe in the "Empowerment Approach"
4. There is a very small group of people who has faith in the ability and the power o
the communities to shape their own destiny. This group of people feels that
community participation should mean empowering the community to plan and
work for their development. They feel that Government should help the
community in making their own village health plan, and implement it. This should
however not become an excuse for withdrawal of the Government, but should the
lead to a more meaningful partnership between the Government and the
Community. "Right to Health" is an inalienable right of the people, and it is the
duty of the Government not only to make all the services available to the people,
but also empower the communities so that they can demand, and get what is due
to them.
5
We are a firm believer in the Empowerment concept of people's participation and are
committed to ensure this the field of Public Health. Government of Chhattisgarh has
launched the "Mitanin " scheme for this purpose. Mitan in Chhattisgarhi means a close
friend. Mitanin is a female friend.. In this scheme it is proposed that one woman will be
identified in each habitation in villages, and in each lane in cities, to work as the main
link person between the Government and the community. This person will be a friend of
the community, and will therefore be known as the "Mitanin
This scheme involves some guarantees to the community from the Government, and
some responsibilities, to be taken by the Community, and Panchayati Raj Institutions.
These responsibilities are described below.
1.
Responsibilities of the Community and Panchavat:
1.1. Publicity of the scheme in the communities.
1.2. Mobilizing the communities for Health.
1.3. Helping the communities to identify one "Mitanin" for each habitation.
The Mitanin can be any woman living in the habitation acceptable to the
community. It is not necessary that she should have formal education, but it will
be helpful if she knows how to read and write. She should be willing to devote her
time to activities relating to the health of the community.
1.4. Helping the community in deciding a compensation package for the Mitanin. The
Mitanin will be a volunteer, who will not get any honorarium or salary from the
Government. However she will need to be compensated for her time and efforts
by the community. No uniform compensation package is being suggested in the
scheme. The compensation package should be agreed between the community
and the Mitanin.
Some suggestions for the compensation package are: The community may pay the Mitanin directly a fixed amount, either in cash or
in kind (in the form of grain). This can be monthly or yearly. Payment to be
made in kind every year at harvest time.
The Panchayat may decide to pay the Mitanin something from their funds.
The community may decide to pay the Mitanin a certain amount either in
cash or kind for services rendered as user fee.
The Panchayat may decide to allocate five acres of land along with a
source of irrigation as "Mitanin land". This land will not be transferred in the
name of the Mitanin, but she or her family will be allowed to cultivate this
land and take the usufruct till she is working as the Mitanin of the habitation.
This is similar in concept to the "Kotwari land"
Cash contribution by each family to be paid to the "Mitanin" every
week/month/year or cash fee at predetermined rates for services to the
individual families.
Any other method of compensation, which the community and the "Mitanin"
agree upon.
6
One should attempt to get the agreement reached between the "Mitanin" and the
community of the habitation to be in writing. The scheme recognizes that this is a
difficult process and may be possible to initiate only after at least one year of the
programme has passed and its utility is visible to the community. If she regularly
gets the drug supply and the slides she sends get reported in time and her referrals
gets honored, then the community would be much easier to convince for
supporting her,
1.5. Provide space in each habitation for health related activities, including
immunization, labor, storing of medicines, etc.
2.
Guarantees bv the Government:
If the Community and the Panchayat fulfill their responsibilities, they can make an
application to the collector of the district for the Government to fulfill its guarantees,
and the Government will then guarantee the following: 2.1.'Government will train the Mitanin identified by the community and the
Panchayat.
2.2. Government will give refresher training to the Mitanin as often as is necessary,
and till such time as the Mitanin is fully competent to do her job well.
2.3. Government will integrate the Mitanin in the Government Health delivery
system.
2.4. Government will provide all the free medicines, other materials, and services to
the community through the Mitanin.
2.5. Government will provide an essential equipment and medicine kit to the Mitanin
for Maternal and Child Health, Reproductive Health, Family Planning, safe
drinking water, sanitation and epidemic control.
There are 54,000 habitations in approximately 20,000 villages, and 10,000 village
Panchayats of Chhattisgarh. Ideally, when the scheme is fully implemented, we hope to
have a trained Mitanin in each of these 54,000 habitations, and also in every lane of the
slum areas of the cities. Thus we are aiming at training approximately 60,000 Mitanins. It
is hoped that these trained Mitanins will be the cutting edge of actual delivery of all
Primary Health related services to the community. They will work in close coordination
with and under the supervision of the ANM. They will be compensated for their services
not by the Government but by the community.
In order to implement the scheme the following steps were taken: Action Aid India was identified as a strategic partner NGO for the scheme, and the
State Government entered into an agreement with Action Aid India for this purpose.
2. A dedicated core team of professionals was developed at the State level for the
implementation of this scheme. This team is called the State Health Resource Center
(SHRC). The personnel for this core team have been drawn from NGOs working in
the field of Health from all over the country.
3. Training modules for the Mitanin were developed. The modules are in many parts.
There is an inception training, which is given to every newly recruited Mitanin, and
then other training capsules, which are administered at the Primary health center or
1.
7
training institutions at regular intervals, as the Mitanin starts her work. The training
module is in Hindi, and has been made keeping in mind that the trainee is a neo
literate. The module has lots of practical exercises, and field work. Difficult concepts
should are explained with examples from the local environment. The training has a
provision of being run at the pace of the learner, and takes into consideration different
learning styles, and different learning capacity of different people. The training
module has detailed and clear cut instructions for the trainers. Go’od quality and
appropriate teaching-learning material is being developed.
4. Development of a training package of training of trainers (TOT).
5. Training of trainers.
6. Publicity of the scheme, and training of Panchayati Raj representatives.
7. Community Mobilization.
8. Identification of Mitanins. More than 20000 Mitanins have already been identified,
and have undergone the first phase of training.
9. The continuing training of the Mitanin and her integration with the Health Delivery
System is an ongoing activity in all the Mitanin blocks.
10. Certain activities which are important for the programme include Training of PHC
doctors and training of MPW (M) and ANM. These activities should be started soon.
Role of "Mitanin"
"Mitanin" in Chhattisgarhi means a friend. In fact She is much more than a friend. It is an
age old tradition in the villages of Chhattisgarh, that people make other people their
"Mitan" or "Mitanin". It is customary in the villages of Chhattisgarh for girls to become
Mitanin of their close girl friends. This is done ceremoniously. Once the two girls have
become Mitanins, they are closer to each other than real sisters. This relationship
continues for the rest of their life, even after they are married, and becomes a bond
between families The "Mitan" or the "Mitanin" is a friend not only in this life, but even in
heaven. The friendship continues even after marriage, and becomes a bond between
families. The "Mitans" and "Mitanins" are ready to sacrifice everything for each other. It
is this tradition that the scheme seeks to revive. The "Mitanin" therefore is not just a
voluntary worker, but will be a friend, philosopher and guide for the community of the
habitation. The community of the habitation should have full faith and confidence in the
"Mitanin" and they should have a rewarding, friendly relationship, which may also have a
sentimental element. In this sense the "Mitanin" will be a true guide to the community of
the habitation in all their endeavors. In the field of Public Health the "Mitanin" will have
the following functions: -
1. She will give health education to the community of the habitation.
2. She will take on the leadership role in all Public Health activities of the village,
„ and will encourage community service for public health specially in a. Cleanliness of the village.
b. Ensuring safety of drinking water.
c. Making a parapet wall on all wells and covering all wells.
d. Making soak pits and proper drainage system in villages.
e. Teaching proper drinking water storage practices to the people.
8
f.
g.
3.
4.
5.
6.
Encouraging people to make and use sanitary latrines.
Taking care of the health of women and children specially promoting good
health practices by i. Teaching good nutrition practices.
ii. Teaching good breast feeding and weaning practices.
iii. Taking care of iron and iodine deficiency by propagating the use of
iron folic acid pills, and iodized salt.
iv. Propagating the use of iron and Vitamin A rich foods, and giving
supplementary Vitamin A to children.
v. Ensure regular weighing of children to monitor growth and
development.
vi. Ensure at least 3 Ante natal checkups for all pregnant women.
vii. Ensure that all deliveries are institutional deliveries.
viii. Ensure 100% registration of births, death, marriages, and
pregnancies.
ix. Provide consultation on MTP services.
x. Provide consultation on Family Planning services, and ensure
regular supplies of contraceptives.
xi. Help women in reproductive health.
xii. Provide counseling to youth on matter related to adolescence,
puberty and sexuality, with special reference to STD, and HIV
AIDS.
xiii. Important health education inputs on diseases like Malaria,
Leprosy, Tuberculosis, Diarrhoea and Dysentery.
xiv. Be a link between the Government Health system, and the
community for all National Health Programmes.
xv. Provide Health Education for other important things.
She will provide first aid, and over the counter (OTC) drugs for minor ailments.
She will be trained in taking care of common illnesses in the village, and will
gradually take on the responsibility for treating these diseases in the village. This
will be done gradually during the refresher training organized every fortnight in
the sector hospitals. The emphasis in these trainings will be on skill development.
The "Mitanin" will be allowed to treat diseases only when she has attained the
required proficiency levels in both knowledge and skills. She will be examined
periodically, and given certificates of proficiency. The important thing in deciding
whether she should be allowed to treat a disease is the confidence, which she has
in her own ability, and the confidence, which the sector health team has in her
ability. A detailed system of examination, and certification will be worked out.
She will be given the knowledge to refer all cases beyond her competence to the
proper place where they can receive proper health care.
Relationship with the ANM and other Health Staff: - The ANM and other
health staff will look at her as the most important asset in the habitation through
which they can reach out to the community. The "Mitanin" will look at the ANM
as her chief source of knowledge and strength. The two will not be competitors
but will complement each other. Essentially the interrelationship of the "Mitanin"
9
and the ANM or other sector health staff will be positive fulfilling, rewarding,
friendly and supportive.
a. The ANM will do the following for the "Mitanin" i. Train the "Mitanin" in the fortnightly refresher training courses.
ii. Teach skills to her by making her do things under supervision.
iii. Conduct examinations at frequent intervals for certification.
iv. Be the main link between the "Mitanin" and the health system.
v. Provide support to her in all difficult situations.
vi. Build confidence of the "Mitanin" in taking care of the village
community.
vii. Be the chief spokesperson of all the "Mitanins" in her area to the
government system.
viii. Ensure supplies of health education material, essential drugs,
record keeping material, contraceptives, etc.
ix. Counsel the "Mitanin" in her work specially in unforeseen
situations.
x. Provide legitimacy to the health related work of the "Mitanin" in
the community.
xi. Help the "Mitanin" in all referrals.
b. The "Mitanin" will do the following for the ANM i. Provide support to her in the community of the habitation for all
Public Health work.
ii. Provide her basic data about the community of the habitation.
iii. Help her in the registration of marriages, pregnancies, births and
deaths.
iv. Determine the contraceptive preferences of the community and
help the ANM in the CNAA strategy of family planning.
v. Be the main source of information about the community of the
habitation.
vi. Create an environment in favor of positive health in the
community.
vii. Help the ANM in staying in the village, and organizing camps and
other health related activities.
viii. Provide legitimacy to the Public Health work of the ANM in the
community.
ix. Help the ANM in surveillance of important diseases.
x. Help the ANM in organizing relief, and in the prevention of
epidemics.
xi. Help the ANM in all health related campaigns.
7. Relationship with PRIs - "Mitanins" will work in close association with PRIs.
The selection of "Mitanins", and the agreement between the "Mitannin" and the
community of the habitation will be approved by the Gram Sabha". Public Health
is an important function of PRIs under the 73rd Constitution amendment. At
present the PRIs do not have any mechanism of performing this important
function. With the introduction of the "Mitanin" scheme the PRIs will be able to
discharge their duties easily. Civil society, and a free press are important pillars of
10
a democracy. These two do not really exist in a village. The "Mitanin" can
perform the functions of both "organized civil society", and a "free press" in a
village to provide succor to and sustain democracy at the Village Panchayat level.
She will be in constant dialogue with the people of the village on all important
issues, and therefore she is competent to be the voice of the civil society.
Similarly she will the main source of transmitting information about development
schemes, and work of the Panchayat, and government to the people. In this
manner she is similar to the free press.
a. Panchayats will do the following for the "Mitanin" i. Gram Sabha will approve the selection of "Mitanin", and also the
agreement between the "Mitanin" and the community of the
habitation.
ii. Panchayats will ensure that the community of the habitation
honour their side of the agreement.
iii. Panchayats may decide to pay the "Mitanin" something for the
services they render.
iv. Panchayats will help in the irrigation of the "Mitanin land" if
provided by the community of the habitation or the collector.
v. Panchayats will monitor the work of the "Mitanin", and if they find
that the "Mitanin" has not performed her duties well, the Panchayat
may remove her, and ask the community of the habitation to select
a new "Mitanin".
vi. Panchayats will ensure that the "Mitanins" get good training, and
get regular supplies of publicity material, contraceptives, essential
drugs, and other things.
vii. Panchayats may use the "Mitanin" in the implementation and
monitoring of other welfare, and community empowerment
schemes.
b. "Mitanin" will do the following for PRIs i. She will send regular reports to the Panchayat about the health
status of the community.
ii. She will attend meetings of the Panchayat whenever she is asked to
do so by the Panchayat, and will give all information about the
health status of the habitation, which is necessary for the
Panchayat to make informed decisions about the programmes, and
schemes being run in the habitation.
iii. She will help the Panchayat to implement, and monitor such other
welfare schemes, and community empowerment schemes, as the
Panchayat may require her to.
iv. She will follow all lawful instructions of the Panchayats.
8. The "Mitanin" will gradually take on such other responsibilities, and perform such
other functions as the Panchayats and the district administration may decide. She
will be trained for performing these duties, and duly compensated for them by the
concerned departments.
11
The "Mitanin" will be the main link between the government and the people in a
habitation. It must be stated here that in order to derive full benefit of the scheme it will
be necessary that health department delegates full powers of programme planning, and
implementation to PRIs. Capacity building of PRIs will also be necessary.
Selection of "Mitanins"
"Mitanins" are to be selected by the community of the habitation. The selection has to be
formally approved by the "Gram Sabha". However, just a formal approval of the Gram
Sabha without involving the community will defeat the very purpose for which the
"Mitanin" scheme has been conceived. The selection process described below is to ensure
that the community actually decided who the "Mitanin" will be, and the process of
community does not remain on paper. It is therefore important that the process is
followed in letter and spirit.
The selection process follows the following steps: -
1. A series of workshops and sensitization meetings were held at the state level and
district level to orient the representatives of PRIs and key officials and convince
them about the scheme. PRI representatives not only understood the full import of
the scheme, but are also committed to its success.
2. A team of facilitators was then selected and trained to sensitize the community in
each habitation, and help the community in the selection of the "Mitanin". One
team of facilitators was trained for each block. It was ensured that facilitators
know the local language well, understand the local culture, have positive social
attitudes, and faith in the inherent strength of communities, are good
communicators, know how to work with groups and are willing to live in villages
with the villagers, and make night halts in villages. Some examples of persons
selected as facilitators are: i. CDPO or Supervisor of ICDS.
ii. ANMorLHV.
iii. Village level workers of various government departments.
iv. Panches.
v. Members of Didi Banks (Credit and thrift groups of women)
vi. Members of Zila Saksharta Samitis.
vii. Members of Watershed committees or JFM comittees.
viii. NGO workers.
3. The facilitator then visited the selected habitation as many times as necessary.
Often they made night halts in the habitation. They spent time with the
community, so that the community feels that they have become one with them,
and freely share their joys and concerns. This is a rather prolonged process, and
should not be hastened.
4. Once the facilitator has the confidence of the village community, the subject of
the "Mitanin" scheme is discussed with them. The concept is explained in detail.
The facilitator then discusses the possible choices, and the pros and cons of
choosing various prospective women as "Mitanins" These discussions are held in
12
an informal environment. The facilitator tries to develop consensus amongst the
members of the community on the choice of the "Mitanin". The facilitator also
discusses with the prospective "Mitanins" the things, which the job entails, and
the responsibilities, which they will have to undertake.
5. Once the facilitator is convinced that a consensus is emerging on the choice of
"Mitanin", the facilitator calls a meeting of the community of the habitation to
make a formal choice. In this meeting the voluntary nature of this work and the
possible different ways of the community compensating the "Mitanin" for her
services are also discussed freely.
6. A number of village level activities, which are mobilisational in nature, are
carried out. Of this the use of the kalajatha for spreading the spirit of the
programme and enthusing the people to participate in this programme is one
major step. There can be other major publicity and mobilisational activities like
wall writings, posters, meetings, cultural events etc to build interest in the
programme.
7. Once this stage has been reached, a formal meeting of the Gram Sabha may be
called, and the agreement approved by the "Gram Sabha". The sarpanch of the
Panchayat will then endorse the agreement, and then send a request to the Block
programme team to train the "Mitanin"
Training of "Mitanins"
After a "Mitanin" is selected, and a formal agreement is signed between the "Mitanin"
and the community of the habitation, and approved by the Gram Sabha, the Village
Panchayat endorses the selection and in effect sends a request to the Block Medical
Officer to train the "Mitanin". All the expenditure on the training is bome by the
Government. "Mitanins" are provided training in many stages. First stage of the training,
itself made of six rounds is institutional. The second stage of the training will be a series
of refresher trainings organized at regular intervals at the panchayat or cluster level or
PHC through suitable training institutions and training arragnements.
First Stage : Institutional Training: - This training will include the following: -
1. Attitudes: - The training is designed to bring in positive attitudes in the "Mitanin"
about the power of people, empowerment of women, the strength of community
work etc.
2. Knowledge: - She is given knowledge about basic concepts in Public Health.
various Government schemes, and programmes, National Health Programmes,
Signs and Symptoms of common diseases, etc.
3. Skills: - Skills relating to communication, management, group behavior etc. will
be developed during the course of the training. Skills relating to disease treatment
are also developed.
The "Mitanins" are trained through a participative process of group work, field visits and
studies, visiting areas where community health volunteer scheme has been successful,
13
practical demonstrations, and field exercises. After each round of training they are
deployed and supported in a set of activities at the village level. The first two rounds are
on health rights and knowledge of available public health services and on child health.
The third round is on women’s health. The fourth round is on control of communicable
disease and the fifth and sixth rounds are on first contact curative care. At the end of an
year they would also have a training on village level health planning.
Second Stage : Refresher Training" : - Refresher training are organized monthly at the
sector PHC/ cluster level. This training will concentrate on reinforcing what was learnt in
the first stage plus further practical aspects of diagnosis and treatment of common
illnesses and a lot of troubleshooting and on the job training. It will aim at skill
development and practice so that the "Mitanin" gradually develops confidence and is able
to take care of the health needs of the community. This training will need to go on
indefinitely- it is a continuous process.
The specific skills she would be trained in include: -
Making of peripheral blood smears.
Detection of anemia.
Antenatal care.
Weighing of children.
Recognizing malnutrition and being able to counsel the family on integrated
management of childhood illness with a focus on malnutrition.
6. Recognizing Acute Respiratory Infections, and giving specific drug from her kit
when required.
7. Recognizing fever, and giving choloroquine presumptively.
8. Recognizing when a patient should be referred to a hospital.
9. Recognizing signs of dehydration, and administration of ORT.
10. Conducting local level health education meetings for specific groups.
1.
2.
3.
4.
5.
The Sector/cluster training team will make an assessment of the knowledge and skills of
the "Mitanin" from time to time, through an assessment system,on the basis of which she
will be provided refresher training and allowed to take on more of the responsibility of
health care of the community gradually.
In conclusion:
This chapter only outlines the basic concept of the "Indira Swasthya Mitanin " Scheme,
and the broad contours and outlines of its implementation. The remaining chapters of this
book will describe the processes in far greater detail. It needs to be stated that the scheme
is in its infancy yet, and therefore it is premature to assess the impact of the scheme on
Public Health. It must however also be mentioned that the scheme has evoked great
enthusiasm in all the villages, and peoples' participation is very visible for all to see.
14
C.0 o-i VA -I 3~.
HEALTH SECURITY FOR THE POOR :
HEALTH INSURANCE THROUGH HEALTH CARE COOPERATIVE
Dr P.R.Panchamukhi
Nayantara Nayak
Fears are sometimes expressed particularly in the context of developing countries
that economic reforms consisting of liberalization, privatization and globalization,
primarily focus on economic objectives of efficiency of resource allocation and the social
objectives of distributive equity and social development are likely to receive a back seat
in the course of pursuit of economic objectives. Much is documented in the literature on
the compression of the government budget in general and the overall budget of the social
sector in particular, especially in developing countries during reform. This compression is
more likely to affect primarily the poor and the less privileged in the society. Obviously,
it is not enough if the problem is diagnosed.
What is necessary is to introduce
immediately the counter measures to tackle these likely developments. It should be noted
that such counter measures to safeguard the interests of the poor are required under all
occasions, whether there are economic reforms or no economic reforms, for, the
problems of equity ( inequity ) lie very much in the nature ol the components of social
sector itself, particularly in the context of a stratified society like India. This will be
brought out from Section I of the present paper. Economic reforms however are likely to
aggravate the problem.
Demand for health and education, the main components of social sector, is
generally highly income elastic. Similarly, access to health care and educational
opportunities is also found to be highly income elastic. In a regional perspective.
demand for and access to health and education seem to be elastic with respect to the level
and rate of economic development of the region. It is also worth noting that health and
Director CMDR Dharwad Karnataka
Associate Fellow CMDR Dharwad
Acknowledgements: Thanks are due to Dr.G.K.Kadekodi . V.B.Annigei i . S.l’ullusw amiah and Mythili N
for their observations on earlier draft oI' the paper. B.I’.Bagalkot olfered secretarial assistance.
1
education confer both private and social benefits. Opportunity costs of education and
health are generally fairly high particularly' for low-income households.
Costs of
maintaining health, costs of getting education and avoidance c^ih||ill’health and non
education are too high to be overlooked. From all these pointi^«iew,. education and
health are considered in public finance literature as merit goods, implying that they
are so meritorious from the point of view of social welfare that issues of their provision
cannot be left to the decision making of the individual or private sector alone but they
need to be considered by the collectivity or public sector also. In the present paper an
attempt is made to focus on issues relating to the provision of health care facilities
particularly for the poor keeping in mind the characteristic features of health calling for
involvement^ of the collectivity or public sector in its supply or making provision for it.
The paper suggests a mechanism of involvement of the collectivity - community and the
government, which would help better access and utilization of health care services by the
poor. The focus of the paper is on health insurance facilitated by the health care
cooperative ofproviders of and beneficiaries from health care services.
The paper is divided into four sections.
In Section I, unique characteristic features of health relevant in the present
context are briefly outlined.
Section II examines some of the resource allocation plans to the health care sector
suggested in the literature, keeping in mind the requirements of the poor in general and
the poor among the socially less privileged sections of population in particular. Its main
focus is on the basic issues that need to be considered while implementing the plan.
Section III presents a brief review of the experiments of health care cooperatives
and health insurance as in practice in selected countries with a special focus on the
experiments and proposals in India.
a
•
There is no universally acceptable yard-stick for measuring health level of
individuals. Also, there is no acceptable definition of health. AS a result, there is a
greater probability of episodes of general ill health (whicli^ighf^t'tinics. lead to
major ill health episodes) being overlooked or treatment KJf^hlchTs likely to be
postponed. This happens particularly in the case of poor households and in the
case of those who have low social status even in the case of a well to do family
On the other hand, rich households and only socially better off members of even a
better off family ( such as earning members or male members or members who
are accepted as heads of households, even though they are not earning members.
or those who are ritually superior, such as mother in law rather than daughter in
law, etc ) are likely to receive more attention regarding even small health
"
problems also, since they can afford the high costs of such medical attention and
treatment or resources are made available for them rather than for others for this
purpose in view of their ritual status. Thus, the probability of medical care
attention is a positive function of socio-economic and ritual status of the
individual / household in question. In other words, in the Indian context,
availability of medical care attention is not just in accordance with the demand
and need for it but it is most often in accordance with factors other than these.
•
In view of the low economic status of the members of poor households, who
depend upon their physical capabilities and skills
for meeting their daily
subsistence needs, it would be imperative for them to maintain their physical and
mental well-being at a fairly high level, which enables them to put in work and
earn daily livelihood. Illness causes immiserization of the poor and hence it is
I
necessary for the people to avoid illness or debilitating morbidity causing further
impoverishment and immiserization.' This is particularly seen in the case of those
members who work in the unorganized sector and who work on a daily wage
basis. Thus, what one may call, the 'subsistence need for medical care attention '
1 Hsio and Sen reported that 40 percent of the entrants to poverty in a particular year in India attributed
poverty to illness episodes in the family. Hsio, William and Priti Dave Sen (1995) 'Cooperative Financing
of Health Care in Rural India’ Quoted in TN Krishnan : Economic and Political ll'cekly April 13 1996
4
Section IV, which is the concluding section, outlines major elements of a health
security plan for the poor incorporating the insurance strategy first in general terms and
then particularly for one of the villages in Karnataka, for which Held data were collected
for the purpose. This example attempts to indicate the order of resource requirements if
such a plan needs to be implemented on a wider scale. It also examines whether there
would be resource savings if such a plan with community involvement and contribution
is implemented in place of the present practice of government itself taking the entire
responsibility towards health security for the poor.
I.
HEALTH AND HEALTH CARE SERVICES AS AN ECONOMIC GOOD IN
THE INDIAN CONTEXT
Health is art economic good, the peculiarities of which need to be explicitly
recognized in any health security plan. We briefly outline below some of these peculiar
features particularly in the typical Indian context, with her own unique value system.
traditions and socio economic conditions. In the Indian context health services would also
have their own peculiarities in respect of their supply and demand, which deserve a
special attention while developing a health security plan for the poor. It can be seen that
inequality in access and utilization are inherent in the very nature of health and health
care sendees as an economic good, particularly when it is left to market forces.
Is Inequality in Access and Utilization Intrinsic to
Health and Health Care ?
J
From the following characteristic features of health and health care it would be clear that
conscious efforts have to be made to safeguard the interests of the poor so far as'the
needs of the poor are concerned. Social and economic backwardness would further
aggravate these inequities.
is a negative function of economic status of the individual member in question.
This should not be taken to mean that better off people give less importance to
health and health care. On the other hand, they pay more attention to even a small
disturbance in their health, as stated earlier. What is implied here is that for the
purpose of subsistence earning, meeting the need for health care is more
mandatory for the poor than for the rich.
Some of the health care facilities are, by and large, in the nature of indivisible
goods, while services from these facilities are characterized by a fair degree of
divisibility and rival-ness in consumption. These may be termed as lumpiness in
supply but a fair degree of divisibility in utilization. In view of this lumpiness,
large investments are needed to supply these facilities. There is a tendency of
cost recovery charges from the purchasers of services being over estimated in
such a situation. In view of speedy technological changes in the field of medical
science and public health and hence expectation of foreign initiatives in the
background of globalization, uncertainties associated with the occurrence of
morbidity episodes requiring the use of a particular facility, uncertainties
associated with the use of the created facilities by the affected persons, ’etc. there
seems to be an undue haste in cost recovery by the investors making the charges
for the users unduly high. Added to it, the instinct of greed and a desire for more
and more and more also contributes to this tendency for over -charging.
Another factor also contributes to this tendency, which is the result of some of the
recent developments under economic reform regime. In view of the declining
interest rates on borrowings and trends of privatization, such facilities are likely to
be created with the help of borrowed funds2 by few private initiatives that can
provide the necessary collateral required for loans from financial institutions..This
would also give rise to a situation of few sellers operating in the health care
CMDR proposes io study the changes in financing of activities of medical care providers before and
during (he period of economic reforms. For such a study micro level field data need to be collected from
private sector providers. We have not come across any such longitudinal micro level study in the literature.
commodities markets.
Such sellers can control price of services and also
indirectly the clientele utilizing these services. This characteristic feature would
have significant implications for access of the poor to health care services.
•
Health care services consisting of both material and manpower services - are
likely to get concentrated in urban areas in view of their characteristic
features outlined above. Since large percent of agricultural labourers are located
in rural areas, they are more likely to be deprived of the necessary benefits from
health care facilities, which are not adequately available in rural areas. Health
facility mapping for rural and urban areas in different stales of the country would
reveal how the facilities get clustered disproportionately to the population in
urban areas.3
It is useful to work out regional inequality indices of health care
facilities in rural and urban areas of different stales.
District-wise facility
mapping would more clearly bring out the deprivation of rural areas. Field studies
show that the rural folk have to walk down / travel in bullock carts or tractors for
miles together in search of medical assistance in the case of illness episodes. It is
also worth noting that most of the health care centres located in many villages are
mostly non-functional, ill equipped and inadequately manned. This also suggests
that the health facility mapping needs to be done keeping in mind the functional
existence of the facilities rather than merely their physical existence.
Intra
regional facility' distances are most often found to be an inverse function of
the level of economic development of the region, suggesting that the poor in the
less developed regions are likely to be more adversely affected than the poor in
the more developed regions.
•
Considering gender dimensions of commodity of health and health care would
bring out many important aspects worth noting while developing a health security
plan for the poor. Generally, women are considered as health care providers in the
family.
However, health of the health care providers in the family is generally
■' One such attempt is in progress at CMDR in the case of Karnataka state. In view of information gaps only
public medical care facilities are being mapped.
6
overlooked, not only by oilier members of the family, but also by women
themselves. Traditionally, low social status of girls and women in Indian family
contributes to this. As a result, female members, right from baby girls to elderly
women in the family are likely to be more deprived of health care services than
male members, starting from baby boys to elderly men in the family. This
discrimination is more severe in poorer families, rural areas and poorer states.
Health condition of female members
in
poorer environment- regions and
households is likely to be much worse than that in more developed regions.
Access to, utilization of and benefit from'health care services are thus a
function of gender with adverse effects in the case offemale members.
If health and health care are under-priced in the present period even though
the price payable for them by the beneficiaries in the long-run works out to be
much higher, then generally, there is a likelihood of the normal law of
demand to operate vigorously in the short run keeping in mind the price in
the present period only. Thus, in the case of demand- for health care services
defective telescopic faculty seems to operate. Price elasticity of demand is
generally very high for the people of all economic levels and at all price levels.
But. at high income levels and at high price levels price-elasticity is likely to be
higher, other things remaining the same.
There is an asymmetric information flow for medical care providers and
patients, with some information available more with-providers and some other
crucial information available more with' patients.
For example, scientific.
medical information about diseases-causes ancLcure in general., is available with
medical care persons-doctors. nurses, etc. But. information about how they feel
while suffering from disease, while receiving treatment and after treatment, etc
lies essentially with the patients. Information about preventive care and promotive
care is available with medical and public health personnel whereas information
about the effects of these measures of care is available with only the clientele
beneficiaries.
7
•
Considering the,aspects under the above two paragraphs. it follows that there is a
risk of overuse of certain types of care by the people, particularly at higher
income levels, since they can afford larger expenditures on drugs. Excessive use
of drugs and medical services is termed in the health insurance literature as 'moral
hazard’ implying probably that people consume more of medical care than what
they really require and that such over use is likely to be hazardous also. People’s
expenditures might be guided by what one may call, presumptive prescriptions by
medical experts, who in turn might act under wrong information or self-interest
considerations. Provider-induced-over-use of drugs and medical services or even
self-induced over use might ultimately exaggerate demand for drugs and services
and distort long term planning in the case of the health care sector.
•
Price and income elasticities of demand for health and medical care are likely
to be high at high income and price levels than at low income and price levels.
In view of this, generally, special attention seems to be paid by providers to those
drugs and services, which cater to the needs of high-income groups of population.
This leaves the needs of the poor unconsidered in normal circumstances, unless
special initiatives are made for the purpose. This is evident from the location of
medical care services in
urban areas, where, generally richer sections of
population live, the rate of growth of tertiary care investment is higher than that in
primary care in rural areas and similar indicators, Analysis of drug prices meant
for the common care and for tertiary care should also be revealing from this point
of view.’’
•
Preventive health care services are characterized by special features, which
deserve attention of analysts, while designing health security plan for the poor.
Demand for preventive care is much less clearly articulated than demand for
curative care. Also, effort for meeting this demand is also much less in this case
as compared to curative care. Articulation of the need for preventive care is
4 CMDR has commissioned a study of drug prices, the results of which would throw a light on these issues.
8
obviously a function of level of awareness among the people about its importance.
Since the effect of absence of such care is felt much later after a long time lag
immediate appreciation of the importance of preventive care is generally not
seen both by the individual beneficiary or the collectivity as a whole. This is one
of the reasons why the decision makers do not undertake the projects for
preventive care so enthusiastically. Even at the individual level much attention is
not given to measures for preventive and promotional care as in the case of
curative care.
As indicated above, preventive care can be of two types, viz. individual-specific
—
preventive care and collectivity specific preventive care. Demand for both types
of preventive care is a positive function of level of income of the individual
and the collectivity' apart from the level of awareness about the importance of
such care in the functional capabilities of the individuals. Hence, preventive
care becomes a predominant merit good, being so meritorious from the point of
social welfare that it calls for collective intervention for provision over and above
private initiative for its provision. Since the poor in particular, are likely to be
more vulnerable if such care is not available it becomes necessary to devise
ways and means for its provision to help them.
From the above conceptual background relating to health and health care services
as economic goods, it is clear that generally the poor cannot safeguard their own health
care interests and that such interests can be safeguarded only if suitable mechanisms arc
evolved. Such mechanisms should be developed incorporating the involvement of the
people, invoking the spirit of altruism and mutual sympathy among those who have
higher ability to pay and belter capacity to organize services with a longer out-reach
both with respect to time and number of people. It is fell that the spirit of cooperation.
which already prevails among the people in India, particularly in villages, needs to be
aroused for invoking this spirit of altruism and mutual sympathy Sympathy and mutual
sympathy have been considered as one of the six springs of human conduct by Adam
Smith. In his
Theory of Stored Sentiments Adam Smith devotes one full chapter to
9
eulogize the ‘ Benefits frorti'Mutual Sympathy'. Mutual Sympathy has received the
highest importance in the codes of conduct sanctioned by many religions of the world
also. Therefore it would be useful if this spirit of mutual sympathy is utilized for
helping the poor in their health care needs. Since the poor cannot bear the high costs of
health and medical care it would be necessary to devise a mechanism invoking the
spirit of mutual sympathy and cooperation, through which it is possible to provide
health care services at reasonably low current costs spreading the rest of costs in
suitable installments in the future.
The mechanism should
explicitly note the
seasonality ( as in the case of agricultural labourers, for example, who get earning
opportunities mainly during the agricultural seasons ) and al limes irregularity of the
income flows to the poor households and adjust the payments towards health care costs
to such income flows. This mechanism should also recognize the fact that occurrence of
illness and its duration are uncertain. Any organizational mechanism that can pool the
risks of illness of the poor households and that can provide for convenient cost
payment arrangements should greatly help the poor. Health insurance is considered as
such a mechanism, which can greatly help the poor. Health insurance is also a
mechanism for gaining access to health care that would otherwise be unaffordable/
If ,
cooperative elements were integrated with health insurance then il would have an added
advantage for the poor.
II
MAIN ISSUES REGARDING HEALTH INSURANCE AND HEALTH
CARE COOPERATIVES
Health insurance and health care cooperatives can be considered as the methods
for pooling of risks of different types of ill health across individuals and over the period
of lime. A number of issues in this connection have received the attention of researchers.
Some of the important ones are briefly outlined below.
5 John A.Nyman : ‘The Value of Health Insurance : The Access Motive' Journal <>/1teuhh Economics 18
(1999) This study shows that even in the U.S. access motive is facilitated by insurance and that the poorer
of the Americans are enabled to have access to costly medical care, which they could not have afforded
before
10
•
When health sector budgets are getting compressed during the period of economic
reforms can health insurance mechanism maintain the overall budgets for health
care sector at high levels ?
In other words, can insurance be considered as a
dependable source of financing of health ?
•
Government provision of health care services is believed to safeguard the health
care needs of the poor. In this background, to what extent can health insurance
mechanism be considered as responsive to the needs of the poor ?
•
Does health insurance mechanism lead to what is termed in the literature as moral
hazard, implying more than an optimal use of medical care services ? Choice of
’ the best health insurance plan involves a trade off between the gains from risk
reduction in connection with the disease/s covered under insurance and the loss of
moral hazard.6 How far are people in a country like India in a position to make
such a best choice ?
o
Does this excessive consumption of medical care has e its own implications for
health of the users ? Studies have tried to show that having insurance is
associated with having belter health.7
The hypothesis of effect of excessive
consumption on health status, needs to be tested with micro level data.
•
Does this excessive use of medical care services by the rich result in less
availability of services for the needy, who may not be in a position to bear (he
cost of health insurance itself? Does this also result in inefficient allocation ol
I
scarce medical care and financial resources of the economy
in the ultimate
analysis ?
" Willard G. Manning. M. Susan Marquis Health Insurance : the trade on between risk pooling and moral
hazard Journal oj Health Economics 15 ( 1996 )
Beth Hahn. Ann Barn.' Flood 'No Insurance. Public Insurance and Private Insurance . Do these options
contribute to ditferences in general Health ?' Journal of Health Care lor the I’mir ana I nderservecl VI 6
1995.
I 1
o
In view of its effect in terms of excessive demand for medical care services, does
health care insurance lead to further rise in price of such services and also in
insurance premia in the long run, making health care more costly for the
poor, the very problem, which the insurance mechanism wanted to tackle itself?
These aspects would be very crucial in the context of developing countries where
cost escalations would lead to further deprivations of the vast masses of the poor.
•
Making health insurance mandatory is likely to result in a welfare loss for
those who had not purchased it earlier. This issue needs to be examined in the
specific context about which not much research seems to have been done/
•
Docs insurance mechanism sustain itself in the long run?
This question is
relevant because the overhead costs and operating costs of such a mechanism arc
likely to be quite heavy and which might not be recovered from the clients
through premia ?
•
If the premia are hiked up significantly in order to recover the costs then in what
way would this mechanism be different from the private market based supply of
health care services ? A rise in premium might discourage the less privileged
people to go in for insurance cover. One of the studies in US has estimated that
a 1 percent rise in insurance cost would lead to a 1.8 percent reduction in the
probability of persons seeking insurance cover.9
•
Should health insurance be provided by government itself or by the private
sector initiatives or by both ? If both private sector and government are
operating at the same time, would there be a tendency of government being
crowded out by the normally aggressive private sector initiatives ? In the context5
*
5 Michael Chernew et alWorker Demand for Health Insurance in the Non Ciroup Market: a note on the
calculation of welfare loss' Journal of Health Economics 16 (1997)
Gruber, Jonathan and James (1994), Tax incentives and the Decision lo purchase health insurance :
Evidence from the self employed. Journal of Health Economics . 109(3).
12
of the U.S. however, employer delivered health benefits are reported to have been
replaced by the government insurance mechanism."’
•
Some studies have also shown that significant health status differentials among
the insurers are observed in the case of public and private health insurance
systems, with lower status in the case of the former." Would this mean that
provision of publicly managed insurance for the poor and privately managed
insurance for the rich would lead to health status disparities among the poor and
the rich in the society ? What is the optimum public private mix in the case of
health insurance ?
•
Does insurance mechanism in general ensure high quality of health care services
? Does government operated Health Insurance ensure better quality of services or
private sector operated insurance would achieve that objective ?
•
Whose out reach is better- private sector’s or government’s, so as to ensure
availability of health care services to the poor, to the socially less privileged, to
the people in remote areas, to children and to the elderly also ( as, normally
private health insurance operators are found to exclude people outside a certain
age)9
•
Does health insurance mechanism provide for articulation of the health care
needs by the people who are in need of such services ? Or. does this
mechanism strengthen the dominance of the providers in (he health care sector
? Would this imply the relevance of Say's Law of Markets in health care market (
Supply creates its own demand/) with its concomitant implications for the
clientele ?
»
Can health insurance mechanism be so structured as to integrate the-equity
considerations ? Thus, can there be differentiated premium system, distribution
of claims in cash or kind, coverage of all types of health care needs such as*
' A number of studies are conducted to examine the relationship between public and private health
insurance systems. For a list of some of such studies please see references at the eml of this paper.
13
prcv< itivc, promotive and curative needs, etc.
Can a Health Insurance
mechanism cover the risks also of common ailments of masses, which at limes
become economically costly for those who lose (heir work days on account ol
such weakening common ailments and which reduce their work output ? Should
premia alone be graded or service charges also be so graded or both, to ensure
equity in access and utilization ?
«
Arc people in a country like India aware of (he advantages from health
insurance so that it would have a fairly good demand just enough to sustain it in
the long run ? What measures need to be taken to raise the level of their
awareness about the value of health insurance ? 11
12
•
Can health insurance be extended to rural areas, tin organized sector, all types of
occupations and all income levels, all age groups, etc. for. inclusion of these
under the insurance cover is feared to increase the risk of losses of insurance
providers who are traditionally considered as loss leaders in the economy ?
•
If health insurance supply is opened up to (he private sector and also to the
international operators then there is allegedly a risk of foul practices in health
care supply. In the case of foreign companies operating in the system there is also
a risk of repatriation of profits and resources from India to the other countries.
Under such circumstances, what countervailing checks and safeguards need to
be introduced to regulate their activities ?
•
How should clientele beneficiaries’ involvement be ensured in the functioning
of the health insurance system so that people themselves become a watch dog
for its functioning ? Can co-payment, coinsurance, group insurance, etc serve this
purpose ?
11 Beth Hahn and Ann Barry Flood : Op cil.
I_ Over 92 percent of the non insured households both in rural and urban areas are not aware of the existing
health insurance schemes. This is the result of a NCAER -SEWA survey (1999) as reported by Anil
Gumber: ‘Health Care Burden on the households in the Informal Sector' Indian Journal of Labour
Economics Vol 45 No. 2. 2000.
1-1
These and many other issues deserve the attention oh policy makers and analysts
having an objective of improving the access and utilization of health care services for the
poor and provide a useful health security plan for them. We believe that health insurance
can be a useful health security plan for the poor if it is managed neither by the public
sector nor by the private sector but by the people's sector. By people's sector we mean a
cooperative of the people, which is specially created for the purpose of fulfilling the
health care needs of the poor. Health insurance through health care cooperative is thus
considered as a mechanism worth trying in the Indian context. Such a mechanism has
been tried in some form in India and in some other countries also II would be useful to
learn from these experiments and design a mechanism based upon the principles of
mutual sympathy and pooling of risks for the benefit of the poor particular!} in the rural
areas of the country.
HI
A BRIEF REVIEW OF EARLIER EXPERIMENTS;
We noted above that health care cooperative and health care insurance are the two
organizational initiatives that can be suitably integrated to help (he cause of the poor. In
what follows we briefly review the experiences of selected countries
for which
information is available, about the experiments of health insurance through health care
cooperative. This review would help us in designing a health security plan for the poor.
which we propose to develop in one of the villages of Karnataka lor which data were
specially collected. CMDR. proposes to adopt this village or a cluster of villages in the
region to implement the plan in its action research programme.
The review is presented for thirteen countries, for which the information was
readily available, starting from a developing country like India to the developed country
like USA. Only the salient features are outlined without going into the details, for
convenience the Indian experiences are outlined at the end.
The
ic]
aceineni
of
colccl.vc
agii ullmal
pro
iction
by
'he
house hole
responsibility system as a result of economic reforms is said to have led to the decline ol
collectively funded Co-operative Medical Scheme (CMS) in China. I he study by Yu Hao
and others" reports that during collective farming CMS assisted farmers to meet health
care costs in more than 90% villages. Considering this
the government of China is
encouraging the establishment of such CMS, which tire said to have been set up in rural
China with the help of local government.
Cooperative Medical Scheme (CMS) in Wuzhaun Township:
The plan for CMS was drawn by researchers of Shanghai
Medical University.
Based on household survey, the design for CMSs with varying service coverage.
premium and reimbursement ratio was developed.
Features:
%• Membership
in 5 villages is said to be voluntary and
open to all
rural
households.
v
¥ 5 per member, with ¥ 4 (0.5% of annual per capita) from
Premium of
individuals
and
¥ 1 from count}' government. Village collective or local
government though agreed to pay premiums for extremely poor households, did
not pay in actual practice. Few farmers paid in terms of produce (grains). ($ 1=¥
8.3, ¥l=Rs. 5.5)
<•
Services: Free registration, reimbursement for treatment and injection Ices
al
village level, free immunization for children(up to 7). pre and postnatal maternal
care and delivery service.
11 Yu Hao el al (2000), Financing Health Care in poor rural Counties in ChinaTxperience from a
Township- Based Cooperative Medical Scheme, IDS Working Paper 66
16
•>
Management: Committee established with members from township government.
Salary of Manager was paid by local govt.
v
’Drugs: Village doctor is allowed to buy drugs from township health center and
sell them to patients at fixed prices.
<•
Village
*
doctor has
to
hand
over
prescriptions
to
CMS
Committee
for
examination and reimbursement of drugs, treatment and injection fees. 1/3 rd of
the difference between wholesale and retail price of drugs was paid to the
Committee which redistributed the money to village doctors al the end of the year
as a performance bonus.
<•
In
*
each of the five villages one village doctor was contracted to pro', ide health
care irrespective of membership Maternal and preventive care were organized
with the help of township health center.
Health Bureau supplied equipments and published regulations, cards and forms.
54 per cent of the households were members (984 HHs with 3355 population).
HHs. which had access to health care did not haconie members. There was an average
of 2.2 visits per member per year. The level of reimbursement was
member and it varied from ¥ 3.73 to ¥ 0.8.
¥ 2.08 per
Full time doctors were more popular.
Share of drugs in total fees reduced due to CMS. which was service oriented (from
90% in 1993 to 76% in 1997).
Need for continued assistance from government.
encouraging poor households to become members. Increasing maternal care, which is
lacking and promotion of health education are suggested measures.
2.
Philippines14
Voluntary
Health
Insurance
for
residents
of
poor
rural
communities:
In
Philippines National Health Insurance Law passed in 1995 aims at universal coverage for
Ron Aviva and Kupferman Avi( 1996), A Community Health Insurance Scheme in the
Philippines: Extension of a community based integrated project. Technical Paper No. 19,WHO. Geneva.
17
a range of health care benefits. In the meantime government has encouraged communit}
health projects to develop health insurance scheme.
ORT (Org. for Education Resources and Training) Mother and Child Care
Communit}’ Based Integrated Project (MCC) is run by ORT which is an International
Voluntary Organisation. This project was launched in La Province of Philippines. The
project provides pre- school
education and
basic health services
ORT Health Plus
Scheme was launched in 1994.
Population: Covered the families of children attending 13 OR 1 centers, members of
ORT co-operative and the general population of the communities where day-care centers
were located. Total coverage was expected to be 2500 HHs. But. onl} 300 families
registered in the first year. Family was the membership unit.
Services: ambulatory and
in-patient care, prescribed drugs and ancillary
services
provided by doctors and nurses in day care centers.
Finance: considering the income flow patterns in the population contributions were
collected monthly, quarter!}, bi-annual and annuall} Differential level of contribution for
members and non-members of medi-care and famil} size was followed.
Contributions:
P 50-single person
P 100- standard famil}’
P130-large family (2cj pesos=l S)
These accounted tor less than half the amount that the families spent on basic
health care, excluding in-patient care. For those with medicare the premium for out
patient care was P 70 per month.
For the initial period ORT project continued to pay the salaries of doctors and two
nurses in day care center. Non insured persons had to pax' P 50 per consultation and for
18
drugs al cost plus 50%. For insured the cost of drugs was cost plus 20% much below the
market rales.
Management:.CMS is administered by OR.T Multi-Purpose Cooperative which is
formed by parents and staff of day care center to increase household income and
sustainability of day care centers.
3. Brazil
One of the largest provider(usually owned by doctors)
owned Cooperatives
is
said to have been established in Brazil in 1967. By 1994 its member owners were said to
be 60000. with independently practicing doctors(l/3 rd of national total). Under this
Unimed system an individual or 30000 enterprises which provided health insurance to
their employees could get agreed services from any member doctor anywhere in Brazil.
4. Tanzania1'
Tanzania is reported to be among the first countries in Southern Africa to
introduce prepayment scheme. Tanzania has implemented Community Health Fund
(.CHF) based on prepayment system in rural areas. Strong community organizations
existing in the country are reported to be the facilitators of growth of community
dispensaries. The CHF aims to provide primary health care, maternal and child health
care (including deliveries) preventive and promotive health care. The risks and
benefits are shared among large pools of households and each pool is reported to be
consisting of 50000 individuals. Each household will be given a health card at a cost
of S 2.57 per-person per year and hospital charges add up to additional premium.
There is political support, matching funds by donors and government to community
fund and cooperation from health care providersfdoctors). But. these CHFs are said to
be facing operational problems, management and rising costs.
Beatlie Allison et.al.ed.f 1906). Sustainable Health Care Financing In Souihern Alrica-EDI Policy
Seminar held in Johannesburg. South Africa. EDI-World Bank.
19
5.
Spain
In Catalonia, a combination of user-owned and provider- owned
known as integral
Health
Care
Cooperative system
is developed
cooperative
the
by
Espriti
Foundation.
Similar cooperatives operating at community level are said to exist in Italy. In
Malaysia, it is reported that government and doctors are exploring the ways to set up a
complementary system of provider - owned and user-owned coopcrali ves.
6.
Ghana"'
An evaluation studs' undertaken by the PHR reveals that Nkoranza community
health
insurance
scheme
in
Ghana
has
proved
to
be successful
in
terms
of
sustainability and making quality care affordable to a high percentage of vulnerable
households in the district. The study was undertaken after eight years of operation of the
scheme and was funded by DIDA and WHO.
The scheme is said to be self-funded (premium income). It is said to be first of its
kind in Ghana and has brought fame to the district by its mere survival. But. the PHR
study pointed out that there is a lol of scope for improvement and expansion of coverage.
Presently the scheme is reported to be covering only 30% of the total district population.
The reasons for low coverage have been identified as inappropriate registration period.
misconceptions in the community about the scheme, lack of marketing (educational)
communication, lack of accounting and computing, lack of monitoring and evaluation.
negative attitude of hospital staff and massive adverse selection i.e. tendency to register
only the high risk groups (aged, children...). One of the encouraging factors noteworthy
to be mentioned is that, though the district is reported to be having high level of poverty.
poverty is not recorded as a major factor for poor coverage. There is said to be demand
'■ Alim Chris and Sock (2000). An external Evaluation of the Nicoranzn Conununiii I innneing Health Insurance
Scheme. Ghana. 1 echmcal Report. 50. PHR Project Publication.
20
for maternal and child health services including deliveries lor which members were
willing to pay extra amount. But. there is said to be resistance i’or co-payments or
deductions
on
the
existing
hospitalization
cover.
The
PUR,
research
team
has
recommended incentives for registration of all members organizing Annual General
meetings with the help of funding from district government, supervision from community
volunteers, steps to improve relations between the hospital staff and the community and
inclusion of maternity care to boost membership.
7.
Italy:
In Italy, it is reported that local governments support community based health and
social service cooperatives
8.
Canada:
The report of the International Cooperative Alliance states that in Canada, as per
the study undertaken by Federal and Provincial governments, community health centers
were a cost-effective alternative to private practice as they are operated at lower cost per
patient and offered more preventive and health promotion sen ices and also accessible to
disadvantaged persons.
9.
(i)
USA
In USA. user-controlled health cooperatives operate as IIMOs.
Group Health.
I
Cooperative of Puget Sound in Seattle is said to be the
largest of these with
478000 members (1993). Medical care along with prexenlive care is provided for
a fixed prepaid fee;
(ii)
1
The United Seniors Health Cooperative provides the 91)00 elderly owner members high quality, affordable long term health care sen ices.
21
iiii>
User owned health cooperatives operating in partnership of government exist in
USA. In 1994, there were 900 democratically governed anti community owned.
Community and Migrant Health Centres in rural areas anti inner cities serving
low-income communities. For 500 such centers funding was available from US
Public Health Services.
10.
(i )
Japan
Members of the consumers movement have set up Health cooperatives supported
by the Medical Cooperative Committee of the Consumer's Cooperative Union.
(iit
Members of
services
multi-functional agricultural cooperatives have organized health
supported
by
the
National
Welfare
Federation
of
Agricultural
cooperatives.
11.
Singapore
In Singapore Health Cooperatives have been established b\
The National Trade
Union Congress in 1992 which represents 52 trade unions.
12.
Sweden
In 1990s. the Medicop Model, a model for consumer owned cooperative medical
care centers is reported to have been developed in Sweden on behalf of the' housing and
insurance cooperatives. It is reported to be providing cooperative partners for local
government authorities interested in contracting health care services and facilities.
13.
India
The following paragraphs present a somewhat detailed account of some of the
important experiments1' in India in this connection. We also briefly evaluate a plan of
medical care provision for the poor through insurance as presented by TN Krishnan, one
of the pioneer thinkers in this field.
1.
SEWA: The Self Employed Women's Association (SEWA) provides health care
to its members through two health —co-operatives viz. Mahila Sewa Lok Swasthva
Co-operative
and Krishna Dayan Co-operative. The services are particularly
preventive health and immunization services. Rational drugs are supplied at low
prices at 3 centres. Childcare is provided through 3 childcare centers and Creches.
Health Insurance coverage is reported to be not mandatory for SEWA
households. Coverage is extended to members who make contributions. And. for
members who have linked their fixed deposit savings with the insurance scheme.
there is also the coverage for maternity benefit.
SEWA bank runs Integrated
Social Security Insurance Scheme with the help of I.IC and United India
Insurance Corporation. It covers events of death, accidental death, sickness.
accidental widowhood and loss of household goods and work tools. On an
average insured person in SEWA households is reported to be paying Rs. 70 to
Rs.80 p.a. (Gumber A. and Kulkarni V., 2000). Cumber and Kulkarni's study in
Gujarat brought that. SEWA beneficiaries are interested in extending coverage to
additional household members and that there is strong preference
type of health insurance scheme by the people.
for SEWA
People in rural areas preferred
public sector hospital services with some contributions from community and
managed by Panchayat.
Their study revealed that out-of -pocket expenses of
insured (ESIS) households were lower by 30% for acute and chronic diseases and
NIHFW (2000), Development of Health Insurance in India- Seminar Report.
Other studies worth considering in this context front which information is gathered lor the analysis below.
■tie listed in the References at the end of this paper.
23
by 60% for hospitalization cases as compared to SliWA and non-insured
households.
2.
Sugar
Producers’
supply,
processing
and
marketing
cooperatives
in
Maharashtra State are reported to have set up a chain of hospitals and
dispensaries for members throughout the region of (heir operation. These
function in the nature of cooperatives though they are not formed as health care
cooperatives themselves.
3.
According to a study by Dr. P.R.Sodani in Rajasthan, people preferred to pay an
annual premium of Rs. 243 per capita under health insurance given a package of
sendees and coverage of expenses excluding transport. I’or coverage of transport
they preferred to pay Rs. 286 p.a. and Rs. 347 for coverage of transport and wage
loss.
4.
A public school in Delhi has introduced Health Insurance coverage with the
help of GICI. to its students (a group) with a premium of Rs. 50 per child per
year covering a risk unto Rs. 100000 per year.
5.
According to a study conducted by K.S.Nair in Delhi's slums, households in
informal sector spent 8.87 % of their per capita income on health care as against
4.47% by households in formal sector. Households in formal sector were willing
to pay Rs. 145 per capita per annum and households in informal sector were read}
to pa} Rs. 103 per capita p.a. The}' preferred a combination of hospitalized, non
hospitalized and chronic illness care benefit under health insurance.
6.
VHS in Tamil Nadu has been providing health care services to rural poor for
near!} 30 years. Based on the joint family income, membership fees are charged.
The scheme provides members, free annual check-up and curative and diagnostic
services at concessional rates. There is no wailing period between joining the
■ scheme and the right to receive health care. Dr. N.S.Murali reported that most
24
members renewed or enrolled only at the time of acute illness.
He has reported
that ait i\'GO cannot sustain Health insurance scheme from the premia received
from poor members. Support by government in terms of subsidy and levying
minimal user charges to users are important for the sustainability of the
insurance scheme.
1.
U.N.Jajoo's and Co-Professors from the Dept, of Medicine. Mahatma Gandhi
Institute, Wardha set up a co-operative health service unit in a village, in a
school building with an initial contribution of Rs. 4 per family.
Later a health
insurance scheme was mobilized by collecting agricultural produce @ of 2.5 kgs
per acre for farmers and, at a flat rate of 5 kgs for agricultural labourers. Village
dispensary is linked to Sewagram hospital. Village dispensary is run by VHW.
VHW is supported by a medical kit and monthly service of a mobile medical
team. Only acute and emergency cases are treated free of charge and for normal
deliveries and chronic illnesses 25% of the hospital bill is charged.
8.
In Mallur village in Karnataka, a Health Cooperative attached to a Milk
Cooperative was set up long back in 1973. Encouraged by the success of the
milk cooperative the members persuaded doctors of the St.John Medical College
to start a health care center which would be self sustained, financed and managed
by the community. The health cooperative provides services to nearby six
villages. In the first two years,
members contributed one-two paise per litre of
milk. Later. 5% of the profits from milk sale were given to health center.
Presently there is no funding from milk cooperative. Interest earnings from the
initial fund created by milk cooperative and user charges are the source of finance
for health center. State government has given land. ANM service, family planning
service, vaccines and nutritional supplies. St.John Medical college contributes Rs
250 p.m towards health care costs of the poor. The Health center is managed by
Gramabhivruddi Sangh and a Committee of 9 members including doctors from
' Jaioo U.N.et.al (1985). Rural Health Services : Towards a new strategy
Health Forum 6:WHO.
I leallh Care Who Pays? WHO
health cooperative and St.John Medical college. There is said to be frequent
absence of doctors in health center as the cooperative cannot pay the service
charges of doctors at market rate.19
9.
Insurance scheme for the Poor as proposed by TN Krishnan :
.
T.N.Krishnan proposes202hospitalization insurance plan for persons below poverty
line, which he suggests, can later be extended to other sections of the society.
Health insurance for the poor is justified on the ground (hat illness episodes take
away a major portion of the income of the poor. The present Jana Arogya
Scheme seems to be similar to the insurance scheme proposed by Krishnan.
He argues that as the proportion of falling ill requiring hospitalization is
small in a large population, risk pooling can be done al a small cost with an
appropriate insurance scheme.
Total cost of hospitalization is based on the NSS data (1986-87) which.is-'
adjusted to 1995. The average cost of treatment is taken to be Rs.500z-
for the
poor. The NSS data showed that about 4% of the bottom 40% of the population
were inpatients. Taking 50% increase for 10 years the proportion of inpatient for
1995 is taken to be 6%. With this rate the total cost would be Rs.900 crores (6%
of 300 million poor i.e. 18 crores x Rs.500) This works out to be an average cost
of (900 crores / 30 crore population) Rs.30 /- per poor person which would cover
cost of medicines, room rent, tests and consultation charges upto a limit of
Rs.5000/- per family per annum. He suggests that the Govt. should provide for the
total cost under anti-poverty programme or by re-allocation of expenditure.
19 Dase Priti Scn( 1997), Community Control Of Health Financing In India: A icsivu of Local Experiences.
'lech. Report No.8. PUR., Maryland
2l’Krishnan T.N.(1996). Hospitalization Insurance : A Proposal. 1:1’W. April 3. Vol.XV’l
26
To manage the health insurance implementation he suggests that the
subsidiaries of GIC be converted into separate Health Insurance Corporations
which work as not for profit organizations.
Panchayats
will
be
responsible
for
identifying
the
poor
and
the
consolidated list at the block level should be sent to Finance Ministry Health
insurance corporations should canvass and cover other population groups to meet
their administrative costs and it is felt that the expansion ofcoverage may help to
cross subsidise the poor, which will ultimately reduce the burden on government.
Hospitalisation is to be referred by the PHC doctor and Corporations are required
to directly settle the bills with the provider hospital. The cost of treatment should
be indicated on the card issued to families. It is also proposed to set up block level
Hospital Monitoring Committees to check the quality and price structure in
hospitals.
He suggests that, village panchayats should
levy a health cess on
landholdings and businesses for universalizing the health insurance coverage. As
suggested by Hsiao & Sen, he opines that
a portion of this can be retained for
strengthening PHC. In urban area health insurance is proposed to be implemented
through trade unions, business and factor}' establishments and through NGO’s for
the urban poor. Contributions to health insurance could be made compulsory for
all persons who have regular employment. These experiments he suggests should
be taken up initially in two districts in each state and later can be expanded to all
the districts based on experience.
OBSERVATIONS ON HEALTH INSURANCE SCHEMES IN INDIA.
•
People are ignorant about health insurance. Mediclaim and. the .Ian Arogya Bima
policies designed to help the poor arc not known to people.
Many diseases are excluded from risk coverage (treatment for cataracts, dental
care, sinusitis, tonsillitis, hernia, congenital internal diseases, fistula in anus, piles
etc.) in the first year of policy unless such diseases are total!) excluded as pre
existing. Expenses incurred in respect of any treatment relating to pregnancy and
childbirth is also excluded.
Jan Arogya covers only patients who are hospitalized. Il is not for out- patients.
There is lack of marketing. Villagers and the poor have to come to district places
to know about the scheme and to become members. Offices of the insurance
companies have not made any efforts to popularize these schemes in rural areas
and even among urban poor and also middle class people.
Officers of the insurance companies say that it is waste of lime and money to go
to people and market Jan Arogya Bima Policy.
convey common man about the policies.
They say that it is difficult to
The)' agree that they have not taken
up comprehensive marketing for popularizing the scheme.
Health insurance policies for the employees of the organized sector are highly
subsidized by government. Employee's contribution accounts for a small portion
of total coverage (ESI and CGHS).
Health insurance policies are introduced mainly by public sector.
Health insurance adopted so far (except for employees) is a reimbursement policy.
Individual patient has to pay to hospitals first and then claim the reimbursement
and there is a long delay in getting the claim.
28
MAIN LESSONS FROM COUNTRY EXPERIENCES
The above thirteen country experiences seem to suggest the following conclusions
that would help designing a Health Security Plan for the poor in the selected regions of
Karnataka.
•
To formulate a health insurance scheme for a community or a region reliable
data on health care costs and expenditure, utilization patterns and morbidity
in the target population would be useful.
•-
The Indian and other countries' experience in community financing of health care
through pre-payment suggests that co-operatives linked to economic activities
have been the base for creating health co-operatives.
Members have
contributed a part of the sale or produce or the profits to meet the health care
expenses of their families and themselves.
•
China’s experience with CMS reveals that it is not possible to sustain them with
voluntary' contributions. Contributions need to be mandatory and members
should confine to rules and regulations set in for CMS.
•
The study on CMS in China emphasizes that
in
addition
to community
contributions there is need for specific and effective mechanism to support
CMS in the long run.
•
In developing countries the issue of cross subsidization for the poor to meet health
care needs through health insurance needs to be worked out.
In the absence of
mechanism to make rich compensate for the poor, the local. Slate or the Central
government should subsidize the provision of health insurance.
•
In rural areas people are unaware of health insurance.
People are willing to
provide land, building and labour for setting up health facilities.
If there is
29
proper guidance and education, they are even willing to contribute in terms
of cash for future health risk. The Indian studies by Dr. Sudani and K. S. Nair
reveal this. The currently on going study ofCMDR in Karnataka also brings out
the willingness of the people to contribute to the development health care
cooperative.
People prefer
health
insurance schemes which
are
cheaper
and
with
minimum administrative procedures for getting the claim.
People prefer maternal health care, hospitalisation and outpatient curative
care to be covered under health insurance.
People do not prefer to join health care co-operative when there are health
facilities near by.
Co-ordination with government agencies and officials in implementation of
certain health services like maternal health care is
essential for a health
cooperative.
Though members of co-operative health centers make prepayment for health care
in terms of membership fees, it is necessary to levy user charges for two
reasons.
Firstly, to avoid misuse or over use of health facilities (as reported in
L'.N.Jajoo’s Study). Secondly, it is generally opined that people do not take free
services seriously.
To control ‘moral hazard' or the excess use of medical care, we can also adopt an
incentive
mechanism
membership fees
in
the
insurance
plan
in
the
form
of
reduced
for those who have not taken treatment for two or more
years. As said above, in Sewagram hospital, to present excess use nominal
charges were taken from hospitalized
patients for treatment of certain cases.
30
Contributions should be based on economic status of the families. But. there
should be fixed minimum payment for the poor.
•
Since community programme involves creation of awareness, erosion of interest.
trial and error in the application of the project and adoption of the project by the
community, it takes a long time (nearly 5 or more years) for any programme
to be deep rooted in the community.
•
Treatment by VHW at the village level indicates that a trained health worker
can attend many of the diseases suffered by villagers and there is no need for
expert doctor all the time.
•
Hiring the services of a medical expert daily would be cosily for the villagers.
Existing health insurance structure, which relies on low and differential premium
system cannot meet these expenses.
Therefore, as done in some experiments.
monthly or fortnightly or alternate day services of expert doctors can be provided
in different villages by mobile medical unit.
•
It is not possible to treat
all the cases free of charge. A financial limit needs to
be fixed based on the severity of illness, number of cases/times of treatment
per patient, etc. Based on these considerations the extent of contributions by
beneficiaries can be determined. All these aspects can be incorporated in the co
operative health scheme financed by health insurance, as is done in Sewagram
health care services in Maharashtra.
HEALTH CARE OF THE POOR THROUGH HEALTH INSURANCE
IV
AND HEALTH CARE COOPERATIVE:
A
CMDR
PROPOSAL
In the background of the above experiences about people's involvement in health
care plan for the poor, we have attempted to develop such a plan for a small region of
Karnataka. The main elements of the health care strategy for the poor should be the
following:
i.
This plan should cover all the poor, irrespective of their social status and
ability to pay.
ii.
It should provide for curative care in the case of all ailments, starting
from the common cough and cold to major diseases.
iii.
The
plan should
assign
an
added
weightage
to
the
medical
care
requirements of the poor and female members of the family for the
reasons mentioned earlier.
iv.
The plan should make efforts to provide lor cross subsidization of costs of
care. This
implies that
there should
be
a
provision
for community
contribution according to ability to pay rather than benefit received. This
community contribution should be mandatory and not optional.
v.
The plan should cover not simply curative care but also promotive and
preventive care services.
I
vi.
Health care needs should be articulated by the people themselves and
medical services set up should only aid this process of articulation.
vii.
Services should be supplied in accordance with the articulated needs.
Considering the above norms, it appears that a mechanism with cooperation
between providers and beneficiaries for the purpose of suppl) of health care services and
32
l
1
also for recovery of service costs would be helpful. As it is, in the Indian social set up.
forces of mutual cooperation do exist in the institution of family, neighbourhood, village .
etc.. Family is the most effective health care cooperative with elements of cross
subsidization and support. Any health security plan for the poor should consider
integrating the main elements of cooperative spirit witnessed in the case of family.
Health Security Plan should also recognize that costs of services are found to be
rising in recent years so fast that individually they cannot be met, as incomes do not
rise as fast as the costs. In such a situation cost sharing has to be visualized through a
mechanism of a cooperative among beneficiaries and providers and through the principle
of cross subsidization. The following flow chart brings out the important components of
the suggested Health Security Plan for the Poor keeping in mind some of the norms laid
down above.
Health Security Plan particularly for the Poor
through H('C and Health Care Insurance mechanism
as -atfaciiita io r-:'oRv,a ri his links
OPERATIONAL ASPECTS OF METHODOLOGY OF HEALTH INSURANCE
THROUGH HEALTH CARE COOPERATIVE:
The proposed health insurance through pre-pav ment and user charges is to be set
up initially in one village (Chandanmatti or a manageable group of villages) and later
extended to other villages each Panchayat being the unit of administration.
I. Membership:
Each Household will be a membership unit. All the households in
the Village will be covered under health insurance. A card will be
issued to each household with details of No. of members, category
of households and the details about the amount of user charges to
be taken for treatment from household members. Each card should
have provision to enter details of illness, treatment and cost of
drugs for each member during one year.
II. Services:
HCC will provide to its members curative, out patient and in
patient care, child
and
maternal
care
(excluding deliveries).
preventive and promotive health care services. Out patient care is
provided at HCC clinic in the village. For in-patient care a link wili
be established between HCC and a private or district hospital
which will provide referral service to members.
Hl. Management:
The health insurance scheme will
be managed by a
Health
Committee consisting of HCC doctor. PHC doctor, panchayat
president, local doctor, mahila mandal . youth center member.
school headmaster and five members from 1 ICC.
IV. Membership fees: Considering that the burden of illness will be greater on poor
households, a differential rate structure for membership'may be
visualized for households based on income level.
Dining the household survey in Chandanniatli village in
Dharwad district of Karnataka, for example, respondents from the
surveyed households expressed their willingness to pay an average
of Rs.225 per household. Membership fee can be fixed keeping
willingness to pay by the households. In view of different income
levels willingness to pay by
the households also
would be
different. Hence, differential membership fee can be determined
accordingly. Membership is fixed fora family of two plus two.
Advantages from the Proposed Health Security Plan
From the proposed health security plan there are main!} four ty pes of gains.
First, each individual becoming a member of the HCC and also linking his health
care needs with insurance system through HCC. would find that he would get the health
care facilities at his door step, without being required to meet various types of transaction
costs. Transportation costs, cost of loss of wages for those attending upon the morbid
person, additional food and other costs, etc can be avoided under this scheme. These
health care sendees would be available at lower costs now than wilhoui I ICC.
Second, provider of health care services like the providers’ cooperative, would
Find costs of provision to be lower than before in view of the likely economies of large
scale of operation. Even the insurance agency linked with providers’ cooperative would
find ready clientele for its insurance business ensuring better business.
Third, under the present scheme there is less chance of any resident member of
HCC being deprived of health care facilities when needed, for. through the operation of
the force of mutual sympathy, felt needs for health care services would be articulated, the
needed services would be provided through the linkages of HCC and insurance schemes.
As a result, finally, the likely direct and indirect costs of morbidity would be avoided.
Cost avoidance is obviously the gain for the needy, particularly the needy poor.
36
Fourth, since the government had to bear the entire responsibility towards health
care needs of the poor in a scenario without HCC the financial burden on the government
would be higher than in the scenario with HCC. for. some of the costs of provision are
now borne by the community itself through the system of cross subsidization. The spring
of human conduct, viz. sympathy and mutual sympathy, which is a tremendous resource
for social welfare, would be used and would stand promoted by the health security' plan
for the poor.
A concrete Health Security Plan for the Poor with data for one of the villages of
Dharwad district of Karnataka is presented in the Appendix to this paper.
.Appendix
A CONCRETE PLAN FOR IICC IN A VILLAGE IN
DI I AR WAD DISTRICT
About the Village
Chandanmatli is a small agricultural xillage situated 8 Kins. horn Dharwad. The
village consists of 172 households with 1018 population.
Fill) two percent of the
population belongs to SC/ST, backward and minority communities Fifty six percent of
the population is literate. Twenty Seven percent of the households live below poverty
hne(< 11000).
annually.
But. nearly fifty eight percent of the household earn less than Rs. 20000
Villagers do not have access to health facilities in the village. There is a
primary school in the x illage. Bore well water is the main source of drinking water in the
x illage. Villagers get this water through tap connections to individual houses.
Baseline Scenario
Analysis of out-patient situation
1.
On the basis of reporting from the village during the survey, the estimated
probability of incidence of sickness (outpatient type) -(). 13
2.
Therefore, annual prevalence of illness on average per resident
person=
*12=1.56
0.13
3.
As per the reporting during the survey, the average cost incurred per
morbid case per month =Rs.221
4.
Therefore, the average annual expenditure on such sickness per resident of
the \’illage=Rs.344 (=221 * 1.56)
4.
The UCC's
>st on each out-patient pci' annum then works out to Rs. I 15
(is.68 on medicines +rs. 47 doctors’ fees).
With the prevalence of 1.56.
the average cost to be borne by 1 ICC per resident is Rs. 179 (1.56
*
115).
5.
The patient himself spends Rs 86 (68+16 -2) pci illness. Therefore, with
the prevalence of 1.56. the private cost to the average resident is Rs. 134
*1.56).
(68+16+2
6.
The average based on a three tier differential rales, a membership plus
user charges of Rs. 87 to be collected per resident.
7.
The balance sheet of financial and direct costs and benefits of 1 ICC :
(in Rs.)
i
1
i
For HCC
i
1
For resident
For
Travel
For (he village
p roinoting
and
economy
agency
special
food
1
Cost
179
134+87=221
92
()
221+92+0=313
Income or
87+92=179
179+134=313
0
31
313+0+31=344
[
j
benefit
J
Com ments:
1.
The individuals have to spend only Rs.221 on average, and get benefits
worth Rs. 313.
2.
For HCC, there is a break even.
3.
The promoting agency will bear the initial burden at the rale of rs.92 per
resident as additional system cost.
4.
Saving in travel cost and food costs: since the patient and the allendent do
not have, to travel to places outside of the village, the saving on account of
)
As against this private cost directly incurred by the residents of the village,
5.
)
the average indirect costs likely to be incurred
)
(based on the FGD and
survey) are also estimated:
)
According to the survey, the time lost by the morbid person is four
•
)
days on average per incidence. With a prevalence of 1.56, the
)
labour time lost per average resident is 6 person days. Value of
)
this labour time is Rs. 300.
J
3
On average two person-day of time is lost by another member of
•
the morbid family to attend the patient. The implied opportunity
9
’ wage Cost is rs. 100. Therefore, for a prevalence of 1.56 on average
■ ‘
per resident, the value of labour time lost is Rs. 1 56.
•
3
With the treatment to be availed from outside of the village, as per
the survey, the
3
3
cost of travel plus incidenals such as food per
morbidity is Rs 20. Therefore, the incidence of this cost per
average resident is Rs 31 (=1.56
*20)
3
•
3
The total indirect cost per resident
= 156 + 300 +31=487
Scenario with HCC
e
Assumptions:
£
1.
Onlv 50%of medicines will be provided free of cost, the rest will be borne
I
by the patient.
2.
Cost of pathological/radiological tests will be borne by patients.
3? A promoting agency will provide the subsidy for the initial yearsfcovering
costs of consultation and
50% of medicine cost. There is avoidance o!
travel and special food cost due to HCC.)
travel cost and food costs will be 3 I (1 8+2
*
1.56)per resident (as worked
out under the baseline scenario).
5.
The gains (indirectly) in the reduction of transactions costs are:
•
On average the morbid patient loses only 3 days of his/her labour
time (as against 4 days in the base scenario): This amounts to a
labour time loss per average resident as
value of this time is Rs 250.
5 days (=1.56
*3).
The
Therefore the net gain because of
HCC in labour time is Rs.50 (= 300-250)
•
The loss of labour time of another member of the morbid family is
also reduced. Assuming that only one day of labour time is lost, the
value of the lost labour time is Rs. 78. The net gain in saving in
labour time is Rs. 78 (as compared to the base line scenario, 156-
78).
•
The total indirect benefit therefore will be rs.50+78=128 per
resident of the village.
Total savings
,
-
a. Residents =Rs.92+31 + 128 = 251
b. Village economy = Rs.31+Rs.128 -92 = 67
The case of in-patient treatments
•
As per the survey, the average cost of an in-patient per year was Rs.
3084.
•
The probabiliyl fo illness leading to hospitalisation, according to the
survey data is 0.035
•
<
Therefore, the hospitalisation cost per year per average resident is Rs.
109 (=3084
*0.035)
41
1
< ase, a health in: ur: cc schc nc i. .■< iked nul for all . -e resit -jus
with {he jan arogya scheme of united insurance co (or any other), the
insurance premium is Rs. 107 per year.
o
Therefore, with proper promotional efforts and implementation, the
1 ICC can bring in the insurance scheme to cover till the residents of the
village, al no extra cost either to I ICC or to the government.
•
Needless to mention that the promotive and implementation efforts
will be the basic catalists to be set in motion by the promoting agency.
How to manage the HCC in the long run????
1.
In the long run, the HCC has to breakeven at the average cost of Rs. 179 per
resident. There are several options that can be considered.
•
The tnemebrship fee and user charges can be gradually increased to go up
to cover the cost at Rs. 179 per resident. This can be designed al a
gradually increasing rate of 10% per year. Then, it will take a minimum of
7 years to be self-reliant. Till such time, the HCC will have to subsidised
by one or the agency, be it the governemnt or a non-governmenl.
•
Alternatively, since the HCC will reduce the pressure on the government
outlets in health care (phc. die and subcentres), the slate governments can
transfer some funds to manage the HCC under the zp or other direct
allocations to the health sector.
42
References
Abel-smith Brain (1986). Funding health for all is insurance the answer ? World Health
Forum. 3-32.
Abusaleh Shariff. Anil Gumber, Ravi Duggal & Moneer Alam (1999).
Health Care
Financing and insurance : Perspective for the ninth plan. 1997-2002’
Margin. Vol 31. No.2. (Jan-Mar 1999)
Atini Cliris and Sock (2000), An external Evaluation of the Nicoranza Community
Financing Health Insurance Scheme. Ghana. Technical Report. 50. PHR
Project Publication.
Berman Peter (ed.) (1993), Health Sector Reform in Developing Countries : Making
Health Development Sustainable. United Stales Agency for International
Development. Office of Health and Nutrition.
Beth Hahn. Ann Barry Flood (1995). No Insurance. Public Insurance and Private
Insurance: Do Tltese Options Contributed to differences in General Health
.Journal oj Health Care for the Poor and Underserved. Vol.6. No. 1. 1995.
Biswajit Chatterjee and Amil Kundu (2000) Health Insurance for Rural Poor and
Employment The Indian Journal of Labour Economics. Vol.43. No.4..
2000
Blomqvist
Ake
(1997),
Optimal
non-linear
health
insurance. Journal of Health
Economics 16(1997), 303-321.
Blumberg Linda J (et.al'...) (2000). Did the Medicaid expansions for children displace
private insurance '.’An analysis of using the SIPP. Journal of Health
Economics.
19(2000). 33-60.
43
Charles Normand. Axel Weber (1994) Social Health Insurance
.1 Guide Book fot
Planning, World Health Organization.
Chernew E.Michael (et.al...) (2000), Optimal health insurance : the cae ol observable.
severe illness. Journal of Health Economics 19 (2000). 585-609
Deolalikar & Vashishtha Prem S. The health and Medical Sector in India : Potential
Reforms and problems.
Douglass. Richard L & Others, Health and Human Resources. Health and Human
Resources 559.
Dranove David. Spier Kathryn E, Barker Laurence. ‘Competition’ among employers
offering health insurance Journal of Health Economics. 19 (2000) 121140.
Families USA (2000), Go Directly to Work, Do Not collect Health Insurance : Low
Income Parents Lose Medicaid, zl Report The Open Society Institute.
2000.
Farber (Henry' S) & Levy Helen (2000), Recent trends in employer-sponsored health
insurance coverage : are bad jobs getting worse ? Journal of Health
Economics, 19 (2000). 93-119.
Gumbar Anil (2000). Health care burden on households in the informal sector :
Implications for social security assistance. The Indian Journal Economics.
Vol43.No.2, 2000.
I
Gumbcr Anil and Kulkarni Veena (2000). Health Insurance for Informal Sector : Case
study of Gujarat. Economic and Political Weekly. September 30.
Hahn Beth. Flood Barry Ann (1995). No insurance, public insurance and private
insurance : Do these options contribute to differences in general health ?.
Journal of Health care for the poor and underserved. V0I6. No.1.1995.
44
International Co-operative Alliance (ICA), Co-ops and the Health Sector. Background
Information note 6.
Jajoo UN. Gupta OP, Jain AP (1985), Rural Health Services : Towards a new Strategy ?
World Health Forum, 6, 150-152.
Kabra Kamal Nayan (1986), Nationalization of Life Insurance in India. Economic and
Political Weekly. Vol XXL No.47. November 22. 1986.
Krishnan T.N. (1996), Hospitalization Insuraqnce : A Proposal Economics and Political
Weekly April 13, 1996.
Liljas Bengt (2000), Insurance and imperfect financial markets in Grossman's demand
for health model - a reply to Tabata and Ohkusa. .Journal of Health
Economics. 19 (2000), 821-827.
Marquis Susan.M (1992), Adverse selection with a multiple choice among health
insurance plans : A simulation analysis. Journal <>/ Health Economics. 11
(1992) 129-151, North Halland.
Michael Chernew. (el.al...) (1996), Worker Demand for Health Insurance in the non
group market : A note on the calculation of welfare loss. Journal of Health
Economics. 15(1997) 375-380.
NCPA-NCPA. Twenty Myths About National Health Insurance. Policy Report it 166.
NIHFW (2000) Development of Health Insurance in India : Current Status and Future .
I
*.
Directions, The Seminar Report.
December-29.30. 2000.
Nyman John A. (1999), The value of health insurance : the access motive Journal oj
Health Economics 18(1999). LI 1-152.
Ormand Barbara, (et al..J (1999). Health care tbi low-income people in the district of
Columbia The Urban Institute .
45
Pant Manoj (2000). What do we do about healthcare
The Economic Times. July 18.
2000.
Pant Niranjan (1999). Insurance Regulation and Development
Bill: An Appriasal.
Economic and Political Weekly, November 6. 1999,
Parikh. Jyoti. Laxmi Vijay (2000). Biofuels. Pollution and Health Linkages : A Survey of
Rural Tamil Nadu Economic and Political Weekly November 1 8. 2000.
Petretto Alessandro (1999). Optimal social health insurance with supplementary private
insurance. Journal of Health Economics. 18 (1999) 727-745.
Ranade Ajit. Ahuja Rajeev (1999), Life Insurance in India : Emerging Issues Economic
and Political Weekly January 16-23. 1999.
Rao Tripati D.
Life Insurance Business in India : Analysis of Performance. Economic
and Political Weekly, July 31. 1999.
Rask N.Kevin & Rask, J.Kimberly (2000), Public insurance substituting for private
insurance : new evidence regarding public hospitals, uncompensated care
funds and Medicaid. Journal of Health Economics. 19 (2000). 1-31.
Selden M.Thomas (1999), Premium subsidies for health insurance : excessive coverage
vs. adverse selection. Journal of Health Economics. 18 (1999). 709.725.
Sheppard Shore Lara (el.al...) Medicaid and crowding out of private insurance : a re
examination using firm level data. Journal o] Health Economics. 19
(2000), 61-91.
Sloan Frank A.(1992), Adverse selection : Does it preclude a competitive health
insurance market ? Journal of Health Economics
II (1992). 353-356.
North-Halland.
Sodani P.R. & Gupta SD. Household Health Care Expenditure in Tribal Areas of
Rajasthan, Asian Economic Review.
46
Stephen H.Long (eta/...) (1998), Do people shift their use of health services over time to
take advantage of insurance ?, Journal of Health Economics, 17, (1998),
105-115.
Strohrnenger R. WamBach A (2000), Adverse selection and categorical discrimination in
the health insurance markets : the effects of genetic tests. Journal of
Health Economic, 19 (2000), 197-218.
Stubbs Michael (1996), Co-operative Enterprise in Health and Social Care. Review of
Intgemational Coperation Vol.89.
Susan L.Ettner (1996), Adverse selection and the purchase of Medigap insurance by the
elderly, Journal of Health Economics. 16(1997) 543-562.
Swamy T.L.N (1999), Employment and Manufacturing Sector in India : Some Issues.
Margin, Vol.31, No.2 (Jan-Mar. 1999)
Tabata Ken. Yausashi Oltkusa (2000), Correction note on
The demand for health-with
uncertainty and insurance. Journal of Health Economics. 19 (2000), 811-
820.
Wickramasinghe J.W (abt), National Health Insurance Scheme lor a Developing country
with special reference to Sri Lanka. Asian Economic Revie.
Wynand P.M.M (et.al...2(1999), Access to coverage tor high-risks in a competitive
individual health insurance market : via premium rate restrictions or risk-
adjusted premium subsidies ? Journal of Health Economics
19 (2000).
311-339.
International Co-operative Alliance (ICA). Co-ops and the Health Sector. Background
Information note 6.
Stubbs Michael (1996). Co-operative Enterprise in Health and Social Care. Review of
Intgemational Coperation Vol.89.
47
The Jawar Rural Health insurance (Assurance) Scheme of the
MGiMS Hospital. Sevagram : A micro experiment in the sprint of
Sarvodaya ideology.
By Dr. Ulhas Jajoo,
Dr. Anant Bhan
The idea for the scheme started from the Medico Friends Circle (an informal
group that is concerned about issues of public health importance) students group that
Dr. Jajoo initiated in MGIMS. Sevagram when he joined as faculty there in the
Department of Medicine after completing his masters from the Medical College, Nagpur
in 1976. The group would regularly meet and discuss the various issues of relevance in
medicine Fed up of their indoor discussions and ideological debates, the group decided
to move out into the community' and work with them The students divided themselves
into groups, which went to four different villages, one of which was to be chosen for the
proposed fieldwork. The students finally zeroed in on Nagapur village, which was around
5 kms away from the Sevagram hospital because of practical considerations, and not the
other village like Pujai though needy but was quite far away and transport facilities to
which were abysmal it was the first lesson that roads and transport are related to health
care.
The group initially talked to the villagers about their health needs. In consultation,
it was decided to run a dispensary in the local school on a weekly basis They decided
against using drug samples given by medical representatives because it was unethical
A small token amount was collected towards the drug bank from the villagers and the
dispensary was started The drug selection was based on effectivity. cost and toxicity
The generic drugs were used, in the process, the group could get insight of the
exploitative drug market
However, pretty soon the durgs ran out and on analysis, the group realized that
the rich of the village were not paying up and it was actually the poor who had paid
regularly. In the next village meeting, this was brought up and addressed. The rich felt
hurt for being exposed publicly but then the flow of money became more regular.
Realizing that some kind of regular follow up was needed, it was decided to have
a village health worker (VHW). Initially, they thought that the traditional ‘Dai: could be
given inis responsibility but they realized soon that the community did not give her
enough credibility'. It bolied down to selecting a male health worker, from the community
who was not necessarily poor. Also, he needed to be respected by the community to be
able io provide a leadership role.
1
It wss also decided that only those who could pay would be allowed to access
the services at the dispensary. This led to a situation where the absolutely poor were not
able to access the services. To cater to this target population, which needed support, the
scheme was linked to the hospital which would help in sustenance of the scheme Dr
Sushila Mayya r, the Director and founder member of M G.I.M S agreed to a policy that
any person from the scheme would get free treatment from the hospital
The next step was the establishment of a village fund Dr. Jajoo had visited
various health projects before initiating this scheme and these visits had shown him that
the main reason for starting these projects was on comoassionate grounds. The all
enveloping love often created dependency among beneficiaries It breeds relationship of
a doler and the begger. Moreover, these projects were so heavily financed that their
replicability was not possible (PRIA, 1986 study). Dr Jajoo did not rant donations from
outside to finance the healthcare (based on the feeling of “Charity Corrupts People1').
The purpose of the fund was not to raise financial support to the outreach programme .
but to generate demand for qualitative service from the providers: in fact it was a
tradition among villagers to collect voluntarily contribution graded according to capacity
for religious village function, sport competition or for temple construction. The fund would
finance the salary of the VHW and the drug requirements of the local dispensary,
besides transportation cost of the mobile health team Since Jawar (Sorghum) cultivation
was quite common and it was easy to contribute in kind, it was decided to accept the
contribution in the form of Jawar (Sorghum) - the contribution would be according to
capacity and the services according to need (trie poor needed more support).
The fund would act as a pre-payment scheme subscription, entitlements being
free primary health care and subsidized referral care (Jajoo. 1993). A minimum amount
was decided which would have to be paid by every family and also additional amount of
Jawar would be charged depending on the kind of work that the family members were
engaged in or on additional holdings At present the health insurance contribution from
the lowest income group (landless labourers) is 12 payali of Jawar per family per year (a
payali is a. measure equivalent to 1.25 kgs and a Payali of Jawar sells for around Rs. A
at present market rates)
Since this ensured that uniform healthcare would be available to all those who
paid for the village fund, some of the rich farmers felt that they were financing the
healthcare of the poor and did not pay up. Thus, only 60% of the village was paying up
for first year, i his was brought up at the next village meet. To ensure payment, it was
made clear that oniy those who contribute will get the benefits of the scheme. The
persons from the village who had paid would get free treatment, but who did not
contribute to the village fund would have to pay for the treatment. Those who had not
2
paid (after treatment) and absconded would he held accountable by the village and
made to pay
To prevent misutilization of services at the hospital, it was fixed that 25% of the
costs of elective admissions like cataract, hernia, normal pregnancy would have to be
paid by the patient, while the treatment for an emergency / unpredictable illness would
be free at the hospital.
Gradually over subsequent years, as scheme gained credibility', the coverage of
the scheme grew from 60% to 75% and finally 90-95%. The village fund would pay for
the drugs in the local dispensary, the VHW’s salary' and the visit of the hospital vehicle
once in three months.
The meetings in the village (Gram Sabhas) about the various aspects of the
scheme would be held every' year before Jawar collection and would occasionally be
'stormy' and heated discussions would ensue. This Gram Sabha would sen's a dual
purpose of evaluating the performance of the health structure and also enacting
disciplinary' action on irregularities committed by the villagers themselves. The Gram
Sabha helped to facilitate communication between the health system and the beneficiary'
on one hand, while on the other it helped the villagers to command control on the VHW
and the health team On occasion, the Gram Sabha decided to change their VHW
(Jaioo, 1993) The scheme helped the community have a right to demand good quality
care from the system It also ensured politeness and better behaviour in the hospital on
the part of the providers.
On the basis of the lessions learnt from Nagapur, the team extended the health
insurance scheme to other villages (presently there are 40 villages within a radius of 25
kms around the hospital, covered under the scheme).
Initially the VHW was paid a fixed amount in the form of Jawar. but later on it was
decided that the honorarium would be decided in the village depending on the VHW’s
work performance, whether he had been helpful and accompanied the patients in the
time of the need. This was to bring in accountability to his / her work.
As the scheme slowly started spreading to other villages, each village opened an
account with a withdrawal oy cheques facility. Ail the Jawar collected as premium would
be sold and the money would be deposited in this account as the village fund. At the end
of the year, the money remaining in the accounts wouid be transferred to the village fund
for the next year - occasionally, a part of the fund wouid be transferred to the Kasturba
Health Society io form a common pool of money for all the villages - a corpus, the
interest of which could be used for procuring drugs (centralized distribution from the
hospital). The money would also be used for organizing educative camps and
5
'Prabhodan Saptabs’ (Educative lecture week series) where non health related topics
including social / spiritual issues would be discussed
Only 10% of the expenditure on the scheme as recovered form the contribution in
the form of premium and 90% of the cost came from the hospital Since the MGIMS
hospital runs predominantly on Govt financing, which is public money, it was felt that
this would be a appropriate utilization of the same.
The structure of the scheme revolves around (Jajoo ; unpublished)
> Accessible hospital services of optimum quality
> Accountability of Heath care system to the consumers.
> Affordability' of the services to the poorest
Dr. Jajoo and M.G.I M.S realize that the sustainability of the scheme (that it has
to cater poor) without external support is not possible. It was and is their belief that the
government needs to support these kind of schemes and subsidize them as a part of its
social responsibilities.
Social financing has the following spin off benefits (Jajoo, unpublished)
> It increases the accessibility of the health services
> It promotes the operators concern of the health in the community
> It generates the concept of the right to demand a quality health care
by the beneficiary population
> It responds to priorities as judged by the community.
> It ensures that the services are acceptable.
> It keeps the service providers on their toes
> It stimulates organizational self-confidence and paves the way for
participatary culture at the community level.
At this stage, the pre-requisite for adopting the scheme was - at least 75% of
village families should contribute for the village to be insured. The scheme found
acceptability among villagers and once they Insured, did not look back for the years to
come.
it was at this time when the scheme extended focus from curative care to
preventive and promotive health aspects. Tne strategy of cluster immunisation to
achieve herd immunity was successfully implemented for vaccine preventable illnesses.
The village sanitation was addressed by evolving an appropriate model of latrine. 'One
house one latrine scheme' aimed at 100% coverage of village families. It was not a dole.
The pari contribution in cash came from beneficiary villager and the rest from Gram
Panchayat and state funds. The model found acceptance of the state and central
government for its replication.
4
Poverty being the greatest evil behind most of the health problems, as a logical
corollary, the scheme extended its web to income generation programme, addressing
village as a social unit for development All familes in a village were offered membership
of co-operative society for dairy development or lift irrigation scheme for agriculture
where ever feasible The later initiative could come through the bank funds The
constitution of co-operative society was framed in such a way that decisions could only
occur with no less than 75% majority, thus making elections obsolete.
At this stage village health insurance scheme underwent first qualitative change
In addition to 75% participation at least one of the following criteria was needed for
elligibility
> Participation in "one house - one latrine" scheme with near 100% coverage
of village families
> Organising lift irrigation scheme for all village families
> Organising milk co-operative for all village families
> Electing village panchayat by consensus
Organisation of people through income generation schemes became a focus
issue, benefitting the whole community The eligibility criteria now heavily weighed in
favour of community action The health insurance scheme had now reached a stage
where it was helping and initiating action oriented culture of the village The changed
face of the insurance scheme gave impetus to 'one - house one latrine' scheme in many
villages.
The various schemes available to the village are -
a) Jawar insurance scheme - under this 50% subsidy is given on outpatient
care and 100% on all indoor care except for elective admissions (50%
subsidy)
b) Subsidised family insurance scheme for rural area (Rs 15 / person/year)
when 75% of village families contribute. In this scheme outpatient and
impatient services are provided with 50% subsidy. The village need not fulfill
~
v V
ThP ahnvp pnlictari
nritons
fr\r onmllmanr
VI
V f | L V I I <-/< I VZI Uli || VZl | | | I
IL.
c) indoor insurance scheme in which there is no insistence on 75% of village
families to contribute. The contributions are at the rate of Rs. 15 / person /
year. There is no outpatient subsidy offered, inpatient charges are subsidised
by 50%.
d) The hospital runs a health insurance scheme for families living in semiurban
pockets and in Wardha town, at the rate of Rs. 150/year for a family of five.
The entitlement includes 50% subsidy in out patient and inpatient charges.
5
Income generation programme became quite successful and brought in visible
economic upliftment, with it vices like alcohol, gambling, fierce
party politics and
competitiveness found inroads in the village. The police frequently found entry and visits
to judicial court galloped. It was a lesson to be learnt - cultural development must race
ahead of economic upliftment for a effective change It was a turning point for the ethos
of health insurance scheme
If the ultimate aim of the health insurance scheme is organising people at the
lowest ebb of society, we opted for women’s self help group (SHGs), since the women in
poor families are the ‘prolitariat of the prolitanat (as quoted by Dada Dharmadhikari).
The women are hard working among all classes and the ultimate sufferers. They are
also culturally sane. The organisation of this culturally sane section of society found its
initiative in the early 90s
The organisation of women in to SHGs was need based, so that their
dependence on money could be addressed by forming collectives that would be able to
provide economic support when neded it was noticed that the women would stand by
each other and there would be transparency, leading to more accountability. The culture
of decision making by consensus was thoughtfully inculcated in SHGs. As the money
started coming (linkages with bank), women's status in family changed as she was now
looked upon as a bread winner for the family too. The process helped empowerment of
women.
By now it was realised that though health care offers an ideal medium to get
entry in village life (albeit costly), organising the entire community around it had not
taker/ roots, simply because it was not and is not the priority need of the masses, illness
as a calamity affects individuals and is rare to find epidemics sweeping the community
around which a sustained mass action can be initiated.
The income generation programmes’attract people as they serve their individual
interest. Since the programmes addressing all village families were chosen (lift irrigation
and milk co-operatives), every one hugged together to harvest the gains, creating a false
impression of an organised community. In fact these programmes inculcated competitive
life style and the greed that comes with it. The realisation dawned, that short of cultural
ethos, mere economic upliftment treads the wrong path.
The health insurance scheme had now reached a stage where it was helping
identify not only the action oriented culture of the village but also action oriented
individuals with capacity to do good. All are not equal in a village, some are more
reverable than others. The culture evolution needs active participation of these revered
ones (Sajjan Samarth). With aim to organize them, the focus of health insurance scheme
shifted to individuals and families than the earlier insistence on an entire village. Action
6
plans for individuals now emerged like - organic farming and Vastra Swavalamban
(Cloth self sufficiency) These are acts in faith. For an intelligent direction of this kind,
study circles (Prabodhan) became the need of the hour. It could not have been
classroom learning It had to be experiencial sharing
The educational talks based on experiencial Wisdom were organised after the
month of February, when the crop harvest was over. The usual site was temple, after
“Arati" was over at 8 p.m A discussion would be initiated on issues relating to their day
to day life linking them to social - cultural values Organic farming was encouraged The
‘Role models’ in various fields were put before the community'. The educational trips to
Role model’s work place helped people imbibe goodness Thus evolved programmes
aiming Vastra Swavalamban and sustainable agriculture
The focus of the scheme now shifted to organise and empower the revered ones.
It aimed at breaking their culture of silence with a hope that reigns of power be vested in
moral leadership. It is from this empowerment and leadership the anti-liquor movement
has taken roots in the villages around Sevagram
The Jawar insurance scheme underwent a major conceptual change, focusing on
individuals and families than the entire village The family had to fulfil at least one
Criteria for eligibility of enrollment
»
Member of the SHG
«
Experimenting organic farming
»
Taken a vow for Vastra Swavalamban
e
Active member of study circle in the village.
When the scheme began in 1379, the focus was on curative care; later on it
became preventable care, it then reached the stage of promotive care through income
generation schemes; the focus moved on to being social and now it is to encourage
moral issues in society. Those that give priority to moral issues are insured under Jawar
scheme, while the rest can choose any of the other schemes listed above.
The changing focus gave impetus to SHG movement. SHGs were linked to
banks, enabling them to offer crop-loans to the members. It being a unregistered body,
entirely runs on faith. It selects office bearers by consensus who by rule, do not stay in
office for more than two years. All codes of conduct were .evolved through group
discussions The culture of decision making by consensus and transparency in all
transactions buttressed the faith women enjoyed among themselves. Since it enjoyed
credibility of a dependable source of financial support, hence it did not see any
defaulters of loan. The forum slowly took up educational role through experiencial
sharing sessions, educative trips and by attending educational camps.
7
It was realized that common man/woman in particular, acts in faith and that is the
driving force for him/her. This faith needs to be properly directed by the wise people.
Characteristics of the Oasis :
1. Affordable and accessible'
It is due to fact that families enrolling for Health Insurance contribute
according to capacity but services are provided according to need
2. Acceptable .
More that 95% enroll in the village. It speaks of its quality. All
The evidence -
indoor hospitalization from adopted village occur in Kasturba
Hospital, Sevagram. They do not go to the flourishing private
sector in Wardha town.
3. Effective :
The Evidence - No maternal mortality in past 15 years.
- No death due io non-accessibiiity of medical care.
- No Tetanus, Poiio, Whooping cough, Measles in last 15 years.
Measles is the most sensitive indicator of herd immunity achieved.
- No misutilisation of resources.
4. Accountable :
The social finance has generated right to demand, which keeps the service
providers of their toes.
5. Wholistic :
It is not an experiment planned from ivory towers with a tubular vision. The
experiment has evolved with the involvement and feedback from the people and has
transcended wholistically to the priority needs of the people.
6. Credible :
It is something that can not be quantitated but has be felt. It can be witnessed in -
* Late night village meetings where discussions turn in to educative sessions.
» Self-help groups not only as a transparent financing body but transforming in to a
educative forum and Empowering women,
8
• Vastraswavalamban (Khadi for own use) and sustainable agricultural practices
as a step towards freedom from exploitative market.
Self reliance in priority needs is a key to empowerment.
7. Trustworthy :
The gains of this experiment have been the relationship of a friend / partner, the
free tines of oommunication with the beneficiary and the conversion to a big family
There is implicit trust involved and this enables the poor to share their pathos They
come to health care professional with the belief that they would do their best and leave
the rest to destiny A relationship of trust is thus established which brings people
together and keep the scheme going on
8. Replicability '
The credibility' of scheme revolves around the will of the hospital management to
support Dr Jajoo is a pivot around which the scheme revolves In his absence the need
based health insurance scheme would continue, though the outreach activities and other
dimensions of health would suffer.
Research:
The service to the people was main concern. Research was not really a focus
because of lack of interested manpower The focus was instead on operational research
and on extending the scheme to community by emphasizing other dimensions related to
health ethics Over the years, the scheme has generated a lot of data but this needs to
be analysed
The operational aspects :
The hospital has now become much more accessible to the community and this
has helped bring down the incidence of deaths like that due to pneumonia and
diarrhoea. Vaccine preventable illnesses (tetanus, polio, whooping cough, measles)
have disappeated once herd immunity was established and maintained by cluster
approach to immunisation. From the year (1995) government adopted cluster approach
to immunisation, vaccination is left to government ANM The village worker performs a
watch aog function to see that all eligible receive it.
The deliveries are free in the hospital for pnmiparous and for complicated
pregnancy. The women can choose to have delivery either in the villages assisted by
traditional birth attendant (TBA) or in the hospital. The services now being accessible,
women choose to have hospital delivery. ANC (Antenatal care) up io 7th month are
3
handled by village health worker. While around 7th month, women report to Kasturba
Hospital for assessment of pelvis, toxaemia and for receiving booster of tetanus toxoid.
The area catered by health insurance scheme has not witnessed maternal mortality from
last 15 years and the natal / prerinatal mortality has reduced significantly.
The monthly ANC visits in the villages have been given up ANM visits villages
once in three months, checking all records maintained by village workers (ANC
registration, Vaccination, Birth, Death). With appropriate strategy for vaccination and
ante-natal care, which utilises village based manpower to the maximum, the need of
skilled manpower is reduced to the obligatory minimum. The ANM under the scheme
acts at the second tier managing the administrative work of all the villages in addition to
supervision of village based activities in 40 villages She visits all hospitalised patients,
assures expeditious services entertains their complaints, keep records and informs
tricky' problems to Dr Jajoo.
The process of selection of VHW has undergone a sea change, initially TBA was
preferred with a notion that she has natural access to pregnant women and new-borns.
She belongs to lowest socio-economic class, is needy, hence would be most appropriate
choice. The experiences was contrary. She was called only for conducting delivery and
taking care of new born for next ten days since no body else would do it She did not and
does not enjoy enough credibility' in the minds of people, that advice would be heeded.
She had to take permission from her husband to accompany a patient in the night to the
hospital, if emergency so demands.
The option shifted for a male member. With the evolving role of VHW, a person
with leadership qualities, one who is respected in the community and has aptitude to
serve, happened to be the choice. Since the village fund that could be raised from
prepayments did not permit lucrative honorarium (it is hardly 1000 -1500 Rs. Per year),
only a person from middle class background with aptitude to serve could be selected.
Since the selection was done in consultation with wise and elderly men and women of
different caste groups in the village, often in front of the temple, the person acceptable to
aii hsc
*
to be one beyond villspe psrty — politics
With SHG movement taking shape, it was easy to locate women with leadersnip
potentiality and serving aptitude. Most of the villages, at present have two village
workers, one male and other female, assisting each other for the comprehensive
development of village.
As the vision behind the scheme was ever evolving, Dr. Jajoo, ANM (Mrs
Bagade) and village workers all underwent a problem based learning. Frequent
meetings (Late night) with Gram Sabha, generated directions which way to go. At no
time, need for a formal training was experienced. The team learned by doing and
10
experiential sharing Every thing needed had to be learned by all The learning
transcended beyond scientific to socio-economic-political-spiritual dimensions of life.
According to Dr. Jajoo, the propagated glorified role of VHW as a liberator in late
80s and early 90s had to settle down to ground realities For a peripheral health workers
to perform successfully, an effective back-up referral system needs to be in place. The
credibility, ultimately in the community is for curative care and not preventive care. The
experience in Sevagram has shown that the acceptability of VHW depends greatly on
how much support the medical team can give him / her as a link between the community'
and health delivery' system (PRIA study 1986).
Community' involvement in health care :
Community involvement is a glibly used slogan. It has different shades Community complacence where community' is a passive receiver.
Community co-operation - where manpower support is offered by community.
-
Community partnership - demands material support from the community in. addition
In all these, there is a ‘big brother that dictates
Community participation is a politicised concept. The decision making lies with the
people. There is a common feeling and hence spontaneity in action
Health being a service sector, professional relationship is vertical
Health
insurance scheme, has honzontalised this relationship to the extent possible
It
exemplifies health for the people Sevagram could achieve community partnership while
evolving models like ‘one house one latrine scheme’, milk, co-operatives and lift irrigation
co-operatives The scheme did succeed in unifying village community through income
generation programmes. But money brought with it liquor, gambling, party politics, police
and judicial courts The fact brought home the painful realisation that pooling people
together for material gain is not development.
Village around Sevagram has witnessed community participation emerging
during farmer's movement. It breathed Its last because it aimed only for material gain.
The scheme experienced right kind of community participation emerging with
Vastraswavalamoan Yojana, sustainable agricultural practices and SHG movement of
women in particular. It is an empowering experience, evidenced by the anti-liquor
movement that is taking roots in village around Sevagram. The right kind of community
participation emerges when spiritual wisdom leads and lights.
11
Experiencial Wisdom of last 20 years
For pro-people (poor) health services, self reliance is a myth. The Jawar scheme
could raise around 10% of what is spent, by social finance. The private insurance which
worxs on ;ne principle of financial risk snaring on no loss basis, can never cater poor. Dr.
Jajoo emphasizes that pro-poor health care must be domain of state's welfare activity.
it is possible io offer just primary health care to all within presently allotted
government resources ('250 Rs/Per capita year). The maldistribution of centrally pooled
resources is what primarily ails our system The percolation theory - that centrally
allotted funds will reach to the periphery - fails If the government decides to hand-over
its percapita expenditure on health directly to Gram Sabha then there can be better
control of the health services Where they control health finances, they can negotiate
services from the providers, it gives them a better pedestal. The community can then
buy the services from the public or the Voluntary' sector which is arguably propeople.
Empowerment of people without ownership of resourses is not possible. The bottleneck
of Sevagram experiment was the fact that people die not own resources and were on
receiving end and hence the programme remained vertical and complete participation
was not possible.
It requires a radical political will to truly decentralise up to Panchayat Raj system
and distributing resources to it on percapita basis. The structural adjustments of this kind
can see replicability of Sevagram experiment.
Short of these structural adjustments where-ever 2Q% of the finances can be
granted to the voluntary sector (as is the case of Kasturba Health Society'), mechanisms
and organisational part of the scheme would be replicable. The will has to exist, it can
not bs reolicstsd
Ethos :
We live in a society where “al! men are equal, but some are more equal than
others'11 It is not an egalitarian society, social relationships are exploitative.
The fact reminds of a story' form Panchatantra "There was a forest. Out of all the animals, a wolf and a crane together were
invited for the feast KHIR. (sweet rice-milk) was served to them in a plate and both were
invited to enjoy the same. Guess who must have gulped it? The wolf had its day. The
host was intelligent. He invited them again for a second round, but KHIR was now
served in a MATAKA (earthen vessel). It was the crane's turn, whose beak could reach
the depth of the vessel while wolfs tongue could not.”
12
(ViGfG availability of public facility doos not make it accessible to “Have-Nots In a
democratic society, "more equal” (Haves) have to be restrained, for public benefits to
percolate down. It calls for appropriate structural adjustments.
Sevagram Village Health Insurance Scheme idolizes Health Care for the people.
Uniqueness of the Oasis :
> The Health Insurance Scheme reaches out to the unorganized sector,
□oorest of ooor
x It is ths Ions hsslth ssrs experiment. which considers villeoe ss 2 sects! unit
and adopts villeges.
y Thereby it attempts to empower the Gram Sabha in Panchsyat Raj System
y We believe that blind charitv corrupts people. It is not a dole. It raises social
finance
> It evolves a relationship with the people by talking ‘with them’ and not talking
‘at them
> The vision behind this experiment comes from our role model - Vinoba
Bhave.
Our generation has heard about Gandhi and read of Gandhi We have not seen
Gandhi in action We saw Vinoba in action. The line sketch of Vinoba that appeared on
"First Day Cover’ where his postal stamp was released aptly depicts what Vinoba stood
for
13
He has a lantern in his hand The title reads - Lead kindly light or tamso ma
Jyotirgamaya He leads the path
He nas his vision on the norizon, which dreams the concept of an ideal society - a
society based on principles of freedom and fraternity i e Gram Swarajya.
Look at the compassion that embraces the poor He empathizes with the poor and
the dewntrodden (Antyodaya) and leads them from darkness to light.
It is this specter that haunts us.
14
The ethos of the whole process of the scheme’s evolution has to develop a
democratic society, especially revolving round the village as a unit of society. The
concept of village republic (Gram - Swarajya) of Gandhi- Vinoba - Jaiprakash Narayan,
is the ultimate vision of the scheme Vinoba gave a structural form to the vision in
Gramdan The power lies with the Gram Sabha which consists of one adult male and
female member of each family in the village It is the highest decision making body. The
decisions are needed to be taken by near consensus. Election is considered a foul mean
and purity of end is decided by purity of means The leaders are selected and not
elected It is in sharp contrast to Panchayat Raj system which has in place narrowly
elected (51% against 49%) group of representatives. The representative democratic
structure is not pro-people in true sense and has been replaced by participatory'
democratic structure of Gram Sabha.
The concept is detailed under the Gramdan act of the Indian constitution that was
engineered by Vinoba Under this act. at least 75% of the population of the village
should transfer the title of their land to Gram Sabha, then only such a village be called as
Gramdan village The villagers enjoy the right to plough, cultivate and consume the
produce (Crop) from the land However the land can not be sold to any body outside the
village They decioe their own land records Under this act, the ownership is collective,
but the individuals continue to enjoy consumption right over fruits of their labour for
generations to come Thus it promotes a society which survives on, ‘bread labour’ and
does not permit Intellectual labour’ to exploit The idea! society would be one that would
revolve around concept of ’bread labour In such society there would not be much
difference between the members and interdependence be obligatory. The decision
making then would be a collective exercise which would decrease the possibility of unfair
or wrong decisions.
The concept of 'labour currency' which equals physical labour to intellectual
labour is considered prerequisite for the equality in socialistic philosophy. By
underpaying for physical labour, exploitative society pools the 'surplus value' in control
o*
more equals', thus creating classes. By' virtue of collective ownership of natural
resources like land, water ana forest, the Sarvodaya philosophy in Gramdan digs out
roots of exploitative.structure in present society and paves the way to nurture values of
equality and freedom.
Empowering Gram Sabha is the key to Gram - Swarajya. Empowerment occurs
when resources are owned and freedom of decision making rests with Gram Sabha,
when decision making is obligatorily by consensus or overwhelming majority, no wrong
decisions can occur. The opinion of the silent majority now supervenes The 'culture of
15
silence' of revered-ones is now broken As is a saying in eastern culture - "God speaks
through them."
It is not a wild dream. A tribal village - Mendha (Lekha) in Gadchiroli district of
Maharashtra, having population of around 400, has implemented their slogan "Delhi-
Bombay exemplifies 'Our government, 'We' are the government in Mendha ” The poor
and illiterate people of Mendha exemplify empowering of people and the culture of Gram
Swarajya.
How should health system be in the context of Gram Swarajya ? It has to be
health by the people, for the people and of the people. Since the resources must be
owned by Gram Sabha. the Sevagram experiment proposes distribution of centrally
pooled resources by the State and Central government to be distributed back to village
on per capita basis SeeeThe freedom-whioh services to buy - should also rest with
Gram. Sabha so that just decisions can evolve Short of these structural adjustments
(which requires strong political will). Kasturba Hospital Sevagram holds the government
grants in trust and distributes public money appropriately by raising a model of health for
Jawar health insurance scheme at Sevagram is an attempt to identify revered
individuals (SAJJAN SHAKTI), empower by bringing them together, inculcate a culture of
decision making by consensus and initiate acts of common faith.
Looking back at the experiment that this scheme has been Dr Jajoo feels that a
model has been developed, which is ideal and is replicable in an ideal kind of society
envisaged The lamp needs to keep burning until the fire catches on This is a 'micro'
experiment for a 'macro' ideal Multiple experiments need to be done and time would
only decide when they would be replicable. The need is to act locally, while thinking
globally. One step in the right direction is enough.
16
References :
1. Key informant interview with Dr Jajoo Ulhas, Professor, Dept of Medicine. MGIMS,
Wardha and Incharge, Jawar Rural Health Insurance Scheme.
2
Jajoo UN ' When the search began Mahatma Gandhi Institute of Medical Sciences
Sevagram, Wardha, 1985
3
Ranson Kent M, ; Community Based Health Insurance Schemes in India : A review ;
National Medical Journal of India 2003, 16 (2) 79-89
4
Ora! discussions with scheme beneficiaries
5. Health Insurance Scheme : Learning for Health Care 1986 : a PRIA publication , 74 -
100.
6. Jajoo UN The Social Security in Health Care for the Unorganized Sector the
Sevagram alternative : The Journal of MGIMS 1997 ; Vol 2 ; 43 - 49
7. Jajoo UN
Role of the village health worker - a glorified image "Under the lens
health and Medicine . Medico Friend Circle 1986.13
8. Jajoo UN ' Community participation in primary health care ' Under the lens - Health
and Medicine : Medico Friend Circle 1986 : 37 -44
9
Jajoo UN : Health is not villagers first priority . World Health Forum 1983, 4 365.
10. Jajoo UN : Rural health services towards, a new strategy . World Health Forum
1985, 6, 150 and Health Care - WHO pays ? " WH01987.99
11. Jajoo UN : Health education alone can do little ; World Health Forum 1985. 6, 220
12. Jajoo UN . Risk sharing in rural health care World Health Forum 1992 :13 :17.
13. Jajoo UN
Annual Cluster (Pulse) immunisation experiences in villages near
Sevagram . Journal of Tropical Medicine & Hygiene 1985 : 88 277.
14. Jajoo UN . Feasibility of measles vaccine in and around Sevagram : Indian Journal
of Paediatrics 1963 : 50 : 379.
15. Jajoo UN : A decade of community based immunisation : world Health Forum 1993,
Vol. 14, No. 3 : 290-91
16. Jajoo UN . Towards an appropriate maternal care (unpublished)
17
Com K O-. I'D-
ASHWINl’s Health Care System and
the Composite Health Insurance Programme for Adivasis
January 2004
1.0 Introduction
Group Insurance is not a new thing to the Adivasis I Even now in many adivasi villages, whenever
somebody becomes seriously ill and needs to be taken to a hospital, there is a “collection” among all
the houses in that village. With this money, they hire a vehicle and come to the hospital in a group. This
kind of ‘sharing the risk’, which is fundamental to any group insurance scheme, had been practiced by
the tribals for ages I However, the modern economic systems and lifestyles made it necessary to fine
tune these traditional practices. This is the basis of the Composite Tribal Insurance Scheme of
ASHWINI.
2.0 Genesis of ASHWINI
Though ASHWINI as an independent organisation was started only in 1990, its genesis dates back to
1986 when Stan Thekaekara and his wife, Marie started ACCORD, a Non-Governmental Organisation
in Gudalur. Their main objective was to to fight the unjust alienation of the adivasi lands and other
human rights violations by organising them as a strong group.
They facilitated the formation of village level sangams and these sangams enabled the adivasi families
to prevent any of their land getting encroached by powerful non-tribals of that area or by the
Government authorities. More than 200 such village sangams had been formed within two years. These
sangams were federated at the taluk level into "Adivasi Munnetra Sangam" which till today remains
the representative organisation of the adivasis, fighting for their just rights and striving for the socio
economic development of the adivasi community.
But, it was not only the problem of land. The village sangams again and again brought up the issue of
health care. Women were dying during childbirth. Children were suffering from easily preventable
diseases. Some intervention was urgently required. But, Stan and Marie were not doctors. They started
looking out for some doctors through their contacts. Fortunately, they met two young doctors,
Dr.Devadasan and his wife, Dr. Roopa, quite eager to take up the challenge.
3.0 Community Health Programme
Deva and Roopa joined ACCORD in 1987 just after their graduation from the Christian Medical College,
Vellore and launched a community health programme in the adivasi villages. The main focus was to
train village level Health Workers (HW) selected from the community itself, to identify and prevent
illnesses like diarrhoea, to provide immunisation and nutrition to the pregnant women and young
children, and generally to improve health awareness among the adivasi community. The team went
from village to village, participated in the sangam meetings and regularly monitored the progress of the
pregnant women and children.
Within a few years, the preventable deaths among the adivasis (like due to diarrhoea or during
childbirth) were more-or-less eliminated. The HWs did a tremendous job in the programme, kept
highlighting the health issues in the villages and closely followed-up the individual cases. The
immunisation status of the children & pregnant mothers dramatically improved with the launch of
Page 1 of 6
the community health programme. Issues like growth monitoring and nutrition were constantly brought
to the notice of the parents by the health workers. Thus far, the health programme consisted entirely of
these field activities. In spite of the successful community health programme, there were inevitable
cases needing hospitalisation, there were high-risk pregnancies which required the women to deliver in
a hospital, and acute cases of diarrhoea and fever among children too needed hospitalisation. Deva
and Roopa used to refer such patients to the local Government hospital or to the private clinics.
But the experience with these hospitals was not very encouraging since the care and treatment given to
these patients was not satisfactory, the doctors weren't there many times in the Government hospitals,
the costs of treatment in private clinics were high (ACCORD subsidised these costs). Deva and Roopa
were tom between following a few cases in these hospitals and visiting the villages all over the taluk.
Quite encouraged by the success of the community health programme and the role played by the
adivasi health workers, the adivasi community felt that the next logical step would be to start a hospital
of our own. There was a heavy demand from the village sangams to start a hospital. But the doctors
were reluctant, saying that Hospital is a permanent institution which needs to be run 24 hours a day, all
through the year - and for many years. The health team at that time was not equipped to handle such
an institution. Moreover, the ACCORD team strongly felt that their intervention had to be time-bound
and they will withdraw after a few years when the AMS can take over the initiative of protecting the
rights of the adivasis. But, hospital is a permanent form of intervention which cannot be withdrawn. And,
in any case, where are the nurses in the adivasi community (another basic philosophy of ACCORD was
to identify youth from the community itself to deliver all the services to the people and to train them I) ?
And, Doctors ??
4.0 Gudalur Adivasi Hospital
However, the community was strong in its demand and felt that the community health programme
needed a hospital of its own to make it much more effective and acceptable to the people. So, they
started a search for suitable people. Again as a curious coincidence, there landed up a doctor couple,
Shyla and Nandakumar, willing to be part of the health programme. Having the idea! combination of
skills as Gynaecologist and Surgeon, they were what the "doctor ordered" and the people were looking
for! Young adivasi girls were identified by the sangams and the new doctors started training them as
nurses. Thus was born the "Gudalur Adivasi Hospital" [GAH]. In 1990.
With the establishment of the Hospital, we realised that this intervention is going to continue for a many
years, and structurally it has to be different from that of ACCORD or AMS. So, the health programme,
activities and the staff were hived off from ACCORD and a separate legal entity called ASHWINI was
registered. From then onwards, Ashwini took care of the health issues concerning the adivasis and poor
people of this area. While Deva and Roopa continued their focus on the community health programme,
Shyla and Nandakumar started training tribal girls as Nurses. It was a major cultural change for the girls
- from innocent village life to a three-shifts-a-day routine in the hospital. Training had to start from
elementary Maths and English.
These adivasi nurses have come a long way in the next 10 years. They have become experts in
conducting deliveries, in assisting the doctors in surgeries, in the general administration of the hospital,
in ordering and managing the drug stocks, in designing systems to monitor the performance of the
hospital (All the patient details have been computerised after 1996) and in analysing the financial
aspects of the hospital management. They are constantly trained and their skills are upgraded to keep
up with the growth of the programme.
Page 2 of 6
Today, the Adivasi Hospital is one of the most sought after hospital in the Gudalur valley, not only by
the tribals but also by the non-tribals of the local area. Patients are brought from distant villages by
ambulance and good quality care is given. As all the staff are from the community and can talk the tribal
languages, the tribal patients feel at home. Efforts were constantly made to keep the place culturally
acceptable to them and the community gradually adjusted to the change. Today, there are cots in the
hospital, they come forward for surgeries and many of them regularly show up for antenatal checkups
etc. Some more young doctors came and worked in the hospital for brief periods - the health team
getting enriched by the interaction with each of these doctors.
5.0 Sub-Centres
Til! 1994, the health programme consisted of preventive care given by the HWs at the villages and
curative care provided at the GAH. However, during many interactions with the sangam members, a
need was felt to have another intermediate level comprising of a group of villages. The AMS had
already divided the sangam villages into eight administrative zones called "Areas" and an Area Centre
was coordinating the sangam activities of that particular Area. From 1995 onwards, a health Sub
Centre was started in each of these Area Centres.
These Sub-Centres coordinate the community health programme in the villages of that Area, provide
first aid and primary level curative care by dispensing medicines, Screen patients regularly, refer those
needing doctor's intervention to Gudalur Adivasi Hospital and follow-up the patients discharged from
the Hospital. Initially the senior nurses and health staff took responsibility to manage these sub-centres.
Later, a few more adivasi girls were trained specifically to run these sub-centres - They are called
"Health Animators". As per the need, they keep shifting between the hospital and the sub-centres, so as
to strike a balance between the curative and preventive programmes and to keep their skills sharpened
and updated.
6.0 Management
Monitoring and review of the activities, both in the villages and in the hospital are done by the staff
themselves in the monthly meetings. Besides, a Working Committee comprising of a few senior nurses
and health animators has been constituted. This group looks ahead, takes care of the long term
planning, budgeting and other policy issues.
ASHWINI is registered as a Charitable Society under the Tamilnadu State Societies Registration Act.
The General Body of the Society is constituted from the senior AMS activists, the adivasi nurses /
health animators and the doctors. Al! the members of the Executive Committee are adivasis. Thus,
though ASHWINI is legally an independent identity, it continues to function under the umbrella of the
AMS as an institution owned and managed by the adivasis themselves for their own development.
7.0 Breaking the Financial Barrier-The Insurance Scheme
The main objective of the insurance scheme is to break the financial barrier of the adivasi families at the
time of illness. We have noticed that lack of liquid cash at the time of illness is one of the most serious
barriers to the adivasis, preventing them from getting safe medical care and accessing hospitals. Our
challenge was to encourage them to plan ahead and save something for the possible event of sickness
in the future. For a community, eking out a day-to-day existence, this was a radical change. Saving for
Page 3 of 6
the future itself was a new thing - leave alone for their health needs. But, we were convinced that this
had to be done and hence, pursued our idea with the people relentlessly.
When Gudalur Adivasi Hospital was started in 1990, we discussed with the village sangams about the
financial aspects. On the one hand, none of us wanted the hospital treatment to be totally free as this
would not be sustainable in the long run. However, on the other hand, it would be difficult for the adivasi
patients to pay the entire costs of hospitalisation. Combining this need for resources with the adivasi
tradition of sharing, we arrived at the concept of group insurance. Though providing health care through
insurance coverage is a very modern idea, we hit upon the same solution, but through a very different
route and rationale.
We approached various agencies including some insurance companies. However, the insurance
policies existing at that time were targeting primarily middle and high-income people living in the cities.
The premiums were high as the claims ran into Lakhs to cover "costly" diseases like heart attacks and
bypass surgeries. These policies would be totally inappropriate for the adivasi community where
anaemia, malnutrition, safe delivery and care of young children were the major problems.
So, we needed a simple package covering these illnesses. Fortunately, following a long search, we met
some enterprising officers of the New India Assurance Company who were willing to design a special
package for the adivasis of Gudalur. After more than two years of discussions and negotiations, we
were able to design a scheme, which would address the specific health needs of our people. We finally
launched the composite tribal group insurance scheme in 1992.
According to this policy, for a premium of Rs. 15 per person per year, hospitalisation expenses up to
Rs.1500 would be reimbursed by the insurance company. The Adivasi Munnetra Sangam decided to
insure all its members. We started by insuring 5000 adivasis in 1992 and the number has risen to
13000 by 2002, as new villages and members join the AMS.
8.0 Policy Details
To avail of the Group Discount and Long Term Discount offered by the insurance company, ASHWINI
insured all the members of the AMS for five years by paying the premium en bloc. In turn, the activists
of AMS, including the Health Animators of ASHWINI collect the premium from the members every year.
So, in essence, ASHWINI has taken a Policy with the Insurance Company for five years, whereas the
AMS takes a policy for its members with ASHWINI every year.
This arrangement made sense, considering the many
restrictions imposed by the insurance company on the
diseases covered under the policy, the Rs. 1500 ceiling
and the delay in the reimbursements. To encourage the
tribal patients to seek health care at the earliest and to
make the health system more effective, our health care
system has to be comprehensive and should provide for
all the health needs of the community.
Policy Highlights (1992-2002)
Started : in 1992
Membership : About 12000
Agency : New India Assurance
Company
Annual Premium : Rs. 15
Claims : Up to Rs. 1500 of
hospitalisation expenses
For example, pregnancy related admissions were not covered under the policy during the first seven
years. But, one of our major aims was to reduce the maternal mortality and to encourage the tribal
women to choose safe confinement. So, even while the insurance company was not reimbursing the
expenses of pregnancy related admissions, we continued to provide free treatment to the insured tribal
Page 4 of 6
women who get admitted for pregnancy related causes. However, due to our persistent efforts and
representations to various authorities including the Finance Minister of Government of India, the policy
was subsequently modified in 1997 to include pregnancy related admissions for the 1st and 2nd
deliveries ! The table below gives the differences between the policy offered by the company and the
scheme offered by ASHWINI for the comprehensive health care of the AMS members.
Details of the Health Insurance Policy
Particulars
Expenses covered under
the policy
Ceiling on the amount
reimbursable
Diseases which are not
covered
Time taken to reimburse
claims
Insurance Company
*
ASHWINI
Only hospitalisation expenses Apart from hospitalisation costs,
includes OP treatment in the
hospital and in Sub-Centres
Rs. 1500 per year
No limit on expenses.
Chronic illnesses like
All illnesses are treated free of cost.
diabetes, TB, etc.
From 3 to 9 months from the Patients do not pay any amount on
date of sending claims.
discharge, and hence claims are
instantaneous.
* Details of the policy with New India Insurance Company between 1992 and March 2002.
Summary of the Financial Details of the Insurance Programme from 1992-1997
Description
Total Premium paid to the insurance company
Amount reimbursed by the company
1992-1997
Rs.4,35,722.25
Rs.5,94,566.00
1997-2002
Rs.5,94,566.00
Rs.12,68,051.00
9.0 Premium Collection
Insurance collection is a major annual event! The collection season commences with a meeting of the
tribal staff of ASHWINI and the field activists of AMS to decide the premium to be collected from the
members that year. Apart from the financial status of ASHWINI, issues like the income levels of Adivasi
families and the genera! economic situation of the Society are considered while deciding the premium.
Year
Premium
per
person
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Rs. 4
Rs. 6
Rs. 8
Rs.10
Rs. 12
Rs. 12
Rs.15
Rs. 17
Rs. 17
Rs.20
Rs.22
No. of
people who
paid
premium
3726
2744
3624
4125
3812
4899
4768
4619
4464
4291
4268
We started with Rs.2 per person per year in 1992, gradually
increasing it every year. We are collecting Rs. 22 per person for
the year 2003. The collection period commences on December
5th, a special day celebrated as Adivasi Day by the AMS and
goes on till April 14th, another special festival, “Vishu” [New
Year]. Depending on the situation each year, the collection
period may get extended. In the earlier years, the sangam
activists used to go from house to house, from village to village
explaining the insurance scheme and collecting the premium.
Now, as people are aware of the scheme, they come to the
sub-centres to pay the premium.
The exercise of insurance collection is an important aspect of
ASHWINI’s health programme, as it keeps the focus
continuously on the community, instead of interacting only with
the patients in the hospital, the insurance scheme gives an
Page 5 of 6
opportunity for the field workers and sangain activists to interact with all the sangam members, to
explain the health programme and to get a true feedback from them.
The percentage of AMS members who pay the premium to ASHWINI has been hovering between 35%
and 50%. A survey done among the AMS members revealed that one of the main reasons for non
payment of premium was the lack of ready cash during the collection period. At present, we are trying
to evolve different methods to improve the premium collection from the sangam members and to
increase the awareness about the scheme in the villages.
10.0 Current Status
When the policy expired in March 2002, the New India Assurance Company informed us that they were
considering a steep increase in the premium from Rs.15 to about Rs.40 per person per year. ASHWINI
was not prepared for this precipitous hike, as it was using all its resources to meet the operational costs
of the health programme. Subsequently Sir Ratan Tata Trust, Mumbai was approached for
financial assistance to pay the insurance premium and we were extremely happy to get a positive
response from them in July 2002.
With the help of Tata Trust and some experts, we had undertaken a comprehensive review of our 10
year experience with the insurance scheme. The conclusions of this study have given us some direction
and guidelines to take forward our health care programme. Based on these findings, Tata Trust has
extended funding towards paying the premium for about 12000 adivasi members and for some
administrative costs in January 2003.
Based on the findings, we approached various insurance companies to restart our insurance scheme.
Our negotiations with the Royal Sundaram insurance Company Limited were successful and we
designed a new insurance policy called ‘Tribal Health Shield’. This scheme came into existence from
May 19, 2003 and will be in operation for a period of one year. The major highlights of this policy are
given in the table below:
Tribal Health Shield
•
About 12200 members of the Adivasi Munnetra Sangam are insured
under this health insurance policy.
•
Coverage of all illnesses including common illnesses.
•
Coverage for Pregnancy related admissions for first 3 pregnancies.
•
Maximum coverage limit is Rs. 1000 per year (Rs. 500for pregnancy
related admissions).
•
Annual Premium is Rs. 20 per person.
We are also working to create an awareness about this model of providing health care to other NGOs
and disadvantaged groups also by networking with them.
11.0 Future Plans
During the next five years, our efforts will not only be to consolidate our insurance programme in the
sangam villages, but also to share our experience with other charitable organisations working with
underprivileged people, so that a larger insurance scheme involving them could be created. Thus our
successful experiment with group insurance could spread to other people who wish to address their
own health needs effectively.
Page 6 of6
C_©oa H
The Community Insurance - Which way to go.
( Wisdom out of experiential learning from SEVAGRAM )
Dr U N Jajoo
Professor in Medicine &
Incharge Health Insurance
Mahatma Gandhi Institute of Medical Sciences
Sevagram
The Concept
* Primary health care should be considered a fundamental right of the people (as it
should be for primary education )
The Challenge
* The poor spend considerable amount on medical care to unregulated and
exploitive private sector . primarily due to poor credibility of public hospitals .
* The privatization of public health services offers opportunity to misutilise state health resources for private sector.
Thus . the private sector requires regulation .
The Disease
* Inspite of wide health care infrastructure in public sector. medical care has not
reached the poor. rural people in particular. essentially due to i) paucity of funds and
lack of efficiency .
ii)
* The misdistribution ofcentrally pooled resources is what primarily ails our system
. The distribution of central and state government funds is lop sided , favoring "haves " and
neglecting "have-nots” . favoring “urban “ and neglecting “rural “masses .
Thus , the optimal resources allocation (per capita basis ) to primary health care
hospitals is the first step to building credible services .
The Pre-requisite
*Primary health care services must provide free curative care for its acceptability to
the poorest of the poor.
* The egalitarian health service can never be economically self reliant, if they have
to preferentially serve the poor.
Thus , no private insurance will cater to the poor , and
The pro-people services must be shouldered by the state .
The Soul
* The credibility of the system revolves around
a) Accessible hospital services of an optimum quality
b) Accountability of the health care system to the consumers , and
c) Affordability of the services to the poorest.
The Fact
* It is possible to offer a non-biased primary care to all, within existing government
resources , provided funds are locally available and locally governable in a efficiently
managed decentralized setup.
\y ■ 'S
The Direction
* The accountability of health care systems cannot be enforced vertically down . to
incaiculate responsiveness in public health care systems , a vigilant public audit system is
required .
Thus , the empowerment of the people is the key towards accountability . The power
emanates through the control of public funds and performance evaluation of public sen ants
The public body empowered to undertake the above is a decentralized structure .
Thus , the gram sabha in the panchayat raj system be empowered with public funds
(per capita basis , expenditure that central and state governments undertake ).
The Participatory Nature
* Since charity corrupts people and does so absolutely . beneficiary should
contribute towards health care services , albeit, according to their capacity and the priority
need .
* The contribution according to capacity and services according to the needs .
must be the guiding principle , for pro-poor services .
* Though the social finance so raised cannot meet the expenses of medical care .
they can at least supplement them .Apart from offering an affordable post-payment
mechanism to persons who need services but who are unable to pay (Risk sharing ), Social
financing has some spin of benefits i)
It increase accessibility of health services ,
ii) It promotes operator’s concern for health in the community ,
iii) It generates the concept of right to demand a quality health care among the
beneficiary population .
iv) It responds to priorities as judged by the community ,
v) It ensures that services are acceptable ,
vi) It keeps service providers on their toes , and
vii)
It simulates organizational self-confidence and paves a way for
participatory culture at community level.
The Essence
* Primary Health Care is a fundamental right and the welfare state has an obligation
to fulfill it.
* No private health insurance can cater to the poor.
* The pro-people health care services must be financially shouldered by the welfare
state.
Thus , it should be obligatory for a welfare state to offer a health insurance scheme
through its existing infrastructure .
* It is possible to offer just primary health care to all within allotted resources by
central /state governments , provide it is distributed on capita basis in a decentralized
panchayat raj setup.
* The credible emergency services should be for free , for them to be accessible by
the poor.
* The social finance raised through consumer-contributions according to their
capacity , raises the demand for quality care and incalculates community participation in
medical care .
The Path to Tread
* As a part of constitutional obligation , let the state run community health care
scheme, through its rural hospitals ( village or Mohalla of a city as a unit of community ).
* The health care scheme should raise the finances as prepayments from gramsabha in panchayat-raj system .
* The health care budget of central and state government can be allotted on percapita basis to panchayat raj system . The amount can be routed as pre-payment towards
community health care scheme .
*Let private sector compete with the public sector by floating a community health
care scheme of their own . The choice of selection rests with the gram sabha in panchayat
raj system .
* Gram Sabha should raise social finance for unforeseen emergencies which rural
hospitals fail to meet.
Kev Words
Structural Change
- Decentralize
Empowering people - Just distribution of resources
Credible system
- Affordable , accountable , egalitarian
PREAMBLE
We. the 700 delegates from 44 countries', gathered at the
•
End Corporate led Globalisation
•
End war and occupation
•
Implement Comprehensive and sustainable Primary
III International Forum for the Defence of the People’s
Health at Mumbai on 14th and 15th of January 2004,
Health Care
reaffirm the validity and relevance of the People's Charter
for Health, the foundational document of the People's
•
Health Movement, which describes increasing and serious
Confront the HIV/AIDS epidemic with Primary Health
Care and Health Systems approach
threats to health in the early 21 st century.
<i
Environmental
damage
caused by
unsustainable development strategies
Since the Charter's adoption in December 2000 at the
first People's Health Assembly, at GK Savar; Bangladesh, the
Reverse
•
End discrimination In the Right to Health
health of the world’s poor has worsened and more threats
End corporate-led globalization
to people's health have emerged.
Social,
political,
economic
Corporate-led globalization continues
and
environmental threats to health
identified as the basic causes of ill health
and the inequitable distribution of
health within and between countries
have increased.
The III Intemao'onol Forum for the Defense
of the People's Health provided
opportunities to hear inspiring testimonies,
to be a major threat to health. Since
Social, political, economic
and environmental
threats to health
identified as the basic
causes of ill health and the
inequitable distribution of
health within and between
countries have increased
from the world's poor and health activists:
the People's Charter for Health was
adopted in 2000, the International
Monetary Fund, the World Bank and
the World Trade Organisation have
continued to advance the economic
health of corporations at the expense
of global health.
The protection of intellectual property
(through trade agreements such as the
•
•
•
Denouncing the demal of health to
Trade Related aspects of Intellectual Property Rights,TRIPS)
their communities and their efforts to overcome this injustice.
and unfair trading practices (through the General
Threats to health from the unfair system of global trade
Agreement on Trade in Services, GATS) have caused
and the imperialist policies of developed countries including
enormous damage to people's health.
unjust wars and efforts to counter them
The tobacco industry offers a clear examplerTobacco kills,
The Demands for acknowledgement of health as a universal
yet transnational companies continue to target youth and
human right and the implementation of Comprehensive
marginalized communities with their tobacco marketing
Primary Health Care as a strategy to achieve Health for All
strategies.
The Forum recognized the particular discrimination suffered
The epidemic of privatizations of water, electricity, education
by many groups which makes achieving Health for All even
and health care, imposed by Structural Adjustment Packages
more difficult. These included women, people with disabilities,
(SAPs), has limited access to or removed the foundation
sex workers, children living in difficult circumstances (including
upon which public health is built.
street children), migrant workers, people with mental disorders,
Public-private partnerships, as promoted by World Bank,
Dalit people. Indigenous peoples in rich and poor countries.
Global Funds and International health agencies including
and all those affected by wars, disasters and conflicts
WHO, have removed responsibility for health from the
The Forum demanded Health for All, Now! and reiterated that
public sector, essentially privatizing health and treating it as
Another World in which health is a reality for All is necessary
a commodity rather than a human right. User fees have
and possible.
further decreased people's access to health care services.
The Forum brought together all the concerns and
This Declaration;
experiences shared into a Declaration for action, entitled
Calls for Action by People's Health Movement and Civil
'The Mumbai Declaration". This Declaration is an update
Society to;
on the state of people’s health across the globe at the i
•
Pressure the World Bank and the International
beginning of 2004 and calls on People's Health Movement,
Monetary Fund to acknowledge their culpability in the
Civil Society and Governments to evolve action in six key
current health care crisis, especially the damage caused
areas to achieve the goal of "Health for All Now!" dream,
by Structural Adjustment Programs:
)
Argentina. Australia. Bangladesh. Belgium. Brazil. CamlKidia. Cameroon. Canada, Costu Rica. Culxt, Denmark. Ecuador. Egypt. Rann. Germany, Guatemala llong Kung. India,
Iran. Italy. Kenya. Korea. Lebanon. .Malaysia, .Mauritius. Netherlands. Nicaragua. Nigeria. Norway. Pakistan. Palestine. Petti. Philippines South Africa. Sri Linka Sweden
Switzerland. Tanzania. Thailand. USA. I'K. Vietnam. Zambia. Zimbabwe
<
Iho Mumbai Declaration
Build the Campaign "NoTo Intellectual Property Rights"
•
■
to resist the efforts of the WTO and translational
■
Monitoring the impact of war, occupation, and
■
Targeting corporations which benefit from the war
corporations to patent, own and trade in them:
Demand the representation and active participation of
•
militarization through a globaT'Occupation Watch";
people's organisations, health workers, and farmers in
in Iraq, invasions and military occupations and those
policy-making processes related to Access to Health
•
Building the global campaign: "No to War; No to
WTO, Fight for People's Health":
in our traditional systems of medicine and our seeds,
that enrich themselves (eg. arms industry,
Expose, shame and stop government officials, academic
pharmaceutical and food companies) by fostering
institutions, and civil society organisations from accepting
ill-health through a "Boycott Bush" campaign:
money from the tobacco and other industries which
»
undermine public interest initiatives internationally and
Establish peace initiatives at various levels based on
justice and equality.
nationally.
Calls for Action by Governments
Calls for Action by Governments
•
■
Refuse to take part in unjust and imperialist wars
■■
Work for world peace as a key determinant of health.
Regulate the entry and behaviour of the corporate
and occupations
sector in the social services such as health, education,
transportation, etc., and ensure that public health
concerns always take precedence over trade
Implement Comprehensive and
Sustainable Primary Health Care
agreements and corporate profit:
•
Resist "TRIPS-plus" through bilateral or regional trade
Since 2000, the Global Fund and other
agreements driven by the United
States government and the
institutions it controls;
•
Ensure negotiations on "FreeTrade"
treaties and the like are transparent
and democratic and not conducted
behind closed doors;
•
Resist pressure to privatise health
essential industries (health care,
electricity, water and education)
and renationalise these industries;
•
international health programmes of
Since 2000, war,
occupation and militarism
have become ever more
devastating threats to
people’s health.The
violent imposition of
imperial will has led to
death, Injury, and social
arid environmental
destruction for untold
numbers of people.
Framework
Convention
continued to promote selective and
vertical health programs which corrupt
and weaken Comprehensive Primary
Health Care as defined in the WHO
Alma Ata Declaration.
Health professionals educated in the
developing world and migrating to the
developed world represent a transfer
of billions of dollars from South to
North. This unrequited training
Sign, ratify and implement the
investment further burdens health
on
Tobacco Control (FCTC);
WHO. UNICEF and World Bank have
systems already suffering from a precarious lack of human
resources. The "brain drain" flows not only from developing
End War and Occupation
Since 2000, war; occupation and militarism have become
to developed countries, but also from the public to the
private sector.
ever more devastating threats to people's health The violent
Traditional and alternative systems of medicine are vibrant
imposition of imperial will has led to death, injury, and social
parts of Comprehensive Primary Health Care. Traditional
and environmental destruction for untold numbers of people.
Birth Attendants provide the first and often the only access
Actions in support of international law and pro-health and
against the war in Iraq; the occupation of Iraq and Palestine;
the construction of the Wall in Palestine are urgently needed
to reproductive health in many areas of the world.These
knowledge and traditions should be validated and their
skills reinforced through continuing education, and support
to the revitalization of local health traditions.
This Declaration;
New areas, relevant to Primary Health Care, not adequately
Calls for Action by People's Health Movement and Civil 1
addressed in the Alma Ata Declaration need to be
Society to;
Strengthen the international anti-war movement through:
promoted in an integrated way. These include gender,
environment,disability, mental health and traditional systems
of health.
3
This Declaration;
orphaned by HIV/AIDS and women who are more
Calls for Action by People’s Health Movement and Civil
WHO has recently become stronger in its technical support
Society to;
•
Demand that universities and other training institutions
to HIV/AIDS and has made an official commitment to
incorporate Comprehensive Primary Health Care into
pursue its 3 X 5 goal (3 million persons with AIDS receiving
the curriculum for all health professionals updated to
Anti-retroviral Treatment (ARV) treatment by 2005)
address gender, environment, disability, mental health,
through strengthened health systems. Yet addressing the
HIV/AIDS epidemic requires contextual solutions.
traditional systems and other issues ;
•
vulnerable take a heavy toll.
Lobby for widespread adoption of Community Health
Workers and Traditional Birth Attendants as integral
•
The 3x5 initiative focuses on treatment alone, ignoring
the complexity of the epidemic;
members of multi-disciplinary Primary Health Care teams
•
Calls for Action by Governments
•
High drug costs can lead to long-term dependency on
donors;
Develop national policies on traditional and alternative
o
medical systems and include them
in national health programmes;
•
Involve marginalised sectors in
decision-making regarding policies
that affect them;
•
Strengthen health systems in the
context of access, quality and
equity;
•
We
are however, particularly concerned that;
Establish Comprehensive Primary
Health Care services based on the
principles and strategies of Alma
Ata outlined in this declaration
and related to local needs and
updated to address gender,
WHO has recently become
stronger In its technical
support to HIV/AIDS and
has made an official
commitment to pursue its
3X5 goal (3 million
persons with AIDS receiving
Anti-retroviral Treatment
(ARV) treatment by 2005)
through strengthened
health systems.
phM Is concerned that the 3
persons living with and affected by
HIV/AIDS ar.d civil society in planning,
implementation and evaluation
o
"•••r'jL'ilrJittxsulu •!
There is inadequate budgetary and
related commitments on improving
health systems, particularly Primary
health Care to provide drugs and
general
health
services
and
information in the long term.
o
X 5 initiative focuses on
treatment alone, ignoring
the complexity of the
epidemic.
environment, disability, mental
There is inadequate involvement of
There is inadequate attention to life
skill education, women's health
empowerment and utilization of
traditional systems of medicine.
While endorsing concern about the HIV/
;>.t •
AIDS epidemic, the need for Primary
health, traditional systems and other issues.
Health Care oriented and Health Systems strengthening
Calls for Action by WHO
approaches to other communicable and non-communicable
To reaffirm the principles of Alma Ata and ensure that
diseases in an integrated way is urgently required.
comprehensive approaches that focus on primary health
care and strengthen health systems are the basis of all
This Declaration;
WHO global and regional strategies.
Calls for Action by People's Health Movement and Civil
Society to:
Confront the HIV/AIDS epidemic
•
Continue campaigns for the rights of people in poor
The HIV/AIDS epidemic has continued to worsen since
countries to receive ARV treatment delivered through
2000, especially in Africa and increasingly in Asia and
comprehensive PHC services.
elsewhere. Spreading along migration routes related to
globalization and to social and economic distress due to
•
war. global trade and economic policies. HIV/AIDS is now
prices.
associated with the resurgence of other communicable
diseases of poverty, such as tuberculosis.
Access to ARV treatment has increased the life expectancy
and quality of life of those who can afford it The majority
of AIDS patients being impoverished are denied access to
Facilitate Public Interest Litigations to oppose changes
in Patent laws that is expected to escalate the ART
•
Make the links between the spread of HIV/AIDS and
the underlying societal determinants such as poverty.
war, displacement and participate in efforts to redress
these injustices
\
treatment in violation of the principles of the international
covenant on social, economic and cultural rights. Children
4
fhe Mumbai Declaration
Calls for Action by Governments
Develop a comprehensive Primary Health Care
oriented and health systems' strengthening approach
to address the HIV/AIDS epidemic through
This Declaration;
Calls for Action by People's Health Movement and Civil
Society to:
»
interventions, including:
■
■
»
Oppose stigma and promote respect of and care
for people living with HIV/AIDS:
■
industrial and military toxic wastes, etc.;
Peer education that includes sexual and reproductive
health and rights information:
Monitor environmental damage caused by unsustainable
development strategies with specific focus on pesticides,
Link PHM with other organisations working for
environmental justice at the grassroots,
•>
national and international levels. Join them in their
Increased access to basic services by people living
struggles and invite them to join in our struggle for the
with HIV/AIDS;
People's Health.
■
Immediate availability of ARV drugs;
■
Support those affected by the epidemic through
Calls for Action by Governments
empowerment
•
•
Pass legislation to ensure governments can hold
corporations accountable for environmental damages.
Calls to WHO
•
»
To evolve a comprehensive
End Discrimination in the
Right to Health
approach emphasizing Primary
The People's Health Charter asserted
Health care and health systems'
the right to health for all people. We
strengthening
approaches
reaffirm this by noting that the
including preventive information
marginalized groups listed below suffer
and services and ARV treatment;
particular and
Worktowards reduction ofhigh
problems requiring urgent attention:
on-going health
drug costs;
»
Enhance involvement of people,
women lack access to basic health
affected communities and civil
care, endangering them and their
society in its planning and
initiatives through proactive dialogue.
Around the world, many
families. Women's right to health,
including sexual and reproductive health, is violated not
only by current socio-economic and political structures
Reverse Environmental Destruction
but also by religious and cultural fundamentalism.
The People's Charter for Health recognized that
Population control policies violated human rights,
environment, livelihood, and people’s health are
including the use of disincentives and such reprehensible
interconnected and environmental degradation is a major
practices as forced sterilization of women. Newer
threat to global health. Since 2000, continuing environmental
contraceptives and reproductive technologies often
destruction has had a highly negative impact on health.
ignore hazards to women's health and other ethical
and moral issues;
Rivers around the world, like the Abra in the Philippines
and the Narmada in India, are in danger of being destroyed,
Trafficking of women and girls is a major public health
as are the lives and health of the people and communities
problem, little addressed by governments where the
who depend on these rivers.
trafficking is most rampant;
Toxins in pesticides, fertilizers, defoliants (such as Agent
Sex-selective abortion is a misuse of technology that
Orange and those ofthc"Waron Drugs" of Plan Colombia),
discriminates against the girl child;
waste from US Military Bases (such as those in the
The rights of sexual minorities and sex workers.
Philippines), dust from exploded depleted uranium
including access to health care, must be respected;
ordinance (such as that used in Iraq. Puerto Rico), and
medical and nuclear waste as well as from mining run-off
and exploration for petroleum; are all poisoning our
environment and represent a critical hazard to health.
The health and human rights of persons with mental
disorders are currently ignored or inadequately
addressed throughout\he world. There is an urgent
need to provide effective community based programs
for persons with mental illnesses.
5
The unjust social systems like caste in India and ethnic
discrimination in other parts of the world have created
a health apartheid and human rights reality for the
socially marginalised;
This Declaration;
Calls for Action by People's health Movement and
Civil Society
•
Make concerted efforts to incorporate all the above
Indigenous people in developed and developing
marginalized populations, the "unheard and unseen",
countries suffer health problems at a higher rate than
into their networks and facilitate their access to and
the general population of the country in which they
influence in mainstream discourse.
reside. As they are forced to follow the hegemonic
»
cultural and development paradigms, they are being
Ensure gender equity within the movement and within
their own networks and communities
deprived of traditional knowledge and traditional
systems of medicine and access to basic resources;
The health and other human rights of persons with
Calls for Action by Governments
•
Make concerted efforts to incorporate the needs of
disabilities are currently ignored or inadequately
marginalized populations, the "unheard and unseen", in
addressed throughout the world;
health and development strategies and social policies
in a Right's context
Migrant workers living and working in the developed
and developing world suffer poorer health than the
«
Ensure availability of disaggregated data on health status
general population surrounding them Their basic human
and access to health services for different groups ( age.
rights are denied through lack of access to health,
sex, region, ethnicity etc.,) in the community to make
education, housing, etc.;
discrimination to the right to health more transparent
Children living in difficult circumstances, such as street
and enable actions to be taken.
children. AIDS orphans, children of war, etc. face
increasing discrimination. Corporate-led globalization
only increases the poverty in which they live and robs
them of a dignified future.
IN CONCLUSION
We, the members of the People's Health Movement and the participants of the III International Health Forum for the
Defense of People's Health commit ourselves to promoting the People's Charter for Health 2000 and the concerns and
calls for action of the Mumbai Declaration 2004
•
We believe that an Another World is Possible;
•
A Healthy World is Possible;
•
Health for All Nowl is Possible;
Join us - Endorse the People’s Charter for Health 2000 - Endorse the Mumbai Declaration 2004
.
SIGN ON AND PROMOTE the People's Charter for Health
(visit http://www.phmovement.org/charter/index html)
•
SUPPORT the Million Signature Campaign demanding Health for All, Now!
(visit www.TheMillionSignatureCampaign.org)
•
PROMOTE the Mumbai Declaration
People’s Health Movement
Global Secretariat,
C/0 CHC,
# 367, Jakkasandra 1st Main, 1st Block, Koramangala, Bangalore - 560 034.
Tel: +91 -80-51280009 Fax : +91 -80-25525372
Email : socretarlatl3>plimovomont.ora Wobslto : www.phrnovnmnnt.ora
Health for All: An Alternative Strategy
nV
( Peoples’ Role in their own Health Care )
Dr. N. H. Antia FRCS, FACS (Honorary)
Foundation for Research in Community Heaith
3 & 4, Trimiti-B Apartments, 85 Anand Park, Pune - 411 007.
Tel: +91-20-25887020 Fax: +91-20-5881308
E-mail: frchpune@giaspn01 .vsnl.net.in
Health for All: An Alternative Strategy
( Peoples’ Role in their own Health Care )
Dr. N. H. Antia FRCS. FACS (Honorary)
The Alma Ata strategy of ‘Health for AH’, was an attempt to improve the
health of the people of the 'need based' countries which had not improved but even
deteriorated 25 years after their gaining Independence. It had certain basic flaws as
enumerated below:
°
It failed to address the basic underlying cause namely poverty and the reasons for its
continuation and increase even after achieving Independence, under the guise of
Representative democracy which was promoted by the departing colonizers.
•
Unfortunately, in the attempt to impose a western techno-managerial solution, WHO had
failed to consider the major factors responsible for the failure namely, the entirely different
socio-economic, cultural and political conditions of these countries from that of the West.
°
It attempted to provide a universal solution to a complex problem of health which varies
from country to country, region to region and often even from village to village.
0
It attempted to impose a western science based techno-managerial solution to what is
essentially a socio-economic and political problem.
0
The 'experts' who were recruited from the 'need based' countries to give an international
image to WHO are also trained in the western medical mode in their own countries.
•
WHO imposed a series of vertical programmes e g. for population control under the guise
of Family Planning with immunization, ANC, PNC and RCH as its accessories. Also for
diseases like malaria, tuberculosis and HIV/AIDS these vertical programmes were to be
implemented through a centralized and bureaucratic government Public Health Sector
which was already alienated from the people.
This also undermined the integrated
concept of health and health care and diverted attention from basic curative services for
the poor, leaving them to the mercy of a highly exploitative profit oriented private sector.
a
The dominant role that the people and community can play in their own health and
medical care viz. the PEOPLES sector has been almost entirely ignored with only lip
service given to ‘peoples participation'.
o
The inroads of the World Bank and IMF by imposing the Structural Adjustment policy
followed by Globalization, Liberalization and Privatization has not only adversely affected
the health sector, as many others, but has also resulted in polarizing the countries,
societies and their wealth. This has created increasing poverty among the masses, while
promoting 5-star facilities and services for an affluent few.
Dr. N. H. Antia is the Director of The Foundation for Research in Community Health, Pune,
India Tel: +91-20-25887020, Fax: +91-20-25881308, E-mail: nhantia@vsnl.net
I
Elected leaders who now control the political system of these countries have readily
°
accepted the Representative form of Democracy based on the peoples vote; a form of
governance devised by the West for its industrialization with disastrous consequences for
their own poor. This has also resulted in co-option and corruption of the new leaders to
help ensure a new form of economic re-colonization of these countries
*
Medical education and health infrastructure has been in keeping with these trends rather
than for serving the majority.
These factors were failed to be addressed while devising the 'Health for AH' strategy.
The government of India appointed a Joint Panel of the Indian Councils of
Social Science and Medical Science Research (ICSSR/iCMR) in 1979 to
study these social and technical components of health. Their report ‘Health For Ail: An
Alternative Strategy’ of 1981 provides a new approach based on a detailed study by
some of the seniormost panel of social and medical scientists of our country.
The salient aspects of this report are as follows:
o
That both health as well as medical care, as well as their implementation, primarily
concerns the individual, family and local community.
o
That the health of the people cannot be achieved unless there is simultaneous
development of the economy and its even distribution, but also by factors such as
education, nutrition, women’s status, water, sanitation, housing and above all the political
will and support for providing an egalitarian and decentralized form of governance viz.
Panchayat Raj. Hence the dominance of several other factors in determining the health
of the people.
o
That even in the techno-managerial aspects of health and medical care, it is the people at
the village and community level who have the ability to tackle almost 70% of all
preventive, promotive and even curative medical care using the simple but highly costeffective knowledge and technology available from all sources and systems of health and
medical care.
o
That this information and knowledge has to be conveyed to locally resident village women
in a simple and effective manner, who with the intimate knowledge of their own village
and their inherent social skills can also mobilize the community to solve the majority of
their own problems.
•
For the few problems requiring greater knowledge, skills and facilities a Community
Health Center at the 1,00,000 or 30,000 population level with a hospital and training
center should be made available as part of a graded referral service upto broad based
me’dical and surgical specialty level
•
That the administrative and financial control of their services must be under the control of
their own Panchayats upto the Panchayat Samiti level.
2
•
That 95% of all health and medical care of the population upto the 1,00,000 to 30,000
level can be undertaken by such a PEOPLES' own Community Health Care System in
a highly cost-effective manner.
•
This would provide an accessible, acceptable, personalized, humane and cost-effective
service, accountable to the people at every stage, in a face to face interaction.
°
The report also stated, that this would have to await the advent of Panchayati Raj (people
based decentralized form of governance) which has been subsequently implemented by
the 73rd and 74,h Constitutional Amendments of 1993 for both rural as well as urban
areas.
The implementation of such a PEOPLES’ Community Health Care System is even more
relevant today with the failure of the Public System, burgeoning cost of the Private System,
commercialization of health care by the Pharmaceutical and Medical Instrument industry, the
spawning cf 5-star hospitals operated as a commercial industry governed by CEOs, Medical
Tourism and Health Insurance.
Such a Community Health Caro System would ensure a far superior form of health
and medical care under the control of lhe people, without recourse to legal measures to
control the Private sector.
It would also provide a humane, readily accessible and cost-
effective Peoples own Health Sector. This would also eliminate the need for Health Insurance
by providing health care well within the present 'out of pocket’ expenditure of Rs.750 per
capita per annum as enumerated by the NSS in 2000 A D.
If such a system can undertake almost 95% of all health and medical care under the
Panchayat within Panchayat Samiti level, there is no reason why three quarters of the current
Public sector expenditure on health of Rs.250 per capita can also be handed over to the
Panchayats at each of these levels.
References:
•
ICMR/ICSSR (1981) Health for All: An Alternative Strategy, Indian Institute of Education, Pune.
I
•
Antia N.H., Dutta. G.P., Kasbekar A.B. (2001) Health and Medical Care: A People's Movement,
Foundation for Research in Community Health, Pune.
°
WHO (World Health Organization), (1978) Primary Healthcare: Report of the International
Conference on Primary Health Care, (Alma Ata, 6-12 September 1978), Geneva, WHO.
•
Antia N.H., Kavita Bhatia (1993) People's Health in People's Hand - A Model for Panchayati Raj,
Foundation for Research in Community Health, Pune.
3
POLICY BRIEF
Co
ffj)
rv
Save Public Health - Ensure Health for All NOWl^j
Make Health Care a Fundamental Right!
^^
7
'
One of the best ways to judge the well being of the
people of any nation is by examining the standards
o: health that ordinary people have attained.
Healthy living conditions and access to good quality
health care for all citizens are not only basic
human rights, but also essential prerequisites for
social and economic development Hence it is high
time that people’s health is given priority as a
national political issue. The current health
policies need to be seriously examined so that new
policies can be implemented in the framework of
quauty health care for all as a basic right. The
following sections first take a look at the hard
realities of people’s health in India today, and
examine some of the maladies of recent health
policies. Next the availability of various resources,
which could be utilised for an improved health care
system is discussed, finally followed by certain
recommendations to strengthen and reorient the
health system to ensure quality health care for
all. We hope these recommendations will be
incorporated by political parties in their election
manifestos for the upcoming general election as
a demonstration of their commitment to public
health. Jan Swasthya Abhiyan, a national platform
workmg for people's health, looks forward to such
a commitment from all political forces in the
country.
Infant and Child mortality snuffs out the life
of 22 lakh children every year, and there has
seen very little improvement in this situation
in recent years.1 We are yet to achieve the
National Health Poiicy 1983 target to reduce
infant Mortality Rate to less than 60 per 1000
live births.- More serious is the fact that the
rate of decline in Infant Mort? ty, which was
significant in the 1970s and . s, has slowed
down in the 1990s, (See graph elow)
Three completely avoidable child deaths
occur every minute. If the entire country' were
to achieve a better level of child health, for
example the child mortality levels of Kerala,1
then 18 lakh deaths of under-five children
could be avoided every year. The four major
killers (lower respiratory tract infection.
diarrheal diseases, perinatal causes and
vaccine preventable diseases) accounting for
over 60% of deaths under five years of age are
entirely preventable through better child health
care and supplemental feeding programs.2 The
most
recent
estimate
of complete
immunization coverage indicates that only
54% of all children under age three were fully
protected?
130,000 mothers die during childbirth every
year. The NHP 1983 target for 2000 was to
reduce Maternal Mortality Rate to less than 200
per 100.000 live births. However, 407 mothers
die due to pregnancy related causes, for every'
100.000 live births even today.1 In fact, as per
the NFHS surveys m the last decaae Maternal
Mortality Rate has increased from 424 maternal
deaths per 100,000 live births to 540 matemai
deaths per 100,000 live births.’
o About 5 lakh people die from tuberculosis
every year-3, and this number is almost
unchanged since Independence!19 20 lakh new
cases are added each year, to the burgeoning
number of TB patients presently estimated at
around 1.40 crore2 Indians !
o
1
India is experiencing a resurgence of various
communicable diseases including Malaria.
Encephalitis, Kala azar, Dengue and
Leptospirosis. The number of cases of Malaria
has remained at a high level of around 2
million cases annually since the mid eighties.
By the year 2001, the worrying fact has
emerged that nearly half ,of the cases are of
Falciparum malaria, which can cause the
deadly cerebral malaria. The outbreak of
Dengue in India in 1996-97, saw 16,517 cases
such deaths might be prevented by tobacco
control measures2.
and claimed 545 lives'. Environmental and
social dislocations combined with weakening
public health systems have contributed to this
resurgence.
•
•
Diarrhea, dysentery, acute respiratory
infections and asthma continue to take their
toll because we are unable to improve
environmental health conditions. Around 6
lakh children die each year from an ordinary
illness like diarrhoea. While diarrhea itself
could be largely prevented by universal
provision of safe drinking water and sanitary
conditions, these deaths can be prevented by
timely administration of oral rehydration
solution, which is presently administered in
only 27% of cases2
Cancer claims over 3 lakh lives per year and
tobacco related cancers contribute to 50% of
the overall cancer burden, which means that
The Constitution of India guarantees the ‘Right to
Life' to all citizens. However, the disparities relat
ing to survival and health, between the well off and
the poor, the urban residents and rural people, the
adivasis and dalits and others, and between men
and women are extremeiv glaring
■>
The Infant Mortality Rate in the poorest 20%
cf the population is 2.5 times higher than that
in the richest 20%. of the population. In other
words, an infant bom in a poor family is two
and half times more likely to die in infancy.
than an infant in a better off family2
<,
A child in the ‘Low standard of living' economic
group is almost four times more likely to die
in childhood than a child in the better off ‘High
standard of living' group. An Adivasi child is
one and half times more likely to die before
the fifth birthday than children of other groups2.
c
A girl is 1.5 times more likely to die before
reaching her fifth birthday, compared to a boy!
The female to male ratios for children are
rapidly declining, from 945 girls per 1000 boys
in 1991, to just 927 girls per 1000 boys in 2001?J.
This decline highlights an alarming trend of
discrimination against girl children, which
starts well before birth lin the form of sex
selective abortions,, and continues into
childhood and adolescent t- (in the form of worse
treatment to' girisj2.
i
.'<<•!:; Women are one and a half times more
l.k-.-iv tn sttfier the consequences of chronic
r.:r:(stunted hm'-.ht) «■; compared to
other cm.Children below 3
•
Estimates of mental health show about 10
million people suffering from serious mental
illness, 20-30 million having neuroses and 0.5
to 1 percent of all children having mental
retardation2 One Indian commits suicide
every 5 minutes5!
As a nation, today there is a need to look closely at
the deep problems in the health system, rather
than making exaggerated claims. There is a need
to recognize the growing health inequities, and
urgently implement basic changes m the health
system.
With political will and people’s involvement,
ensuring good quality health care for every Indian
is possible!
years of age in scheduled tribes and scheduled
castes are twice as likely to be malnourished
than children in other groups.
o
A person from the poorest quintile of the
population, despite more health problems, is
six times less likely to access hospitalization
than a person from the richest quintile. This
means that the poor are unable to afford and
access hospitalization in a ven.' large proportion
of illness episodes, even when it is required.
o
The delivery of a mother, from the poorest
quintile of the population is over six times less
likely to be attended by a medically trained
person than the delivery' of a well off mother^
from the richest quintile of the population.
adivasi mother is half as likely to be delivered
by a medically trained person3.
o
The ratio of hospital beds to population in rural
areas is fifteen times lower than that for urban
areas14.
o
The ratio of doctors to population in rural areas
is almost six times lower than the availability'
of doctors for the urban population14.
•
Per person, Government spending on public
health is seven times lower in rural areas,
compared to Government health spending for
urban areas.
These health and health care inequities are
increasing, and are deeply unjust - a just health
system would ensure lat all citizens, irrespective
of social background or gender, would get basic
cjtiiility health care . i t: nes of ,
1.
Public health being weakened, people's health being undermined
the most privatised in the world. Only five other
countries in the world are worse off than India
regarding public health spending (Burundi,
Myanmar, Pakistan, Sudan, Cambodia6). The
W.H.O. standard for expenditure on public health
is 5% of the GDP. The average spending today by
Less Developed Countries is 2.8 % of GDP, but India
presently spends only 0.9% of its GDP on public
health, which is merely one-third of the less
developed countries’ average6 1
The ND A Government has recently claimed that
one oi its signal achievements has been the
allocation of 6% of GDP to Health care. In reality,
the government spends just 0.9 % of the GDP on
Heaith care and the rest is spent by people from
their own resources. Thus only 17% of all health
expenditure in this country is borne by the
government — this makes the Indian public health
system grossly inadequate to meet healthcare
demands of its people, and makes the health sector
The .'onsequence of this dismally low allocation,
which, stands at the lowest levels m the last two
aecac.s. (in contrast to 1.3% of GDP achieved in
19851. is deteriorating quality of public heaith
services. For example, Primary health centers
(PHCsi. meant to serve the needs of the poorest
and most marginalized people have the following
shocking statistics:
•
•
o
Only 38% of all PHCs have ail the critical
staff
Only 31% have all the critical supplies
(defined as 60% of cnucai inputs), with only
Source: 7
3
3% of PHCs having 80% of ail critical inputs.
In spite of the high maternal mortality
ratio, 8 out of every 10 PHCs have no
Essential Obstetric Care drug kit!
Only 34% PHCs offer delivery services, wnile
only 3% offer Medical Termination of
Pregnancy!
A person accessing a community heaith
center would find no obstetrician in 7 out
of 10 centers, and no pediatrician in 8 out
of 10!
Private health care and essential drugs areincreasingly unaffordable ! .
The dominance of the private sector not only denies
access to poorer sections of society but also skews
the balance towards urban biased, tertian- level
health sen-ices with profitability overriding equity.
and rationality of care often taking a oack seat.
•
Irrational medical procedures are on trie rise.
According to jus: one study in a community in
Chennai. 45% ofali deliveries were performed
by Cesarean operations, whereas the WHO has
recommended that not more than 10-15% of
deliveries
would
require
Cesarean
operations1".
A growing proportion of Indians cannot afford
health care when they fall ill. National surveys
show that the number of people wno could not
seek medical care because of lack of money
increased significantly between 1986 and
1995:< The proponion of such persons unable
to afford health care almost doubled.
increasing from 10 to 21 % in urban areas, and
growing from 15 to 24% in rural areas in this
decade
•
Forty percent of hospitalised people are forced
to borrow money or sell assets to cover
expenses
.
Over 2 crores of Indians are pushed below the
poverty line every year because of the
catastrophic effect of out of pocket spending on
health care-' I
Due to irrational prescribing, an average of
63 per cent of the money spent on prescriptions
is a waste. This means that nearly two-thirds
of the money that we spend on drugs may be
for unnecessary or irrational drugs211
The pnarmaceutical industry is rapidly
growing...yet only 20% of the population can
access ail essential drugs that they require.
There is a proliferation of brand names with
over 70.000 brands marketed in India, but the
2002 Drug policy recommends that only ^5
drugs be kept under price control13. As a resu^
many drugs are bemg sold at 200 to 500 percent
profit margin, and essential drugs have become
unaffordable for the majority of the Indian
population.
Health policy developments since the 1990s have critically
weakened the health system
The effectiveness of the public health system and
access to quality health care, especial!', for the poor
has worsened since the decade of the ,990s aue
to a variety cf policy developments, at both national
and state levels’
•
Stagnant public health budgets and
decreasing Government expenditure on
capital investment for public health
facilities
•
Introduction of user fees at various levels
of public health facilities.
•
Freezing of new recruitments and
inadequate budgets for supplies and
maintenance in the public neaith system.
.
Contracting out health services or
privatisation of health facilities
•
Encouragement of growth of private
secondary and tertiary hospitals through
tax waivers, reduced import duties.
subsidized land etc. ■vincn nave led to afurther expansion of the unregulated
private medical sector.
Promotion of ‘Health tourism’ for foreign
visitors, while basic health sen-ices remain
inaccessible for a large proportion of the
Indian nonulation.
Conducting occasional, expensive and
largely ineffective ‘Health melas’ instead
df upgrading the public health system as a
sustainable solution.
Deregulation of the pharmaceutical
industry, lax price controls on drugs — the
list of drugs under price control being
oroposed to be reduced to 25 drugs
(compared to 343 drugs under price control
in 1979 i
•
4
Many bulk drug manufacturing units have
closed down due to liberalized import and
dumping as a result of the implementation
of the WTO agreement and autonomous
economic liberalization policies. Due to
reduction of customs duty and increase of
excise duty, imoorted drugs will become
cneaper wnile local drugs will become more
expensive.
Is this inevitable ? Can only developed countries manage
goodhealth careifortheirpeople ?
Indians need not accept poor health as their
inevitable rate! Many other developing countries.
•.vnich have given a high priority to people s health.
nave achieved much better health outcomes
compared to India. As a country, we spend a higher
proportion of the GDP on health care compared to
these countries - but an overwhelming percentage
of this (83%) is private expenditure. As a result we
have a weak public health system with poor health
outcomes forcing families to spend a lot on private
medical care, which is expensive, and not always
appropriate, leaving us with ‘poor health at high
cost’! Here is how some other Asian countries are
doing in comparison with India...
Health Outcomes in Relation to Health Expenditures in some Asian countries10
Total Health
Expenditure
as % of GDP
Public Health
Expenditure
as % of total
Under 5
Mortality
Life Expectancy
1
Male
Female
India
5.2
17
95
59.6
61.2
Sri Lanka
3.0
45 4
19
65.8
73.4
| Malavsia
F
2.4
57.6
14
67.6
69.9
As a country, Indians spend more on health care
than most other developing countries, but this is
mostly out-of-pocket spending Health care
facilities have grown substantially, but these are
mostly in the private sector. The system is
producing more and more healthcare professionals.
but we lose them to the private sector, or to western
countries To give some idea of the available health
care resources in inaia -
o
We have an annual pharmaceutical
production of about 260 billion rupees--', and
we export a large proportion of these drugs
- Sadly, while our exports grow, 80% of our
people do not have access to all the drugs
they require.
In short, we have substantial health care
resources, but because of the privatised.
unregulated and inequitable nature of the health
care system, it is unable to ensure good quality
health care for a majority' of citizens. Rather than
producing more doctors or setting up more private
hospitals, what we need is a reorganisation of the
health system, with substantial strengthening of
public health, greatly enhanced public expenditure.
regulation of the private medical sector and an
overall planned approach to make health care
resources available to all.
Compared to 11.174 hospitals m 1991 (57%
private), the number grew to 18.218 (75%
private) in 2000'". In 2000. the countrv had
12.5 iakh doctors and 8 lakh nurses! At the
national level, there is one allopathic doctor
for every 1800 people, or one doctor from
systems including ISM and homeopathy for
SOO people. This means there are more
doctors than the required estimate of one
doctor for 1 500 population-.
Approximately 15.000 new graduate doctors
and 5.000 postgraduate doctors are produced
every year and one-fifth oi them leave the
country for greener pastures ’
5
The objective should be to make Health care a
Fundamental right and an operational
entitlement. This would require a National Public
Health Act, which mandates right to basic
healthcare services to all citizens through a
system of universal access to healthcare The
Indian Constitution through its directive principles
provides the basis for the Right to health care, and
the Indian state has ratified the International
Covenant of Economic. Social and Cultural Rights
which makes it obligatory on its cart to complv
with Article 12 that mandates right to healthcare.
Universal access to healthcare is well established
in a number of countries including not only
developed countries like Canada and United
Kingdom, but also developing countries such as
Cuba. Brazil, Costa Rica and Thailand. There is
no reason why this cannot be made a reality in
India. Hence we need to set in motion processes
which will take us towards the goal of universal
access to health care, in a Rights-based framework
and with equity.
increased substantially, targeting the 5%
of GDP as public expenditure on health care
as recommended by the WHO.
If the public health system fails to deliver
it should be treated as a legal offence.
remedy for which can be sought in the
courts of law. The public system must
ensure all elements of care like drug
prescriptions, diagnostic tests, child birth
services, hospitalization care etc. One way
to ensure this could be that in exceptional
situations, where patients who do not
receive these services from the public
facility they may be referred to seek them
from alternate facilities, which are
registered with the state agency. Such
registered and regulated facilities would
honour such referrals, for which the state
would reimburse them at a mutually agreed
rate. This would maintain pressure on tha^
public health system to provide all eiement^P
of care, and would ensure that the patient
is not deprived of essential care at time of
need.
Various vulnerable and marginalised
sections of the population have special
health needs. There is a need for a range
of policy measures to eliminate
discrimination, and to provide special
quality and sensitive services for women.
children, elderly persons, unorganised
sector workers, HIV-AIDS affected persons.
disabled persons, persons with mental
health problems and other vulnerable
groups. Similarly, situations of conflict,
displacement and migration need to be
addressed with a comprehensive approach
to ensure that the health rights of affect ec^^
people are protected. The People’s Healti^^
Charter deals with issues related to such
special sections of the population, and can
provide a basis for formulation of
appropriate policy initiatives, in
consultation
with
organisations
representing these social segments.
Putting in place a National legislation to
regulate the private health sector, to adopt
minimum standards, accreditation.
standard treatment protocols, standardised
pricing of services etc.
Adopting a rational and essential
medications-based drug policy. All States
must have an essential drugs and
consumables list and all the drugs and
consumables on this list must be under
price control. Further all state governments
must adopt procurement and distribution
Some immediate steps related to the health care
system that need to be taken include:
• Making healthcare a fundamental right by
suitable constitutional amendment. The
formulation of a National legislation
mandating the Right to Health care, with a
clearly defined comprehensive package of
health care, along with authorization of the
requisite budget, being made available
universally within one year.
• Significant strengthening of the existing
public health system, especially in rural
areas, by assuring that all the required
infrastructure, staff, equipment, medicines
and other critical inputs are available, and
result in delivery of all required services.
These would be ensured based on clearly
defined, publicly displayed and monitored
norms.
• The declining trend of budgetary allocations
for public health needs to be reversed, and
budgets appropriately up-scaled to make
optimal provision of health care in the
public domain possible. At one level adopting
a fiscal policy of block fund.ng or a svstem
of per capita allocation of resources to
different levels of health care, with an
emphasis on Primary Health Care will have
an immediate impact in reducing ruralurban inequities by making larger
resources available to rural health facilities
like Primary health centers and Rural
hospitals. Simultaneously, the budgetary
■■ allocation to the health sector must be
6
We the people of India, stand united in our condemnation of an iniquitous global system that, under the garb of
'Globalisation' seeks to neap unprecedented miser.' and destitution on the overwhelming majority of the people on
this globe. This system has systematically ravaged the economies of poor nations in order to extract profits that
nurture a handful of powerful nations and corporations. The poor, across the globe, as well as the sections of poor
m trie rich nations, are being further marginalised as they are displaced from home and hearth and alienated from
the.: sources of livelihood as a result of the forces unleashed by this system. Standing in firm opposition to such a
system we reamrm our inalienable right to and demand for comprehensive health care that includes food security.
sustainable livelihood options including secure employment opportunities: access to housing, drinking water and
sanitation; anc appropriate medical care for all, m sum - the right to Health For AH, Now!
“he promises made to us by the international community in the Alma Ata declaration have been systematically
renudiated by the World Sank, the IMF. the WTO and its predecessors, the World Health Organization, and by a
government that functions under the dictates of International Finance Caoital The forces ‘Globalisation’ through
measures such as me structural adjustment programme are targeting our resources - built up with our labour.
sweat and lives over the last fifty years - and placing them in the service of the global "market” for extraction of
suner-proftts. The benefits cf the public sector health care institutions, the public distribution system and other
infrastructure - such as they were - have been taken away from us. It is the ultimate irony that we are now blamed
for our plight, with the argument that it is our numbers and our propensity to multiply that is responsible for our
covert" and deprivation. We deciare health as a justiciable right and demand the provision of comprehensive health
care as a fundamental constitutional right of every one of us. We assert our right to take control of our health in our
own hands anc for this the right to:
.A truly decentralized system of local governance vested with adequate power and responsibilities, provided with
adecuate finances anc responsibility for local level planning.
A sustamabie system of agriculture based on the principle of land to the tiller - both men and women - equiu^pdistribution of land anc water, linked to a decentralized public distribution system that ensures that no one
goes hungry
Universal access to education, adequate and safe drinking water, and housing and sanitation facilities
A dignified and sustamabie livelihood
A clean and sustamabie environment
A drug industry gearec to producing epidemiological essential drugs at affordable cost
A health care svstem which is gender sensitive and responsive to the people s needs and whose control is
vested in peonie s hands and not based on market denned concept of health care.
Further, we deciare our firm, opposition to:
.
.
."
.
.
.
.
.
Agricultural policies attuned to the needs of the market’ that ignore disaggregated and equitable access to food
Destruction of our means to livelihooa and appropriation, for private profit, of our natural resource bases and
appropriation of bio-diversity.
The ccnvers:or. of Health to the mere provision of medical facilities and care that are technolog}' intensive.
expensive, and accessible to a select few
The retreat, b-> the government, from the principle of providing free medical care, through reduction ol public
sector expenditure on medical care and introduction of user fees in public sector-medical institutions, that
place an unacceptable burden on the poor
The corporatization and commericiaiization of medical care, state subsidies to the corporate sector in medical
care and corporate sector health insurance
Coercive population centre: and promotion of hazardous contraceptive technology which are directed primmaly
at the poor and women.
The use of patent regimes to steal our traditional knowledge and to put medical technology and drugs beyond
our reach
institutionalization of divisive and oppressive forces in society, such as communalism, caste, patriarchy, and
the attendant violence which have destroyed our peace and fragmented our solidarity.
in the light of the above we demand that'
The concept of comprehensive primary health care, as envisioned in the Alma Ata Declaration should form the
funcamental basis for formulation 01 all policies related to health care. The trend towards fragmentation of
health delivery proeramm.es through conduct of a number of vertical programmes should be reversed. National
health programmes .be integrated within the Primary Health Care system with decentralized planning, decision
making and implementation with the active participation of the community. Focus be shifted from bio-medical
and individual based measures to social, ecological and community based measures.
The primary health care institutions including trained village health workers, sub-centers, and the PHCs staffed
b'. rmetors and the enure range of community health functionaries including the 1CDS workers, be placed under
tn-, direct .idministranve anti financial control of the relevant level Panchayati Raj institutions. The overall
mfr.-structure c th-- nr:m.:rv health care institutions be under the control of Panchayats and Gram Sabhas and
nro-.is’on .-. free and .. .cessible secondary anti tertiary level care be under the control of Zilla Panshads, to be
.: .cessed primarily through referrals.fjogg^iHUs
Tie essential components of primajy-aSn§jisKbt;!<:: be:
Tillage ieve. health care basisdjo)
the Gram Sabna / Panch^JStfeBr
.md adequate resource'sttppqtttK-
ge Health Workers selected by the community and supported by
fthe Government health services which are given regulatory powers
8
.
•
;
policies similar to what has been done by
the Tamilnadu State Medical Services
Corporation and hence ensure that
essential drugs in the list are actually
available in every facility.
The state should introduce a new
community-anchored health worker
scheme, and implement it in a phased
manner with involvement of people’s
organizations and panchayati raj
institutions, in both rural and urban areas.
through which first contact primary care
and health education can be ensured.
Integration of medical education of all
systems to create a basic doctor ensuring
•
•
a wider outreach and improvement, of
access to health care services in all areas.
All state level coercive population control
policies, disincentives and orders should
be revoked. Disproportionate financial
allocation for population control activity
should not be allowed to skew funding from
other important public health priorities.
Integration of medical education of ail .
svstems to create a basic doctor ensuring
a wider outreach and improvement of
access to health care services in ail areas.
Effective regulation of the growth of
capitation based medical colleges.
CdncIusibnE
What is needed is a major restructuring and
strengthening of the health system. This involves
two major ingredients: popular mobilisation for
operationalising the Right to Health Care, and thei
political will to implement policy changes
necessary to transform the health system Jan
Swasthya Abhiyan is today involved in the former
task, bv reaching out to people across the country.
enabling them to mobilise for their just health
rights. It calls upon political parties, which
recognise people's right to healthy lives, to address
the latter task, and to perform their historic duty
by establishing and operationalising the Right to
Health care as a Fundamental right.
The persistence of unacceptably large numbers of
avoidable deaths, resurgence of communicable
greases, declining quality of public health services
unaffordable, often inappropriate private
medical care need not remain the lot of over a
billion ordinary Indians. Recent policy changes of
privatisation, declining public health budgets and
pro-drug industry measures need to be replaced by
strong public health initiatives, with the active
involvement of communities and civil society
organisations.
Bv and large. India today possesses the
_ humanpower, infrastructure, national financial
'resources and appropriate health care know-how
to ensure quality health care for all its citizens.
This document focuses on the need for strengthening of the health care system, and certain immediate
steps required for this. However, improvement of people's health requires equally importantly, provision
of other necessaiv facilities and conditions required for a healthy life, such as sale drinking water.
sanitation, food security, healthy housing, basic education and a safe environment. The People’s Health
^Piarter has dealt with these issues, and may be taken as a guideline to develop effective policies and
improve people's living standard in order to achieve better health.
Published by CEHAT for JAN SWASTHYA ABHIYAN
7
•
•
•
*
Primary Health Centers and sub-centers with adequate staff and supplies which provides quality curative
services at the primary health center level itself with good support from referral linkages
A comprehensive structure for Primary Health Care in urban areas based on urban PHCs, health posts
and Community Health Workers under the control of local self government such as ward committees
and municipalities.
Enhanced content of Primary Health Care to include all measures which can be provided at the PHC
level even for less common or non-communicable diseases (c.g. epilepsy, hypertension, arthritis, pre
eclampsia. skin diseases) and. integrated relevant epidemiological and preventive measures
Surveillance centers at block level to monitor the local epidemiological situation and tertiary care with
all speciality services, available in every district.
3.
A comprehensive medical care programme (inanced by the government to the extent of at least 5% of our GNP,
of which at least half be disbursed to panchayati raj institutions to finance primary level care. This be accompanied
be transfer of responsibilities to PRls to run major parts of such a programme, along with measures to enhance
capacities of PRIs to undertake the tasks involved.
-.
The policy of gradual privatisation of government medical institutions, through mechanisms such as introduction
of user fees even for the poor, allowing private practice by Government Doctors, giving out PHCs on contract,
etc. be abandoned forthwith. Failure to provide appropriate medical care to a citizen by public health care
institutions be made punishable by law.
5.
A comprehensive need-based human-power plan for the health sector be formulated that addresses the requirement
for creation of a much larger pool of paramedical functionaries and basic doctors, in place of the present trend
towards over-production of personnel trained in super-specialities. Major portions of undergraduate medical
education, nursing as well as other paramedical training be imparted in district level medical care institutions,
as a necessary' complement to training provided in medical/nursing colleges and other training institutions No
more new medical colleges to be opened in the pnvatc sector. No commodification of medical education. Steps
to eliminate illegal private tuition by teachers in medical colleges. At least a year of compulsory rural posting for
undergraduate (medical, nursing and paramedical) education be made mandatory, without which license to
practice not be issued. Similarly, three years of rural posting after post graduation be made compulsory.
6.
The unbridled and unchecked growth of the commercial private sector be brought to a halt. Strict observance of
standard guidelines for medical and surgical intervention and use of diagnostics, standard fee structure, and
periodic prescription audit to be made obligatory. Legal and social mechanisms be set up to ensure observance
of minimum standards by all private hospitals, nursing/maternity homes and medical laboratories. Prevalent
practice of offering commissions for referral to be made punishable by law. For this purpose a body with statutory
powers be constituted, which has due representation from peoples organisations and professional organisations.
7.
A rational drug policy be formulated that ensures development and growth of a self-reliant industry for production
of all essential drugs at affordable prices and of proper quality. The policy should, on a priority basis:
.
.
.
.
.
.
.
.
Ban all irrational and hazardous drugs Set up effective mechanisms to control the introduction of new
drugs and formulations as well as periodic review of currently approved drugs.
Introduce production quotas &, price ceiling for essential drugs
Promote compulsory use of generic names
Regulate advertisements, promotion and marketing of all medications based on ethical criteria
Formulate guidelines for use of old and new vaccines
Control the activities of the multinational sector and restrict their presence only to areas where they
arc willing to bring in new technology
Recommend repeal of the new patent act and bring back mechanisms that prevent creation of monopolies
and promote introduction of new drugs at affordable prices
Promotion of the public sector in production pf drugs and medical supplies, moving towards complete
self-reliance in these areas.
8
Medical Research priorities be based on morbidity and mortality profile of the country, and details regarding the
direction, intent and focus of all research programmes be made entirely transparent. Adequate government
funding be provided for such programmes. Ethical guidelines for research involving human subjects be drawn up
and implemented after an open public debate. No further experimentation, involving human subjects, be allowed
without a proper and legally tenable informed consent and appropriate legal protection. Failure to do so to be
punishable by law. Ail unethical research, especially in the area of contraceptive research, be stopped forthwith.
Women (and men) who. without their consent and knowledge, have been subjected to experimentation, especially
with hazardous contraceptive technologies to be traced forthwith and appropriately compensated.. Exemplary
damages to be awarded against the institutions (public and private sector) involved in such anti-people, unethical
anti illegal practices in the past.
,
a
All coercive measures including incentives and disincentives lor limiting family size be abolished. The right of
families and women within families in determining the number of children they want should be recognized.
Concurrently. access to safe and affordable contraceptive measures be ensured which provides people, especially
women, the abilitv to make an informed choice. All long-term, invasive, systemic hazardous contraceptive
technologies such as the injcctablcs (NET-EN, Dcpo-Provera. etc.), sub-dermal implants (Norplant) and’anti
tertilnv vaccines should be banned from both the public and private sector. Urgent measure be initiated to shift
onus of com raceotion away from women and ensure at least equal emphasis on men’s responsibility for
contraception. Facilities for safe abortions be provided right from the primary health center level.
|ij
nppoil be province
irialilional healing -sy'slrinn, including local and home-bused healing irnditions. for
systematic research and community based evaluation with a view lo developing llie knowledge base and use ul
these svstems along with modern medicine as part of a holistic healing perspective.
9
11.
Promotion of transparency and decentralization in the decision making process, related to health care, at a
levels as well as adherence to the principle of right to information. Changes in health policies to be made’onl)
after mandatory wider scientific public debate.
12.
Introduction of ecological and social measures to check resurgence of communicable diseases.
should include:
Such measure;
Integration of health impact assessment into all development projects
Decentralized and effective surveillance and compulsory notification of prevalent diseases like malaria,
TB by al! health care providers, including private practitioners
Reorientation of measures to check STDs/AIDS through universal sex education, promoting responsible
safe sex practices, questioning forced disruption and displacement and the culture of commodification
of sex, generating public awareness to remove stigma and universal availability of preventive and curative
services, and special attention to empowering women and availability of gender sensitive services in
this regard.
13.
14.
Facilities for early detection and treatment of non-communicable diseases like diabetes, cancers, heart diseases,
etc. to be available to all at appropriate levels of medical care.
Women-centered health initiatives that include:
o
«
o
>
15.
Child centered health initiatives that include:
o
.
o
o
16.
A comprehensive child rights code, adequate budgetary allocation for univcrsalisation of child care
services
An expanded & revitalized 1CDS programme. Ensuring adequate support to working women to facilitate
child care, especially breast feeding
Comprehensive measures to prevent child abuse, sexual abuse and child prostitution
Educational, economic and legal measures to eradicate child labour, accompanied by measures to ensure
free and compulsory quality elementary education for all children.
Special measures relating to occupational and environmental health which focus on:
.
»
.
°
17.
Awareness generation for social change on issues of gender and health, triple work burden, gender
discrimination in upbringing and life conditions within and outside the family; preventive and curative
measures to deal with health consequences of women’s work and violence against women
Complete maternity benefits and child care facilities to be provided in all occupations employing women,
be they in the organized or unorganized1 sector
Special support structures that focus on single, deserted, widowed women and minority women which
will include religious, ethnic and women with a different sexual orientation and commercial sex workers;
gender sensitive services to deal with all the health problems of women including reproductive J^^lth,
maternal health, abortion, and infertility
Vigorous public campaign accompanied by legal and administrative action against sex selective abortions
including female feticide, infanticide and sex pre-selection.
Banning of hazardous technologies in industry and agriculture
Worker centered monitoring of working conditions with the onus of ensuring a safe and secure workplace
on the management
Reorienting medical services for early detection of occupational disease
Special measures to reduce the likelihood of accidents and injuries in different settings, such as traffic
accidents, industrial accidents, agricultural injuries, etc.
The approach to mental health problems should take into account the social structure in India which ^kkes
certain sections like women more vulnerable to mental health problems. Mental Health Measures that p^fcte
a shift away from a bio-medical model towards a holistic model of mental health. Community support & community
based management of mental health problems be promoted. Services for early detection & integrated management
of mental health problems be integrated with Primary Health Care and the rights of the mentally ill and the
mentally challenged persons to be safe guarded.
18
Measures to promote the health of the elderly by ensuring economic security, opportunities for appropriate
employment, sensitive health care facilities and, when necessary, shelter for the elderly. Services that cater to
the special needs of people in transit, the homeless, migratory workers and temporary settlement dwellers.
19. Measures to promote the health of physically and mentally disadvantaged by focussing on the abilities rather
than deficiencies. Promotion of measures to integrate them in the community with special support rather than
segregating them; ensuring equitable opportunities for education, employment and special health care including
rehabilitative measures.
20. Effective restriction on industries that promote addictions and an unhealthy lifestyle, like tobacco, alcohol, pan
masala etc., starting with an immediate ban on advertising, sponsorship and sale of their products to the
young, and provision of services for de-addiction
10
The Jan Swasthya Abhiyan at the national level is the coalition of the networks of voluntary organizations
and peoples movements involved in healthcare delivery and health policy, who made themselves a part of
the Peoples Health Assembly campaign in India in the year 2000, and have continued to participate in this
process. These national networks have numerous constituent organisations, which implies that a few
hundred organizations are involved directly in the national process. Beyond these networks, several hundred
other organizations have been involved at state, district and block level activities across the country. The
networks that constitute the National Coordination Committee of Jan Swasthya Abhiyan are:
1.
All India Peoples Science Network
2.
All India Democratic Women’s Association
3.
All India Drug Action Network
4.
5.
Asian Community' Health Action Network
Bharat Gyan Vigyan Samiti
6.
Catholic Health Association of India (CHAI)
7.
3.
19.
10.
Christian Medical Association of India (CMAI)
Federation of Medical Representatives and Sales Associations of India (FMRAI)
Forum for Creche and Child Care Services (FORCES)
Joint Women’s Programme
11.
Medico Friends Circle (MFC)
12.
National Alliance of People's Movements (NAPM)
13.
National Alliance of Women’s Organisations (NAWO)
14.
National Federation of Indian Women (NFIW)
15.
Ramakrishna Mission
16.
17.
Voluntary Health Association of India (VHAI)
Association for Indian Development, India (AID-India)
18.
19.
Breastfeeding Promotion Network of India (BFPNI) National Resource Groups:
Centre for Enquiry into Health and Allied Themes (CEHAT)
20.
Centre for Social Medicine and Community Health, Jawaharlal Nehru University
21.
Community Health Cell (CHC)
The representatives of all the above organisations constitute the National Coordination Committee of JSA,
wJjch is the national decision making body of the coalition. N.H. Antia is the Chairperson and D. Banerjee
isBne Vice-Chairperson of JSA. National organisers of JSA include B. Ekbal as Convenor, Abhay Shukla,
Arnit Sengupta, Amitava Guha, Thelma Narayan and T. Sundararaman as Joint convenors, with Vandana
Prasad and N.B.Sarojini as National secretariat members.
Jan Swasthya Abhiyan presently has state units or contacts in the following states:
Andhra Pradesh, Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Haryana, Himachal Pradesh,
Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Tamil
Nadu, Tripura, Uttar Pradesh, West Bengal.
ro^v
-
-"’<1
Jan Swasthya Abhiyan contact addresses
B. Ekbal,
National Convenor, JSA
Ph: 0471-2306634(0)
c-inaiP ckbali7 vsnl.com
Abhay Shukla
National Secretariat, JSA
Ph: 020-254514 13 / 25452325
e-mail : cehatpunltzvsnl.com
Ainit Sen Gupta
Jt. Convenor, JSA
Ph:01 1-26862716/ 26524324
e-mail: ctdclsf@vsnl.com
Amitava Guha
Jt. Convenor, JSA
Ph: 033-24242862(0)
e-mail:
guhaamitava @hotmail.com
Thelma Narayan
Jt. Convenor, JSA
Ph:080-5505924 / 5525372
e.nlail: sochara@vsnl.com
T. Sundararaman
Jt. Convenor, JSA
Phone: 0771-2236104, 2236175
e-mail:
sundar2@123india.com
Vandana Prasad
Member, National Secretariat
Phone: 0120-2536578
e-mail: chaukhat@vahoo.com
Sarojini
Member, National Secretariat
Ph: 011-26968972 / 26850074
e_maj[. samasaro@vsnl.com
Sources:
1.
2.
SRS Bulletins-Government of India. 1998.
...PteffinHig^ommissioh. Government ofJndia. Tenth. EiKe..Year-Rlan-20Q2--.2Q07. VolufheJE ‘-'ijzsj-.■"
3.
International Institute for Population Sciences and ORC Macro. National Family Health Survey (NF'HS-
4.
International Institute for Population Sciences. RCH-RHS India 1998-1999.
5.
National Crime Records Bureau. Ministry of Home Affairs. Accidental Deaths and Suicides In India
6.
World Health Organization. The World Health Report 2003.
II) 1998-99. India.
2000.
7
International Institute for Population Sciences. Facility Survey. 1999.
8.
Misra, Chatterjee, Rao. India Health Report.Oxford University Press, New Delhi.2003 •
9.
Morbidity and Treatment of Ailments. NSS Fifty second round. Government of India. 1998.
10.
Changing the Indian Health System - Draft Report, ICRIER, 2001
11.
Shariff Abusaleh. India Human Development Report.Oxford University Press New Delhi.
12.
DuggaI.Ravi. Operationalizing Right to Healthcare in India. Right to Healthcare, Moving from Idea to
Reality.
CEHAT Mumbai.2003.
13.
National Coordination Committee for the Jana Swasthya Sabha. Health for All NOW. 2004.
14.
Central Bureau of Health Intelligence.Directorate General of Health Services, Ministry of Health and
Family Welfare. Health Information of India i000 &2001.
15.
National Sample Survey Organization. Department of Statistics.GOI.42nd and 52nd Round.
16.
Census of India 2001: Provisional Population Totals.Registrar General and Census Commissioner GOI.
17.
Pai M et al. A high rate of Cesaerean sections in affluent section of Chennai, is it a cause for concern?
Nat Med J India. 1999.12:156-158
18.
TB India 2003. RNTCP Stats Report.Central TB Division.DDHS GOI.
19.
20.
Health Survey and Development Committee. GOI 1946 (Shore Report)
Mahal A. ww^.worldbank.org
21.
Phadke A. Drug Supply and Use. Towards a Rational Policy in India. Sage Publications New'Delhi.
22.
Ministry of Chemicals and Fertilizers.
■7.-'
:
■
.
. .. • • ’
• ■ -
1.12
■ -yf v-'t i I -Y;A':.7.
i
The CHW: Survivals and Revivals
Cr>r/\\
Abbreviations: CHW: (Community Health Workers), COPC: Community
Oriented Primary Care, JSR: (Jana Swasthya Rakshak-the new CHW programme in Madhya Pradesh) FCC:
(First Contact Care), FRU (First referral Unit- the rural 30-100 bedded hospital), PHC: Primary I -tealtit Care,
CHW DEBACLE IN INDIA
CHW scheme, an important 1978 option for reaching primary care/first contact care to
villages of India was a dying scheme by mid-eighties; and now it is no more in 2002. The vacuum
has been filled partially by somewhat similar variants from Govts, but in the main by the private
doctors of various kinds in different states of India. As the already belated option of CHW failed to
answer an important social need, markets have provided some options; for which the State and its
policy makers and bureaucrats have to share the blame. Recent evidence suggests that there is very
little that is iearnt from this nationwide failure.
To set the record straight, Govt must publish the formal post mortem report of the CHW
scheme, and if anything what was done to salvage the scheme through the two decades. It
concerned five lakh CHWs and their villages. In absence of such an official statement on the issue, I
am sharing my thoughts and concerns.
First of ail, the Indian health system planned under the Bhore committee report hao
little to offer on village level services, based as it was on a doctor-hospital centric state
model of health care. The CHW appendix did not stick to the system. (In contrast
China's effort was much better, but our policy community is unwilling to admit this fact.
It is noteworthy that Mahatma Gandhi had started preparations for village level healers
(See home & village doctor d? Dr DasGupta) but the initiative was lost in oblivion after
the Independence.
Even though it was a belated effort to make amends, esp after the Alma Ata mandate,
the scheme lacked steam in several departments—conceptualization, technical design,
content, training, political management, finance, monitoring, linkages etc. Subsequent
handing over to Family welfare dept put the last nail in the coffin. The Janata regime
lasted only 30 months and the later Congress Govt was not impressed with the scheme.
Medicines were withdrawn in eighties and then people forgot the CHW. Honoraria
continued as litigations dragged and finally that too stopped.
There was not much light at the other end of the tunnel either—the global experience
on CHWs. A 1992 WHO review (WHO TRS) was seized of this and so were other experts
The CHW: Survivals and Revivals
(Frankel). In a personal conversation in 2000, David Werner, the author of the famous
WTND also could not find any large-scale country CHW programme worth mentioning.
China was a solid exception and others countries who had the CHW scheme offered
attenuated versions (Philippines for instance). Brazil has introduced a CHW programme
as late as in 1995. Was there then something genetically wrong with the CHW
programme? Was it unfit for any national system and only good for NGO islands?
A hard look at various states in India shows that village-doctors that nobody made or
dreamt of In Nirman Bhavan or Lodhi Road have been spreading in every state of
India—east and west, south and north.
Although some states like MP and Chattisgarh are trying CHW variants in the states, at least
the MP JSR scheme is headed the same ..ay as the old CHW scheme (our own study in 2601-not
published). This makes it imperative that we take a closer look at the issues and problems.
Understanding the jig-saw puzzle
Tne social engineering of CHW scheme is a complex matter and we see very different
models in various countries and NGO areas. To make the issue more explicit, all the three words in
the classical nomenclature 'Community Health Worker' are rather vague concepts, esp in
practice.
Community?
Health?
Worker?
Village?
'Development'?
Liberator, change agent?
Panchayat?
Health-esp. health primary
Worker (lackey)?
prevention?
National health programmes?
Guide? (Only IEC?)
NGO?
Narrow or vertical programmes?
Volunteer (little or no pay)?
SHG?
Primary medicare?
' A doctor' where there is no
Government
health dept?
doctor?
Only left to
individual?
Little of each above?
The CHW: Survivals and Revival
Are CHWs necessary for primary care in India?
In the new century, primary care is surely still necessary and valid; but is a CHWnecessary
for primary care?
CHWs (or some of its variant; are surely necessary for primary care in villages (also parts of
urban areas) in many states, if not all. Situation varies, as it may not be necessary like in Kerala.
Conversely, in Bihar it may be frustrating to reintroduce the CHW as most villages have a home
grown local medical practitioner1. Come to states like Maharashtra and Madhya Pradesh, there are
large number of private medical practitioners in rural areas, but they are clustered in some rural
centers. In One study in Maharashtra 'ashtekar) we found that in 737 villages there were 555
doctors of all types, but they were all practicing in just 16% of the villages. On a roadside village in
MP, we found over 30 clinics of doctors (in addition to the mini PHC) and obviously they depended
upon surrounding villages for their clientele. In such situations, it is still possible to introduce CHWs
in peripheral villages but they will have to prove themselves against the 'doctors'. I am aware that
many experts may not like this connection but the reality is that even good CHWs find they lose out
when an injection-doctor even starts visiting their village. First goes the curative and later go other
health components. In short, a CHW may be theoretically necessary in all villages, but in the vicinity
of'doctors' the CHW option melts away. This is difficult to understand from a planner's and activist's
end but very easy to grasp from the community's perspective. This leaves us with, two tasks, an
easy one and a difficult one—of choosing villages for CHW programme and of improving the content
of the programme in several ways.
There are some fresh initiatives on CHWs in some states- MP, Chattisgarh, AP and in
Maharashtra. The National Health Pci-cy also makes some nuanced or wooly references about
options. To make things clearer for .new initiatives on the CHW I am making a matrix to underline
the various issues and layers involved. Most of the early and current Indian CHW programme tried
to steer clear the complexities and give an innocently simple 'minimal version' CHW programme and
we know that they have faltered or faned.
1 This is an impression from JANA?. . an organization working in Bihar and adjoining states. Their understanding
is that each village has more than 1 PMP.
The CHW: Survivals and Revivals
Place in
Health
System
Formal/
external/
mainstre
am
Contributi
on to/
share of
health
services
Who
Owns
it?
State
Comm
unity
Provide
r
(privat
e)
Larger Matrix of factors related to Primary caic by CHWs
Political
Stability Access
Technical
Personne Supports
situation
factors
and
content
I policies
trends
Pi ogram
Distance Dem oc rati
Entry/
Political
Task listfactors
selection
expected/a
life,
■
attrition,
ctual
centralize;:
Training
systems,
books,
software
Mobility/
Transfers
Orientation
Promotion
Legal
Age/sex
institution
al
Financial
Cost
factors
Democrat!
c and
decontrols
cd
Social
factors:
(caste
and
gender
in India)
Oligarchic/
authontari
an
->
preventive
curative
Use of
different
healing
systems
Expandin
gor
shrinking
Problen
s?
Su.-.wai
One party
rule
Expanding the search for primary care 'model'
Since the main objective is and must be primary care and CHW only a means to it, i have
included village doctors as a pragmatic and existing option, and I am not alone on this since there
are experts like John Rhode who wrote a book on rural doctors (Rohde). On this wider canvass of
primary care by CHW schemes, NGO experiments and private village doctors, the complexities
deepen. The approaches, inputs, processes, and outputs change according to the vehicle of primary
care. My argument is that even if a classical State CHW model is not feasible in some
states/districts, it is still feasible to make use of private PMPs and share the agenda with them on
institutional basis. 2
I am giving a schematic sketch (see figure 1) here of three perspectives on the CHW—the
planners, the community and the candidates/care providers. Unless we combine the prime concerns
of each perspective, there can not be a 'successful model'
At the end I am presenting a table (see table 3) depicting what is likely to happen to aii the
issues of concern when we deal with different models of primary care- Govt, private or combined.
21 had a brief interview with Or Gerald Bloom, an expert of the Bristol University, who has an intimate
understanding of the China health scenario. As I was describing the ubiquitous PMP-quacks in india, he shrugged ano
said that it sounds much like China's rural doctors in the village health stations, many of whom have little training and are
rarely monitored. I was taken aback by the comparison, can products of two entirely different systems bn alike?
The CHW: Survivals and Revivals
APPENDIX
Fig 1: First Contact Health Care: perspective mapping
Planners7 Concerns
Selection: gender, age, education
System links-does CHW fit well in the health system’
Not clashing with other HWs, gets along well with them
Preventive tasks, national health programmes
payment to be linked to performance/more from users
Relations with Pnvate/iSM doctors
Training /system/books/CDs/TV channels/speciaity
trainingMonitoring and controls, fine tuning
Supplies/logistics/multi-sourcing/ non-drug healing
Works within rational therapeutic framework/CME
Not to be part of salaried staff,
Low attrition rate
Programme durability, gets rooted in the health system
Sen/ice authorization/ CPA immunity
Universal or Village selection on criteria’
'True attitudes' of Govt health system about JSR
Institution for CHW’
Programme
Content:
•
•
•
Provider \ •
Concern's
Basic needs-survival
Monetary
gains/incentives
Self worth
Sense of belonging
Security- professional
Motivation for action
learning opportunities
I Inward mobility
n-VartirlpctA^F-CHW rlrv- ?0 Opr ?nn?
Skills and tasks,
Attitudes of
providers,
Knowledge,
Relations
.
Community
Concerns
•
Does CHW answer usuai
medical needs?
linkages
Better than other available
healers?
’
•
•
Friendly? Arre^ .■'Ip?
■, ;:e ClIVJ: Survivals and Revivals
SIBILITES WITH 'PRIMARY CARE' MODcLS
(A) PLANNER'S CONCERNS
Sub-issues
Major
Selection
i
' Attitudes of
i candidates
Usual Possibilities3
■ with staff model
. Gender: men or i Men or women
women
i depending upon policy.
I Women tend to take
I
i even small pay jobs.
Age
1 late teens/early twenty
j candidates hunting for
i Govt. iobs
Education
Age strata will decide
entries,
(caste)
Any
Work motivation
Declines with tenure,;
upward mobility if any.
Learning
Generally programmerelated. Little motivation
of their own.
More with
administration, less with
peoole/users
From anywhere, unless
salaries limit choice to
locality
All, even hamlets,
depending upon
available funds and
pattern
|
Communication
i
: Csncidate
: iocality
Distribution
j
1
■ Training
Initial course
. Mcnitorino
1
L
Social asoects
Technical
asoects
Govt PHC/CHC
; Medicine
sue civ.
■ Healing
i systems
Generally allopathic
Preventives
•
National
therapeutics
Program
durability
Attrition
System
linkaces
Can begin small,
stepladder
Poor control
Theoretically possible
Overall
Programme-specific
NHPs
NHPs cn priority
protocol-driven/ narrow
Yes and No
Nealiqible
In built
i A combination model
I Mixed-alternate
villagc/both man and
women in each
village/couple
Post-twenty five yr.
candidates, other health
' cadres
Negotiable
Village doctor model
‘ Men mostly
• Generally post 25
1
1 'lee: I It. : e
- ;■ for
I respectable earning
Any is possible..on criteria i Generally upper and
middle.
Depends upon
Monetary gams are the
candidates/returns/ work
deciding factors for
satisfaction
attitudes.
Combining self-interest
1 Self-learning, limited to
plus programme interests. | skills that can sale.
Possible to ensure with
both administration and
users
Generally from locality
Usually from outside
Not so evenly spread
small hamlets can be
attached though.
Sustainability is prime
concern. May not survive
in less than 2000 without
contract oavments.
Qualifying necessary, CME
can be done
FeasiblePossible- programme wise
Only big villages,
cluster-centers. Can not
survive on small
population-below 2000.
Overcrowding of PMPs
can pose serious
problems.
Initial crash course,
little CME later
Poor control
Poor control
Govt for NHPs, from
market for other needs.
Can increase choices with
better training and public
education
Programme-specific, but
expandable
NHP on contract
Market, Medical Reps
Possible with standard
lists and rates.
Can be stable
Can be keot^at moderate,
Need to be.feigned and
administered ■■
’ Assumes appointment of one primary care worker I each village.
(
Only client-oriented
I
i
Generally allopathic
No interest (actually
sickness-interest)
Poor compliance for
NHPs
Weak
1
i
Generally stable, though j
with some flux.
Increasing competition •
can destabilize PRMPs
Neolioible
Difficult &. tenuous
alwavs abhorred.
survivals and Revivals
■
Costs
To the Govt.
To the
consumers
Payment
modes
Hiqh
Low or ml (except in
case of bribes)
Salaries/honoraria/pensi
ons
Financial
Sources
Venue for
work
Taxation/grants to local
bodies
Formal center necessary
Legal status
for providers
'Couple'
Easy-with Govt
notification
Not possible
Examples
ANM/MPW
Medium
Medium to both
Low-nil
Highest
Combined: user paid at
prescribed rates +
contract payment for
NHP/State programmes
User-fees or insurance
plus programme grants
Former center desired, but
interim arrangements
possible
Possible to work out
User fees
Possible, as payment is on
contract for tasks/services
Omnibus-GLY scheme
in the 10,b FYP of
Maharashtra,
Community nurse in AP
Fees or may be
insurance at later stage.
Private room in bazaar
lanes essential.
'Do not care", generally
some cover is available.
Unlikely, except when
both husband and wife
are practicing.
JANANI programme
in Bihar
I--------------------------------------------------------------------------------------------------------------------------------------------
(B) POVIDER (CANDIDATE) CONCERNS
Major
Usual Possibilities4 with
staff model
Planners can manage5 with
a combined model
What happens with PMP
model
Basic needs
Mandatory-housing/
food/transport/security/
Felt as ’always meaqer'
Fixed-effort or no effort
Some costs are less thanks to
local residence.
Always eager
Adjusted to services and tasks
High, ever increasing.
Unduly low, tormented
Can live respectfully and socially
useful career.
Limited to directives
Can be woven into the
programme.
Both
Incentives
1 Income
j Seif
' worth/public
I image
1 Learning
I belonging
(sense or")
Professional
security/stabi
lity
Supplies
Upward
Mobility
To Govt, system
fair, because of unionization
generally fail to keep pace with
needs
Limited, (a neglected issue tn
India)
Variable with services and
opportunity
Unduly high
Limited to sales promotion
In between, banks somewhat
on Govt policy
To professional guild and user
community
Ever searching for better
position
Limited, but skills can be
improved.
Self-procured, so usually
ensured.
More equipment, facility
upgrading.
4 Assumes appointment of one primary care worker I each village.
5 Assumes provision of facility on village showing some preparedness, proper candidates etc
7
The CHW: Survivals and Revivals
(C )COMMUNITY CONCERNS
Major
1 Healing:
i (Medical
! needs)
i Access
I
Economical?
' Friendly?
Lasting?
dependable
User control
Usual Possibilities5
6* with
staff model
Only limited, may not satisfy,
may or may not heal.
Planners can manage'' with
a combined model
Good healing t- satisfaction
mandatory for survival
What happens with PMP
model
satisfying it must be, (but
may or may not heal)
Time bound, programme-linked,
not dependable
Ensuring good access is
precondition
Time-elastic, but often
distant. So access is limited
May be free, if not doing
private practice
Can save access costs and
needless medication
High costs, and also
hidden costs
Deoends upon the person
transfers, and visiting nature
makes it look less like lasting
Not really-because of various
factors
Poor, works through long
politico-administrative links.
Professional requirement.
Can be
Professional requnemenl.
Generally
Can be fairly controlled.
Generally dependable and
accountable
Poor control on quality of
care____________
Omnibus scheme on Gramin Lokswasthya Yojna in 10th FYP in
Maharashtra
Even as the CHW scheme vanishes in thin air and pada health workers scheme is equally
evanescent, the primary care group of Maharashtra was arguing for a comprehensive and realistic
alternative scheme for needy villages. Thanks to various'circumstances and forces, five years of
efforts resulted in inclusion of GLY in the 10th FYP of Maharashtra. I call it 'omnibus' for various
strategic and conceptual reasons. The scheme will be tried on a pilot basis in 1000 villages first,
with help of NGOs to start with. Later it will be expanded. We are trying to mainstream it with help
of the Open University, legal status under MMC, panchayats & SHGs. The accompanying summary
note may be helpful8. .
References
1.
Dasgupta, Home Village Doctor, Khadi Pratisthan Calcutta, 1942
2.
WHO Technical Report Series no. 780 Strengthening the Performance of Community Health
Workers in Primary Health Care, WHO Geneva 1989
3.
Frankel, Stephen, in Overview, The Community Health Worker, OU Press 1992, pp 1- 62
4.
PHA Calcutta document Resolutions: p3 : PHA Secretariat Dec 2000
5.
Ashtekar Shyam, Mankad Dhruv, Who cares" Rural Health Practitioners in India: Economical and
Political Weekly, February 3-9, 2001 pp448-45
6.
Rohde and Hema Viswanathan. The Rural Private Practitioner, OU Press Delhi 1995 pp 37-57
5 Assumes appointment of one primary care worker in each village.
1 Assumes provision of facility on village showing some preparedness, proper candidates elc
3 A larger note submitted the planning board is available tor those who want it
The CHW: Survivals and Revivals
GRAMIN LOKSWASTHYA YOJNA
(Submitted by Bharat Vaidyak Sanstha, Dindori, Nasik on behalf of PHC Group,
Maharashtra
Even as we are nearing the end of year 2000, four out of five of our villages in Maharashtra
do not have any resident health care facility. Even today many mothers die during deliver/ and
health messages do not reach the poor and illiterate women. Vadi-Vasti Davakhana Scheme, will
solve this problem without the need for large investments by the Government. What's more is that
the scheme is people-owned and sustainable, and will immensely improve the reach of National
Health programmes. NCP, which is part of the present Govt, had promised in its election manifesto
to implement Gramin Lokswasthya Yojna.
Vadi-Vasti Davakhana: Roles and Resources
Place and Soace for the 'Davakhana'
Given by village Panchayat /people
Cost of medicines for treatment’
To be shared by the Govt, and the people
Remuneration for the 'Vadi-Vasti
Doctor'' /Health Practitioner
Training of Vadi-Vasti Dr.’/Health
Practitioner
Monitoring of Vadi-Vasti Dr. /Health
Practitioner
Basic honorarium from Public funds routed through Panchayat or
other local body PLUS service fees fixed by viilaoe Panchayat.
Certificate course followed by continuing education.
Technical - PHC Group + Local NGO + PHC MO
Social & Cost - Panchayat + local SHGs.
What would be the benefits of the scheme?
1.
Resident Health Care Facility will be created in every village providing health care for all.
2.
All National Health Programmes' coverage will increase substantially.
3.
Reduction in Infant and Maternal Mortality rates.
4.
Effective linkages with the Public Health infrastructure for appropriate referral and reduced
burden on the government hospitals.
Who will implement the scheme7
The PHC Group*1® will help Maharashtra University of Health Sciences and/or Yashvanrao
Chavan Maharashtra Open University to develop and conduct training course and continuing
education. Technical monitoring will be by local NGOs and PHC MOs with inputs from the PHC
Group. Social & Cost-monitoring will be done by the Village Panchayat and local self Help Groups
What is the State Government's role?
'
'
*
Recognize the proposed certificate course under S/28 of Maharashtra Medical Council Act.
Resolve to establish and facilitate linkages of the Vadi-Vasti Doctors'/Health Practitioner with the
Primary Health Centers and the National Health Programmes.
MUHS I YCMOU to be involved in the training.
'
Involving Primary Health Centers in training and technical monitoring of Vadi-Vasti
Doctors'/Health Practitioner's work and supply of NHP medications to them.
'
Contribution to basic honorarium (routed through Panchayat or other local body ) and towards
cost of drugs
‘ Modified WHO Primary Care lisl
' Village residenl. selected and (rained under lhe scheme
1 Detailed curriculum, training methodology and retraining strategy proposed under the scheme
@ The PHC group: Individuals and organizations working for decades on lire issues c: Primary Health Care like). Dr
Shashikant Ahankari. Dr. Anant Phadke. Dr Abhay Shukla. Dr. Dhruv Mankad. Dr Kranli Raimane. Dr Panka, Gandhi. Dr .'.lira
Sadqopal, Dr. Deepli Chirmulay, Dr Ashok Kale and Or. Shyam Ashtekar (Coordinator)
Contact: Dr Shyam Ashtekar, Bharat Vuidynka Sanstha. Contact. Si it am wadi. MG Road. Nasik, -122 l'l) I,
Telefax 0253-580147, email: ashtekareibnin6.vsnl.net in
In Search of Self-Sufficiency the Field Experience of a
Department of Community Medicine
RAVI NARAYAN,
PARESH KUMAR
up/with the discovery of a 'model'
approach. In each area we tried to
build the best possible approach
Medical College Bangalore, has
been involved with the development with the resources available
following an informal process of
of community health projects in
analysing the local situation.
many villages of Karnataka. The
primary purpose of the depart
Case studies
ment's mvoivement in health care
he Department of Commu
nity Medicine of St John's
T
delivery was the establishment of
health centres for training intern
doctors who have a compulsory
three months rural posting during
their rotating internship. This is a
university and curriculum regula
tion.
From the very beginning it was
decided that health projects would
he planned and evolved in such a
wav that the community would be
encouraged to participate in the
-------_g 2ncj management of the
centres. This decision arose from a
pragmatic assessment of many
other programmes that had been
externally funded.
Whether the fund was governmen
tal or voluntary, private or foreign,
it was found that the process of
externa! funding resulted in the
suoer-imoosition on the local com
munity of a system planned,
organised, budgeted and executed
for the community through deci
sions taken outside the community.
Such systems were often irrelevant,
and consisted of structures that
were too costly, too unwieldly and
unrelated to local reality.
From 1973-1983, the department
was involved with the development
of three health care programmes in
three different areas. While each
project drew inspiration and
caution from the previous experi
ence. we tried NOT to get caught
32
Village M: The first venture was
an attempt to tag on a health
function to an existing successful
milk cooperative. Village M had
responded enthusiastically to the
promotion of dairying by the gov
ernment. Forty five per cent of the
families owned milch animals and
were members of a registered milk
cooperative. The production of
milk ranged from 2500-3000 litres
per day. The milk cooperative
committees agreed to a health cess
of three paisa per litre of milk to
be deducted at source when the
payment to farmers was made. A
sum of Rs 2500-2700 would thus be
available every month for a basic
health care system.
The health fund collected was used
to employ a doctor and a nurse.
Three villagers were selected for
on the job training as dai, dis
penser and records clerk. Apart
from staff salaries the fund was
also used for drugs, rentals,
travelling allowance and
other materials.
Resources like vaccines, vitamin
and iron supplements, contracep
tives, surveillance of communicable
diseases and health education files
and pamphlets were tapped from
government health centres to avoid
duplication. The college depart
ment provided supportive technical
HEALTH for (he Millions June 1990
supervision and posted interns to
assist the health team to various
activities. It also supplied some
equipment through courtesy of
UNICEF.
The health cooperative was man
aged by a committee consisting of
representatives of the milk coop
erative, the department of commu
nity medicine and the government
health department. This met every
month to plan the activities of the
centre.
Fifty five per cent of the families in
the village were not members of
the cooperative. These were
families that were involved in
sericulture (25 per cent) and
landless labourers and harijans (30
per cent). In order to ensure an
equitable and just availability of
health services to the member and
non-member sections of the
village, the following policy was
evolved.
Preventive and promotive services
which included immunisation,
vitamin and iron supplements.
ante-natal and post-natal check up,
chlorination of wells and so on was
made available free to all members
of the community. Curative
services were free for members but
non-members had to pay. A
section of the village through this
cooperative endeavour, were con
tributing the total costs of non
curative primary health care
services available to all. This was
an added and unusual benefit of
the scheme.
The leaders of village M showed
great foresight, entrepreneurship
and ability to.handle crisis. This
was very much evident in some of
(he decisions they took as the
programme evolved.
Six months after starting the pro
gramme the village leadership
boldly decided to sell milk to a
private party rather than the
government dairy because of the
gover:—ent's indecision to change
proctr ■ — t trices in spite of
increasing cants. This was done in
spite of the risk involved in the loss
of certain subsidies promised by
the government dairy. Even more
remarkable was the decision to
raise the health cess from three to
five paise per litre in view of the 25
paise increase in returns per litre.
In later ; :
there was a shift in
the economy of village M from
dairying to sericulture due to a
massive World Bank supported
programme in that district. Milk
production decreased to 900 litres
per day and the health cess had to
be increased to 15 paise per litre to
maintain committed costs. Sericul
ture boomed in that area but
efforts to cooperatisc it had failed.
The options available to the centre
were to either ciose down or start
charging for services irrespective of
membership. Some money had
been saved over the years for
investment in a chilling piant. With
decrease of miik production this
had become unnecessary and the
leaders with their usual foresight,
unanimously decided to invest the
money in a health endowment for
the centre in taxed deposits in one
of the local banks. The health
cooperative thus became a health
endowment.
Nine years later, the village leaders
once again put aside some coop
erative savings and tapped addi
tional funds from a government
scheme to invest in the construc
tion of a perm'■-.ent building for
the health centre as well as a
—edical officer's quarter. Till then
’he centre had functioned in a a
rented building. It is to the credit
of the village committee that even
ten years after involvement, the
department of community medi
cine was not called upon to invest
■n a single brick in the village 1
The relationship which evolved
between the villagers and leaders
of village M and the professional
staff of the centre and department
was one of respect and partnership.
The professionals had to change
their patronising and superior
there was little dairy or sericulture.
The church was an important
feature of this village and had over
the years responded to the need:, of
the people through sponsored
charity and distribution program
mes.
It was decided to start a health
programme funded initially by
Every new investment, whether it was for polio vaccines,
refrigerator or even health education materials,
could be made only after the health committee was convinced
of the need. This sometimes took weeks or months.
In the years to come this patience resulted in a confident,
active and sound local leadership ...
attitudes, often the result of
‘professional education’, and get
used to discussing with the leaders
and villagers as equals and co
workers. The health team’s role
changed from the traditional one
of ordering, advising and prescrib
ing to a new way of sharing and
awareness building.
Since the community was paying
for the whole scheme, another
important learning experience
which the team had was on the
need for patience with representa
tives of the community. Every new
investment, whether it was for
polio vaccines, refrigerator or even
health education materials, could
be made only after the health
committee was convinced of the
need. This sometimes took weeks
or months. In the years to come
this patience resulted in a confi
dent, active and sound local
leadership which was neither sub
servient nor dependent.
Village S: At the request of a
Women’s League, the Department
adopted village S to organise a
health programme. Unlike village
M, the economy of village S was
very different. Most of the villagers
were wage earners who had jobs in
the city. They commuted to and fro
through a government bus service.
Very few families owned land and
grants from the Women’s League
and a foreign funding agency. A
committee consisting of local
leaders, the parish priest, the
Medical Officer of the project and
representatives of the Women's
League and the Community
Medicine Department was formed.
This committee, in addition to
managing the centre, was required
to initiate development program
mes in the village which would
gradually contribute to the health
fund and take over some of the
costs of the programme.
Over the years the committee and
more specially the medical officer
and her husband, a social scientist
(both resident in the village)
initiated a poultry, a women's
handicraft centre, a dairy and other
programmes. They organised a
youth club and a women’s club to
plan and run the development
programmes. The health pro
gramme which was initiated con
currently concentrated on maternal
and child health and two village
girls were trained informally as
heaith workers to assist the
medical team'.
However, all attempts at tapping
local financial support for the
heaith programme failed. Il was
neither possible to put a health
cess on development activities nor
convince the villagers to pay for (he
June 1990 HEALTH for (he Millions
33
services. Years of church spon
sored welfare had created a
stubborn dependence. In the past,
appeals to the Bishop routed
through proper channels had
.. ■_ most of their needs —
looc, jobs, education and medi
cines. They failed to be convinced
of any need for self-support.
were keen to establish local health
centres. In each of them, village
health committees were formed to
manage and supervise the centre,
operate local bank accounts,
supervise funds. The assumption
made was that payment for service
even on a no-profit, no-loss basis
would run up a deficit if no patient
77te village leaders participated, in village committee meetings
enthusiastically, offering advice, providing frank feedback
and criticism, registering protest, offering support and
encouragement when necessary, sharing perspectives and
ensuring execution of decisions
Villagers from neighbouring
hamlets were ready to make
contributions, including fee for
services but in the absence of any
participation from the two primary
ullages attempts at self-sufficiency
were given up. To this day, the
centre continues to be funded from
external sources.
V:".-gcs of A-Block: In 1978, the
State Government affiliated a
government primary health (situ
ated in Community Development
Block A) to the community medi
cine department. This centre
catered to a population of 72,000
spread over 101 villages. For two
years the Department had a pro
gramme of supportive participation
in all the activities of the health
centre especially its maternal and
child health and family welfare
programmes. Then it was decided
that the department team would
try and establish health care pro
grammes in the sub-centre villages
of the block using a strategy
evolved from the experience in
villages M and S. These program
mes would tap village resources
and enlist community participation
in their organisation. They would
also compiemcnt/supplement the
extension work of the government
health centre auxiliaries.
Villages were identified, which
J4
was to be refused treatment. Since
there was a sizable proportion of
the community who could not
afford even the minimal costs, sup
plementary collections were vital to
ensure the viability of the centres.
A nationalised bank was tapped, by
the department for basic infras
tructural costs for initiating such a
programme. These included costs
of a jeep, a social scientist’s salary,
internship stipends and seed grants
per health programme for equip
ment and initiating a roiling drug
bank of Rs. 3000 per centre.
In about a year’s time villages
B,G,Y and H were identified and
four small programmes initiated.
Village health committees were
formed in al! of them. These
committees found accommodation
for the doctors (interns from the
medical college) and the clinic. The
types of accommodation were a
village cottage, a room of the
village school, an unused parish
■priest’s quarters and a village
teacher's quarters. Rules for
payment of services were drawn up
and a committee member was put
in charge of supervising collections
and maintaining accounts. Follow
up of defaulters was the responsi
bility of the committee.
Supplementary income was raised
by each 'village committee in
different ways. In one village
HEALTH for lhe Millions June 1990
donations were collected from the
village families: others made col
lections during festival time, put a
health cess on a milk coopcraiivc
collection, tapped, panchayat
funds, got a water diviner to
contribute his earnings during a
season, or contributed the pro
ceeds of a village drama to the
fund, and so on.
In addition to financial resources, a
host of other non-monetary re
sources were also contributed to
the centres. These ranged from
repair and maintenance of clinics
and residences with materials
obtained locally; hospitality for
visiting staff and specialists during
camps; assistance in the organisa
tion of formal and informai health
education programmes as well as
village dramas and street theatre:
prizes for baby shows; village vol
unteers for camps and clinics: par
ticipation of school teachers, dais
and youth clubs and women's clubs
in organising programmes and so
on.
The village leaders participated in
village committee meetings enthu
siastically, offering advice providing
frank feedback and criticism.
registering protest, offering
support and encouragement when
necessary, sharing perspectives and
ensuring execution of decisions.
This active involvement in decision
making and management ot the
centre turned out to be an impor
tant component of the dynamic
totality of self-sufficiency. No
doubt political wrangles, personal
ity clashes and differences of
opinion were part of the process
but the overall experience was
quite positive. Three village centres
continue to function to date. Only
one centre was closed down and
this due to local politics which pre
vented the committee from func
tioning effectively.
These three case-studies ( seven
centres) represent a small attempt
in the search for self-sufficiency of
community health programmes. It
is important to clarify that these
were evolving processes with
phases of smooth functioning and
points of crisis. More important
than the micro-level study and
analysis of these projects, is the
derivation of broad conclusions
based on the reality of these field
experiences which pertain to the
relevance and rhetoric aspects of
this whole quest for self-suffi
ciency.
Self-suffic^ncy: Relevance and
rhetoric
Wo are convinced that given an
open, informal, decentralised
approach, it is possible to initiate
and sustain processes of self.'.ufficiency in health care program
mes. Such processes can help take
over a substantia! part of the
recurring costs of a programme.
Wider definition
of self-sufficiency
Self-sufficiency as a goal should
not be visualised in its narrow
definition of local finances or
monetary resources but must
include a host of non-monetary
materia! resources and human
resources in the community. In its
broadest sense, active participation
by represe-'.r.ives of the local
community in decision making in
the programmes should be a
crucial component of the coal of
‘self-sufficiency’.
Funding 'process’ not ‘structures’
in the present socio-political
reality, funding from external
sources. ? ? the'-' government or
private, industrial house or foreign
funding agency will continue to
remain a starting point for health
care intervention programmes,
even those in quest of self-suffi
ciency. however, if such external
funds were used cautiously to fund
•'rc-cer.s rather than constructions’
nr structures', then self-sufficiency
would make some headway. Large
buildings not only raise expecta
tions in villagers but convince them
of the vested interest that project
personnel will have in the continu
ity of an externally funded pro
gramme. Both these put a stamp
on future dependence and stimu
late local initiative to extract
advantage and exploit the project
rather than contribute to its future
support or development. In the
Indian experience, buildings are
quite often available for use in the
village. In our experience, invest
ment in brick and mortar is not
only unnecessary but also counter
productive to the quest of selfsufficiency.
Tapping government sources
Even when non-governmental or
ganisations are involved with .
health care programmes that aim
at self-sufficiency, our experience
has shown us the importance of
tapping all the available govern
ment resources as part of the
strategy. Apart from preventing
overlap or duplication of efforts,
tapping government resources,
especially if it is done through
generating pressure groups or
some degree of social activism in
the community, is almost always a
good policy. Il ensures that the
NGO realises its catalyst role and
does not get carried away with in
stitutional or project development
nor the pursuit of an unrealistic
parallel services.
Maintaining status quo
Our experience evaluated from
the perspective of social justice for
the under-privileged and poorer
sections of the community raises
serious concern about the pursuit
of self-sufficiency as an end by
itself. If financial self-sufficiency
becomes a primary goal of the pro
gramme then this will ensure that
the main contact of the programme
will be with the existing leadership
of the village which in the Indian
situation consists of land owners
and rich farmers.
Two experiences clearly taught us
the subtle but definite way in which
this aspect of village reality
operates:
* When harijans and landless
labourers began to invest in milch
cattle, because jobs in sericulture
provided alternative green fodder,
the village leadership intervened by
closing cooperative membership
and forcing prospective members
to sell milk to the cooperative
rather than participate in it - thus
effectively keeping out the lower
sections and affecting the availabil
ity of health services to them.
* Another case in point was that
village leaders had agreed that Rs.
200 would be set aside every month
from the cooperative fund for
concessional or free treatment of
poorer sections in village M. When
there was an economic crisis due to
shift in economy from dairy to
sericulture this subsidy was slashed
making health services once again
inaccessible to the poorer sections.
Unethical Medical Practices
With the escalating cost of drugs.
health teams committed to quests
of self-sufficiency are often pres
surised to balance the budget by
resorting to practices such as
administering of unnecessary injec
tions and tonics, selling of pnysicians’ samples, prescribing unnec
essary drugs. These practices heip
to increase the returns. However
even though these practices may be
directed towards the affluent
sections of the community, they arc
in principle unethical in both a pro
fessional and a social sense and not
compatible with the principles of
community health.
(Com.’/mcc on page 44 j
June 1W0 HEALTH for the Million.-.
What next? A plan of action
At the cad of four days, out of
the floating, colliding, and explod
ing of issues, a plan of action
somewhat miraculously emerged.
It addressed the workshop’s many
recurring themes. First, a commit
tee was formed to pursue the
acquisition of management skills
and the documentation of heal;;.
financing experience.
Second, a commitment was made
and a committee formed to
increase the sector’s advocacy role
in policy making; particular priority
was placed on regulation of the
private health sector.
Finally, the importance of of
continuing the debate over the
sector’s future directions was
asserted.
To this end. a second annual health
financing meeting was scheduled.
- '■fadeline Hirschland has been a
consultant with VHAI on health
financing. Her background is in the
inancial management, administra:ion and politics of voluntary
organisations.
/ This report is based on the work
shot} papers listed below, presenta
tions, and give and take during
animated and often fast-paced
discussion. As the presenters alone
are explicitly referred to in the text,
we would like to acknowledge and
thank all the workshop participants,
many of whose ideas are included
above, for their contributions to this
evolving assessment of health
finance in the voluntary sector.)
Dave, Pr:;. ‘ Community ana c
financing Health Programmes;
Experiences from India's Volun
tary Sector’’
(Cvnunued from pa^e 35 )
Duggal, Ravi, “State Health
Financing and Health Carp
Services in India’’
Ghosh, Sanjoy, “The Gas? of
Urmul Rural Health and Develop
ment Trc-.t”
Jajoo, UN, "Financing of Health
Projects; Mahatma Gandhi
Institute of Medical Sciences: The
Sevagram Experience”
Mahapatra. Prasanta. “The Need
for Developing a Svstem of SubAllocatior. of Resources for Health
Instituti-r.s in Developing Coun
tries”
Menon, Raja. “Income Generating
Projects for Health Fmanci.-.r’
Menon, Raja, “Heait.-.
The CINT Experience 1
-
Mukherjee, A.K., “Government
Funding of Health Care”
Kumar, .'.resh and Ravi Narayan,
“In Sear. •; Self-sufficiencv: The
Field Experience of a Department
of Community Medicine”
Poddar, D.P., “Financing of Health
Projects: WBVHA CDMU Experi
ence"
Prabha, Sr., “Financin' - 'Health
Care - The Expencr. :c ■■; RAHA
Serman, Peter, “Information
\'eeds for Programme Financing”
Rao, K. '.'mkateshwara, “Financ
ing of
,1th Care - The Experi
ence of Voluntary Health Services”
Berman, Peter and Priti Dave, “
Experiences in oaving for Health
Cure -- India's Voluntary Sector”
Sharma, S.C., “Government
Funding of Healthcare Program
mes”
Bhagalt. A.K., “Management In
Talwar, Prem P., “Strategies for
Development of Technical Skills
Among Voluntary Organisations:
Some Experiences”
i''.rmation and Supervision"
HEALTH for ihe Millions June 1990
The goal of arriving at some sort
of a model project in one village
which can then be replicated in
every other village has plagued the
organisers of community health
programmes all over the world.
Our experience has clearly shown
mat this pursuit of mod. . _pproaches is nonsense ir. _ _ ity.
In the final analysis, sei.’- ufficency
in terms of generating .. cal
community resources, be they
monetary or material, should be on
important but not exclusive objec
tive of a community health pro
gramme. When it is exclusive it will
ultimately keep out the poorer and
under-privileged groups in society.
For self-sufficiency to mean much
to people and particularly the poor,
the good should be reappraised
and strengthened in its human
sense of participation in planning
and active decision making.
Community health programmes
would then strengthen the people’s
own ability to plan and organise
programmes for maintaining their
own health. These would mear. _h
increasing commitment to dem;J.ifying m^'icine, health education.
skill transi_r, promoting autonomy
and improving group relationships.
Only such a process would make
the pursuit of self-sufficiency
’relevant’ rather than ‘rhetoric.
- Ravi Narayan and Paresh Kumar
are both at the Department of Com
munity Medicine, St. John’s Medical
College, Bangalore .
(This paper was first presented at
the ACHAN workshop on "Selfsufficiency in financing community
health programmes — rhetoric or
reality" held at ECC, Whitefield.
Bangalore, in January 1983. )
An alternative learning
initiative for young
persons contemplating
community health work
as a career vocation
Building on CHC's
experience and on
the social paradigm
PROMOTING CAREERS
IN COMMUNITY
HEALTH & PUBLIC
HEALTH
A Fellowship /
Internship Scheme
Supported by the
Sir Ratan Tata Trust.
Mumbai, for 3 years till
March 2006.
commencing
1st April 2003
What should the scheme be called?
Promoting Careers in CH/PH - Dr. TiN’s Presentation
1
AIMS
To promote career vocations
in community health through
semi-structured.
flexible.
creative
placement
opportunity in
CHC
in partnership
with selected
community
health projects
in India
Promoting Careers in CH / PH - Dr. TH’s Presentation
2
OBJECTIVES
To foster a deeper understanding and praxis of
community health by :
<>
building on individual needs and pace of participants
4
strengthening motivation, interest and commitment to
community health (personal affective domain)
0
Sharpening analytical skills through study-reflection-self
learning - guidance (cognitive domain)
❖
deepening understanding o f social paradigm of
community health and social context of work in India
Promotin'.; Careers in CH / PH - Dr. Ti\"s Presentation
DURATION & TYPE
a. Two short term internships of 6 months
each :
0
for young graduates of medicine, dentistry,
nursing, social work, social sciences,
pharmacy, other systems of medicine.
4
annually 4 placements.
b. Two short term fellowships of 1 year :
0
for PGs in community medicine / PSM
public health / health management
community health nursing / social sciences
♦
annually 2 placements
Promoting Careers in CH / PH - Dr. T.V’s Presentation
4
5. SELECTION METHODS / CRITERIA
a. Note by them on
□ interviews & discussion to assess social
sensitivity and technical competence.
why and what they
want
to
do7 peer-
□ previous social exposure, involvement
and initiative
reviewed
□ creativity and openness
□ conceptual and intellectual abilities
□ broader knowledge base and interests
□ Social skills, self awareness and
ref lection
□ use a 3 member multi-disciplinary
committee of SOCHARA members
where necessary.
b.
All India eligibility.
Special focus on central, north
and north-eastern India.
Promotin'.; Careers in CIl/' PH - Dr. TN’s Presentation
6. SEARCH METHODS
A.
Announcements
in
health journals (NGO
& professional)
B.
C.
D.
Liaison with health
professional institutions
with quality LG I PG
education
Liaison with training
centres and resource
centres
Lecture discussions with
interns & PGs.
E.
Promotin'’ Careers in C/1. PH - Dr. TX’s Presentation
b
Alerting key persons
during travels and
meetings
7. PROGRAMME OUTLINE
Semi structured, flexible approach
w
A set of core knowledge and skills will be
identified for a curriculum that will evolve
Q
presentation, discussion, reading
O
Participation with graded responsibilities in CHC
activities
Q
Visit one community health project for 1-2
months to learn from action, training, research,
using an integrated approach, writing a reflective
report
Q
Write an article on a selected health topic for
publication
do an annotated bibliography
Q
undertake small research projects with
community health / public health perspectives
Promoting Career. in CH/PH - Dr. TX’s Presentation
A panel of CHC associates and
SOCHARA members will be
available for support
In NGOs selected for field
placements, sp ecific mentors will
be identified. An MoU will be
established. There will be email
contact a& field visits by CHC
staff.
,____________________________________ J
A senior CHC team member /
peer will be designated as
mentor for each candidate
8. MENTORING
Promoting Careers in CH. PH - Dr. T.V’s Presentation
s
9. PERSPECTIVE BUILDING
critical, creative thinking and understanding through:
cum
g
weekly journal clubs / presentation
discussions, team meeetings
g
writing
g
CHC will organise an annual workshop on key
community health issues with innovative community
health practitioners
g
peer-interaction between each other with networking,
background papers, reflections
Promoting Careers in CH / PH - Dr. 7'.\'s Presentation
9
10. PLANNING
a) A meeting with previous participants from
informal phase and some mentors to evolve
programme
b) A meeting of organisational heads and mentors
from NGOs to develop components, processes,
MoUs, review mechanisms
c) Setting up an advisory group to steer and evolve
the process
Promoting Careers in CH / PH - Dr. T\ 's Presentation
10
11. REVIEW AND EVALUATION
a. Annual internal reviews in CHC
b. Concurrent evaluation
- self-evaluation and reflection of candidate
- peer review at end of fellowship
!|
- review by mentor / coordinator - quarterly / final l|
c. Ongoing informal feedback from participants and :|
mentors
d. Follow up and tracking of fellows, and helping with I
placements in community health programmes. |
e. Terminal external evaluation - in middle of third year I
- to plan for continuity, modification or
metamorphosis, possible into a University linked
course.
il
I
Promoting Careers in CH PH - Dr. TX's Presentation
I I
INTERNSHIP / FELLOWSHIPS IN COMMUNITY HEALTH (SRTT)
COMMUNITY HEALTH WORKSHOP - 1
14.16th April 2004
Questions for Panelists/facilitators
. Globalisation and Right to Health Care
All “progressive” reports on health reforms and ‘health for all’ have spoken of
“mass movements” or community involved initiatives (as opposed to community
based / centered initiatives). However, mass movements in health are relatively
unheard of. Over the years have we lost that vision or is it that, mass movements
and initiatives involving communities are difficult / not possible in our current
situation.
2. Defining the components of Right to Health Care and also the linkages with the
Access to Essential Drugs, Right to Food / Water etc., and other campaigns.
3. How do we as civil society get together to work for ensuring the Right to Health
Care! Ways forward.
4. In the context of the middle-class and the rich having access to reasonably good
private health care in cities, towns and even large villages, is a mass-based
campaign possible?
5. When talking of community health and primary' health care, shouldn’t the means
of our campaign also follow tire principles of these concepts?
6. In the context of globalization, are forums such as PHM being realistic and
practical by taking principled stands against WTO, privatization, etc., and
shouldn’t it instead gear itself to find solutions in tire existing scenario?
7. Isn’t the ‘Right to Health Care’ campaign in India too legalistic (meaning preferring the legal route over others).
8. Discussion around the changing patterns of investment by agencies like the
World Bank (with investment in health decreasing from the state) and the funding
agencies deciding the priorities of health care in funded areas!
9. Issues surrounding Brain Drain and how this phenomenon affects the health care
delivery in developing countries!
10. Who decides about research priorities globally - why is most of the funding still
going for first world diseases and those diseases which will provide more profits
to multinationals? What is the role of WHO in this?
11. Positive outcomes of Globalization like the proliferation of the WWW through
which we can reach out to the other parts of the world, know practices there and
compare, know what is banned where; role of the information highway in
facilitating transparency.
1.
. Community Health Workers
1.
2.
3.
4.
5.
6.
7.
8.
How can we learn from past experiences and design better CHW programs? Are
they still relevant?
Successful CHW schemes as well as those which were failures.
What all should the CHW be doing? And what is out of bounds?
How does one prevent CHWs from becoming “quacks/injection doctors”?
Whether or not pay? Who should pay?
Who should the CHW report to?
What are the problems in upscaling the CHW scheme from a successful NGO
experiment to a public program level?
Why is there a sudden pessimism about the CHW scheme?
How has gender played a role in CHW/CHV scheme - as far as I know, the JSR
scheme in Madhya Pradesh had mostly or all males working while the Mitanin
scheme has only women working in the system? Which one is beneficial?
10. Is it better to have a Community Health Volunteer. (CHV) scheme where the
CHV is not paid then the CHW scheme? (the Mitanin scheme being a CHV
scheme)
9.
C. Community Health Financing
Why community' health financing is important?
What are the various models of community health financing tried nationally and
internationally?
3. A few success stories in community health financing and a few failure stories
4. How did conununity' health financing evolve? (a brief history)
a) Who pays?
b) How much do they pay?
c) What do they pay?
d) How much do they pay - they default on payment?
e) What form of payment is there? (like the Jowar scheme of MGIMS)
5. In very poor communities is it possible to have community health financing?
How?
a) In a mixed community of poor, middle class and rich, how to work out
community health financing?
b) How to assess the capacity' of people to contribute to community health
financing?
6. Is Community Health Financing possible on a large-scale?
a) How do we upscale?
7. What is the role of the government in these schemes?
8. What is the role of insurances schemes - public or private in community health
financing schemes?
9. When we are calling it community health financing, how do we ensure that the
community' has control over the scheme?
10. To what level of care should the scheme cover costs? Should there be a limit on
costs?
11. Should it be only for acute conditions or also for chronic conditions?
12. What is the difference between community health financing and profit oriented
medical industry?
13. Can you keep offering scheme coverage to a family that has repeated pregnancies
- say more than three or four - and thus spend precious community resources on
a planned event? Would you not be denying the reproductive rights if you don’t?
Who decides?
14. How to deal with situations where poor people go into massive financial crisis
due to profit oriented health care?
15. What are the other ethical issues associated with community health financing?
1.
2.
(Contributers: Anant, Mathew, Naveen)
COMMUNITY HEALTH INTERNSHIP CUM FELLOWSHII
SCHEME
MENTORS REPORT FROM FIELD PLACEMENT
Points to be covered (check list)
1.
Attendance
2.
Punctuality
3.
Regularity
4.
Work I labit -
5.
Tempo of work
6.
Sense of responsibility
7.
Student found to be a hard worker
8.
Professional development
9.
Sense of Commitment
10.
Ability to take initiative and leadership
11.
Level of interest in work
12.
Level of self awareness
13.
Sensitivity to the problems
14.
Ability to respond objectively, promptly and appropriately
15.
Ability to manage workload
16.
Ability to use integrated practice skills consciously and appropriately
17.
Any other comments and suggestions
Date :
Place
Name & Signature
COMMUNITY HEALTH CELL
COMMUNITY HEALTH INTERNSHIP/FELLOWSHIP
SCHEME
Note for Mentors
*
Background, objectives and structure of the scheme
The Community Health Cell (CHC) has over the past two decades
provided short term placements for young professionals wno
were in the process of considering / beginning or reflecting on
their own personal commitments to community health. They
spent 3-12 months at CHC.
The learning process was
individually oriented, with peer support, short assignments, self
study, presentations, writing of reports etc.
Over 95% of
persons continue to work in community health.
Through the internship/fellowship scheme, which commenced in
April 2003, this learning / reflection opportunity will be made
available to a larger number of persons. CHC is being supported
by the Sir Ratan Tata Trust, Mumbai for the first 3 years of tne
scheme (April 2003 - March 2005). CHC will build on past
experience, developing a semi - structured learning program
through an ongoing participatory process, while retaining
flexibility and individual orientation. Every year six persons from
multi disciplinary backgrounds will be taken, two for a one year
period and four for six months each. Selection criteria ano a
selection process have been evolved.
The learning process will include: a) inputs from CHC team
members, associates and others, b) participation in field
programmes of CHC c) field placements in NGOs running
community health and development programmes in different
parts of India d) participation in discussions, workshops, health
related campaigns e) reading, self study, reflection, writing f)
undertaking small research assignments.
A set of core knowledge, attitudes and skills are being developed
as a guideline or checklist. A reading list is also being developed
Feedback from persons who have gone through the process is
being obtained through meetings and correspondence in order to
evolve the programme content, process and structure
*Mentor-n. an experienced arid trusted adviser; an experienced person in an
institution who trains and counsels new employees or students, v. to be a
mentor; origin from greek mentor, the name of the adviser of the young
Tciemachus in Homer's Odyssey.[Ref. Oxford English Dictionary
Each person will be allocated a specific mentor in CHC for the
training period. Mentors will be identified in the field MGOs
where they will go on placement. Correspondence and meetings
with field mentors will also be held. The role of the mentors is
critical to the learning process.
2. The role of mentors
Each mentor will have one or two interns / fellows under their
guidance. The allocation will be decided latest by the end of the
first week of placement by the coordinator in consultation with
all concerned.
The choice will be based on the needs,
background and interest of the student and the area of
experience, expertise and interest of the mentor.
The mentor will be the person responsible for the overall
guidance, nurture and development of the person placed witn
her / him. The relationship will be of partnership, with mutual
respect and learning. Regular discussions will be held at a
frequenc/ decided mutually, but not less than once a week.
Submission of written reports will also be discussed mutually.
Previous experience has found that reflective reporting of
events, monthly process reports and writing on health related
issues helps in deepening ones understanding.
The mentor will help to plan the overall direction and structure of
the placement within the overall framework of the scheme, in
consultation with the student. While the senior CHC team as a
group will develop the schedule of structured inputs the mentcwill a) arrange the field placements in Bangalore / at CHC; b)
identify topics for assignments / research, c) arrange the
placement outside of CHC; identifying
the NGO for field
placement and negotiating the linkage within the framework or'
the scheme; d) she / he will keep in touch with the field mentor
in the partner NGO and, e) will establish mechanisms of
communication with the student during this period.
The mentor will refer the students to colleagues in CHC '
SOCHARA members / CHC associates where specialized inputs
are required outside one's own area of expertise. When students
being mentored by colleagues come for discussion, mentors will
share insights, experience and expertise, but will not interfere in
the process of mentorship by the colleague. This is a caution to
avoid’ confusion.----’ Where necessary discussion between the
mentors will be held. It is necessary for mentors to have a
clarity of one's roles and responsibilities and to recognize
boundaries.
If there is a need for change of mentorship, this can be done
through mutual discussions with the coordinator.
If the mentor is traveling for a long period, the students will be
temporarily provided an alternative.
The mentor will write up a 3 monthly assessment or status
report for discussion with the student and the coordinator.
3. Given below is the "Expectation from a Mentor" written by a
young professional who has been on placement with CHC in the
earlier phase.
”1. to discuss the history of community health and also the
history of CHC giving reading assignments and fixing a
time for meetings at least twice a week in
Beginning of week: stock of week and reading and pian
for the week.
Towards
end
of
week:
evaluating
the
week
and
assigning weekend reading.
2.
to coordinate interactive sessions with other team
members on topics of interest and also possibly with
partner organizations.
3.
establishing
a
framework
of
expectations
and
responsibilities that is doable and flexible but is also time
bound so that work assigned gets finished by deadline.
4.
help the candidate critically evaluate and consolidate on
learning experiences from seminars, meetings, field trips.
5.
identify the strengths of the candidate and also help the
candidate to work on his / her deficiencies.
6.
to network with other mentors to ensure uniform
methodology in the overall context to avoid too much
differences in the pace of learning of various candidates
assigned to different mentors.
7.
to not just give to the candidate but also imbibe from him
/ her.
S.
encourage documentation of experiences so as to benefit
others also.
9.
to make the candidate comfortable by being a senior, more
experienced colleague and friend and not just a drill
master.
10.
to ensure that at least the minimum goals and objectives
of both the candidate and the fellowship are met at the
end of 6 months / lyear."
4. The core elements
The core role of the mentor is to facilitate the search for a
deeper meaning that young persons are seeking through
community health. A supportive, encouraging environment, with
some gentle direction will be provided by the mentor, keeping in
mind an ''ashram'' ethos of reflective action. The technical
component will be supplemented equally by a humane
relationship to facilitate the growth of the young person in a
unique way and direction that will be special to each one.
Com y-1 IA-,
INTERNSHIP / FELLOWSHIPS IN COMMUNITY HEALTH
COMMUNITY HEALTH WORKSHOP - I (2003)
&
COMMUNITY HEALTH FELLOWSHIP MENTORS MEETING
Date :
14-16,h April 2004 (Wednesday to Friday)
Venue :
Indian Social Institute. .No. 24, Benson Road. Benson Town.
Bangalore - 560 046. Phone: 23536960
OBJECTIVES
I.
To facilitate a collective learning experience bringing together a select 'ample of
community health innox ators for a dialogue with
future community health
innovators.
2.
To explore some current challenges in 2004
in a
Primary Health Care
Community Health systems context with a particular focus on
a.
Community Health Workers
b.
Community Health Financing
c.
Globalization and the Right to Health paradigm.
• ''
METHODOLOGY
The overall method will be participator)', interactive with the team of fellows playing
a more proactive role in facilitating the process of learning and documenting the key
learning experiences from the workshop. This will include :
ai
Teams of fellows - past and current to identify questions and issues in tiie 3 focus
areas of the
workshop
i.e.. commuhity health
workers, community health
financing: globalisation and Right to Health Care through e group dialogue and
literature review to be sent to resource persons in advance.
b)
Four teams of fellows - past, current and new will facilitate the panel discussions:
document or draw out learnings on charts during the panel process: raimoneuring
the proceedings and integrating the learning experiences from all the sessions for
presentations at subsequent sessions as reports or using other low. cost creative
communication techniques
PARTICIPANTS
a)
Community Health Resource Persons
I.
Narendra Gupta (Prayas. NAPM/JSA. Rajasthan)
2.
Sunil Kaul (ANT). Assam (SOCHARA)
3.
L’lhas Jajoo (MGl.MS). Wardha. Maharashtra
4.
IT. John Valtaniattom. Sangamitra . SOCHARA. Andhra Pradesh
5.
Sr. Dr. Aquinas CRHP. Hanur. Karnataka. SOCHARA
6.
Dr. H. Sudarshan. VGKK
7.
Dr. C.M. Francis (CHC)
8.
Dr. V.Benjamin (CHC)
9.
Dr. Thelma Narayan. (CHC)
10.
Dr. Ravi Narayan. (CHC)
KTFW. Karnataka (SOCHARA)
■ II. Dr. Paresh Kumar. (CHC)
12.
Mr. S.J. Chander. (CHC). and
13.
Mr. Prasanna Subrahmanya Saligram
14.
Ms. Kumudini Kudalkar. SRTT
15.
Ms. Rajani Med. SRTT Representative
b) Community Health Fellows — present and past
I.
Dr. Mathew Abraham - 2003:
2.
Dr. Abraham Mathew - 2003:
3.
Mr. Naveen Thomas - 2003:
4.
Mr. Amen Xavier Kaushal - 2004:
5.
Ms. Shalini - 2004:
6.
Dr. Sandhya. Y.A. - 2004:
7.
Dr. Deepak.
8.
Dr. Rakhal Gaitonde
9.
Dr. Anant Bhan
10.
Dr. Gautam Hazarika
I 1. Dr. Sylvia Selvaraj
12.
Ms. Sowbhagya
13.
Mr. Ameer Khan
14.
Dr. Asha Kiran
COMMUNITY HEALTH CELL
COMMUNITY HEALTH INTERNSHIP CUM
FELLOWSHIP SCHEME (INITIATED IN APRIL 2003)
Background
'
The Community Health Cell (CHC) has over the past two decades provided short
term placements for young professionals who were in the process of considering
or reflecting about their personal interest or commitment to community health.
They spent 3-12 months in CHC. The learning process was person centered
with peer support, short assignments, self-study, presentations, writing of reports
etc. Over 95% continue to work in community health.
During the 1998 CHC Review certain directions emerged.
suggestion for a new initiative was :
One such important
“CHC should consider the evolution of a more structured training programme in
community health, which explores ami focuses on Indian experience and
stimulates participants to the 'social / community' paradigm " (Proceedings of the
CHC Review. April 1998).
The prophetic words of one of our senior peers were more specific:
"Fellowships of appropriate duration may he offered to interested young persons
to expose and involve them, in a partially structured way. in activities of mutual
interest. Hopefully, a small proportion of them may opt for longer association
with CHC. Pei haps the more senior members of CHC should set apart more lime
for cultivating younger people " (Dr.P.Zachariah. ibid).
This idea was further developed in a note titled
“Towards a Centre for
Community Health ", Subsequent Executive Committee meetings and the Vision
Mission meeting supported the need to strengthen and expand CHC's teaching
role. CHC in 1999-2000 look responsibility for Training of T miners through the
Womens Health Empowerment Training programme; and continued providing
teaching inputs on invitation to a number of academic institutions and to NGO
groups.
Genesis of the Community Health Internship cum Fellowship Scheme
I he idea and details of the scheme look concrete shape through discussions with
the Sir Ratan Tata Trust. Mumbai in 2001
2. They had approached CHC
indicating their interest in health. A recent review of the Trust had recommended
that they focus on human resource development in health. Cl IC was also looking
for Indian sources of funds for its work. The time had come to actualize a
community health teaching programme which would base on the values and
ethos of CHC and build on its experience. As a preparation, in 2001 and 2002,
CHC increased its intake of persons on placement. Most were postgraduate
students in social work, and community health related disciplines.
3.
The Scheme
The community health internship cum fellowship scheme commenced in April
2003, offering an opportunity for learning and reflection to a larger number of
persons. CHC is being supported by the Sir Ratan Tata Trust, Mumbai, for the
first 3 years (April 2003 - March 2005). The team competencies, infrastructure,
work involvements and networks built over the years, supported by our other
partners. Misereor and Cordaid, form the base.
The objective of the scheme is to " promote life options in community health hv
offering a semi-structured, placement opportunity in CHC, in partnership with
selected community health projects
a) Strengthening motivation, interest and commitment of persons for community
health.
b) Sharpening analytical skills and
c) Deepening the understanding of the societal paradigm of community health
(Ref- Project Proposal) ",
A semi structured learning programme has been developed through a participatory
process, retaining flexibility and individual orientation or person centeredncss.
Every year, six persons from multidisciplinary backgrounds will be taken, two for
a one year period, and four for six months each.
Selection criteria and a selection process involving 4 senior CHC team members
have been evolved and become operational. A search process has been set in
motion. A list of core knowledge, attitude and skills, to be nurtured through (he
scheme, has been developed. A reading, list is also ready Feedback has been
obtained from persons who have passed through the informal phase of the
programme. An action plan for Year One has been developed. I wo persons have
commenced the one year internship and fellowship scheme respectively. One is a
dentist; the other has an MD in Community I Icalth. The Sir Ratan Tata Trust has
appointed a consultant for process review and accompaniment of the scheme for
the first year. She has spent a day in CHC interacting with senior team members
and in a meeting with (he whole team along with past and present fellows.
Each fellow / intern is placed with a specific mentor in CIIC who is friend
philosopher and guide. (A guiding note for mentors has been developed.) They
participate in the various field prograinmes and involvements of Cl IC and interact
w ith all Cl IC team members and some of our associates
They take graded
responsibilities in the field programmes and in organizing training programmes in
community health. Making presentations, participating in group discussions,
reading and written assignments, participating where possible in cultural forms of
expression and popular education are undertaken as part of the learning process.
They also have the opportunity to participate in workshops and meetings
conducted by other organizations on themes relevant to their interests.
Placements with field NGOs involved in Community Health and Development in
different parts of the country for a few months is part of the learning programme.
Agreements arc made between the partner NGO and CHC and a field mentor is
identified. Building linkages and communication between the CHC and field
mentors will be done. A meeting of partner organizations is planned. Increasing
peer interactions through newsletters, and organizing an annual community health
workshop on a current theme, is also planned.
The community health fellowship scheme is being seen as a twentieth year
milestone project of the Community Health Cell. It will help CHC/SOCHARA
become a higher level educational and research centre in Community Health. Into
what has been termed the Community Health College (CHC).
3
C_cj rA
COMMUNITY HEALTH CELL
INTERNSHIP / FELLOWSHIPS IN COMMUNITY HEALTH
COMMUNITY HEALTH WORKSHOP - I
Supported by Sir Ratan Tata Trust
Venue : Indian Social Institute. No. 24, Benson Road, Benson Town, Bangalore - 560 046.
14 - 16th April, 2004
TT--I
SI
No
Name of Department / Organisation &
Address
Name
Sigiiaim :
c^/c
Xavier J\‘T4sLftL
11
LCiMUti
IhllL'l^l
( Ooo',)
C hU -
12
IfjrtArl
C^)
1
cytc ,
//-/Tt.t"’
^'TT
/
£Z7 7-
13
1^1 =• f\M nv^i v->.
'
~v<
Xl-.
11
15
16
/> c<
L
u L l ] fl
<?
(^l.)
d't V'f ! VyCH\-|, ( Y| A c
) 11 ) <' o
1*
<;■ (■■)'!■ ■; . -.
i z..
l'l( rHoiL
y-/:7
-;■>■'< h..
lzU.; .f?;i
I'ia.-j;
1/
■
18
<jL A l '~nz^
/-ft>- ’-
>,
Hi i > 11 m
C\.\(
pi-li-l I C vic
1'i
■^l1- /. ' i
BKA'V'-
A’.. ,V.-7.
^cr/Mrr
C/K
2
Name of Department / Organisation &
Address
Name
No
XovOWna/jUcc
^orn&-Haclhan
21
TofeeL TnsHticte. t>f
(SeLOictc o c
p>la.cemen-t
x£ocL<xL
./A y.
c
1
)cuma A-
pA'WSvv •
V)a_J-^3O.
-^O> 1
£
{toM 1 GMj-Ga^
£*2
G
l T ^-
Vv
C-HC •
<L- £T<si^a^
,y
I?/
■'/
GtL
C
<AJZXcp\CX-'K.\ l^CXO
t-<c
/\T) _ /Gy^X^vZXz?
c//<
*
P^Jk
\A< <—-Lb'
A
Zv
4Z/1w —
__ _______________ ______________ _
il
(< Il ;j'
_______________________
3
cl -
SI
No
Name of Department / Organisation &
Address
Signature
A^<j\aA^AVY^
.
wir
zV/Zzy/z?/
7z>/>z/z.
rtc.c.'S/Zfr
/V//-<$"?/
p/tr
*• VK- £«V
!>
$> kJ TN 1 I
GlcOPs&C
R. £. 'DC >~1 T> Tg>5' 1 ST
St. M 1 WAR S
Rtri-i A i_crt
T$£7)EM\?T0^lST
s £,m \
G,AJ\)6iA
A <V|
SA
Com
h
*
PROGRAMME
“ Pro\ isional
Date & I'inie
Programme Details
14'" April 2004
1
Wednesday
i)8.3O -09.30 a.m.
Fellowship (most participants reach venue on 13'" night)
09.30 - 11.00 a.m.
Introductory session
1
•
Getting to know each other
•
Background of workshop
•
Finalising programme, process and methodology.
1 1,30 - 1 >)0 p.m.
Session 1
Panel One : Globalisation and Right to Health
: Panelists
;
1.
Dr. Narendra Gupta - PRAYAS. Rajasthan
2.
Dr. Thelma Narayan : CHC
1.00 - 2.00 p.m.
02.00 - 3.00 p.m.
j
Tea
11.00 - 1 1.30 a.m.
.ISA. Karnataka
Lunch
Group Discussion - Fellows in 2-3
Meeting - 1
group
•
Fellowship Mentors
Right to Health
:
A SWOT ’
Analvsis
•
03.00 - 4.00 p.m.
•
Reports from Group Discussion
•
Panelist responses
•
General discussions
Tea
'>4.00 - 04.30 p.m.
'14.30 - 06.30 p.m.
Repons from current'fellows
(field experience in Karnataka. Jharkhand. Andhra Pradesh. [HF
-WSF)
"6.00-08.00 p.m.
Informal interactionsand own time
1 iS.OO - 08.30 p.m.
Dinner
■18.30 - 09.30 p.m.
Videos
Slides
(panelists
initiatives or campaigns).
to
bring
slides of their work.
15'" April 2004
Thursday
08.30 - 09.30 a.m.
Informal interactions alter breakfast
09.30 - 11.00 a.m.
Panel Two : The CHW Revisited
Session III
Panelists
1.
Dr. Sunil Kaul - CHWs of L’rmul & ANT tRajasthan M
Assam)
2.
Dr. Ravi Narayan - A CHW overview & JSR Review
(Madhya Pradesh)
11.00 - 11.30 a.m.
11.00
-_
Tea
12.00
Noon
Group Discussion tFellows) in 2-3
Fellowship
groups
Meeting-11
•
CHWs-A SWOT Analysis
•
Reports from Group Discussions
•
Panelists responses
•
General discussion.
12.00 - 01.00 p.m.
01.00-02.00 p.m.
02.00 -02.30 p.m.
Mentors
,.
Lunch
War. Disaster & Health
An update by Dr. L nnikrishnan. Convenor. PH.M Circle
02.30 -04.00 p m.
•
Panel Three : Community Health Financing
Panelists
1
Dr. ClhasJajoo : MGI.MS. Wardha (Maharashtrai
2.
Dr. H. Sudarshan (VGKK/KTFH/LOKA YLKTA) - Health
Insurance Schemes (Karnataka) -/1>«.
3.
Tea
®
Group discussion - Fellows 2-3
groups
Community
M .
h .
Fellowship Mentors
Meeting - 111
Health
SWQT Analysis
C..H a^’Ka-J oan;.
■
Representatives: ACCORD. Gudaluri Tamil Nadu).
04.00 - 04.1 5 p.m.
04.15 - 05.15 p.m.
'•< ■
Financing
\
i 1)5.15 - 06 15 p in.
1)7.00 - 08.00 p.m.
•
Report ot group discussion
•
Panelists response
•
General discussion
ANT - An Overview t- Dr. Sunil and Jennifer Kaul. . ANT Assam
i 08.00 - 08.30 p.m.
()8.30 - 00.30 p.m.
Dinner
Videos
Slides
(panelists
to
bring
slides of their
work.
initiatives. campaigns)
*
16'1’ April 2004
! Friday
i 08.30 -09.30 a.m.
9.30 - 11.00 am.
Informal interactions after breakfast
Creative presentations and reflections bv Fellows on learning
experiences of 14lh and 15"’
1 1.00 - 1 1.30 a.m.
1 1.30 a.in. - 01.00
Tea
Looking ahead - (panelists and fellows)
: p.m.
01.00 - 02.00 p.m.
Lunch
* prov isional
NOTE:
Some of the resource persons
panelists
who are ’mentors' of the Fellowship
Scheme will meet with core CHC team members during the group discussions lime to
explore and further evolve the :;eld training component of the Fellowship scheme.
- Media
RF_COM_H_89_SUDHA.pdf
Export
Not viewed