Neeta S. Rao : Field Swami Vivekananda Youth Movement, HD Kote
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- Neeta S. Rao : Field Swami Vivekananda Youth Movement, HD Kote
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Community Health Fellowship Scheme
June, 04 – Dec, 04
Report
By
Dr. Neeta S. Rao
To rest my tired wings
I perched on a shaky branch.
A hazy dream like desire appeared
To have a nest
To rest and feel secure.
Just then I saw
A flock of friends
Coming with twigs and straw
To help me create
A nest to rest
A yours and mine
To call our own.
- Jagori
Mentors:
Dr. C. M. Francis
Dr. Thelma Narayan
Field Mentors:
Dr. Ulhas Jajoo
Dr. Sundaraman
Dr. Shyla Nandakumar
Acknowledgements
I express my heartfelt thanks to Community Health Cell & Sir Ratan Tata Trust for
having given me this opportunity to explore my area of interest relevant to community
health. This program provides a platform to those interested in public and community
health to get hands on experience by participating in various health related initiatives. It
nurtures and motivates young souls to pursue their goals utilizing their potentials to the
fullest.
I am grateful to Dr. Francis, Dr. Ravi, Dr. Paresh and the entire CHC staff for providing
an ambience encouraging discussions, dialogues and freedom of expression.
I express my indebtedness to Dr. Thelma for being a constant source of motivation and
for guiding me throughout the program helping me identify my interest areas.
Above all I also want to thank my co-fellows and co-interns, for sharing their
experiences and giving invaluable inputs.
Thanks to Dr. Sundaraman, Dr. Jajoo, Dr. Shyla, Dr. Nandakumar and many others for
their timely guidance and support.
Dr. Neeta S. Rao.
Preface
I wanted to avoid the highly egoistic and selfhood word ‘I’ in this report. But unlike
other reports the objective of this is to share my experiences of the past six months of
my journey through the fellowship program, my notions, beliefs, my reflections,
impressions about the community and community health, the changes that induced a
new school of thought and of course about the people ---- the list is exhaustive, with
‘Me’/ ‘I’ at the center. This report might therefore seem to be too self centric!
This report is a brief account of my reflections over various issues and a compilation of
various projects visited and documented during my phase of exploration. It has been
written in the chronological order of my visits and hence might disrupt the sequence of
cogitation.
The first chapter begins with reminiscing the past, the course of life that brought me
here; followed by the beginning of a new phase marked by a period of confusion and
getting prepared for a new start. The third and fourth chapters are a brief account of our
first field visit to Swami Vivekanada Youth Movement at HD. Kote and a visit to the
Foundation for Revitalization of local health traditions, respectively. The next chapter is
a short note on the organization profile of CEHAT, which is titled, as a trip to nowhere
as it wasn’t fruitful in terms of any substantial learning. A Ray of Hope is an annotation
on the Western Regional Public hearing, the event in itself being a ray of hope towards
building a sense of awareness and collectively demanding right to health care for all. The
following chapter ‘In Search of direction,’ is a brief account of the beginning of my
search, my first field impressions and overall learning from this visit. Since there were six
fellows/interns pursuing this program in two batches and we never had the opportunity
to interact with the others and learn from their experience a mid term sharing was
planned, which is documented in brief in the next chapter. Immediately after this break I
visited ACCORD with a co-intern Ameer to know more about the tribals, their lifestyle,
their health and other social and economic problems, and about the organization which
has over the years organized multidimensional programs for the people addressing their
needs-an endeavor beyond health for health. The state level planning and intervention
through SHRC was a crucial learning experience explained in Chapter 10. The second
section comprising of seven chapters is a compilation of various projects
studied/documented during my visit to different project areas.
Table of Contents
SECTION I
1
2
3
4
5
6
7
8
9
10
11
Looking Back
Looking Ahead --- together
The beginning
Thriving towards contemporary relevance
A trip to Nowhere
A Ray of Hope
In Search of direction
Midway through my journey
A voyage beyond health for health
The Search Continues ----Conclusion
1
4
8
13
22
33
36
39
41
46
49
SECTION II
Projects/ Activities/ Organisation – A brief account
12
13
14
15
16
17
18
Community based Health Insurance – SVYM.
Western Regional Public Hearing
Jawar Health Assurance: Beyond the realms of health.
An Insurance Scheme for Referral Services.
Composite Package Insurance for tribals of Gudalur taluk
Supplementary Social Health Insurance Approach
Cost Analysis of Rogi Kalyan Samiti in Chattisgarh
SECTION III
Annex I
Annex II
Annex III
Annex IV
59
62
73
129
136
146
159
Chapter 1
Looking Back
To everything there is a season, and a time to every purpose under the heaven.
A time to be born and a time to die -----
BOOK OF ECCLESIASTES
I can measure the passages of my life by my reflections, inhibitions and a few rich experiences.
Being born in a middle class family in Mumbai, I wasn’t too far located from the slums. It was a
common sight on my way to school everyday----- women cooking food, men and children taking
bath in the open by the side of the pathway, through all the seasons --- summer, monsoon,
winter, spring! But it failed to drive my attention until one day a strange realization dawned over
me. Why are they suffering? Is it the fruit of their ‘purvakarmas’? What if I was born in one of
those families? Its mere destiny and God’s grace that I took birth in a middle class family. I
stopped lamenting on the luxuries of life that I was not blessed with. With a suppressed desire of
doing something substantial for them I passed by them every morning, every evening ----- doing
nothing. Years glided and my ambition overtook my feelings though not completely! I knew
medical profession would serve the dual purpose of serving the marginalised and achieving
academic merit!
The new chapter – After completing B.A.M.S. from Mumbai, which failed to give an insight
into public health, I pursued post graduation in health administration. As a MHA student of
TISS I enjoyed every bit of my curriculum, I was able to relate to issues, express my ideas and
engage in rounds of discussion with my classmates. Though slums were not new to me, I had
never been to one and TISS gave me the opportunity to visit one of the old and dense slum
pockets of Mumbai at Dahisar and the nation’s oldest red light area at Kamtipura. Health status
of people was appalling, people had no drinking water, squatted in the open not too far from the
multiplexes blessed with 24 hr. water supply and more than 2 toilets per house. I was moved by
the stories of people who immigrated to the metropolitan city in search of a job, after starving
for days in their villages being hit by drought, only to be hit by the brutality of the system and
the vagaries of the weather ----- their assets were washed off in the rains! My sleep was disturbed
by the touching stories of women forced by circumstances into the brothel who sold themselves
for a meager 50 Rs. and less per day. The one-month internship in Nainital village, Sitla opened
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my eyes to the problems that people, especially the women faced on the hills. The life
expectancy of women was 50 yrs. and 95% of the women were anemic. Children aspired to
study but due to lack of educational facilities, were forced into the never-ending cycle of family
life. The health situation in rural Karnataka were in no way better, but were of different
dimension. Two years of academic and field exposure opened a new horizon to me.
There was a great amount of unrest after the completion of the course. So much could be done,
but I didn’t know which path to take. Every option had a disclaimer! I chose the safest option of
staying in my hometown with my parents, travelling almost three hours everyday to serve for a
private multinational insurance company. What drove me to this? It was not the pay package or
the comfort of working in a corporate office but my inquisitiveness to know how insurance
works? What is the strategy adopted to ensure financial sustainability of the scheme? What
measures are taken to manage risk? How is risk defined with respect to health? and so on --What did I discover? Though the 11 months experience helped me gain technical knowledge, it
also laid some facts bare – the schemes are so convoluted that it might not necessarily benefit
the insured at the time of need, private insurance is not for charity but for profit or at least seeks
financial sustainability. All my suggestions and proposals were turned off for lack of will of the
company to invest in health insurance. I felt dejected and finally decided to come out of the
monotonous life ----- even if it meant doing nothing.
When the search began ---- What did I want? Where did I want to go? I had no clue. Just
wanted to rediscover myself, unwind my past. Manjunath, my classmate at TISS suggested me to
apply for the fellowship program offered by CHC. He revered Dr. Ravi & Dr. Thelma and said
that they can help me clear my doubts. I was at the crossroads of life where I was totally
directionless and so I decided to apply. But the left half of my brain wasn’t too pleased with this
decision. And so to boost my self-esteem I appeared for the TAA post at IIM (Ahmedabad). To
my amazement I got selected in both the interviews. I still remember the interview taken by Dr.
Thelma in a hotel room in Mumbai. It was 18.30 pm. and being extremely busy she had only half
an hour to spare. We spoke for more than an hour and discussed on various issues. She was so
cordial and welcoming that I spoke without any hesitation and didn’t realize that it was an
interview that would have qualified or disqualified me for the program. Not thinking of the
consequence I openly discussed about my weaknesses and inhibitions. When I left the room I
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was glad ------ though I wasn’t sure of my final decision, I knew that I met a lifetime
friend/guide!
I finally put down my papers, which was outright rejected, and I was offered a better package
and a new profile embellished with a new designation. Indubitably I got attracted to the offer
made. Who would not want a better package, a better and challenging profile? But I was not
comfortable accepting it and questioned myself ---- if I wasn’t able to prove my ability and
contribute substantially in 11 months, how do I envisage doing it now? If they could not provide
me a favorable environment to work in 11 months, how could I be assured of the same now?
Gradually larger issues started bothering me ---
What is the purpose of my life?
-
Have I seen enough of happiness/sorrows of people to be able to decide?
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Where does my heart lie – family, friends or somewhere else; material gains or
something else?
Just not being able to find answers to these questions I just decided to overlook all my
temptations and take the path not tread by many. In the midst of all the confusion and constant
temptation toward IIM, in a flash of a second I decided to join CHC. I walked out of my office,
called up CHC to tell them that ‘I am giving 6 months of my life to you, please take care of me, I
am confused.’
Chapter 2
3
Looking Ahead ----- Together.
The interval between the decay of the old and the formation and establishment of the new constitutes a period
of transition, which must always necessarily be one of uncertainty, confusion, error, wild and fierce fanaticism.
- JOHN C. CALHOUN
So was my state of utter pandemonium! With an aim to gain a deeper understanding about
public/community health issues and hone my skills to enable me contribute effectively towards
building a healthy society, I began my expedition! I was now a free bird all set to explore the
world!
I met Jyoti at CHC and was able to relate to her feelings about health, was glad to meet someone
who thought alike and was as confused as I was. We were in all four, three of us supported by
SRTT. It was an altogether a different experience ---- meeting people from different
backgrounds from different parts of the country. But one thing brought us together ------ a zeal
to explore, a desire to delve into issues by exposing ourselves to the ground realities!
The sessions* – It was a feeling of getting back to the M-School ---- recalling all the discussions we
had at TISS. A wide range of issues were discussed from women’s health, health statistics, policy
issues, health movements to social issues and social reforms all bearing its impact on health.
I was among the few fortunate one’s to have had an opportunity to be mentored by Dr. C. M.
Francis. I however regret for not having utilized this opportunity to the best, especially because I
wasn’t stationed at CHC for long.
Sessions beyond the four walls of CHC were great learning experience, meeting people working
at the grassroots level and knowing their struggle and experiences. Seminars, meetings and
workshops served as a pedestal to share different point of views and meet erudite, experienced
and eminent health activists. It also shoved a sense of dejection due to my inability to interact
with people and express my viewpoints effectively.
Some of the insights gained from these are
*
Detailed feed back report of the orientation session has been submitted by the end of the sessions.
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Education instead of opening our minds has schooled us. To be able to think creatively we
need to break the chains of formal education and look beyond.
The determinants of health are spread through out the canvass of life and society ----
nothing can be ignored and foregone.
Inactive cynicism of researchers and academicians and unbounded optimism of action
oriented activist must work hand in hand for larger and longer impact.
Poor people are not passive receivers of care. It is their right, which they must demand for
which the concepts of health need to be demystified.
Areas forlorn – traditional healing methods, cultural practices which are at the verge of
extinction needs to be saved and revived for the benefit of the people.
The changing economic trends with new economic policies of privatization, globalization
and commercialization are a threat to the economic stability of our nation staking the lives
and earnings of the poor.
Issues on urban health are grave and of different nature as that of rural areas and to be able
to comprehend them the entire process of urbanization and migration needs to be
understood.
Documentary film on Periyaar river, which began with a background score from a malayali
movie Bharya, counting on its cultural significance, unveiled the ugly face of privatization. The
vast spread of water body which is closely interwoven with the life of the local people has its
cultural value is split into bits to be packaged and sold to the highest bidders. It exemplifies on
how privatization and globalization marginalizes environmental protection and human needs,
just for the sake of profit.
Workshop on People’s Charter on HIV/AIDS at ISI - It is a consensus/campaign document that
amplifies the voices of the people affected, infected, living with and suffering from HIV/AIDS,
with an objective to provide a people’s perspective on HIV/AIDS and related issues like access,
rights and trade issues. It is initiated and facilitated by the people’s health movement.
HIV/AIDS was recognized as a public health issue and not merely a medical problem and hence
calls for social and political responses besides medical intervention.
5
CHATA (Community Health Approach for Treatment of Alcohol) – a process of enabling people to
exercise collectively the responsibility to maintain their health with a focus on alcohol related
problem. It includes brainstorming session with different NGOs, building people’s organization,
organize people in rural area, integration of health and development and utilization of local
resources.
Life Skills – Life skills refers to an interactive process of teaching and learning which enables
learners to acquire knowledge and to develop attitudes and skills, which support the adoption of
healthy behaviors. We thoroughly enjoyed the two interactive sessions with Dr. Sheshadri. It can
be effectively used as a tool for prevention of mental illnesses and there are modules designed to
train adolescents in a variety of life skills. Though it is not possible to give a definitive list on life
skills, interplay of variety of communication and interpersonal skills produces powerful
behavioral outcomes.
The orientation session helped us achieve clarity as to what issues we need to look into,
especially when we visited different project areas. The library has an excellent collection of study
materials, which could not be utilized to the fullest as we were stationed at Bangalore for a short
duration.
We thus set our individual learning objectives based on our areas of interest and digressed into
different directions.
My learning objectives for the six months were –
1. To introspect and identify my areas of interest in Community/Public health.
2. To get a clear understanding of the conceptual and operational aspects of different
health interventions.
3. To study the different methods of resource allocation and it implication on the
community and the organization.
6
CourseTo achieve the aforementioned objectives I visited various places/projects during the six-month
internship program, which are as follows –
28/06/04 to 30/06/04– S.V.Y.M. at H.D. Kote.
08/07/04 to 10/07/04- FRLHT
19/07/04 to 11/08/04- CEHAT Mumbai
28/07/04 to 30/07/04- Western Region Public Hearing at Bhopal
12/08/04 to 28/08/04- MGIMS, Sewagram
29/08/04 to 30/08/04- Southern Region Public hearing at Chennai
27/09/04 to 05/10/04- ACCORD, Gudalur
21/10/04 to 30/10/04- MGIMS, Sewagram
01/11/04 to 29/11/04- SHRC Raipur
7
Chapter 3
The Beginning
When old words die out on the tongue, new melodies break forth from the heart; and when the old tracks are
lost, a new country is revealed with its wonders.
-RABINDRANATH TAGORE
From the bustling city to the serene calm and beautiful land of Kenchanahalli, my first
exploration of the tribal life unleashed a New World. This chapter is a mere synopsis of my first
field impression, direct from my diary.
Though primarily with an intention to get an overview of the mission and objective of the
organization (Swami Vivekanada Youth Movement) being translated into action, we moved to
the tribal hamlets; it was more of a guided tour for us, primarily because we did not know much
about the project to be able to demand and the course of our trip was already planned! We did
not confine our roles to mere visitors but also tried to critically analyze the project in the given
context. Though there are active preventive and promotive interventions the approach is
basically medical/curative centric. We drove around 35 kms. to reach Hosahalli to get a feel of
their education program
Education – We visited the Vivekananda Tribal Centre for learning. The school provides
formal education and a platform for the holistic development of young children from tribal
hamlets by encouraging sports. They also provide counseling for further education through
Shikshavahini. It provides every possible facility to the children like well-developed library,
computer education, well-equipped laboratory and above all committed and motivated teachers
and an ambience, which promotes optimum learning. We interacted with primary teacher who
teaches Kannnada language and sociology. His personal experience as a teacher was extremely
good and he termed it challenging as he feels that the traditional system of teaching does not
function successfully in those conditions. He has to follow up with the students and get them
back to school and also ensure that they regularly come to school, which is a Herculean task.
Over the years the enrolment has increased while the dropouts is minimal.
The following day we visited few haadis (tribal hamlet). The first one was Jaagankote haadi – We
met an old man in his 50s but he appeared to be of late 60s. He had been evicted from the forest
8
where he and his ancestors had been living a self-sustained life for ages. On eviction he was
given some land & the government as rehabilitation for the displaced tribal got a house of
cement constructed for him. The forest department now claims that a portion of his land
belongs to them and hence filed a case against him. He was subsequently arrested and
imprisoned for a month. Dr. Bala got him rescued and is fighting for his cause though the case
still remains pending. He got himself operated for cataract and due to the harsh environment in
the prison he is unable to see through one eye. The food quality was also awfully poor, which
comprised of only cooked rice. He earns his livelihood through shifting cultivation, making
baskets and earns around Rs. 15 per day, while by laboring on some other landlord’s land he
earns Rs. 30 per day. He occasionally travels to Coorg in search of work in the coffee plantation,
which fetches him a better wage. Under the PDS for tribal they are entitled to buy grains at
subsidy. Though the stock is generally available it is stored in poor conditions and the poor do
not have enough money to buy the available grains. The government-constructed house is made
of low quality cement, which leaks, and hence the old man stays in a house made of leaves, wood
and grass.
We then went to Brahmagiri haadi – This is the place from where Dr. Bala began his noble
initiative. He practiced in a self-sufficient small place, which is now in dilapidated condition. We
met a localite who was very agitated and unhappy with the SVYM system. He complained that
well educated people visit the place and when they got used to their services they (SVYM)
shifted out without a minimal consideration of what people would face who were now used to
their services. We spoke to few teenage pregnant women and discovered that they both were less
than 15yrs. and had to perform all the household chores, carry water around three to four times
a day from ½ km. distance and as they have no toilet facility they have to defecate behind the
bushes in the forest before dawn. The only intervention aimed at women like them were Iron
and Folic acid tablets, which they had to collect from the health centre while visiting for ANC
check up. We spoke to a dai and discovered that almost 50% of the deliveries were home
deliveries and yet there was no training imparted to these dais.
Gandantur – We met Jannakkamma (name changed) a 35 yr. unmarried women suffering from
breast cancer from the past eight months. She did not reveal about her condition to anyone and
only two months prior to our visit a health worker discovered this. The health worker spent her
money and escorted her to Kenchanahalli hospital where she was admitted for two days. The
9
gynecologist examined her and administered some symptomatic treatment. She discharged her
stating that it is in its terminal stage and is incurable. It is a pitiable sight! ------- Jannakkamma is
unable to work or eat and is in agony, she does not even know what she is suffering from,
thinking that it is just a wound she is hoping it to get cured. She hasn’t even been taught of how
to dress the wound, which is worsening day by day. As she is a non-tribal the hospital is
unwilling to provide her free service.
Learning from the experience –
o There is strong gender discrimination. The wages paid to women is far lesser than that
paid to men. Women are paid around Rs. 25 while men Rs. 35 to 40 for a day’s labour.
The clear difference in the nature of work both at home and in the field is also evidence
to this. SVYM hasn’t tried to tackle this issue despite of several years of active
intervention.
o Equity – More facilities are provided to the tribal by the organization, which might not
reach all the needy people. Thus people like Jannakkamma are denied treatment for
being a non-tribal. On the other hand government hasn’t been sensitive to the poor
conditions of the people, the houses constructed by the government are in such a
condition that the tribal don’t prefer to live in them.
o Social analysis – Schools are functional but are so designed that they take the tribal
children away from their own reality and leave them half way by providing education
only up to higher secondary. Beyond that they are only counseled with no substantial
help being extended to the poor. The bus pass to the far-located college is Rs. 500 for a
year (which is almost similar to the charges in city), which the tribals are unable to bear.
80% of the population consume tobacco and alcohol to combat with their stress.
A SWOT analysis of the organization reflects the overall efforts taken by the organization and
the existing lacunae.
SWOT –
Strengths –
High level of commitment and motivation among the staff.
The organization is flexible and sensitive to the local needs.
Highly qualified and trained staff.
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A good support system to sustain the services.
Innovation within the organization to provide better and effective services.
Integration of the traditional system and the modern system to provide better health care
service.
Comprehensive services including health and non-health components. (though the reach is
confined to few)
Networking with foreign institutions and other native institutions.
Weakness –
Unable to penetrate to the most marginalized section of the community.
Unable to address the local needs of the people as per their requirements.
Strategy for withdrawal is not planned and hence the question of sustainability beyond the
realms of the organization.
Segmented approach towards health, where the focus is primarily on institutionalized care
(hospital centered service provision) missing out on preventive and promotive aspects of
health.
Non compliance in resource management. That is, where there is availability of
infrastructure human resource is lacking thereby leading to sheer resource wastage. [e.g.
labour room in Kenchanahalli hospital and no gynecologist round the clock]
Opportunity –
As they have been providing service in the area for the past 10 yrs. They have been able to
develop their foothold and hence can address other issues of relevance to the local
community, by soliciting co-operation.
As resources especially in the form of medical graduates are available better resource
management can help them penetrate services to the neediest.
Threat –
The community might not be able to take care of their health needs following the
withdrawal of services, as they are not empowered.
Failure to address other socio-economic issues might lead to ineffective service provision.
11
Kindly refer to Section II, Chapter 12 for the details on community based health insurance
scheme designed by SVYM for its community members.
CHAPTER 4
12
THRIVING TOWARDS CONTEMPORARY RELEVANCE
Independent India did not see Ayurveda as a tradition to be celebrated. It was conceived only as formula to be
prescribed or a drug to be swallowed not a philosophy to be lived out. Ayurveda thrives to retain its repute in
the fast changing world.
Foundation for Revitalization of Local Health Tradition [FRLHT]
Located at the outskirts of the city, in the serene and green patch of land at Yelanhanka the
building of FRLHT symbolizes the beginning of a new era. An era where one can hope the long
lost and forgotten science of traditional medicine, the medicine of our land, the medicine linked
to our people, interwoven with the life of people; to be revived!
I first heard about the institute from Dr. Thelma who suggested that I visit it to know about its
initiatives. This chapter encompasses the organizational aims, objectives and activities and a brief
account of my learning and observation during my two-day stay.
Vision of FRLHT –
“To revitalize Indian medicinal heritage.”
The three thrust areas identified by FRLHT are1 –
1. Conserving natural resources used by Indian Systems of Medicine [C]
2. Demonstrating contemporary relevance of theory and practice of Indian Systems of
Medicine [D]
3. Revitalization of social processes (institutional, oral and commercial) for transmission of
traditional knowledge of health care for its wider use and application [R]
Being aware of the magnitude of the tasks involved, FRLHT sees its role to be limited to the
design and implementation of strategic projects that directly support the vision. The role of the
organization is meant to be catalytic. FRLHT therefore endeavors to design primarily pilot
projects on a size, scale, and in geographical locations where these demonstration programs can
1
Refer to Annex I for the Institutional Agenda.
13
have large societal impact. The size and scale may not be very large in order to inspire replication
and adaptation. In order to cause multiplier effect the organization collaborates with
governments, non-government agencies, universities, community based organizations, research
institutions, industries, cooperatives, media and international agencies.
Conservation Program –
Since 1993, a major medicinal plant conservation project in southern India has been underway
with the Forest Departments of Karnataka, Kerala and Tamil Nadu, Research Institutes, local
communities and leading NGOs as key players. Foundation for Revitalization of Local Health
Tradition was incepted in 1995 to build a herbarium and a raw drug reference library on
medicinal plants which has also been coordinating the initiative in conserving medicinal plant
genetic resources the first initiative of its kind in India.
Aim –
To facilitate sharing of resources and experiences amongst members who may be NGOs,
government departments, trusts, cooperatives, companies, research institutes and others who
are actively involved in conservation cultivation and sustainable utilization of medicinal
plants.
Facilitate links between medicinal plant conservation organization (it’s primary members)
and medicinal plant user groups (it’s associate members). These links may result in mutually
beneficial projects and public support for multifaceted conservation activities of the
network.
Undertake advocacy with governments and other bodies on policy matters related to
medicinal plant conservation and sustainable utilization.
The 3 conservation models established to conserve the invaluable forest reserves1. Medicinal Plant Conservation Area (MPCA) Model – State forest departments have
established sites of around 200 hectares in area. These represent all major forest types and
geographical zones, harboring populations of most of the medicinal plant diversity of the
region, including red-listed species. MPCAs act “as live field gene banks” of medicinal
plants I southern India. Over 50 MPCAs have been established in the states of Karnataka,
Kerala and Tamilnadu.
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2. Medicinal Plant Development Areas and Non Timber Forest Produce (MPDA & NTFP)
Model – These have been established by state forest departments in NTFP circles and on
degraded forests for planting locally available medicinal plants and trees. The Forest
departments and the local communities share the returns through sustainable harvest of
plants from jointly managed conservation areas (under the Joint Forest Management
Scheme). These sites are sources of high quality raw material, which are sustainably collected
from natural habitats.
3. Medicinal Plant Conservation Parks (MPCP) Model – This is a network of 17 ethno
botanical gardens that currently grow around 800 medicinal plant species known to local
ethnic communities. They provide planting material through their nurseries to the public.
Some MPCPs have herbarium, seed and raw drug museums. They also engage in training,
local enterprise development and community outreach programs. MPCPs plan to develop
into reliable supply centers of planting materials as well as organically grown raw material.
Some activities Based on these models a botanical team conducted the survey and assisted in selection of
MPCAs.
A comprehensive computerized database on medicinal plants of India has been
systematically built up at FRLHT over the last 8 years.
Around 900 images of medicinal plants have been developed. Information is also available
on primary health care for 128 species and propagation for 200 species.
In recognition of FRLHT and its pioneering work in the area of conservation of medicinal
plants and local health traditions, it has been made an ENVIS (Environment information
system) node on medicinal plants of conservation concern in the country by the Ministry of
Environment & Forests.
The herbarium made by FRLHT is multi dimensional pooling plant images, including
vernacular names, distribution data, plant profiles such as botanical description, threat status,
efforts taken to conserve the threatened species, distribution along with the eco-distribution
maps, pharmacology, pharmacognosy and cultural.
The following issues have been identified for policy studies:
Implications of commercial trade in wild medicinal plants and its impact on conservation
for guiding sustainable management of these wild resources.
Appropriate regulatory mechanisms for such trade.
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Studies relating to the implications of issues of Intellectual Property Rights for such
native medicinal plant species.
Documentation/ Dissemination of information & Research
FRLHT has facilitated the building of local resource centres and has conducted exchange
programs through networking and workshops to improve traditional knowledge and practice.
The organization has also helped to establish kitchen herbal gardens, and income generation
programs through training, sammelan and self help groups to encourage the continued use of
best health traditions. Strengthening of local health traditions.
Major activities undertaken –
A participatory methodology for documentation and rapid assessment of local health
traditions was developed.
This method has been field-tested and is being promoted through training programs.
A training module on documentation and assessment of local health traditions has been
developed and is being shared during training programs.
A software local health tradition home remedies and food and regimen version 1.0 has been
developed as a tool to documentation.
About 22 training programs have been conducted in 4 states of southern India and three
states of Northern India.
Through its laboratory, Traditional Systems of Medicine and Research groups it aims –
1. To conduct meaningful research to interpret the importance of traditional recommendations
with respect to raw drugs and formulations in order to arrive at relevant quality standards
using modern tools such as Chemistry, biology, genetics and botany and
2. To provide testing facility and technical support to small scale units dealing with medicinal
plants and value addition.
The laboratory set up at FRLHT has the required infrastructure, facilities and expertise to certify
the quality of raw drugs and finished herbal medicines as per Ayurvedic pharmacopoeial
16
standards. It has applied to the Dept. of Indian Systems of Medicine & Homeopathy, Govt. of
India to get accredited as a Quality Testing and Certification Laboratory.
It has received a research grant from the National Geographic Society to undertake
documentation of the traditional methods of collection and processing of medicinal plants from
texts and living traditions.
In the last ten years, FRLHT has been documenting and developing databases on the materia
medica of Indian systems of medicine. Medicinal plant databases have been already initiated on
Ayurveda, Siddha, Unani system & Homeopathy.
Promotion of Taluk level Paramparika Vaidya Parishats –
In order to revitalize the diverse health traditions at both the household and the community
levels, a methodology for documentation and assessment of health practices in Karnataka,
Kerala, Tamil Nadu and Maharashtra at several taluk levels has been evolved. The home herbal
garden program is similarly being promoted to revitalize the local health traditions at the
household level in the above states. State level Paramparika Vaidya Sammelana provides an
opportunity for the vaidyas to exchange their knowledge, skills and practices. It is essential to
sensitise the social processes for successful promotion of these useful practices and hence local
groups like women groups, self help groups are chosen as a medium for dissemination of
information and to encourage sharing of local traditions in colloquial terms.
The paramparika vaidya parishats provide a forum for vaidyas and household knowledge carriers
to regularly meet, interact and exchange knowledge, skills and experiences in their respective
fields.
To provide guidance and training to the younger generations by establishment of centers of
excellence in different areas of expertise of local health traditions through a guru-shishya method
of partaking of knowledge and the skills.
In Karnataka an apex body of PVP has been constituted and registered. Taluk level parishats
have been constituted and registered in Bidar, Gulbarga, Gadag, Uttar Kannada, Shimoga,
Davangere, Chitradurga and Bangalore.
17
So far 10 taluk level PVPs have been registered and 14 taluk level PVPs have been constituted.
Constitution of 25 more taluka level PVPs have been initiated.
The institute intends to establish a 100 bedded Ayurveda Wellness Center with a research
oriented hospital, which will demonstrate using modern parameters the efficacy of Ayurvedic
health care management for prevention, promotion and cure.
Before visiting the institute and after a brief discussion with Dr. Thelma and Mr. Abdul Kareem
(from FRLHT) the following learning objectives were laid –
To get a field experience of the interconnectivity of the traditional systems, community
efforts and micro- credit.
To examine the utility of traditional methods and its efficiency in meeting the health
needs of the people.
To understand the initiatives taken by the organization in addressing the rural health
issues through indigenous system of medicine.
To achieve the first objective, a visit to ‘The Covenant Centre for development,’ Madurai; while
to achieve the other two objectives visit to few nearby villages where MPCP (Medicinal Plant
Conservation Program) project of homestead herbal gardens (HHG) is implemented to meet the
primary health care needs of rural communities, was planned. However none of the plans
concretized.
I had the opportunity to interact personally with Dr. Unnikrishnan2, Dr. Gangadharan3 and
Darshan Shankar4 to gain a broader perspective about their beliefs and prospective plans.
2
An Ayurvedic physician qualified from Ayurveda college, Coimbatore, founder of ‘Center for Ayurvedic
Research & Development,’ a network of clinical centers in Kerala; visiting Research fellow at Toyama
Medical & Pharma unit, Toyama, Japan. He is currently co-ordinating the traditional system of medicine
unit of the foundation and is involved in cross-cultural medical research, relevance of traditional medicine
in public health and applied medical anthropological research.
3
President of FRLHT.
4
Director of FRLHT. Began his professional work in 1973 at Bombay University where he conceived,
designed and coordinated a post graduate program ‘ Experiential learning.’ Between 80-92 he lived in a
tribal village in Maharashtra when he worked with an NGO, Academy of Development Sciences. It was
during this period that he was exposed to tremendous social relevance of local health tradition. Since 1993
he has been the Director of FRLHT. In 98 he received the Norman Borlaug award and in 2002 the MPCP
coordinated by FRLHT received United Nations Equator Initiative prize.
18
Discussing about the relevance of insurance to traditional system of medicine, Dr.
Unnikrishanan opined that the exact definition of insurance has been forgotten over a period of
time and for no substantial reason the indigenous medicine is debarred by the sector. It is
perceived as a tool for minting money and hence does not operate as per conventional model.
Various micro credit systems have been functioning since ages especially in agricultural practice
where seeds are pooled as contribution to meet the contingency cost especially for meeting the
catastrophic cost during calamities. The mahahandi parampara in Madurai is fabricated to meet
the expenses during festivals. Different systems are adopted by different communities like
traditional ceremonial tea party in south India where the entire community contributes for the
tea party of a marriage ceremony/ funeral procession. The recipient in turn has to contribute
more in the next tea party. However health though is crucial is so sensitive that people haven’t
yet got used to the concept of saving for health contingencies. As an initial effort a micro credit
scheme has been linked with the Kitchen Herbal Garden5 Project in Madurai where saplings are
provided to the needy and the loan scheme is linked to the micro credit. Thus a blanket scheme
for the entire society cannot be the ideal solution and such schemes for health needs to be linked
to people’s culture & tradition with due consideration of their affordability and availability of
health services besides their health seeking behavior which is most crucial.
Dr. Gangadharan expressed that the only way to augment the faith of people in the system is to
strengthen the educational system, work at grassroot level combining people’s knowledge with
the formal knowledge system and effect policy changes/initiatives by working with CCIM
(Central Council of Indian Medicine)
Some serious thought –
Ayurveda in the form of folk health culture has been a part of people’s lives for hundreds of
years and it seems ridiculous rather ironic to plan primary health care for the rural and tribal
people without taking into cognizance of this! Ayurveda is nothing but the institutionalized and
formalized form of such local traditions or as anthropologists would put it Ayurveda is the
synthesis of the tribal and other folk traditions. They have a symbiotic relationship. Ayurveda
has long interacted with, learnt from and contributed to local folk traditions.
5
The KHG is also linked to malaria control program – decoctions of herbal preparation are administered to the people
in endemic areas as prophylactic and laboratory research is been conducted to assess its potency and mode of action.
19
This has undergone a phase of decay due to extrinsic and intrinsic factors6. The extrinsic factors
relate to the monopolistic economic and political forces unleashed with the advent of
colonialism and its aftermath, culminating in the current process of globalization. External
domination can however gain entry only in the midst of internal infirmities and it would be
unfair to attribute all internal weaknesses to external influences. The indigenous system of
medicine long back reached a stage where methods, procedures, rules derived earlier by a mode
of reason, analysis and logic to interpret the diversity of forms became absolutely authoritative
and sacrosanct which was followed blindly by followers without questioning or rationalizing and
with passage of time some of these have become obsolete.
Contemporary research in Ayurveda follows two broad approaches7. The first being based purely
on Ayurvedic parameters, while the second is based on parameters of western science, which
may also be termed cross- cultural.
Ayurveda has been developed in a culture that views the manifest nature in terms of the panch
mahabhoot sidhant, which is very different from the atomic view of nature in western science.
There are major differences between these knowledge systems at every level with regard to
principles, categories, concepts, logical framework, philosophy and worldview. The Ayurvedic
worldview is based on the shad-darshanas and Sankhya philosophy. Whereas modern science is
based on empiricism, Ayurveda gives importance to apta (testimony of seers), pratyaksa (direct
perception), anumana (inference) and upamana (analogy). It is thus evident that Ayurveda and
modern science have completely different premises.
An important issue is the approach to validation. It is necessary to pint out that there is today in
most societies a hierarchical positioning of medical systems with western biomedicine playing the
dominant role. Due to this hierarchical situation validation of Ayurveda by modern science has
been the tenet. Due to international dominance of western culture that exists today, even within
the Ayurvedic community there is a strong belief that it needs to be validated through western
science. By using a mix of Ayurveda and modern nosologies without sufficient insights into how
6
Darshan Shankar: Cultural Cross-current: Tribal Medicine, Ayurveda and modern medicine in primary
health care.
7
PM Unnikrishnan: Challenges in current cross-cultural medical research.
20
to build a bridge between the two knowledge systems, leads to a stage of bricolage (i.e. a
situation where non rigorous strategies are made for comprehending reality)
Ayurvedic materia medica is reduced to a treasure house for seeking herbal solutions for
bioactivity relevant in modern medicine. This treasure hunt is carried out without having
sufficient understanding of the way in which drugs are used in Ayurveda. In Ayurveda it is not
only drug that matters but also detailed management of the condition through drugs, diet and
lifestyle changes.
Another inherent problem is ‘Knowledge hegemony’ with severe hindrance in the free flow of
knowledge from one generation to the next. In such a situation the total decay of the system is
not too far!
The problem with the system is inherent and within the system and not outside it. The problems
are not lack of adequate resources or gaining access; but the patriarchy, hierarchy and the stale
system are destroying it. Somehow FRLHT is repeating the same mistake overlooking the
lacunae within the system.
Ayurveda is the science of life and not meant only for diseases. The different aspects of
individual as well as social life was well thought by ancient scholars who documented what was
popular and suitable those days and hence was obviously scientific, but with passing time it lost
its charm with no one updating the system. The organization has been busy testing the herbs to
prove its efficacy, promoting traditional medicine and has been totally blind towards the
aforementioned aspect. Though the activities carried out by FRLHT are imperative to strengthen
indigenous medicine, reviving the system to be of contemporary relevance and making it
scientifically more acceptable to the society is the most important aspect in its growth, which is
being missed.
Yet the multi pronged effort of FRLHT is certainly one infant step ahead towards reviving the
system and years of such concerted effort by committed people will indubitably make the
aboriginal system of medicine contemporary relevant!
21
Chapter 5
A Trip to Nowhere!
“If you don’t know where you are going you’re never gonna get there.”
- YOGI BERRA
An unanticipated circumstance changed the course of my plan and I had to plan an urgent trip to
Mumbai. The time that I intended to spend in CHC library, I spent at CEHAT, Mumbai. As a
part of the fellowship program another assignment of studying the organization was clubbed
with it. I spent some time reading books on health finance in the library, but as far as the
supplementary assignment is concerned I gained not much. This is an account of this trip to
nowhere, reflected through a report, which is a mere reproduction of the organization’s manual.
Experience at CEHAT
Date: 19th July to Aug 2004
Learning Objectives –
To comprehend the vision, mission and objective with which the organization was incepted
and to what extent it has been able to achieve it.
To gain an understanding of the organization structure, culture, ethos and activities.
Introduction –
As the primary motive of visiting CEHAT was to explore the study material in the library and
make the optimum utilization of it within the constrained time, a lot of time initially was spent in
the library.
Initial attempts of communicating with the staff did not prove to be fruitful. However
substantial information about the organization could be garnered during the course of discussion
with Dr. Jesani and Dr. Amita. Informal discussion with Kamayani and Bhagyashree (from
Pune) also helped in knowing more about the organization.
Vision/Mission – though they have not been spelt out clearly, they are implicit and can be stated
as
22
Building an institution with high professional standards having commitment towards the
underprivileged people and their organization.
Evolution –
CEHAT was conceived eleven years back from a negative critique of NGO based research
institutions towards creating an alternative health research institution, which would be pro
people and beyond academic interest.
The Anusandhan trust was formed in February and registered in August 1991. The first three
years of the journey were full of dilemmas and the riot experience of Mumbai almost buried the
idea. However continued voluntary work with combined efforts led to the foundation of the first
institution under the Trust, called Centre for Enquiry into Health and Allied Theme on April 1
1994.
The first office of CEHAT was set up in a one room flat at Mumbai suburb. As the activities
grew a larger space was needed and hence the office was shifted to another place rented by
Municipal Corporation of Greater Mumbai. The office was situated above the MCGM run
Maternity home, which was non-functional. As CEHAT did not want to get pressurized by the
government officials they got relocated.
Though the initial years were exhilarating and gave a sense of fulfillment the organization has
experienced a lot of struggles and ups and downs.
Objectives CEHAT is an experiment to convert the unmanageable contradiction between NGO and
academia, into a permanent advantage of linking academia to people and vice-versa.
Thus it aims at achieving the objective of RASA viz. research, action, service and advocacy for
the people and to create a space for the organization existing at the interface of activism and
academics, people’s organizations and institutions.
23
Basic principles of the organization –
These four principles applies to all themes and topics selected by CEHAT for research
Social relevance – Central to the understanding of social relevance are issues of human rights,
equity and empowerment. This is irrespective of whether the organizations have raised the issues
or CEHAT would need to initiate such a demand on its own for advocacy with organizations
and policy makers.
Ethical concerns – It must uphold high ethical and human rights standards while undertaking
research, action and advocacy. This principle complements the first.
In order to ensure social relevance, sensitivity and responsibility to participant people, the
following three important ingredients are made inseparable part of all research projects – Ethics
committee, informing subjects and participants, and taking the findings to subjects and
participants.
Democratic functioning – institutionalization of democracy for internal functioning by using the
following two mechanism-
To emphasize the social commitment and restrict the payment disparity. The salary structure
is such that nobody receives less than minimum wage and the ratio between the highest and
the lowest salary scale is kept below five.
Participation of the staff is directed through mechanism of formal democracy. Working
groups are established for management functions and devolution of power.
Social Accountability – it is an integral part of sustaining democracy as well as autonomy of the
research, researcher and the institution. The individuals have an access to all information on
work – research, finances and functioning. A Social Accountability Group of eminent individuals
is created to conduct social audit of the organization.
24
Areas of work –
Research –
It plans and consolidates its work into interconnected and yet well defined themes. Steady
development of themes in the direction of right to health and health care is one of the ways to
ensure that the project-based work is driven by the social need. Thus each theme has purpose
and continuity and these themes help in systematically enriching knowledge and understanding
in the relevant field.
These themes are –
Health services and financing – The focus of this program is on determinants of health,
peoples’ health problems and health seeking behavior, structure and functioning of health
care services, health expenditure and financing.
Women and health - it not only undertakes research on women health but also informs all
other programs with the gender dimensions.
Health legislation, ethics and patients’ rights – It endeavors to bring people and patients at
the centre of health care, through policies, legislation, system of medical ethics, etc.
Psychosocial trauma – It concentrates directly on issues related to human rights and
violence, and also interrelates with programs with human rights dimensions.
Though considerable work has been done in the last two areas the strength for research by the
organization, lies in the first two.
Action, Intervention and Training –
Although CEHAT was established specifically to undertake research and related activities in the
fields of health and allied themes, in the course of work it also initiated field based activities to
directly reach out to the underprivileged people and their organizations. These field based
activities are making research and the researchers people oriented, providing opportunities to
undertake demonstration, action and intervention projects and above all to link up with
grassroot level organizations.
25
The Arogya Sathi project stresses the importance of developing health programs and health
advocacy that are in tandem with people’s organizations and mass movements. It began in
October 1998 in three marginalized/tribal areas of Maharashtra/ Madhya Pradesh where
people’s organizations are already functioning. The community based health programs have
been established in Dahanu and Jawhar talukas of Thane district and Aajra taluka of
Kolhapur district of Maharashtra. Since December 99 they began functioning in Badwani
region in Madhya Pradesh.
Arogyachya Margavar: Women centred community health and community based response
cell for survivors of domestic violence. This project evolved while doing research on
women’s health in the slums of Andheri-Kurla road Mumbai. High proportion of morbidity
in women, increasing reliance on self medication due to inefficient public health services and
financial barriers in accessing private care led to women centered health project. Began in 98
it covers 10000 people.
Dilaasa: Crisis Centre for women in Public hospital –After several rounds of discussion with
high level officials of MCGM, it was decided to visit such crisis centres in public hospitals
run by women’s organizations and by the government in Philippines and Malaysia. A crisis
centre has been established in collaboration with MCGM in a municipal hospital Bandra
Bhabha hospital to look into the issues of domestic violence, counseling of victims, address
the issues of human rights and advocacy. The project is proposed to run for three years
following which MCGM is expected to handle this centre.
Services, Documentation and Publication –
As the organization was incepted at taking up socially relevant issues for research, it is imperative
to develop two regular activities, viz. – the systematic development of a specialized library,
documentation and a database; and advocacy, teaching and training.
Library and Documentation – The trust did not have sufficient material resources to euip its
institution thus some of the trustees and staff members donated books and materials for the
library and also gave lots of voluntary time to organize and run the library and documentation
service. It now has around 3000 books, 2500 reports, conference seminar, workshop papers and
reprints and back volumes of selected journals, which are easily available for students, journalists,
26
medical professionals, social workers, lawyers, trainers, activists, development workers,
counselors for reference.
The library has adopted Dewey Classification (DDC) system and efforts are being made to
computerize the entire library, which would make interaction with other libraries easier.
Database on health –
CEHAT undertook the task of computerizing state wise time series data on health indicators,
infrastructure, human power and health financing. In 98 this database was released with its own
software program and provides data (with over 500 variables) to central government, state
government from 1951 to the latest available on two floppy diskettes and a manual costing Rs.
300/Slide shows and Films – are available on different subjects like AIDS, women’s empowerment,
Abortion, etc. in different languages (Marathi, English, Hindi).
Advocacy, Education and Campaigns – CEHAT has established linkages with University of
Mumbai, TISS, academic teaching institutions in Pune and in other cities. On the other hand on
specific issues such as abortion, accreditation of private hospitals etc. it has been able to link up
with NGOs, government functionaries, professional associations and so on to build advocacy
for policy change.
Various activities specific to advocacy, education and campaigns are –
Human Rights –
In 1995 some staff and trustees were actively involved in raising a public debate when
hysterectomies were conducted on 17 mentally challenged girls at a state run institution at Pune.
In 92-93 when Mumbai was rocked by large scale communal violence, CEHAT helped a human
rights organization, solidarity for justice, prepare and publish a selected documentation of media
reports on the violence in the city.
Since 1996, CEHAT has also been conducting a formal program of education on human rights
and health (a regular post graduate one year diploma course) from the department of civics and
27
politics at Mumbai University. A 2 day training workshop was conducted in 1999 for doctors on
Medical Ethics and Human rights. Dr. Amar Jesani from CEHAT is also recognized by the
Mumbai University as teacher, examiner and guide for dissertation for this course.
Besides, the International conference on “Preventing Violence and caring for survivors: Role of
Health Services and profession in Violence” held on November 1998 at Mumbai created space
for doctors, nurses and other health workers to interact with activists from feminist, human
rights, humanists and other movements.
Regulation of Private Health Sector
Minimum Quality Standards for private hospitals and accreditation system: An initiative in
Mumbai – This led to the formation of a Forum for Health Care Standards, a voluntary group
constituted of the various stakeholders in the health care system.
Advocacy initiatives to improve women’s access to safe and legal abortion care –
The advocacy campaign has been multifaceted and designed to suit the needs of various
constituencies at different levels. Its continuity in abortion research has made it possible to
interact extensively and in focussed manner with the 2 important constituencies – women and
abortion service providers.
Network and Collaboration –
Given that CEHAT’s place is at the interface of academia and people, it has built linkages within
civil society as well as with the state.
Social Accountability –
The founding principles of the institutions of Anusandhan trust demand that its institutions
should not only be socially committed but should also undergo a social audit, the findings of
which should be made public. Thus the Social Accountability Group was appointed in 1995,
comprising of five socially committed members from various institutions. The report submitted
by SAG showed that the work of CEHAT was in line of its objectives and had few
recommendations. A report was subsequently written based on the actions taken viz. – staff
28
development process, research skill development initiatives, training of health workers,
collaborating with people’s movements and other NGOs.
Organizational Structure and Functioning –
The trustees of Anusandhan Trust constitute a governing board of CEHAT, who are responsible
for the overall vision and mission and to provide guidance. The managing trustee devotes some
time to oversee the administrative matters and the individual trustees give their advice and
inputs. The entire staff meets twice a year away from the office and one of the meetings is
devoted for staff development.
A Working Group was first constituted in 95 by inviting interested individuals from the staff.
Further in 97 the general body of the staff formulated criteria for WG membership and framed
rules for election. They elected 6 members through secret ballot. Since then one-third of the
members retire every year and the ex-officio member is the co-ordinator of the WG. He/she is
not elected. Within the WG all the responsibilities are distributed. The group meets once a
month and reviews all projects/activities and decides on actions.
A co-ordinator of CEHAT is appointed by the trust who has full responsibility for the
development of the institution, achievement of its goals and the co-ordination of work and
management of CEHAT. The co-ordinator has double accountability to the trust and the
working group. He/she has the decision making and implementing powers.
Further for all research projects CEHAT appoints a Consultant Committee and for research
involving human participation an ethics committee. Besides it has internal scientific committee
comprising senior researchers known as peer review committee, which reviews research,
advocacy, etc. periodically. The performance of the staff is reviewed through a well-defined
evaluation process.
Sources of Funding & Expenditure –
A large proportion of funding is from private specifically from foreign sources, share of Indian
sources being very small. This is a reflection of the priority that the government and the Indian
sources accord to health research in general and to social science research in health in particular.
29
The Trust began with lot of small voluntary initiative from its trustees and other friends. Fiscal
grants gradually came from both private and public agencies. The trust’s own fund is very limited
and is concerned that it must increase substantially.
The expenditure has been maximum on research, minimum being on training and service.
However over the years expenditure on research has been gradually decreasing.
Sustainability of the Projects –
It was not possible to examine the projects undertaken by CEHAT, in details. Hence its
sustainability is not clearly understood. However, the project Dilaasa in collaboration with
municipal hospital is a 3-year project and the strategy for withdrawal has been made right at the
time of inception. From the second year onwards the program plans to sensitize and train the
health personnel with respect to violence against women. If this would be achieved the project
would become sustainable.
Critical Analysis –
The time spent with the organization was very less and it wasn’t possible to interact much with
the staff in order to know in details about the functions of the organization.
For this report and critical analysis there has been a high reliance on the booklet obtained from
CEHAT with qualitative inputs from Dr. Jesani and few informal discussions with selected few
staff of CEHAT. This would alternatively affect the quality of analysis.
Moreover the kind and the number of research activities carried out by CEHAT are numerous
and diverse. This has rendered difficulty in gathering complete information about each of the
project (including methodology, objectives, outcome, beneficiaries of the outcome, etc.) which is
imperative for critical analysis.
It has been stated that ‘A research institution like CEHAT is not a people’s organization and it
should never pretend to be so. Its identification with people’s movements and organizations is
more in terms of selecting socially relevant, pro-people themes and topics for research and
30
sharing the findings with such organizations to support their campaigns and advocacy for
change.
The review of the topics of research and publications shows that the organization has been able
to work in line with its objectives and though it is not a people’s organization in due course;
realizing the importance of linking up socially relevant research with advocacy it has reviewed its
strategy by getting involved with people’s movement and networking.
Structure –The constitution of Working Group represents a balance of autonomy and
accountability. The non-hierarchical structure too contributes to the complete freedom and
support given to the staff in the organization.
SWOT Analysis –
Strengths
Opportunities
Weaknesses
Importance of research in health
Implementation
Strategy
–
– Research has highly remained
Research is merely a tool (and not
confined to academics and seldom
an end in itself) to study the
utilized for the benefit of the
intricate
people. On the other hand there is
factors in the society bearing its
a
relevant
impact on health. Thus any
research which can instigate ideas
research should lead to action-
and strategies for implementation
intervention or else it becomes
at grass root level. This endeavor
obsolete
of CEHAT to bring these two
especially in such a fast changing
together will benefit the society at
world. Thus the organization
large.
should
Sensitive to social factors – Health
programs based on the research
has largely been under the domain
findings and assist NGOs. and
of medicine and remained isolated
government organizations in its
from social factors. CEHAT not
implementation.
need
for
socially
only takes up socially relevant
issues for research but
31
also
linkages
with
design
of
passing
various
time
intervention
identifies issues of concern in the
society and tries to study its
impact on health.
Threats
Multi pronged effort – Past
By focussing on different issues
experiences have shown that mere
simultaneously the effort and the
medical intervention is in no way
diligence gets diluted thus certain
going to improve the health
areas like ethics and psychological
situation at large. Organizations
trauma have been neglected.
failing to discern this cannot
achieve
their
objectives
of
providing better health. CEHATs
multi pronged efforts at different
levels and from different angles
like human rights, advocacy, etc.
would aid in tackling health issues
from holistic perspective.
Chapter 6
A Ray of hope.
32
We'd never know how high we are till we are called to rise; and then, if we are true to plan, our statures
touch the sky.
- EMILY DICKINSON
Western Region Public Hearing at Bhopal8
The health system is plagued by the problems of poor allocation and misallocation of resources,
wide disparities in services and knowledge hegemony, which is further augmented by the process
of globalization and privatization giving an impetus to the neo-liberal policies, withdrawal and
weakening of public services. All this shows direct, immediate and severe impact on the poor,
marginalized and the vulnerable, in short on the voiceless and the penniless!
Health has always been measured in terms of illness and the solutions sought have always been
medical, focussing on curative aspect. We have failed to learn lessons from the developed
nations where the economic growth was possible only after social welfare initiatives, thereby
suggesting that economic development is closely interwoven with the general health (beyond
disease) of the nation. When 75% of the total expenditure is made by the public sector in health
in developed nation, India ranks the lowest with 22% public expenditure. And despite of such
low expenditure on health, India vouches for privatization.
Health has social, economic, cultural and environmental dimensions besides the well-known
physical, physiological, mental and spiritual aspects. Health is not dealt in this holistic perspective
while designing and implementation of any program.
In this context, who are the ultimate sufferers? People obviously! Hence it is ultimately in the
interest of the people that we must initiate a second freedom movement- a movement
against tyranny and exploitation, a movement to demand our right; right to quality health
care and just treatment to all in the society. Such a movement holds no meaning without
understanding the underlying factors, causing the collapse of the system. To disseminate the
information to the larger mass; health, health system and the changing face of the system, the
policies adopted by its various stakeholders needs to be demystified and made comprehendible
to the lay man. The cases of neglect must be identified and brought to the notice of the larger
audience. Voices of the people needs to be heard, the shortcomings within the system needs to
8
Refer to Section II, Chapter 13 for a documentation of the event with the commentary
33
be shown, the double standards of the policy makers needs to be understood and the sufferings
of the poor needs to be felt by the concerned authorities and the world at large to create a locus
of peoples power which can lay a clout over the system, awaken them to rise to the needs of the
people.
The public hearing can be seen as a potential mass movement towards this development. In the
darkness of despair, there seems of be a ray of hope!
I have had the opportunity to attend two public hearings, the western regional hearing at Bhopal
and the Southern region hearing at Chennai. Each one had their own importance greatly
influenced by the regional characteristic features. The cases presented in Bhopal reflected the
dereliction of all the resources besides the infrastructural insufficiency and sheer lack of concern
for the patients. The situation in south is in no way better, with numerous cases of inhuman
approach towards the patients, iatrogenic diseases leading to death and total or partial
incapacitation of innocent patients. Cases of environmental abuse leading to long term health
hazards in larger masses were also highlighted. The responses of some of the concerned officials
were encouraging while some got highly defensive.
Some agnostic individuals might just wonder what next? What has been achieved through this or
what can we envisage to achieve and by when? Its true that this is just an infant step whose longterm benefits is very difficult to be envisaged! But it is indubitably a positive step ahead. If
pursued with perseverance, such a collective effort is inevitably bound to bring a revolution, a
revolution that will force the globe revolve faster, that will alter the centrifugal and the
centripetal forces, that will change the course of life and it would no longer be a far fetched
dream when India would be no less than any Scandinavian nations!
“He will win who knows when to fight and when not to fight. He will win who knows how to handle
both superior and inferior forces. He will win whose army is animated by the same spirit throughout
all its ranks”.
Sun Tzu – The Art of War.
34
The article on ‘Right to health care’ by Dr. Abhay Shukla, the discussions with CHC fellows
facilitated by Dr. Thelma and the recent article by Dr. Anant Phadke in MFC bulletin threw
more light on this.
I would like to quote James Wilson “Some try to represent political economy as being a dry, cold
abstract science, which has no warmth of feeling to spare on suffering humanity----- This is far
from the truth; on the contrary, political economy produces feelings so intense for the removal
of these evils, that it will not permit us to rest satisfied ----- but impels us to ----- discover the
true causes of this wretchedness and the mode by which it may be removed -----.”
Political economy as a different subject is relatively new to me and had the first exposure during
MHA. I have started realizing how significant it is with concern to our present situation. How
can health be segregated from the general well being of the nation?
The entire process of public hearing has evolved through infinite efforts of millions of invisible
hands and minds of the past and the present. An event like public hearing may not yield
substantial fruit but is certainly a contribution in the whole process. It is not meant to culminate
at a huge gathering but is a continuous argument for policy measures ensuring equitable
distribution of resources, attention to every individual and making health care available and
accessible to all.
‘Resource crunch’ is the general mantra chanted by government officials as they use as a shield
to protect themselves from all the legitimate attacks. We really need to question ourselves and
probe into this. It is beyond doubt that resources are insufficient, but the larger problem lies in
misuse and misallocation of resources.
35
Chapter 7
In Search of Direction
Direction is more important than speed. We are so busy looking at our speedometers that we forget the
milestones.
-
ANONYMOUS
I traversed the easiest path though my decisions were never driven by monetary or material
gains. In the process of learning I discovered the fact that it is the place and the field of work
which one needs to identify for a long-term objective to be achieved. The insight gained through
any endeavour can be applied to the field of interest and no effort is a waste. However if one
continues to force oneself in a place or working in a field of disinterest a gradual decay is
inevitable.
I wasn’t ever sure of my aptitude for health finance and health policy though I liked these
subjects. I have always been bothered by inequitable distribution of resources and growing
demand for health insurance led me towards it as it is perceived to be an effective tool to address
the issue of misallocation and misappropriation of resource. It is also believed that it can
systematise the whole health system as information is the key to managing any insurance scheme
and this information can be used in the interest of general public. It can also be used as a
magnetometer to detect the direction in which resources are spent, as a weighing scale to weigh
the disease burden and the expenditure on them through different providers and different
medium. CHC provided me space to explore my areas of interest. The only way to examine my
interest was to get involved and discover if I fit or misfit into it. My thesis on health insurance
and experience of working in an insurance company proved to be an impelling force.
With a lot of reluctance I finally decided to visit Sewagram to study the ‘Jawar Scheme’ on Dr.
Ravi and Dr. Thelma’s suggestion. After a detailed discussion and speculation finally the sixmonth plan was made. The study about Jawar scheme would throw light on a rural health
insurance scheme which is confined to a very small population; the next visit to Gudalur will
help gain insights on tribal insurance scheme; at Raipur a state level health finance could be
comprehended and SEWA health insurance scheme at Ahmedabad could give a clear picture of
managing a scheme for urban population. The social health insurance scheme for the rural
36
farmers of Karnataka, ‘Yeshaswini’ could then be studied against the backdrop of the all these
studies.
The expedition thus began from Sewagram. Though the ultimate objective was to know more
about community health finance, a broad aim of exploring all the health and the non-health
programs was formed and hence a detailed report on all the interventions pertinent to the
Insurance scheme was prepared. This chapter covers only my reflections and learning gained
from the visit. For the detailed report kindly refer to Section II, Chapter 14. A Referral Insurance
Scheme for the Hospital staff was also studied which forms chapter 15 of the same section.
Learning objectives –
To gain a better understanding of the operational aspects of the overall health system
with some focus on health finance.
To try understanding the overall health intervention programs.
The exploration began with an initial meeting with Dr. Jajoo, when he explained the whole
scheme right from the time of its inception. This was followed by few field visits and meeting
some key respondents who have contributed in bringing a positive change in the society. Few
field visits helped in understanding people’s perspective.
My learning experience – The jawar insurance (assurance) scheme is basically a brainchild of Dr.
Jajoo and its function is solely responsible on him. This implies that every person with his/her
own will in whatever way possible can affect a change process. However the sustainability of
such a one-man lead initiative is questionable. Most of the initiatives though are aimed at
benefiting the community in the long run it seems to have been imposed on the community as
they see Dr. Jajoo with reverence and hence accept his plans without actually comprehending
and realizing its importance. Moreover they also face the threat of losing the membership of the
insurance scheme if they do not concord to the ideas put forth by Dr. Jajoo.
The charisma that Dr. Jajoo carries is tremendous, to the extent that people worship him. This I
consider as a life time achievement which is unlikely without working for the cause of people
and for their benefit. Dr. Jajoo started with the people from where they were, addressing their
issues of concern trying to meet their felt needs, which inevitably helped him gain the sacrosanct
37
image. Though Dr. Jajoo tries to give some space to the community to handle their
responsibilities and tackle various issues of concern, his leadership at times was found to be
overpowering! He has emerged as a lighthouse for the community guiding their path and taking
care of them.
Few questions remained unanswered like why there is a huge disparity in the salary structure of
the doctors vis-à-vis that of the Class IV workers who are still hired on contract for a meager
salary of Rs. 30 per day, while the doctors earn above Rs. 50000 per month. This is a matter of
concern especially because it is a charitable hospital based on Gandhian ideology!
The exercise on Financial Analysis of the scheme was a great learning experience, except for the
fact that it is not scientifically sound and there are some inherent lacunae in the study. Whilst
carrying out this study, I realized that numbers are exciting only if they convey a message, and as
one proceeds with the computation the level of excitement increases as it orients towards a
definitive finding, which should be necessarily illuminative. It must serve the purpose of guiding
and planning the next strategy.
“I started moving in a specific direction hoping to find solace here.”
38
Chapter 8
Midway through my journey
"We may run, walk, stumble, drive, or fly, but let us never lose sight of the reason for the journey, or miss a
chance to see a rainbow on the way."
- Anonymous
To enable us reflect, share our experiences and hold our hands with other fellows, a mid term
session was organized at CHC. The sessions packed in 12 days were thought provoking and
edifying with each fellow sharing his/her field experiences. I can count upon this as one of a
very important milestone in the learning process as in the fast paced life we are soon loosing on
the very important techniques of garnering information like listening, sharing and discussing. It
wouldn’t be practically possible for me to visit Bissamcuttack, Javadhi hills, Sanghamitra or
SPAD without discounting on my experiences in a short span of six months. It was also a period
to relax and get further more equipped for the second half of the program.
Dr. Ravi’s class helped me gain an insight about the health movement, which gained momentum
in different directions at different period of time due to the driving force of different ideologies.
Thus a movement does not only grow in length with time but also widens by coalescing different
schools of thoughts. And this enriches the movement!
Learning from others learning –
Aameer – from Javadhi hills experience he realized that migration is the starting point of
poverty. Poverty is not merely lack of resources but has deeper connotations attached to it. It is a
consequence of structured and planned exploitation, it is a vicious cycle leading to poor health
and misery. The heart-rending stories of copper sulphate added to starch to make it inedible to
deter the poor from consuming it, mental stress caused due to inability to take bath, were all eye
openers to the hard facts of life.
Amen – His sharing from Bissamcuttak and Omapan gave valuable insights into the problems
faced by the tribal people and health hazards due to mining and its far reaching consequences.
39
Sandhya – Her encounter with the NGO, SVYM the differing ideologies and her endeavor in
modifying her concepts and honing her skills for the benefit of the community; the perseverance
in pursuing it.
Shalini – It was heartening to know about ordinary people with extra ordinary percepts who do
not believe in merely preaching but steadfastly following it in their lives, like Iqbal from Bastar
district, Chattisgarh. Despite being well educated he got married to a tribal woman from Bastar
lived with her and without trying to change her adopted their lifestyle. He claims that he has
learnt a lot from the rich tribal culture and yet a lot remains to be learnt from them.
Abraham – From Sanghmitra and over all CHC experience, that people of the villages have an
identity of their own and take pride in every achievement and possession, which is seldom seen
in city dwellers. The integrity and solidarity of the rural community needs to be safeguarded and
the displacement of the rural poor to urban areas needs to be discouraged for which political will
is indispensable. The street child who offered him food from the trash during their first meeting
just shows how amicable these children are and for no fault of theirs are deprived of basic needs
of life. They are paying the price for the ruthless system, which is totally indifferent to their
needs!
Sunil – about the multi-pronged initiatives in addressing various issues pertinent to the grave
problem of HIV/AIDS and about drop in rooms, enterprising and active workers like Christina.
This is merely a snap shot of my learning during our sharing session, while I am unable to
express everything that I learnt, in words.
40
CHAPTER 9
A voyage beyond health for health.
"Journeys, like artists, are born and not made. A thousand differing circumstances contribute to them."
- LAWRENCE DURRELL
With an intention to study a tribal health insurance scheme, I planned to visit ACCORD located
at the foothills of Ooty. Before visiting the place I met Dr. Roopa, a dynamic lady in her mid
40s, who laid the foundation for community health at ACCORD to get a broader picture of the
work at ACCORD from her experience. This further intensified my desire to visit the place.
Another reason for having shown keen interest in visiting this project was that the health
insurance scheme instituted for the tribal population, was managed by Royal Sundaram Alliance
Insurance company, the insurance company in which I worked. As I never got an opportunity to
visit the place during my tenure in the company, I wanted to study it closely from the other
perspective i.e. the community’s perspective.
About ACCORD –
Over the last 15 years, ACCORD, and its associated organizations ASHWINI and
VIDYODAYA TRUST (the Education Program) each committed to the reinstatement of the tribals
to their rightful place in society have helped to form a strong community organization - The
Adivasi Munnetra Sangam, or AMS. Community owned institutions were set up to deliver much
needed services to the tribal community and to be a tool in facilitating them to enter mainstream
society as equal partners and on their own terms.
The health status of the adivasi community was once appalling. There were countless
unnecessary deaths and the quality of health care available was shocking. In 1987, a community
health program was launched, through trained village health workers (VHW’s), to carry out
preventative health care, monitor pregnant women and children, and improve people’s health
awareness. In 1990, Gudalur Adivasi Hospital was started to provide the good holistic health
care that the adivasi community so urgently needed. And so, ASHWINI was born.
41
ASHWINI’s adivasi staff have been trained to undertake much of the responsibilities of the dayto-day running of the Hospital and Community Health Program and are actively involved in all
the decision-making processes. This training process continues, but already enormous progress
has been made.
Learning Objective - To understand the process of community mobilization, issues of
sustainability, and effectiveness of the program – in a tribal hamlet- both from the health system
and health finance perspective.
The organization was started to help the adivasis stand against the atrocities meted out to them.
In due course of time they realized a potential threat to the community due to the declining
health status of the poor and hence the team comprising of Dr. Roopa & Dr. Deva reached out
to people with health education as a tool. Soon the community developed confidence in them
and expressed the need to have hospital for the adivasis and at a much later stage the medical
aspect of health was introduced. The strategy adopted was apt starting from where people are
and this philosophy remains alive over the years.
Some of my first impressions from the field visit –
o It is heartening to see the high level of commitment of the health animators. At the same
time it is also saddening to see the still prevalent poor health status of the people, especially
the women and children. Despite of 15yrs. of active and multi pronged efforts by ACCORD
the health status of the people though has certainly shown improvement is not a satisfactory
change. The efforts taken by ACCORD are certainly commendable and the lesson learnt is
that medical intervention can reduce the mortality rates but cannot affect morbidity to a
great extent and despite of active interventions in different areas certain factors affecting
macroeconomics severely influences the lives of people, especially the poor.
The climb through the hills to reach the remote houses during the visit to Devasholai,
helped realize the difficulties faced by the local dwellers in accessing the services, which are
far located. Further, socially being from a closed community, accessibility to the services is
further reduced. On interacting with the people it was realized that despite of such concerted
effort by ACCORD, financial instability greatly influenced by innumerable factors like lack
42
of resources, ignorance of one’s rights, unemployment and exploitation by upper class led to
poor living condition which manifests through poor health status.
o Well planned strategy – The strategy for developing self sustained programs aiming at
empowering the tribal communities has been well thought of and successfully translated into
activities (though it is difficult to assess the success of the interventions). The strong value
system, which is the backbone of the organization, supports the project with people from
various field of expertise giving their inputs and the community members viz. the health
animators/ health guides executing the plans.
o About the tribal – Though a lot has been studied about tribal culture, very less has been
adopted by the so-called forward class. The values of unity and solidarity in the community,
collective sharing, earning for sustenance are the prerequisites towards developing a strong
community, i.e. for community organization and community development. It has been
possible to initiate various development programs in the community eliciting their complete
support and gradually handing over the responsibility to them only because of this inherent
value system. Any such program designed for any such community driven merely by material
gains could not have sustained.
Organization and development schemes for the tribal have its own pros and cons. It is
difficult to mobilize them, as they are extremely closed, coy and suppressed. This is evident
from the poor response to health intervention programs in terms of health insurance
coverage, hospitalization rate and number of institutional deliveries.
A very important aspect observed in the process of exploration is the far sightedness the
systematic and the diligent efforts of the health animators in their work towards the
development of their community.
It is certainly a matter of pride for the tribal to own a tea estate and is a revolutionary
progressive step towards sharing a common platform with non-tribal.
43
o Strategy – It is most essential to offer what people need than to what the provider has to
offer. The ACCORD intervention started with addressing the issue of land disputes, which
was a burning issue then. It further provided services in health gauging the poor health status
of people and further education to provide easy access of education to the tribal children.
Income generation programs were initiated with people’s cooperation. As the tribals do not
accept charity the organization did not want to develop a doler beggar relation between
them. Self-support schemes were started like health insurance, collection of funds for
various activities.
Decision made through consensus not only ensures agreement but also empowers people
and stimulates the cognitive process of deciding for one’s own welfare. The strategy of
withdrawal has also been very aptly planned.
In order to prevent power concentration and resource accumulation the organization has
adopted a very good strategy of registering the different units under different societies,
which are being handled by different groups comprising tribal people.
The organization ethos believes in progressive change and hence constantly raises issues of
concern and initiates dialogues with concerned people to ensure further action. This strategy
of perpetual action oriented approach is commendable.
The spirit of this movement can be kept going only by ensuring the involvement of youth in
this, keeping them abreast with the activities and the historical development of these
programs. This is done through youth meetings though its effectiveness is not known.
The hospital set up is also in concordance with the health requirements of the tribal and tries
to fulfil their needs at low cost. The organization has been able to channelize funds through
various foreign agencies and groups.
o Some existing lacunae –
Some bitter experiences with the government have led to distancing from the government
sector. Health being a fundamental right of people and with lots of funds flowing for tribal
44
welfare, it must be tapped as the funds on which the different activities survive would cease
someday.
Though the insurance scheme is innovative and largely benefits the poor, its sustainability on
withdrawal of funds has not been thought of9.
o Prospects for the poor –
The different projects of ACCORD are indubitably pro poor meant for the impoverished
tribal population of Gudalur. These projects would empower these marginalized
communities even if the organisation withdraws.
The insurance company which ends up paying more than the contribution cross subsidizes
their risks with the affordable class of people. However the scheme has been able to provide
services to the needy only because of the HMO kind of structure. Thus the hospital will have
to continue its active role, though the other activities could be withdrawn gradually.
A short span of ten days is insufficient to assess the success of the projects which were
conceived by the community members under the guidance of professionals and which assumed
contour with their concerted efforts and grew to a proportion which cannot be measured on any
scale, as empowerment is dimensionless. Hence the aforementioned comments are merely a first
field impression which could be prejudiced!
9
Refer to Chapter 16 for a detail note on the composite health insurance scheme.
45
Chapter 10
The Search Continues ---“I believe that there is a subtle magnetism in nature, which if we unconsciously yield to, will direct us aright!
It is not indifferent to us which way we walk. There is a right way but we are very liable from heedlessness
and stupidity and take the wrong one. We would take that walk never taken by us through this actual world
which is perfectly symbolical of the path which we love to travel in the interior and the ideal world and
sometimes no doubt we find it difficult to choose our direction because it does not yet distinctly exist in our
idea.”
-
HENRY DAVID THOREAU
Only 45 days of the program were left and I was’nt still sure of my destination. Was I expected
to be so definitive? I guess no, it is difficult to search outside what you want inside! And so with
an open mind I proceeded with my search ---- and reached Raipur.
About State Health Resource Centre –
The government of Chattisgarh and Action Aid India initiated the State Health Resource Centre
for the implementation of the Community Health Worker Program (Mitanin) and carrying
forward the pro-poor reforms proposed under the Sector Investment Program. This was done
under a signed memorandum of understanding. The SHRC acts as additional technical capacity
to the Department of health and family welfare in designing the reform agenda under the SIP,
developing
operational
guidelines
for
implementation
of
reform
program
and
arranging/providing on going technical support to the district health administration and other
program managers in implementing this reform program.
It has a core team of full time experts and support staff to design, build capabilities, monitor
and co-ordinate the mitanin program- a program for building up community health worker in
every hamlet of the state. The other work allocation as per the MOU are –
Produce situational analysis as well as detailed studies on various aspects of the health sector.
Prepare policy change proposals for the consideration of GoC, based on situational analysis
and/or specific studies undertaken by it through individual experts /institutions including
46
Conduct workshops and meetings, as may be necessary, on behalf of the GoC, for effective
operationalization of the reform process
Undertake or facilitate operational research and epidemiological enquiry into disease
prevalence and determinants
Assist in programs to build capabilities of various levels of health department cadre.
For designing and implementation of this reform process/program a number of activities are
essential which are outsourced to individuals and/or institutions on a turn key basis, in which
case SHRC acts as the main link between the GoC and the respective individuals and/or
institutions.
Learning Objective –
To be able to comprehend the various efforts taken at the state level to push health as
priority and to ensure a good health system – right from the stage of conceptualization
to implementation.
Knowing that the organization is involved in multi pronged self-initiated projects, it was
perceived that one needs to move with the pace of work. Inhibited with this pre conceived
notion and with a desire to garner a rich and diverse experience I was all set to work at SHRC to
get a hand on experience! The first rendezvous with Dr. Sundaraman was encouraging as he was
prepared to listen to me and wanted me to share my experiences with his staff. The second tryst
with him during the three hour long journey to Kavardham district was edifying, trying to know
his experience, his opinion about different issues like working with government, the cause for
the success of the Mitanin program, role that health activist can play and need to play, the
contribution that we need to make towards achieving the long yearned dream of all ‘Health for
All’
A month long sojourn included being a part of the field co-ordinators’ meeting, visiting a village,
staying with the field co-ordinator to get a sense of the problems faced by them, working with
other office staff on various subjects like helping prepare RCH budget, assess the internal
evaluation of the Mitanin program, helping in making amendments in the questionnaire to assess
the household expenditure on health, food, etc. Under the guidance of Dr. Sundaraman a
47
proposal for supplementary social health insurance was drafted10. A study on financing of health
care was planned and for collecting data on non-profitable private hospital, we visited Shaheed
hospital and stayed for two days. To undertake an exercise on cost analysis of a User fee scheme
in vogue as ‘Rogi Kalyan Samiti11’ the cost of services from two district hospitals and two CHCs
were collected. Besides I also had an opportunity of getting involved in other routine tasks like
writing letter to the Health Minister, helping other staff organize meetings, etc. It was an intense
learning experience.
Everyday constituted new task and hence I had a dynamic experience without leaving time for
documentation and reflection. Though there are some weaknesses of the organization like any
other organization, it is worth mentioning the strengths of the organization.
Strengths –
The organization exhibits a good team spirit, with all tasks being undertaken and completed
through collective effort.
Dr. Sundaraman has strong leadership qualities, serving as lighthouse guiding every sailing
boat.
Every project is meticulously planned right from conceptualization to implementation.
Though planning is done from a macro level, in order to be sensitive to ground realities and
be realistic, Dr. Sundaraman visits villages frequently without any agenda and stays over
night to have a feel of their problems.
10
11
Refer to Section II, chapter 17
A cost analysis of Rogi Kalyan Samiti forms chapter 18 of section II.
48
CHAPTER 11
Conclusion
This final chapter is an epilogue of my experiences and learning from the six months expedition.
It is an endeavour to encapsulate the answers to the questions raised during this period whilst
exploring the field of community health. It also includes a thought process, which grew, shrunk,
remained static and changed contour triggered by emotions, feelings, inhibitions and
rationalisation.
Looking outward –
There has been constant changes taking place in the world around us. One not only needs to be
updated about the happenings around, but to be able to work for the cause of the marginalized
needs to be sensitive to the community, its needs, which is fabricated from a wide range of
factors – people, their culture, their beliefs, their situation, their circumstances, which is not a
static picture but a dynamic photoplay emanating from its genesis and history.
The fellowship program gave me an opportunity to visit different organizations and through
them different communities and discover more about them. Besides this it also gave me an
opportunity to meet like-minded people, acquaint myself about various issues of concern and
understand it from different perspectives. Some of my learning and contemplation About the community –
We are blessed to be a part of the nation with its large varieties in landscape, climate, culture,
customs, traditions, beliefs and above all people. I had been fortunate for having had an
opportunity to travel to different parts of the nation. Despite of the vast differences in culture,
tradition and attire; there was one striking similarity in all of them – solidarity, which the urban
culture lacks.
We are all full of praises about the rural culture, people ---- but the some of the stark facts stare
us at our face. IMR , MMR, infrastructure, fund allocation, Life Expectancy, etc. unveil the poor
49
condition. These facts are not too far from that of the urban slums. Why are these communities
neglected, used merely as vote banks and deprived even of the basic necessities of life?
It is because they do not have a voice, they are not empowered by education to understand
various complex issues and fight against those that are detrimental to their growth. Though there
is discontent about the system, the so-called modern rulers and the total oblivion of their
existence, the status quo continues. “Neglect creates mindset that accepts the current situation
without protest as being normal12.” How long can we continue ignoring this? External forces
cannot work effectively unless the force develops within the community. And this is possible
only through awareness, evoking the sleeping souls and arousing a mass movement.
People’s Health Movement is an excellent endeavor towards such an initiative. It not only brings
concerned people (both the sufferers and various organizations working for the marginalised
groups) but also provides a platform to share experiences, touch upon all the spheres of life
concerning health.
Change – “The only thing constant in life is change.”
Change is inevitable but was rather slow in the neglected sections of the society, which is now
accelerated by exploitation of the poor by the bigwigs of the society. Change can be termed
progressive or positive in the middle and the upper middle class section of the society, while it is
regressive for the poor.
A NCAER study states 24,000 Indian households have an annual income of more than Rs. 50
lakh and another study by Cap Gemnini Ernst and Young found that 60,000 Indians have an
asset worth more than Rs. 4.5 crore. This potential market crowded in urban India, is being
targeted by various MNCs. These MNCs in turn are flexing their muscles to further exploit the
already distressed poor.
The immediate impact of crashing tea prices on the health status of the Gudalur tribals, the
deteriorating status of people from Raigarh (Chattisgarh) with the expanding empire of Jindal,
12
Dr. Dilip Mavlankar.
50
the displacement of the tribals in HD Kote due to the forest conservation act are all an evidence
to the ugly face of globalization, privatization and liberalization.
By providing assistance to such communities we are initiating a change. We need to bring a
change in ourselves first, as they are already accustomed to their state and in fact far better
strugglers to have survived such vagaries of the society. It is therefore essential to research if the
interventions are actually in the benefit of the community, such that we do not add to their
burgeoning problems.
The tribal and rural culture is deemed to be very rich and there has been an ongoing debate of
the long-term impact of extrinsic interventions, which are believed to erode their conventional
beliefs and practices. By introducing modern education and modern practices there is a fear of
wiping the rich customs and knowledge system. To what extent can external aid be provided?
Till when will such support systems exist? And if they are withdrawn isn’t it being unfair by
luring them with bright prospects and then leaving them half way? It is known that all
conventional practices are not healthy and hence some of them need to be changed. Most of the
practices related to obstetrics are unhealthy which endangers the lives of both the mother and
child. But the whole process of change is a complex process, which carries along both positive
and negative influences. Where do we draw the line? How do we determine to what extent is
change required in different communities? How do we ensure that the community will remain
untouched by the negative influences of the interventions?
Continuous and Collective effort –
I cannot resist quoting the Hundredth Monkey Phenomenon, which I learned about in talks with
Dr. Sundaraman. This phenomenon shows that when enough of us are aware of something, all
of us become aware of it.
That concept confirmed my own intuitive trust in the basic tenet of my work — that the
appreciation and love we have for ourselves and others creates an expanding energy field that
becomes a growing power in the world.
51
There is no need to feel helpless or get paralyzed by hopelessness. We know we have the power
to make changes if we can join together and raise our voices in unison. There is more power in
numbers that we ever hoped to dream about!
The story of the Hundredth Monkey:
The Japanese monkey, Macaca fuscata, has been observed in the wild for a period of over 30
years. In 1952, on the island of Koshima scientists were providing monkeys with sweet potatoes
dropped in the sand. The monkeys liked the taste of the raw sweet potatoes, but they found the
dirt unpleasant. An 18-month-old female named Imo found she could solve the problem in a
nearby stream. She taught this trick to her mother. Her playmates also learned this new way and
they taught their mothers, too.
This cultural innovation was gradually picked up by various monkeys before the eyes of the
scientists. Between 1952 and 1958, all the young monkeys learned to wash the sandy sweet
potatoes to make them more palatable. Only the adults who imitated their children learned this
social improvement. Other adults kept eating the dirty sweet potatoes.
Then something startling took place. In the autumn of 1958, a certain number of Koshima
monkeys were washing sweet potatoes — the exact number is not known. Let us suppose that
when the sun rose one morning there were 99 monkeys on Koshima Island who had learned to
wash their sweet potatoes. Let's further suppose that later that morning, the hundredth monkey
learned to wash potatoes.
THEN IT HAPPENED! By that evening almost everyone in the tribe was washing sweet
potatoes before eating them. The added energy of this hundredth monkey somehow created an
ideological breakthrough!
A most surprising thing observed by these scientists was that the habit of washing sweet
potatoes then jumped over the sea —
Colonies of monkeys on other islands and the mainland troop of monkeys at Takasakiyama
began washing their sweet potatoes!13
13
Lifetide by Lyall Watson, pp. 147-148. Bantam Books 1980.
52
Thus, when a certain critical number achieves awareness, this new awareness may be
communicated from mind to mind. Although the exact number may very, the Hundredth
Monkey Phenomenon means that when only a limited number of people know of a new way, it
may remain the consciousness property of these people. But there is a point at which if only one
more person tunes-in to a new awareness, a field is strengthened so that this awareness is picked
up by almost everyone!
One of us might be the "Hundredth Monkey" and what if we are not-----, we certainly have
certainly added to the reserve of the consciousness property!
Though the impact on the health status of the tribals in Gudalur was not too heartening the last
15 yrs. of concerted effort by committed medical professionals (community health specialist,
surgeon, gynecologist, pediatrician) advocate, social worker, architects, accountant and many
others have certainly changed the face of the society. They are empowered to fight for their
rights.
Having recognized that health cannot be improved by merely providing medical service, most of
the organizations I visited are working in different directions to improve the living conditions of
the people. The tribal welfare initiatives began with mobilizing people to fight for their land
rights at Gudalur, the SHRC’s Mitanin program endeavors to bring health to the people’s hands
and link it up with panchayat and government health system. The Jawar scheme implemented in
rural Sewagram underwent incessant alterations to motivate people to thrive for a better quality
of life and to ensure community organization and participation.
Every inspired soul can make a difference –
The ‘Jawar scheme’ conceived and implemented by Dr. Jajoo and the multidimensional efforts
made by SHRC under Dr. Sundaraman’s guidance both are great examples of strong leadership
qualities. It is also apparent that though it is lead effectively it cannot be executed single handedly
and hence calls for mass mobilization by igniting minds. It is evidence to the fact that every soul
has the potential to bring a positive change in whatever way possible.
“There is more hunger for love and appreciation in this world than for bread.”
53
-
MOTHER TERESA
About community health –
Community Health –
“A process of enabling people to exercise collectively their responsibilities to their own health
and to demand health as their right.”
Some observations
The impact of iniquitous globalization is directly seen on the health status of poor and
margnialized.
We need to take the first step ahead though the final objective may seem to be difficult.
Everyone needs to play their role irrespective of when the fruits would be borne.
Mere medical intervention can never address overall health issue though curative service
is an indispensable for maintaining overall health.
What is community health?
Any endeavor that is –
Committed towards continuous improvement of health.
Focused on tracking area health indicators and eliminating identified disparities.
Community and resident based.
Inclusive of key stakeholders in health improvement: residents, consumers, coalitions,
communities of faith, local and state governments, businesses, and providers of
community-based health, education, and human services.
Reflective of the age, racial, ethnic, gender, sexual orientation, and linguistic diversity of
the area
We are coming to understand health not as the absence of disease, but rather as the process by
which individuals maintain their sense of coherence (i.e. sense that life is comprehensible,
manageable, and meaningful) and ability to function in the face of changes in themselves and
their
relationships
with
54
their
environment.
The link between community health and public health –
It is essential to develop an understanding of public health among the social workers and
community and develop capacity to solve ordinary health problems at local levels for which
training of the voluntary workers is imperative. This however needs to be linked up with
government efforts and the community by empowering them to identify their problems offering
alternative solutions and tackle them. This is true essence of community health.
What is not community health –
Demand generated by the community for services from the government.
Mere participation in service delivery by the community.
Mere acceptance of government programs.
It is empowering the community to shape their own destiny.
About health finance –
Access to health care depends on how the provisions for healthcare is financed. In most of the
developed nations the health care for all its pupils is ensured by the government where a single
pool of resources is created to meet the health finance needs. In most of these countries 85% of
finance comes from the public resources like taxes, social or national insurance which caters to
health needs of over 90% of its population. Canada gives health care access to 100% population.
In India though a large proportion of household income is lost in taxes, a minimum proportion
of less than 1% is allocated to meet the health needs of the people. Moreover it addresses the
health needs of only a fragment of the population not necessarily of the unaffordable. Thus the
intelligentsia forming the upper starta of the society often get the services (of superior quality)
free of cost, while those who barely manage to earn enough for sustenance end up paying more
thereby being heavily indebted and further get pushed to lower socio economic strata.
Thus those who can afford to pay get free services and also evade taxes, while the poor not only
pay their taxes but are also deprived of quality health care services. This gap is further broadened
by privatization and commercialization of medical care, with pharmaceutical companies,
corporate groups and medical entrepreneurs offering hi-tech care at subsidized cost to the
middle and the upper middle class population. They not only evade tax payments under the
55
banner of ‘charitable hospital’ but also get huge subsidies from the government which is
withdrawing its services for the poor!
There are various means of generating resources for health like charging cess earmarked for
health on the sale of high demand low need products like cigarettes, alcohol, vehicles, gold,
diamond, etc. however the problem does not terminate at this end, further a matter of concern is
appropriate resource allocation. In the public health care system there has been a mismatch of
resources. Existing resources if utilized effectively and efficiently can meet the basic needs of all
the people. There is no dearth of management professionals to correct this ailing system. What is
indispensable is political will and people’s commitment without which it is not possible to cure
this ailing system.
Role of information and insurance –
Apollos, Wockhardts have been able to expand their business in the so-called health industry due
to strong market research. Information is the most powerful tool for the successful planning and
implementation.
To ensure a system that meets the health needs of the people, that utilizes the resources to its
optimum, that provides the best quality services to its people, that addresses all the issues of
local pertinence- unmasked, infallible information is essential. However information has no role
to play if it remains sealed in the lockers the authorities, it must be transparent and available to
the public at large.
As per my experience most of the places do maintain some amount of basic data, however its
relevance an importance is not known and hence it is in unusable form. Thus the health
information scenario at the field level is disappointing with few exceptions like at ACCORD a
detailed record of all the relevant data is maintained for the past 10 yrs. Similarly all the
information was available for Jawar scheme though it was a time consuming exercise.
There is a very close and intricate relation between health information and health insurance. The
nature of risk, the value of the risk, the probability of occurrence of the event insured, the time
value of money, etc. which are valuable for the designing a scheme can only be ensured by a
56
good HIS. Just as we blindly accepted the foreign model of health care, so did we adopt a health
insurance scheme that does not befit the requirements of the poor and deprived!
Looking inward –
It is difficult to look within and be true to oneself, as we are in a habit of ‘self deception’ and
most of us inherently suffer from ‘escapism’. These questions helped me realize my potentials
and focus my energies towards building the community with these reserved potentials. It helped
me understand a very important thing that we all are blessed with different talents and abilities.
We cannot perform all the acts that we desire and cannot alone bring a change. We all need to
play our role as a part of the team and create a conducive atmosphere for others to work and
success will indubitably embrace us.
These six months have taught me a lot and brought a change in my life. Few aspects of change
that I picked up
Change happens
Anticipate change
Monitor change
Adapt to change quickly
Enjoy change.
The continuing dilemma –
We are always convinced by our brain of how essential it is to pursue the route commonly
chosen by everyone which takes one up on the ladder of success, the success of having made
materialistic gains. What do we mean by materialistic gain? Is it ‘mundane’ or ‘practical’? With
changing times and changing scenario luxury items have assumed the form of basic necessities.
So it is practical at least in the former years, while after a certain point of time it becomes
mundane. But when and how this line is to be drawn, materials draw upon themselves the
human urges which soon becomes habit and exponentially grows which is too difficult to be
arrested!
On looking back I believe that it provided a fertile ground for learning, from different
perspective and from different levels. It helped me get a macro as well as a micro view of
57
community health. The work culture promotes innovation and allows everyone to express, the
problems faced by one is discussed with everyone so that the team spirit is alive.
Every journey comes to an end! ------ only to convey that a new journey is awaiting to take you
through another fascinating phase of life. So is my expedition coming to an end through
Community Health Cell, a genial place where I met like-minded people, where I got an
opportunity to unleash into the field of community health, a place where I could introspect and
be myself!
“As I travel along, with the years gliding by
Adding to the richness of my experiences
Making me realize how less I know
With more and more that I discover about this wonderful world.”
CHAPTER 12
58
Community based Health Insurance –
SWAMI VIVEKANANDA YOUTH MOVEMENT
The scheme was conceptualized on 1st June 2004 and was yet to be implemented, when we
visited SVYM. A pilot project to assess the success of the scheme and investigate the prospective
problems in implementation and administration of the scheme was planned aiming to cover only
a handful of non-tribal people, who were to be identified by various groups like SHGs and
health workers. The modules for training the trainers (the organization employees) to identify
and train the SHG members on various aspects of the health insurance scheme was being
contrived.
Benefits available - The insured will be eligible for all types (Inpatient care, Out patient care,
Preventive and Promotive) of health intervention either free of cost or for subsidized charges.
The free and discounted services are made available only at SVYM hospital and the listed referral
centers.
Services available for free –
1. Eye Care
2. Health Promotion
3. Health Education
Services available at discounted price –
1. 10% discount on Laboratory charges.
2. 30% discount on surgical procedures.
3. 20% discount on delivery charges.
4. 50% on emergency care.
Listed Referral Centres –
Type of service
Names of hospitals
Cardiac
Narayan Hrudyalaya, Bangalore.
Cancer
Bharat Cancer Institute, Mysore.
Ophthalmic care Minto Eye Hospital, Bangalore.
L.V. Prasad Eye Hospital, Hyderabad.
59
Training would be provided by Orbis, technical inputs from LV. Prasad, while the scheme is
proposed to be managed by SVYM.
Eligibility – In the pilot phase only the members of specific groups or members of the
community identified by specific groups were eligible in order to ensure full contribution and
follow up and facilitate monitoring of the scheme.
Contribution from the insured – The insured is eligible for an annual cover under the scheme
on payment of Rs. 5 per month per head, on the pre-condition that the entire family will be
enrolled.
Basis of the scheme – A HIS (Hospital Information System) at SVYM hospital ensures the
availability of all the requisite information for designing an insurance package. This information
(occupancy rate, length of stay, disease trend, utility rate) was said to have been used to
determine the premium per head. Besides some other social insurance schemes were also studied
and few insurance companies were also consulted to give their valuable inputs for the scheme.
The involvement of specific groups like SHGs would ensure continuous monitoring of the
scheme. Besides this the tie up with specific health care providers like Narayan Hrudyalaya
would in turn ensure monitoring and prevent misuse of the scheme. As the premium amount
will be managed by the hospital itself, the chances of moral hazard are further reduced.
The hospital authorities are open to change in the scheme and want to scrutinize all the possible
effects of the scheme on the community and the organization and hence, wants to try the
scheme on a selective population from whom contribution is assured, i.e. the non-tribal
population. If the scheme is found to be successful by the end of a year, it will be expanded to
cover the entire population, the premium for the tribal segment being borne by the organization.
If the premium amount collected is high an insurance company is proposed to be roped in to
manage the finance and administer the scheme.
Comments – The scheme is in infant stage and hence too early to be commented upon.
Moreover in the limited time a detailed study of the proposed scheme could not be undertaken.
Though we could not have a preliminary look at HIS it is rather difficult to believe that a
60
premium of Rs. 60 per annum could be reached based on scientific calculation. This comment
cannot be rationalized and is based purely on impression. From the community’s point of view it
in fact does not seem to be too attractive a proposition due to the following reasons –
The services are made available only in selected few Centres, most of them being in cities
much beyond the reach of the local poor.
The indirect cost including transport charges, food charges, loss of wages are not being
taken into consideration. This needs to be taken in special consideration because the services
are available only in restricted few hospitals, which are geographically far located.
Despite of 15 yrs. of diligent effort by the organization, it is yet difficult to persuade the
tribal people to seek timely treatment from the hospital. In such a scenario the benefit of the
scheme cannot be expected to be utilized to the fullest.
Financial stability and sustainability can be assessed only on the availability of detailed
information on - the number of beneficiaries, the morbidity rate and pattern in the community,
the health seeking behavior, the cost of care, the hospitalization rate for different ailments, the
average length of stay and the expected utilization rate.
Chapter 13
Western Regional Public Hearing
61
Pre-event Day
Date: 28th July 2004
In order to project the cases with maximum impact within the restricted time provided, a day
before the actual hearing, all the concerned people with the patients and/or their relatives having
faced denial to health care, assembled at Gandhi Bhavan, Bhopal for a pre-event preparation.
28th morning started with arrival of people from the four states namely, Madhya Pradesh,
Rajasthan, Maharashtra & Gujarat to be a part of this historic event, which is first of it’s kind in
the nation. Around noon with all preparedness the program co-ordinator addressed the group,
elucidating the program objective and hence the need to be brief and lucid. The case
presentations were required to reflect two issues primarily – the issue of denial of service
(including the lackadaisical attitude of the health professionals) and the consequence or loss due
to denial (where the loss could be physical, mental, psychological or financial)
Two parallel sessions were conducted – one of Madhya Pradesh & Rajasthan while the other of
Maharashtra & Gujarat cases, facilitated primarily by the CEHAT team and with inputs from the
health activists and health workers from different organizations.
It was decided that each case would be presented by either the patient (sufferer) or his/her
relative in his/her local language in 2.5 mins, which would then be translated by the health
worker in hindi in 2 mins. focussing on the aforementioned two issues. If the cases were
presented in hindi by the patient or kin, he/she could consume 4 mins. allowing the health
worker to expound upon the main issues of concern in 1 min.
As I had decided to attend Maharashtra and Gujarat session on the final public hearing, I
decided to voluntarily attend the rehearsal of the other session, i.e. from Madhya Pradesh &
Rajasthan.
Though the presenters were asked to present in a standing position, which was found essential to
develop confidence of facing the crowd and speaking through the mike, it was not made
mandatory (its significance was not explained to them). Many spoke from the place where they
were seated and in low voice using colloquial terms, which made it difficult for people like me to
62
comprehend. Some inter linkages in few cases were also missing like the date of event/ the kind
of hospital from where the treatment was sought, the chief complaints/the final diagnosis, etc.
In each case Dr. Abhay Shukla, Dr. Ajay Khare and few others pointed out the issues to be
stressed upon or to be highlighted. It was further realized that the time taken was more, the
presenter was unable to comprehend in the time slot, crucial aspects of the cases were not being
adequately highlighted and hence a change was suggested –
Those unable to explain in Hindi would just accompany the health worker or would narrate in
brief while the health worker would be responsible to present the main issues.
By the end of the rehearsal for the states of MP & Rajasthan the following aspects were realized–
Cases from these two states were more fluid, where the denial was more indirect than direct.
As the case presentation was not well formulated it was found necessary to plan and rehearse
again.
Cases from MP reflected the shunting of patients with poor referral mechanism where the
kind and level of health care was extremely important to be known. However this was being
missed out.
Cases from Rajasthan reflected on the mismatch of resources at different levels of health
care and the indifferent attitude of health personal, which was also not duly reflected
through the case.
The following corrective measures were identified –
More emphasis to be laid on the two critical areas.
Level of health service and the kind of service must be specified in each case.
Health co-ordinator and personnel from different organization to assist the team in their
rehearsals.
Lacunae identified in the session –
The significance of the medical documents was overlooked.
The cases were not documented with all specifications and minute details.
63
The cases seemed to be the only one’s selected rather than a sample of the cases, as they
were not too diverse.
In some cases the issue of denial was not clearly understood or reflected.
The issue of violation of human rights was not well thought of in any case and not clear in
some cases.
There was a lot of ambiguity about the criterion of selecting the cases if they were denial or
violation.
Learning from the session –
The objective of public hearing as I perceive, is to reflect the lacunae in the system, wherein the
case hearing would just specify about the existence of such an incompetent system and the
impact of such a system on the lives of people i.e. the official is expected to understand that
these are not isolated cases but an end product of the failing system.
It is just a tip of iceberg and there is a huge chunk of such cases – some which are visible but not
brought to anyone’s notice or known only to grassroots level workers and not known to the
concerned officials or known to those concerned with the system but the top level officials are
still unaware of it.
Thus it is apparent that such a session and case hearings would be highly sensitive – where on
one hand there is a possibility of officials wanting to take corrective actions against the health
personnel responsible for the loss caused to the individual, which may in turn also bear
undesirable consequences on the victims like a backlash on them; while on the other hand the
patient might expect a positive outcome from the same.
It is therefore essential to convey the correct intentions and objective of the program to–
The officials that it is aimed to cure the ailing system and not to punish individuals
responsible for the cases presented.
The patients and their relatives that they would benefit only in the long run and no
immediate relief should be expected.
64
Besides these the following measures needs to be taken into consideration to achieve the
objective of the program to the optimum –
Sampling –
Cases must be representative i.e if there has been a death due to a snake bite and unavailability of
ASV vaccine, the presented case must be one amongst many (with specified numbers) such that
the presentation shows the following statistics
------- Number of deaths in Maharashtra due to snake bites (from secondary source)
------- Number of deaths in Buldana district due to snake bites (from secondary source)
------- Number of deaths in ------- villages, as per the survey (in the specified geographical area)
due to snake bites, due to lack of availability of ASV vaccines (primary source)
And this case represents such cases
This kind of an approach will reflect both the magnitude of the problem and the severity (loss of
human life)
This could be further enhanced with the aid of information (recommendation) like
lack of ASVs in ------ number of PHCs ------ number of CHCs, etc.
Number of lives that could be saved if the vaccine was available.
Need of a primer in local language which includes the identification of bite marks of
poisonous snakes, administration of ASV – test dose, dosage quantity, duration of action,
side effects, other drugs to be administered, etc.
Need of a training of health personnel for the same.
Case Documentation –
Each case must be documented with all its trivialities including some of the following details –
The date when the case was first reported or brought to the notice of the health worker.
Date of occurrence of event.
Flow of the event like referral, experience at each health care facility with the details of how
the health professionals handled the case.
Name of the health service, like rural hospital, CHC, etc.
65
Name of the concerned people (which might be kept confidential)
These details might be required at any stage to resolve the problem faced by the patient, to
lessen the impact or provide compensation. It should therefore be available with the concerned
NGO but must be revealed only on getting an assurance that it will not lead to backlashing of
the sufferers.
Lack of these details poses problems like the Ngo is blamed for not having done their work, the
officials might express their inability to either take corrective measures or even verify the
genuineness of the case.
Importance of Medical Reports –
The patient/relative/ health worker must posses a copy of all the medical reports as it is a
substantial evidence and would aid in figuring out the exact case and how the denial lead to such
a severe loss. It would also aid in assessing the time lag.
It is desirable to seek a medical opinion based on the patients’ experience and the case paper by a
professional who is sensitive and aware of human rights issue. This will strengthen the case
presentation.
Presentation Technique –
The presentation could include NFHS figures or from any other authentic source. However
instead of presenting all the 10 cases first and then presenting the statistics; they could be
clubbed like that mentioned with the snake bite example. Or any other technique of presentation
could be adopted to enhance the impact such that the objective of the public hearing is etched
upon the minds of the government officials and the NHRC who tend to get carried away either
by figures or by individual cases.
Western Regional Public Hearing
66
Date: 29th July 2004
Panelist –
Mr. Murthy, Dep. Secretary NHRC
Justice Bhaskar Rao, Member NHRC
Dr Antia, Member Health Committee, NHRC (FRCH)
Dr. Iqbal,
Dr. Subhash Salunke, Director Health Service, Maharshtra. (for cases from Maharshtra)
Objective (as mentioned by Mr. Murthy) – To work in close partnership with the state
governments, state human rights commission to improve health care.
The inaugural session started at 10.30am. though it was scheduled to get started by 9.30 am. with
a formal introduction of the panelist viz. Dr. Antia from FRCH (also represents the Health
Committee of NHRC), Justice V. Bhaskar Rao (Member, NHRC), Mr. Murthy (Dep. Sec.
NHRC) and Dr. Abhay Shukla from CEHAT by Dr. Ajay Khare.
Excerpts –
Dr. Abhay Shukla stated that it has taken almost six months of collective effort of different
organizations to conduct the survey, identify cases of denial, conduct local hearings and collect a
sample of 10 from the universe of more than 60 cases and document them and lay out the entire
program structure. The objective of this hearing is not to antagonize the public health system
but to enable it strengthen itself with a joint effort of NGOs. Though private sector forms a
major part of health care provider; there is a predisposition of denial cases from public sector for
the case presentation as there are hopes of improving the public health system especially
considering the fact that the lower strata of the society are not being catered to by the private
sector. However in each of these cases the drawbacks in the private health care situation is also
duly portrayed.
Justice Bhaskar Rao in his discourse on public health listed all the public health issues and
legislative provisions concerned with it. He gave a number of suggestions like requirement of
67
strengthening health system, drug price control policy, availability of all essential drugs, mobile
services to remote areas, ascertaining accountability, provision of specialized care for the
vulnerable section of the society, etc.
Ten cases from Maharashtra were then presented by the patient or his/her relative in around 3
mins. and were accompanied by the health worker. These cases were then translated in hindi and
crucial issues were highlighted. Dr. Salunke interrupted the first presenter during his case
presentation and interrogated him about the specifics like the name of the PHC, the name of the
doctor, etc. He also stated that there was a discrepancy in the information provided to him and
in the case presentation. He informed the audience that all the case histories were mailed to him
and just in 48 hrs. he collected all the information about the case from the providers.
By the end of the session Dr. Salunke got very defensive and stated that the state public health
department is too large and manned by lakhs of employees. So loopholes in the system are
apparent. He assured stringent actions against the one’s responsible for these cases of denial but
also stated that the same system provides health care to many people, it also has committed
people working in remote areas with no facilities. He expressed his inability to execute certain
decisions in the interest of the public due to red tapisim and pressure from ministers. He
lamented that there are innumerable vacancies however the qualified doctors just refuse to serve
for the rural segment. He vehemently stated that instead of blaming the public health system, the
NGOs should pressurize the government and the ministry to increase budgetary allocation for
health and to change policy guidelines.
Justice Bhaskar Rao complemented the NGOs for their efforts and acknowledged the difficulties
in correcting the system and stated that it cannot negate human rights and hence the collective
efforts by different groups is indispensable.
Dr Iqbal said that the cases and the survey findings should be read together to be able to
visualize the entire scenario which is very grave. The session was concluded in the evening after
the case hearing from all the four states organized in two different sessions by Dr. Antia who
stated that health has been always dealt in segmentation. If health is merely curative it means
‘failure of health’ however it is a social problem and hence it is essential to impart knowledge to
the people so that they can take care of their own health. When we talk of health from a
68
sociological or a technical point of view we tend to overlook the entire socio-economic
dimension. Role of NGOs is supportive and not a substitute to the public system. He also
mentioned of Human Happiness Index on which we need to focus rather than always looking at
GDP.
Post Event – Meeting
Date: 30th July 2004
Agenda of the Meeting –
Review of Bhopal Regional Public Hearing
Logistics & Budget: -funds for public hearing has been provided by NHRC and a detailed
planning is required for logistical arrangement to be made for the pre-event and the post
event day, which can be easily managed within the budget allocated. However it will have to
be reallocated with a 15-day prior intimation.
Case Presentations: - Overall the session was successful and the variety of testimonies
selected and presented were good. But this primarily holds true for the state of Maharashtra.
Documentation was also very weak in the remaining states. Importance of sampling and
adept presentation techniques were discussed.
It was felt that more number of cases was of personal denial (denial of care by health
personnel) whereas the focus needs to be more on cases representing weaknesses in the
health system. It was also suggested that we need to give a patient hearing to the other party
(the government officials) and then strategically present our points. Presentation skills needs
to be enhanced to allude that these cases are merely a tip of iceberg. The issues of violation
of human rights also needs to be made very clear.
Recommendations: - It was also realized that whilst giving recommendations to the
government officials it is essential to be sensitive to their problems too like procurement of
69
ventilator in a public hospital, which requires a lot of time and effort, posting of a medical
officer to a PHC, while a mini PHC might not necessarily be manned by a MO. There is a
requirement for an Institutional/Administrative reform and the colonial administrative
system needs to be broken off.
Inclusion of cases of denial from Private Sector: - some cases must be presented. People do
have control over the private sector but do not know how to exercise their control over it.
Documentation of the proceedings of this hearing –
After every regional hearing a report with recommendations is expected from NHRC.
However, JSA is expected to assist them in this, rather prepare the document and give it to
NHRC for approval.
The process decided upon for this documentation is –
State wise report will be prepared with a common list of suggestion (besides suggestion from
different states). Investigation of the testimonies will be done by NHRC with the help of
JSA and appropriate measures will be suggested.
Dr. Antia suggested that for the report to be useful, it must be clear of what does it aim to
achieve and who would finally benefit from it. Hence the cognitive process should begin
now and the recommendations must be feasible, comprehensive and selective. It must also
include suggestions for participation (including regulation) from the private sector. The
report must be published in local languages besides English and the national language and
must be easily available to all.
Dissemination of information and Media coverage –
70
The pre-event preparation needs to be more proficient in order to have a wide and extensive
media coverage ensuring that it is known to people even from remote segments of the
society. The experience from the first regional hearing shows that the information has got
disseminated to only urban areas through well known English newspapers like Times and
Indian Express. These were not covered by local newspapers.
The testimonies must be documented and printed in local languages and must be distributed
to as many JSA members as possible. Sharing of information will thereby aid in learning for
other’s experience and will also help in proper documentation.
Other crucial issues –
The importance of informed consent and safeguarding them against backlash was discussed.
It was also realized that though it is not a grievance redressal forum, the aggrieved would
expect some substantial restitution from the whole process.
It was also felt that the case details must be submitted to the officials at least a week in
advance, except for those that are included at the last moment. The public health
professionals and those from ministry need to be treated with dignity in order to avoid
friction and to ensure that this endeavor (of public hearing) would complement the public
health system and aid in improving their efficiency.
Preparation of Other Regional Hearings –
The preparation for other regional hearings was reviewed and various suggestions were
made. Kerala is expected to present cases on environmental health and 10th of August was
fixed for screening the cases, while 19th was fixed for screening the cases from Karnataka.
71
The logistical problems for the case collection, intimation, co-ordination and arrangements
for the north-eastern regional hearing were discussed and it was decided that each of the
issue of concern would be discussed in a regional meeting at either Bihar or West Bengal.
Preparation for National Hearing –
-
The dates for National hearing were tentatively fixed from 13th to 18th, such that it gets
accomplished before Christmas.
-
As it would be a two-day event issues like women’s health, mental health, HIV/AIDS
etc. will also be covered.
-
There would be no individual case presentations and each state will be allotted specific
time to present on the survey findings; the number of cases collected, filtered and
presented at the regional hearing; and recommendations.
-
The state level report and the presentations must comprise recommendations which are
clear and with clear roles for different bodies must be specified.
-
All the reports and work must be directed towards – ‘Health as a human and
fundamental right.’ The operating mechanisms must be clarified.
Groups were created and assigned with specific responsibilities –
-
Analysis group – Responsible for making recommendations and report writing
-
Program group – Responsible for co-ordination and program arrangement
-
For follow up with NHRC
-
To pressurize/ influence Union Health Ministry for budgetary allocation and policy
issues.
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CHAPTER 14
Jawar Health Assurance: Beyond the realms of health.
Introduction –
Inhabited by the great souls – Mahatma Gandhi and Vinoba Bhave, the sacred land of Sewagram
is distinctly seen on the map of India, connecting it to different parts of the country through the
various roads of development. Serenity however still prevails in the air!
Gandhiji first came here in the year 1936 to serve the poor and an ashram was set up in the land
donated by Shri Jamnalal Bajaj. Dr. Sushila Nayar, then a medical student and a disciple of
Gandhiji started a small dispensary in the premises of the ashram. However since the patients
created chaos and disturbed the discipline of the ashram, the dispensary was shifted to Birla
House, which was later developed into a hospital – Kasturba Hospital. The hospital caters to the
health needs of the vast rural populace spread around in wardha district.
Agriculture is the main occupation of the villagers, while other means of livelihood are diary
farming, welding, carpentry, small establishments like grocery and some also have salaried jobs in
sugar mills, steel factories, etc. Besides anganwadis and balwadis, only primary schools and
secondary schools in some villages are the means of formal education. Children traverse on foot
or cycle through the villages to reach the educational institutions. Colleges are concentrated at
Wardha and sewagram. Caste system is not too visible and health care needs are catered by
Sewagram hospital, civil hospital and few private hospitals at Wardha, while outreach services are
provided through Sewagram hospital and PHCs and sub centers.
An initial quest into the well known Jawar scheme brought me here only to explore the role of
health in the larger socio-economic-politico- culture-spiritual milieu.
According to the Hindu teachings, life is a pilgrimage that leads through many lives to God. This
is the story of such a pilgrimage--“Service to mankind is the true service to God.”
Evolution: From then to Now -----
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Endurance unfolds facts! The lessons learnt in the course of an action prove to be milestone for
the next endeavor. Evolution of an organization or scheme reflects on the self organization of
the system and the people – their far sightedness, their commitment and values.
The Sewagram experience is thus a great learning experience as it has emanated from the people,
their commitment and is not an off spring of a vague model created within the four walls of an
institution.
The birth of an institution The history takes us back to 1945 when Gandhiji incepted Kasturba Hospital in the memory of
his wife Kasturba. The 15 bed hospital meant for women and children expanded to a 50 bed
hospital catering to the needs of all, including men. Following Gandhiji’s assassination in 1948,
the management of the hospital was taken over by ‘Gandhi Smarak Nidhi’, which in due course
of time could not manage the hospital finance and wanted the government to take over the
hospital administration.
Genesis of Insurance –
The workers being unhappy with this consultated the village leaders who offered their
contributions, thus Dr. Ranade and Smt. Manimala went around collecting Jowar at the harvest
time – this constituted the genesis of health insurance. It assumed the form of a scheme in the
following years, requiring a contribution of Re. 1 per member of a family.
The Kasturba Health Society was keen to extend comprehensive health care to the villagers
through their own contribution which gave rise to the need of insuring the entire village. Thus all
the services – preventive, promotive and curative were extended to the villages on the precondition that 75% of the villagers contributed a meager amount of Rs. 1 per head per year.
With inflation the contribution was revised to Rs.3, Rs.7 and subsequently to Rs.30. As 25% of
the bill was to be borne by the patients, the poor did not avail the scheme and utilized hospital
only when emergency situation compelled them.
Attempt towards self reliance that failed–
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As the hospital was running in deficit of one lakh per year, the hospital management was handed
over to the Kasturba Health Society registered in 1964, with an endowment of Rs 10 lakhs.
In 1969 when the hospital became a teaching hospital and the bed strength was increased the
students, nurses, staff members and their families were also insured.
Though the hospital provided services to those who contributed, it was imperative to know if
the services were reaching the needy ones.
The Path Ahead –
In 1977, Dr. Ulhas Jajoo joined as faculty in the Department of Medicine, MGIMS, who brought
a new dimension into the community health care. Imbued by Sarvodaya ideology, he founded a
study circle, ‘Medico Friends Circle’ of students who were concerned about the public health
issues afflicting the country. The enthusiastic souls very often had discussions on health issues
especially those concerning the marginalized. Having had enough of such ideological debates
within the four walls, they decided to step outside and work with and for the community.
To make preliminary enquiries about health and social issues of the villages, to provide them
medical aid and then graduate to deeper issues, the group strategized on selecting a village that is
accessible, small in size and cohesive to enable closer and frequent contacts with the community.
With little or relatively no direct exposure to community health, but highly charged by values and
allegiance to improve the situation of the rural poor, the group got divided and set out to explore
different villages. Though villages like Pujai were in dire need of medical services, a village
‘Nagapur,’ which was only 5 kms. away from the hospital and could be transversed on foot, was
selected. This was the first lesson learnt by the group of how developmental factors like road and
transport are interlinked to health.
After an initial assessment of the health needs of the people and in consultation with them, it
was decided to start a weekly clinic, the drugs for which would be provided from the drug bank.
Villagers agreed to contribute Rs. 4 towards the drug bank and offered the school building for
the clinic. Management of the drug bank gave the group an insight into the exploitative drug
market. However, very soon the drug bank went bankrupt and an analysis showed that the rich
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were evading the contribution. It was thus decided to deny drug facility to defaulters and to
impose penalty for delay. Though this problem was solved, it was soon realized that a poor
mother could not take her ailing child to the clinic because she did not have ready money to pay!
Realizing the problem of the services not penetrating to the poorest section of the community,
the group held a meeting with the villagers to find a way out. It was found that though 95% of
the illness were self limiting and treatable in the village, it was the treatment of the remaining 5%
who require hospitalization that earns credibility. The poor had to sell off their assets to meet the
catastrophic cost of hospitalization. As the cost of these 5% illnesses were beyond the reach of
the poor they evaded hospitalization till it attained the end stage. Even the cost of antibiotics
prescribed in the village dispensary was beyond their reach. The lesson learnt was that for serious
illness treatment must be free.
The scheme was thus linked up to the hospital in 1980, with the approval of the Director Dr.
Sushila Nayyar, the founder member of MGIMS.
Risk Sharing –
Dr. Jajoo resolutely believes that charity corrupts people and people must pay to demand quality
service from the providers. He had visited various voluntary health projects of repute in India.
From his observation emanated a belief that mere benevolent service will breed a relationship of
doler and beggar between the provider and the beneficiary. Moreover the schemes were heavily
financed thereby posing a threat to its long term sustainability. The tradition of contributing as
per one’s capacity already prevailed in the villages especially for ceremonial purposes and for
construction of temples. The same strategy was agreed upon by the villagers and it was therefore
decided in consensus with the villagers to create a pool of contribution to meet their health
needs.
The objective of this fund was to ensure –
•
Right to quality health care for health contingency to the rural sector.
•
Making health care services not merely available but accessible to the poorest of the
poor.
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•
Considering village as a social unit, an integral part of the larger society, making health
care services available to more than 75% of the village population with their active
participation.
•
A system to deliver appropriate and prompt health care services to the needy,
irrespective of the amount of contribution.
The collective pool of contribution was expected to finance the salary of VHW, drug
requirement for the local dispensary and transportation cost of mobile health team.
As the contributions were made in kind for other purposes and jawar was locally cultivated the
villagers unanimously agreed to contribute 2 payali (2.5 kgs. ) of Jawar per acre of landholding.
Landless labourers offered to contribute a flat rate of 4 payali in a village meeting. Those having
additional sources of income would contribute 4 payali more. If family members exceeded five, 2
payali per additional member was fixed. For the salaried class, contribution was decided in
proportion to the SALDAR’s (landless labourer on yearly contract) income. The collected jawar
was sold to the market and converted into cash for utilization.
Since universal health care was available to all those who paid, some of the rich farmers felt that
they were financing for the poor and hence refused to contribute. By the end of the first year it
was seen that only 60% of the villagers contributed. To ensure wider contribution a village
meeting was called and it was made clear that only those who pay will get free treatment and of
those who do not pay or abscond without paying will be held accountable in the village meeting.
Health in the hands of people –
As the work progressed, to facilitate an efficient referral mechanism and to provide health care at
the doorstep it was essential to have a village representative who could serve as a lynchpin
between the providers and the beneficiaries. Selection of a VHW was an educative process in
itself. Over the years of experimentation it was learnt that a VHW must be committed,
responsible, possess leadership qualities and above all must be beyond party politics.
Reorientation (1980) –
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More lessons had to be learnt! A pregnant woman was admitted a month prior to delivery
because she complained of recurrent abdominal pains. The husband expected free food and
treatment till she delivered. Others used admission as a convenient alibi for avoiding court
summons. And few others got a paraplegic admitted and took a pair of clean heels! Such bitter
experiences, led to a revision in the criteria for charging indoor patients. Though hospital
services were free for most of the illnesses, 25% of the hospital bill was charged for foreseeable
hospitalization like normal delivery and chronic illnesses like cataract, hernia, psychosis, etc.
The VHW was trained and handed over a drug kit with a descriptive manual in local language
using colloquial terms, for diagnosis and treatment of minor ailments and to enable diagnose
ailments that need referral (such that there is not delay in seeking medical attention).
It was critical to decide on the remuneration of the VHWs as their work being more preventive,
promotive and educative, it was too naïve to imagine people paying for such services. In 198384, the Gram Sabha was empowered to adjudge their performance and thereby decide on their
remuneration. It was decided to set aside 35% of the collection (Jowar), of which 20% to be
given to them, in the beginning of the year and 15% towards the end of the year, based on the
performance. 65% of collection was deposited with Kasturba Hospital to meet the cost of drug
kit, and fuel charges of the vehicle that attended village every month. Periodic meetings were
organized at the village to bridge gaps of communication and to appraise the performance of the
VHW. Though the insurance contribution subsidized hospital expenditure by mere 10%, it was
an appropriate strategy to ensure optimum utilization of resources.
The Gram sabha thus helped to facilitate communication between the health system and the
beneficiaries on one hand, while on the other it helped the villagers have their say regarding the
VHW and the health team, and could also decide to change the VHW (Jajoo, 1993). Through
Dr. Jajoo’s efforts, courteous behavior on the part of doctors and prompt services in the hospital
was ensured.
Thus the scheme gradually started gaining credibility and the enrollment increased to around
90% and villagers from adjoining villages approached Dr. Jajoo demanding that the Jawar
Scheme be extended to them. The team held a meeting during late evenings in these villages and
assessed their needs, their extent of co-operation and feasibility of administering the scheme.
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Thus after examining the practicalities new villages were adopted under the scheme. Since the
aim cherished at that time was organizing village community (the unit of the society), the precondition for adopting village was voluntary participation of at least 75% of population.
With the commitment of more and more health care in the hands of the people a Gram kosh (a
village fund) was raised with the entire contribution. A village fund (a bank account for each
village in 1985-86) was created with three signatories- the Medical Superintendent, the Health
insurance in charge (Dr. Jajoo) and the VHW, and was chiefly controlled by the hospital
authorities to avoid misuse. The utilization of the fund was decided in the village meetings and it
was open for public audit. The Jawar (Sorghum) collected was sold in the market after handing
over the VHW his/ her share and the remaining amount was deposited in the account, which
was utilized for village drug kit, fuel charges of the van and educational activities. With soyabean
replacing jawar sowing, from 1998 onwards, the contribution was converted into cash collection
i.e the villagers had to pay the market price of the stipulated jawar contribution. However those
who wish to pay in kind are still welcomed.
From 1999 onwards the balance amount from each village fund was transferred to Kasturba
Health Society to form a corpus, the interest of which would be utilized for procuring drugs,
educative lecture week series (Prabhodan Saptahs), educational camps and providing Ambar
Charkhas (Spinning Machine) for Vastra Swavlamban program.
Towards Integrated development –
By now close ties were developed with the villagers and parallel to it, some developmental
activities were also being run under the initiation of Dr. Jajoo. The scheme had found its roots in
the community and Dr. Jajoo gained credibility. In the process of addressing health issues, it was
realized that social and economic issues need to be tackled. To address the sanitation problem
government and state funds were channelized to subsidize the cost of latrine and with affordable
contribution, people very soon had latrines under ‘One house one latrine scheme’ which was
aimed at 100% coverage. This model was adopted by the government for replication in other
states. The diary in a village (Nagapur) which was at the verge of shutting down, with community
initiative under Dr. jajoo’s guidance, Diary Co-operatives was rejuvenated. With the aim of
equitable water distribution, lift irrigation cooperative society for the entire village land was
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initiated. The funds came in form of bank loan to be paid back in ten installments. The creation
of the constitution of the village co-operative society was such that, decision could not be taken
with less than 75% majority, making elections obsolete.
Each of these schemes emanated from the needs of people, their participation and cooperation.
No task was undertaken without the initiative from the people. Community involvement has
different shades – community compliance – where community is a passive receiver, community
cooperation – 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. And community participation is a politicized concept. The decision making lies
with the people. There is a common feeling and hence a spontaneity of action. (Dr. Jajoo,
Anantbhan)
The Jowar scheme could now magnetize people and villagers were ready to agree on any terms
or conditions to get enrolled. Taking a cognizance of this, Dr. jajoo with his group excogitated a
new pre-condition for the Jawar Scheme to be offered to the village–
•
Should have initiated the lift irrigation scheme for the entire village.
•
Should have availed to the ‘One house one latrine’ scheme with 100% participation.
•
Each family in the village be a member of the diary co-operative.
•
Elect village panchayat by consensus.
In the whole process of upliftment the most vital, sane and organized but the highly neglected
section of the society- the women group could not be overlooked. In order to initiate a process
of empowering them, Self Help groups were constituted. They were brought under one roof to
imbibe a sense of oneness as they were all sufferers – ‘the proletariat of the proletariat.’ A
collective movement was envisaged to provide mutual support – both morally and economically.
A common pool from individual contributions was made to meet contingency requirements and
meet expenditure on educational activities. Besides transparency, accountability, a culture of
decision making by consensus was ingrained in them. They were trained to handle their accounts
and sent for excursions, to learn from others’ experiences. This gave an impetus to the group to
take bold action against liquor producer.
It was thus realized that credibility earned through health care initiative is a very effective vehicle
to induce change, but being the lowest priority among people cannot sustain the organized and
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collective movement for long. Income generation programs served as an alternative to maintain
cohesiveness. The community compliance was visible in health, community cooperation and
partnership with income generation and development activities, but community participation
was still invisible!
A wind of change –
With all these efforts the per capita income increased thereby bringing about a wave of change in
the lifestyle of villagers. Health indicators showed awesome improvement- infant mortality
shrunk and maternal mortality dropped to zero. However roses are always accompanied by
thorns. Socio-economic improvement gave way to alcoholism, gambling, conflicts, groupism,
and party politics inflating vices like jealousy, greed and competitiveness.
They again reached at the cross roads with questions – What did the village benefit? Is this what
we had aimed at? It was soon realized that economic development must be preceded by sociocultural upliftment. The seed cannot germinate into a plant unless it has adequate supply of
water and the land and ambience are conducive for growth.
The need of the hour was to revolutionize and awaken the sleeping souls which required active
participation of the devout men (sajjan Samarth). The health insurance scheme had now reached
a stage where it was helping to identify not only the action oriented culture of the village but also
action oriented individuals with capacity to do good. The strategy adopted was to exert thrust on
constructive programs in the present context viz. ANNA SWAVLAMBAN through organic
farming, VASTRA SWAVLAMBAN by making use of ambar charkha (spinning machine) and
VITTA SWAVLAMBAN through self help groups. These venerated activities were believed to
aid in cleansing the soul, take one close to nature.
It is believed that these are not merely physical activities but rouses conscious and is an engine to
internalization. They are the acts of faith. To induce faith in people, take this message to people
educative lecture series were started (Prabhodan). These were started as hymns at the temple
where people usually assembled with devotion. However they were unable to perceive it. It was
therefore felt essential not to have such sermons but discussions on issues pertaining to day to
day life, issues concerning them and link it to socio cultural values through experiential learning.
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While organic farming ensured sustainable yield from agriculture without causing any harm to
mother earth, it required a lot of hard work and dedication. Vastra swavlamban aims at achieving
self reliance in clothing. These messages were disseminated in the villages and to ensure its
assimilation, role models were introduced to them.
The kaleidoscope was now focused on identifying the devout and support and empower them to
serve as role models for others to follow. A moral leadership is required to ensure sustained
development which encompasses all – the voiceless, the poor, the marginalized. It aimed at
breaking the ‘culture of silence.’ People were required to be alert to their needs and be proactive.
The focus now shifted from a progressive village to the individual families who participate in
creativity. As jawar health insurance has the bargaining power those actively involved in any of
the following are now entitled to the scheme –
•
Member of Self Help group.
•
Having assumed organic farming.
•
Organizer or participant in Prabhodan
•
Having taken a vow for Vastra Swavlamban.
These activities are believed to morally uplift individuals. Some get involved in any of these
merely to avail to the benefits of the scheme. It is believed that by subjecting to such a process,
change is inevitable! Though the time taken is not predictable! For those who are not interested
in moral issues, alternative schemes are available.
The whole process began with a dream of Gram Swarajya where health was chosen as a medium
of entry into the rural life. Though health is vital to be able to enjoy other benefits in life, it does
not enjoy priority. Issue of income generation larger to it was chosen as a pedestal. However
activities revolving around materialistic gains are driven by individual interests engendering an
illusion of community organization. The focus thus had to be risen to address moral and ethical
issues.
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There has been a paradigm shift in the scheme from an initial focus on curative care to
preventive and further to promotive care. It didn’t stop there and with perpetual experience and
learnings shifted the focus on social aspects, which now rests on moral issues.
As I walk along, I see things gliding away--I halt and ponder to realize that they have been passing through me,
Reforming me! Recharging me! Revitalizing me!
Ethos –
Every society is constituted of ‘Haves’ and ‘Have-nots.’ Inequality is ingrained in nature with
multiple classes and categories of flora and fauna one mightier than the other, topped by human
beings. Human beings are not the superior most merely because of their intellectual capacity, but
because they are blessed with ‘brain power to serve humanity’. Proximity to nature breeds
humanity as nature takes care to suffice the needs of every human but not the greed of any.
Nature ensures adequate resources provided individuals makes the best use of their mental
pursuits and toil to obtain their share.
However our society is not egalitarian with power concentration being highly skewed towards
the intellectual class. Power leads to corruption, contempt and exploitation of the lower class for
accumulation of wealth and personal gains. In order to ensure a fair share to everyone, the
ownership needs to be collective such that individuals enjoy the fruits of nobody else but their
own labor for generations to come.
Thus the ethos of the scheme revolves around the ideologies of Gandhi-Vinobha-Jaiprakash
Narayan, soliciting the concept of village republic (Gram Swarjya). This vision assumed contour
of Gramdaan proposed by Vinoba. As per the Gramdaan Act, the 75% population are required
to transfer their land to the Gram Sabha, the highest decision making body in the village, which
is then no mans land and has a collective ownership. They preserve their right to toil on the land
and enjoy fruits of labour. The leader is selected not elected, as elections are a foul play. ‘Purity
of end can only be possible through purity of means.’
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Decentralization of the power to the Panchayat is by no means an answer to this as the
panchayat constitutes of narrowly elected group of representative which reflexly becomes a locus
of power. True democracy cannot be manifest by representative democratic structure but can
only be attained by collective decision making process. Such an ideal society needs an apt
structure to imbibe the correct values. These two complement each other and the absence of
even one would wreck the society. This structure is reflected in ‘oceanic circles’ and not in
pyramid. Years of experience have shown that the trickle down theory never works in the larger
interest of the poor. For the benefits to seep through the people the structure must be
horizontalized complemented with collective action driven by motives that benefit the larger
masses overriding individual interest. What Gandhi Vinoba propose is participatory democracy,
where in the most decentralized social units (village) decision making body will not be less than
Gram sabha.
Its relevance to health –
Health must be in the hands of people – for the people, by the people and of the people. Health
cannot be dealt in isolation of other social, cultural, economic and political issues which are all
closely interwoven. Trying to view from the ivory tower with the aid of a binocular will not help
the community need to be examined under a microscope and so the soul of this experiment lies
in “Go to the people,
Live with them,
Learn from them,
Love them,
Live like them,
Build upon what they have”
Health being a nodal point of entry it now tries to achieve the mission of ‘identifying revered
individuals in the society, honing their leadership skills to evoke community action for the
benefit of the society’.
Dr Jajoo believes that conscentization of individuals is the stepping stone to create a morally
upright society which is self reliant and self sufficient.
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Objective –
The objective of the entire process is to continually educate people and motivate them through
role models and convert them to change agents for the benefit of the community. This would
ensure a sustained progress.
The model seeks to enhance individual capabilities and sense of awareness by aligning
individuals of high moral values with revered men through various venerated activities. Its
primary focus revolves around igniting minds to progress into better individuals thereby laying
the foundation towards creation of sane society.
Strategy – Perpetual Revision
Every incident served as a learning opportunity thereby necessitating restructuring of the
strategy. Each endeavor was strategically planned and had to be maneuvered from time to time.
The entry point strategy was to take into account the health needs of the people by focusing on
curative care – a strategy which reaches to the poor, involves people, does not make them
dependent and attempts to raise resources locally. The inception of Jawar scheme with all the
changes that it underwent is evidence to this.
Various experiences in the field are a witness to this –
Health Education –
Influenced by the conventional preventive medicine style – talks on various issues like
malnutrition, leprosy, tuberculosis, venereal diseases, diarrhea, family planning, immunization,
etc. were held which fell on deaf ears. The bookish information were neither feasible nor
appropriate to their lifestyle. In a family where two full meals could not be guaranteed, what kind
of nutritional food could be advised to the pregnant mother and the children in the family? A lot
could be learnt from the mothers when they said, “We do not have cattle, milk sold in the village
is diluted and sold at exorbitant cost. We cannot afford, eggs, oil, sugar, vegetables, fruits.”
85
The admonitions on the repercussions of large family size to promote family planning methods
were retorted back by responses like, “Will you support us when we get old?” One old woman
asked “Doctor have you seen a bullock cart with only one bullock? You need at least a pair; if
one succumbs at least the other will drag the cart on.” In a patriarchal society, it was natural that
family waited till they have two male kids. Thus it struck that unless under 5 mortality is reduced,
unless security for old age is provided and unless agriculture becomes profitable any incentive
will not convince them of the benefits of small family. Health education is often glibly used
slogan. People are wise and adapt to situations. It is not they but we who need to be educated!
MCH care –
The door step maternal service was the top most priority – enlisting expectant mothers,
detecting early pregnancy, identifying local dais, supporting her for home deliveries, utilizing her
as link worker during antenatal visits, identifying at risk mothers and supervising their
hospitalization was the popular strategy. However two cases of casualty – (1981) the death of a
second gravida due to post partum bleeding whose delivery was conducted at home by dai; and
(1983) a primi gravida whose fetus died in utero compelled to rethink on the strategy ------Road and transport facilities were the key factors determining accessibility to the hospital was the
lesson learnt. It was now dawned that none should be denied hospitalization under the pretext of
providing health care services at the village. A villager does not demand hospitalization for no
reason. It costs him heavily – apart from hospital bill, lost wages, lost wages of attendant,
transportation, food, drug, etc. everyone has a right to just health care service whether primary,
secondary or tertiary.
The highlights of the learning were –
•
Emergency services must be free to enable accessibility to the poor.
•
The public facility when made available to all, are gulped by the rich powerful and few.
For making the facility available to the poor, the elite few must be restrained by the
system.
•
A trained dai working in isolation can do little. All loud talks of empowering her in the
absence of a well knit referral system only glorify her role. Its purpose is to camouflage
the double standards employed towards villagers and urban elite.
86
Strategy revised on the basis of the learning –
•
The monthly visits by ANM serve no purpose in complicated pregnancy like excessive
bleeding per vaginum. In such cases the patient takes charge of herself and tries to
access the hospital services. She should not be denied care.
•
Fetal growth retardation is not remedial and regular iron, folic acid, and calcium
supplements need to be assured which can be entrusted to the dai.
•
7th and 8th month of gestation being crucial a thorough examination is imperative and
requires a hospital setting. Newly married women being immunized against tetanus
through annual cluster immunization while booster dose for the pregnant woman could
be administered during her ANC visit to the hospital.
Wasteful expenditure on monthly visits were thereby trimmed off and these services were
replaced by that of the dai who is trained well to tale care of minor needs, ensures visits of the
pregnant women to the hospital in the 7th and 8th month of gestation and refers complicated
cases.
Thus the ANM visits the village once in 4 months and is linked with dai who is empowered by
assistance of an alert medical service, centered in the referral hospital.
This effectively brought down maternal mortality to zero and drastically reduced natal/perinatal
mortality in the last 15 years.
Vaccination –
Low priority for preventive health needs coupled with unawareness of its benefits,
misconceptions about it and inaccessibility to vaccination facility kept the villagers away from its
benefit. As it was not feasible to carry out a door step immunization visiting house to house, the
concept of immunization of entire village by an appropriate strategy of cluster immunization was
therefore conducted to check effectively the transmission of infection by removal of host
susceptibility. An appropriate time was chosen to achieve wider coverage and people were
educated about vaccine preventable diseases through CINEMA. The cluster immunization
approach of getting all eligible at one place could achieve herd immunity to be followed by
vaccination of new comers (new borns or newly wed) every year. Since new comers in a village
87
are few the strategy could trim off human power requirement (and therefore the cost) and yet
maintain the herd immunity.
Thus a strategy of health education contributed with pulse immunization was found successful
which drastically brought down the vaccine preventable illnesses.
In search of VHWThe drive began with selecting a young educated representative of the people, elected by the
people. The lean amount of Rs. 25 per month could not hold him for long and being
discontented with the profile of work he soon set up his paan shop at Wardha and hence had
hardly anytime for the village activities. It was therefore decided to select a lesser educated or
uneducated person who is unlikely to settle outside the village.
By this time women and children warranted a lot of attention, it was an appropriate time to
select the village dai as VHW. However illiteracy barred her from taking over the responsibility
of purchase of drugs and maintaining records, gender became a barrier in accompanying patients
at night hours to the hospital and in communicating freely with men on health issues. Her role
remained confined to conducting deliveries and post partum care which was considered filthy
and hence did not command respect in the society. Meanwhile the jawar scheme was started and
the VHW besides all the other health work was now required to collect jawar, store them,
maintain records, etc. She could no longer handle the responsibility and gave up.
Back to square one, a male health worker was needed, however if he would be from low
economic status he is not likely to devote much of his time for social purpose. A people’s
representative would represent only the vocal affluent. A VHW selected by the doctor would be
accountable to the medical fraternity and not to the villagers.
It was realized that only a person with strong leadership qualities befitted this work. Such
dynamic individuals were identified from the farmer’s movement. But they had to be selected by
the people, especially the voiceless. Hence a system was excogitated for the selection process –
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•
The reigns of the village fund and the developmental activities were to be handed over
to the villagers for which a public body was to be identified. This task became relatively
easier due to the credibility earned through health care delivery in the villages and due to
constant liaison with them. Such a body of village erudite was formed known as
“Karbhari mandals.”
•
The gram sabha meet was held at the village temple, where the names of the preferred
candidates were called out
•
The villagers were asked to select one male and one female candidate for the work and
the opinion of the erudite were sought, which was kept confidential.
•
The most accepted candidate was declared the co-ordiantor of Karbahri Mandal who
was most suited for the village health work.
A responsible, committed person beyond party politics but who possessed leadership qualities
was needed for this kind of a job. Such a person whose potentialities were identified by Dr. Jajoo
in consultation from wise people from all caste groups in the village was selected. In the initial
years most of the VHWs were men. With the movement of the Self help groups gaining
momentum the lady with leadership qualities proved to be a better option.
Thus the VHW was selected by the people with an expert opinion of the erudite villagers and
facilitated by Dr. Jajoo (Health Insurance Incharge)
Adoption of villages for Jawar Scheme –
Starting off with one village in 1978, the number increased to 15 in 1985, and currently covers 40
villages under the scheme. On requisition from any village a preliminary visit was made to the
village at late evening to have a discussion with the villagers. The decision of extending the cover
was made after an initial assessment of their needs, accessibility, morality of the villagers and
extent of co-operation.
The criteria have again been revamped to suit the changing time.
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Thus a multi pronged strategy was adopted which was subject to change. The scheme has been
open to change, realizing the ‘only thing constant is change.’ Revision of strategy is seen as a
rider to adapt to the changing needs and demands of the community.
“Adaptation is not imitation. It is a process of reorientation and assimilation.”
The Formula for Success -------- duplication or adaptation?
Every newly identified problem sows the seed of the formation of a new institution as the only
solution to tackle it effectively. Every newly formed institution breeds its own set of
organizational problems. This has led to proliferation of institutions and organizations which
work in isolation, thereby hindering not only each others growth but also that of the society at
large!
With scarce resources it is at the same time difficult to meet the needs of the people. Though
monetary incentives act as motivating factors it cannot be the sole driving force! People from
different fields of expertise can contribute through their skills, experiences, instincts, insights and
recommendations.
The success of jawar scheme is ingrained in this formula of voluntarism and non hierarchical,
non institutional, non structural, collective endeavor of the committed people. The volunteers
represent different fields like medicine, polytechnic, education, funding organization, and from
the community itself. Some have formed facilitators group rendering technical know how, while
some have taken over the role of animators motivating people and still others live their life as
role models to be followed!
The entry strategy for addressing issues of concern in these villages was to tackle their needs.
Gradually funds were channelized, development schemes were started, group initiatives gained
momentum, equipment and means of daily use were designed to befit the local needs ------ all
voluntarily with no direct involvement of the parent organizations. These initiatives are
supported by the organizations but could not have been possible without the will and selfless
and unwavering efforts of the members.
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It is in the light of this that one needs to understand to what extent is the project replicable. The
concept based on voluntarism and non institutional function is replicable, but the vision and the
intervention strategy cannot be replicated. It is unique for every society! Every community is
governed by its own principles and its ethos, culture, creativity, sense of urgency and extent of
assimilation of any new concept varies greatly. Having realized this, a combined strategy of
replicability and adaptability was adopted.
The concept of a program is replicable but needs to be guided by a vision (which is not
duplicable) and fine tuned to befit the culture, ethos and need of the society. The basic concept
around which the lift irrigation scheme, diary cooperative, self help groups are governed is the
same –
•
Every initiative should be need based.
•
It should emanate from people.
•
People must participate in it.
•
Purity of means is imperative for purity of goal and hence the revered path must be
opted.
The lack of power and authority and right to income led to the formation of a women’s group
aiming at empowering them, while the dire need of water for agriculture led to the collective
action towards lift irrigation. The search for an alternative source of income, already existing link
with ‘Goras Bhandar” initiated by Gandhiji – led to the constitution and successful management
of Diary cooperative in Nagapur, which could not be duplicated anywhere else. Jawar scheme
too emanated from people’s need and willingness to contribute in kind.
Thus the aforementioned concept can be replicated but it is virtually impossible to duplicate the
same scheme design. For instance SHGs are functioning smoothly in Nagapur village but
number of groups has fallen apart in another village ‘Takli-kite’
Thus with a vision proposed by a visionary, learning from experience and other successful
models, based on the needs of people, their level of commitment, their ability to organize and
discipline themselves their ethos and culture a scheme can be designed that would be nurtured
and further built upon based on local experiences.
Health: A Social, Economic, Cultural, Political and Spiritual Perspective
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Multiple schemes are running in the villages. All are not equally successful everywhere. Every
village has its own culture according to which it adopts and then adapts itself. Thus a need was
felt to visit some villages and explore the facts. To gain an insight into these activities the Centre
of Community Polytechnic was also visited.
This section comprises a detailed account on various developmental activities carried out in the
villages.
Sanitation –
It was a usual scene in the village – the roads were lined by people squatting engaged in the early
morning ritual. The villagers were explained about its harmful effects; medicines would be of no
use if sanitary conditions were not maintained. It fell on the deaf ears, the medical team hence
decided to take up the issue.
A previous effort of constructing a public utility had proven to be futile. No one shouldered the
responsibility of cleaning it. It was an externality on which free riders would ride, till they could!
And finally it became defunct when people stopped utilizing it due to its unhygienic condition.
A scheme was conceptualized to build a latrine for every house. Though it was welcomed no one
took the initiative and tried finding excuses when the time for action came. It was thought that
financial constraints could be one of the reasons for eluding. A model latrine constructed totally
free for some poor villagers, was thought would inspire others after its benefits were actually
seen and felt by people. A latrine was built within three months and to the disappointment of the
team it served as a store room or converted into a bathroom!
Though the reason behind such behaviour could not gauzed; to probe into the matter Dr. jajoo
tried speaking to a village woman. She informed that “the latrine needs water to be kept clean
and water needs to be fetched from far flung wells. This will unnecessarily increase our burden.”
When he enquired if they did not feel ashamed to defecate in the public, she backfired the
question to him “Where would you go if you were to stay in the village – to the fields located
miles away which is infested with snakes and other creature, lacks proper illumination and is
extremely dirty during the rains or on the pavement of the village which is not plagued by all
these problems.”
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The answer was sought – a latrine needing minimal water to maintain hygiene is the solution and
until a strategy to achieve this was discovered, not a finger could be raised against them.
With the technical inputs from the Center of Science for villages a low cost latrine attached to
soak pit with a flap to ensure hygiene with minimal water was designed. It facilitated the
conversion of feces into manure which could be used for agriculture. Walls were to be
constructed of cement and tin were to be used for door. This odorless dry decomposition and
cost effective model of latrine was easily accepted by people.
As the principle behind any community program was to initiate community participation and
discourage charity, a nominal contribution as per the landholdings was decided by the Gram
sabha – Rs.300 for a landowner, Rs. 500 for the one who owns irrigated land and Rs. 200 for a
labourer. Villagers were encouraged to help construct the latrines themselves (Shramdaan) and
supervise the quality of work in the process.
Meanwhile the Gram Sabha that resolved to divert their funds of Jawahar Rozgar Yojna with the
help of state subsidy and beneficiary contribution could achieve commendable target of 100%
sanitation in their village. This was achieved in Karanji Bhoge within a year’s time and spread to
12 more villages. It gained the acceptance from the government as a role model for replication in
other states. The scheme could address the issue of hygiene through community participation
and self discipline.
The characteristic features of the scheme are –
•
It is not merely a relief work; it commands action, community organization governed by
people’s need. It symbolizes the collective decision making process and conferring of
the power in the reign of people.
•
Just as the five fingers of the hand are different the situations of people are different
and hence the contribution was graded as per affordability and the sources of income.
•
It succeeded in reaching to the poorest of the poor.
Diary Co-operative –
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The only means of livelihood was agriculture in the villages which was highly dependant on
nature’s grace. The lives of villagers were so intricately interwoven with nature that its vagaries
shattered them completely. An alternative means of livelihood was imperative for sustenance.
However it was indispensable to take into consideration the market situation to avoid
exploitation.
Except in Nagapur and few more villages most of the villages were linked to the government
diaries. Nagapur had an old dairy that was at the verge of shut down due to loss instigated by
corruption and its mismanagement. However some families (5 to 10) continued selling their
diary yield to a dairy in an adjacent village karanji Bhoge.
The diary cooperative of Nagapur was revived with people’s participation in 1983 and health
insurance again became a medium of change. The diary cooperative of Nagapur was linked up
with ‘Gosavardhan Goras bhandar,’ a trust formed in Gnadhi’s time to promote exclusive cow’s
milk. The scheme survived due to transparency of management and combined efforts of the
villagers. The credibility enjoyed by this milk federation (which supplies milk at door step in
Wardha town) is such that consumer purchases cow’s milk priced always higher by around 10%
than the market prices. The issue of concern now was how to manage the fund and who would
manage it? How to ensure democratic participation and quality control? The secretary was
chosen and handled the responsibility of managing the account. Monthly meetings of all the
members of the co-operative served as a pedestal to decide on terms and conditions. Dr. jajoo’s
role was confined to a facilitator’s and advisor, while decision were taken by the members of the
co-operative. In one of the meetings it was revealed that the secretary has been attempting some
foul play. Dr Jajoo in the capacity of President of the society, himself could not appoint anyone
as he wasn’t sure that the newly appointed secretary would not repeat such a deed. He however
was aware of the fact that he enjoys credibility and if he quit from the cooperative as president, it
would collapse. He therefore proposed – The amount siphoned to be returned back to the
organization, the account to be handed over to the representative selected by consensus and all
work would be voluntary to discourage misdeeds encouraged by monetary incentive. The system
would continue as it is for a month following which a meeting would be called and each member
will be asked two questions – If the same person should continue as the secretary and if the reply
be No who would befit the role? Dr. jajoo admonished that if this strategy was not agreed to by
the members he would resign from the president ship. The bullet hit the target!
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The strategy was executed and the villagers chose to allow the same secretary to continue,
though he would no more enjoy monetary incentive. This created accountability.
Some standard operative procedures were decided
•
The milk would be collected in a separate clean utensil and would be tested for fat
content and S.N.F. if the content was found less it would fetch lesser value and if foul
play was detected no money would be paid to the producer.
•
The milk producer gets 90% of the selling price which no milk federation in India has
ever practiced. Thus the members themselves did not want to sell it anywhere else.
However the rules also spelt out clearly that milk produced by the members must be
sold in the market only through the cooperative.
For administrative purpose a Secretary and a Chairman had to be elected as per the norms of the
federation. In order to avoid representative election; a strategy was adopted—by a secret ballot
each member would suggest a name for the post. One who gets maximum recommendation is
then selected by consensus for the respective post.
The cooperative had no accumulated fund for administrative purpose. Loans were available from
the Goras Bhandar (federation). This amount was deposited in the cooperative fund and then
disbursed to the farm producers.
Bitter experiences of people not repaying the loan, eloping with money, selling off the cattle
taught few lessons. They were given a notice period of one month to repay the loan with interest
accrued; failing which their membership would be cancelled. In the light of this experience a new
stringent rule was constituted. If the loan would be repaid within a year 2/3rd of the interest was
returned back to the farmers, failing which they were required to pay the full interest. People
obviously yearned to repay the loan as soon as possible!
While applying for the loan the members would require two signatories as guarantee giving
consenting to monthly deduction from their earnings, if the proposer did not repay the loan in
the stipulated time. Gradually the needs started increasing with increase in the cost and
requirement of fodder, cattle and medical attention to them. The fund in the co-operative were
falling short of the needs and so 5 paisa from the amount earned on every litre of milk was
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retained in the account to form a corpus to meet contingency needs of the farmers. Two third of
the interest was returned back if the loan was repaid within a year. When the fund grew to a
larger size it was disbursed to avoid accumulation of money thereby breeding greed and
conflicts.
The practice of utilizing the loans for alternative purposes engendered the concept of loan being
made available for other purposes too, but with a ceiling of Rs. 10000 which has now been
increased to Rs. 15000. A farmer was unable to repay the loan due to the sudden death of the
cow and so a new strategy was devised of retaining 50 paisa as deposit from the amount earned
on every liter of milk till the loan is repaid. This enlarged the corpus and was known as ‘Suraksha
Nidhi.’ The benefits of creating such a revolving fund are –
•
A petty contribution from every member resulted into pooling of money that could be
put to alternative use and meet contingency needs.
•
If due to some unavoidable natural disaster or event the farmer is unable to repay the
loan, the loan amount could be met from this fund.
•
Every penny earned is spent instantaneously by the farmer, this fund would ensure
availability of money at the time of need.
In order to undertake developmental activities 10 paise on the amount earned over every litre of
milk was collected by the federation at the source and was decided that if this amount remained
unutilized for 3 years, it would be transferred to the federation, thereby compelling proper
utilization of this fund. Various developmental activities besides educational tours were
undertaken like making vermin compost, gobar gas, providing Veterinary services, reconstructing
the cow shed, etc.
The crucial learning from the experience were, when people come together for a common
purpose there is bound to be conflict of interest, but decision by consensus and disciplining the
entire community through certain spelt code of conduct which is free of politics and does not
favour anyone, can resolve such issues under a staunch leadership. People have to rise above the
level of self interest to reach for a common goal.
Self help Groups –
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Women represent the lower most strata of the society. Though they toil harder than men, they
do not enjoy any right and comfort. They lack economic power and hence are never involved in
decision making. However it is observed and accepted that they are more sensitive to the needs
of the people and have better organization capacity. As women represent the weaker section of
the society they will not assume power unless they rise to the level of men. Collective decisions
avoid power concentration and reduce dependency on male folks. The goal was to empower the
women folk, ‘the proletariat of the proletariat,’ to unite to fight against injustice.
Self-Help Groups [SHG] were formed to bring them together towards achieving common goal
and becoming self reliant. Though most of the SHGs are created for economic gains and
financial freedom, it was realized that such an association for mere monetary gains would soon
get entangled into politics and will get corrupt. The objective of constitution of such groups
were to bring the women together so that they could discuss individual problems and the
problems plaguing the society, to pool money which would serve as contingency fund and to
instigate collective action against the societal perils.
Strategy adopted –
•
As there cannot be a national or uniform model to form such groups, each group
evolved from its own functional system based on its requirements and goal with the aid
of a facilitator, i.e. Dr. Jajoo and his group. New groups learnt from sharing and
experiential learning from successful ones.
•
To increase the capacity of the members and of groups, emphasis was on fabricating
new relationships in the village, enhancing skills and knowledge, and building local
leadership.
Activities –
•
To save small amounts regularly
•
To mutually agree to contribute to a common fund
•
To meet their emergency needs
•
To have collective decision making
•
To solve conflicts through collective leadership and mutual discussion
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•
To provide collateral free loans with terms decided by the group at specified rates.
Such groups were only confined to women and started in 1990. With Dr. Jajoo as the facilitator,
the women of the villages were called for a meeting, where its importance and its operational
aspects were elucidated. Initially women got enrolled to break the vicious cycle of taking loan
from the landlords at high interest rates. They were glad to have an account of their own. A
nominal amount was decided in the village meeting of women which varied from Rs. 10 to Rs.
25 per month. As a non formal group was envisaged the group size is kept to minimum not
exceeding 20 beyond which it would need registration and involve unnecessary procedures.
Monthly meetings are held to discuss on the financial aspects, resolve individual problems and to
assess the authenticity of the cases when loan is demanded. This process ensures collective
decision making and transparency. There are no elected office bearers. Responsibilities are
distributed and rotated with the aim to involve all the members in the educative process. A
coordinator (Sangthika) holds regular monthly meeting, another member keeps records and
accounts.
A saving account for each group is maintained which requires assent of other three signatories
for withdrawal, thereby avoiding pilferage. The interest rate were discussed and fixed in the
meetings. Since the landlords granted loan at a rate of interest of 10% per month, it had to be
lesser than that. However a very low rate of interest would encourage women to take loan form
the group and grant it to others at a marginally higher rate of interest. It was thus fixed as 5%.
However after linking it with NABARD the rate of interest has fallen to 3%. Compound interest
of 12% per year is added to everybody’s investment while the remaining amount gets converted
into a common fund (samuhik kosh) to be utililzed for contingency, educational tours, educative
material purchase and as seed money to purchase appliance, equipments of use like grinding mill.
Loans are granted to the needy at a nominal rate of interest of 3% of which 2% is paid back to
the bank.
The scheme is run in around 40 villages and there are 90 women SHGs and 25 men SHGs. Of
these 40 are linked to NABARD which grants cash credits double the amount of savings. 90%
of this loan has already been repaid. These groups are very often taken for field visits to show
them role models i.e. successfully running SHGs in different parts of the country. Training,
discussions and ability to take responsibility have honed their skills, which is reflected through
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effective and smooth management of the group and through increased self confidence. They
have not only become active in thrift and credit management but have also undertaken other
activities like anti-liquor movement, managing grinding mills, etc. to serve local needs and are
equally capable of exerting a clout on the gram panchayat for developmental activities. Moreover
as men folk are already seen defaulting, the loans are more easily available to the family through
SHG.
However such a collection of people striving for individual interest and material gain is bound to
fall apart. Some groups have collapsed when individual gains have overpowered collective gains.
However on a large scale this process has empowered them and empowerment transforms them
into powerful change agents. They command more respect as they are also seen as the bread
winner of the house and it is through them that the entire family enjoys the benefit of the jawar
scheme.
Right to income, awareness and education of women ensures better nutrition, education and
living condition to the entire family and hence aids in building towards a better society.
Community Polytechnic –
Community polytechnic is a government of India project under the ministry of human resources
development. Through this project various rural developmental and income generation activities
are undertaken with the cooperation and participation of the community. To attain this purpose
the project embodies flexibility to accommodate with various organization or individuals to
reach to the villages. The project activities are as follows –
1. Transfer of technical knowledge –
Various technical know how which aid in reducing unnecessary hard work and wastage of
resources and energy, to improve the efficiency and which are chiefly environment friendly
are shared with people. Example –vermicompost, gobar gas, techniques that aid in
agricultural activities to improve efficiency and yield with reduced efforts, preparation of
pesticides using locally available resources, etc.
2. Vocational training –
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To enhance the talents of the youth vocational training are imparted to them. These are
targeted especially towards the school drop outs. An entrance exam is used as a tool to
assess their aptitude. Vocational training in various fields is designed for a 3 month to 6
month duration. Example – plumbing, screen printing, photography, motor rewinding,
welding, turner, water cooler and fridge repair, TV repairing, garment making and designing,
computer maintenance, bamboo craft, carpentry, etc. they are also encouraged to innovate.
The marking system is linked to their selling capacity in order to enhance marketing skills.
3. Technical Services –
Expert advices of the teachers and students from the polytechnic are made easily and readily
available to the villagers. To reach out to the rural population and provide them with
technical services various strategies are adopted. Service center at the village level, training
cum production center, rainwater harvesting, construction of bamboo houses are
demonstrated to the villagers. Advice and guidance is also provided to initiate village based
activities as a source of income. Besides all these rural camps to mend and repair devices are
also arranged.
4. Community Services –
To facilitate rural development, it is imperative to create awareness among people and
educate them on various issues, provide facts and remedial measures available. Various
activities are organized aiming at different set of rural population. An orientation course for
school going children, science exhibition, mobile library, male and female self help groups,
educational tours, camps, film shows, etc. are organized.
Thus it tries to make all the services available to the rural population which urban population
already enjoys.
Organic farming –
Organic farming is a pattern of farming in which the ecosystem is preserved by abstaining from
the use of harmful chemicals and fertilizers. Culturing symbiotic life forms ensures weed and
pest control and optimal soil biological activity is undertaken to maintain fertility.
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Pesticides and chemical fertilizers known to increase the yield in the long run pollute the
environment; reduce the fertility of the soil besides poisoning the crop. The farmers have to
spend huge sums to buy them and then to sustain the harvest.
Thus organic farming is promoted to create a pure, poison-free, sustainable environment. This
transformation must start from within — raising the individual and society to live in accord with
Natural Law so that they no longer pollute or destroy life. Only this will bring true balance in
Nature.
Close to the Nature –
This is the story of a couple ‘Vasant and Karuna Futane’ from a village ‘Rawala’ in Amravati
district. They have pledged to live a self sustained life by employing only organic techniques in
farming and would not be depend on the market except for the minimal needs like salt, oil and
jaggery. This has been driven by a principle of accepting the nature’s rule, by offering human
labour and being content with whatever mother soil offers. This is faith! They have
experimented on 2.5 acres of land on which they produce for personal consumption and dwell in
mud house which protects them from the vagaries of nature in all the season.
The drive began by deciding to be least dependant on the market. All the materials required for
agricultural purposes to be cultivated and utilized locally. They decided to never use chemical
fertilizers and pesticides. They use homegrown bio-pesticides and manure from the cow shed
and utilize a number of well known traditional methods which are safe and affordable
alternatives. They would never produce sugarcane or soyabean for the market. They cultivate
cereals, pulses, grains, vegetables, fruits that suffice their needs.
The second pledge that they took was of self reliance. Everyman tries to satisfy his personal and
his family’s needs and desires. So does the farmer satisfy the needs of his larger family – his
cattle, birds, cat, dog, etc. Sufficient amount of yield hence needs to be ensured, thereby
satisfying everyone’s requirements. This requires planning! Nature takes care of not only their
needs but also that of their cattle. Wood is utilized for cow shed and house, besides for fuel;
gobar gas provides fuel for cooking and also serves as a source of energy for illumination. They
do not possess any electronic gadgets and have electric connection only for lifting water from
well for irrigation.
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They use Ambar charkha to attain self sufficiency for clothing and have never been to flour mill.
The flour is ground at home with the aid of modified traditional grinding machine which
requires manual labour. However money is essential in today’s life to meet some indispensable
needs. Money is obtained by selling the diary products, seeds and saplings. In case of illness
natural cure through ayurveda and naturopathy is opted. They have attempted to teach their kids
at home and send for formal education only from 7th standard onwards. They believe in
imbibing right values in their children which cannot be achieved through formal education.
However such a life though simple is not free of hurdles and problems. They have however
discovered that god always comes to their rescue. It is this faith that takes them along on a path
untread! Such a life can only be experienced!
They live a life by example and hence serve as a role model to prove how by hard work,
dedication and faith one can live a simple life but the one which nourishes their soul. They
prefer to adhere to their principles than get swayed off by the glitter of modernism and
technology.
All this is rooted in developing individual life to higher states of consciousness — so that
individual actions nourish the environment — and in creating coherent collective consciousness
in society.
Rendezvous with the villagers –
The exploration would have been left incomplete without a dialogue with the villagers – the
beneficiaries, the providers and the managers of the scheme. The expedition began one
afternoon by traveling in a milk van to the model village ‘Nagapur.’ the meeting of diary cooperative was enlightening and helped me draw a fine sketch of the evolution and the
management of the scheme. Practical issues were dealt with and solutions were sought in
consensus. An interaction with the VHWs and the Dai revealed the problems that they faced as
VHW, besides all the benefits that they have reaped over the years. They face difficulty in
making the ends meet – manage the daily household chores, organizing meetings, entertaining
visitors, managing the SHG activities, etc. however they could not disvow the efforts taken by
Dr. Jajoo and his team in rehabilitating them. They agreed to the fact that there has been
tremendous changes in the lifestyle and values of people and everyone feels empowered. It was
heartening to know that no one fears institutional care and no one needs to be educated about
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the significance of nutritional food, small family size, hygiene and ill effects of addiction. The
villagers with collective efforts of SHG members and staunch support of male members were
able to wipe off the nuisance of alcoholism. Though a more robust effort was made at Karanji
Kaji, without male support the anti-liquor movement succumbed. The VHW being pro-active
and brave continues to inform the police about such miscreants discreetly. The following day I
visited Nandora- another village where 100% target for sanitation and successfully administered
dairy co-operative were achieved. The balwadi teacher who is also an active member of the
SHG, shared her experience of the group. It was a difficult task for her to walk the tight rope as
whenever she refused to grant loan without the consent of the group, she would be accused. The
villagers at times distrust her. She yet feels a deep sense of satisfaction.
An early morning drive through the villages to reach Khadka was pleasant until it we approached
the village as the road was lined by people defecating. On enquiry we were informed that the
‘One house one latrine’ scheme could not be extended to all due to shortage of funds. Ramu
Nagtode who currently works as an insurance agent, serves the community as VHW, furnished
all the technical and operational details on lift irrigation and also escorted us to the pump house
through the fields of cotton, soyabean and pumpkin. We were shown gobar gas and kandi kolsaan equipment devised to cook food for a family of five using coal without creating pollution.
Pimpalgaon tops in the participation where ‘prabhodan’ (educative lecture series) are consistently
conducted in the month of Feb.
Takali kite symbolized a village full of conflicts and party politics. Around 15 years ago the
villagers had got together to construct a community well and link it to tap supply for drinking
purpose. With acute shortage of water the villagers got together and approached the gram
panchayat to help them out. The building cost of the well was assured but labor had to be
provided by the people. Each villager labored in shifts. The prevailing factions in the village and
the party politics led to wreckage of some female SHGs. A SHG coordinator eloped with Rs.
20000 deposited by the group. Sanitation was not available and people had to walk miles on bad
roads to defecate. The ideal place were pavements approaching main roads as they were
illuminated.
In the whole process, a reverence for Dr. Jajoo and his team could be felt and people seemed
willing to undertake that he proposed. Except for Takali Kite the rest of the villages exhibited a
sense of fulfillment cherished their achievements though they were facing numerous problems
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administering them. They had gained self confidence which they considered their greatest asset.
One woman said “Farmers lives are difficult. They possess lakhs of rupees but only for a day –
at the harvest time. Though they know they cannot hold on this money it gladdens them as they
are now assured that they will not be indebted. All these schemes are good and boosts our
confidence, but we are blessed only by Mother Nature. They day she destroys our crops we will
be wiped off.”
Salient features of the scheme –
1. Available – primary care is available to the people in the villages itself and they can avail
to secondary and tertiary care at the medical college hospital. Thus all the services are
available round the clock to the villagers.
2. Accessible to the poor – Mere availability does not make services accessible. The system
where payment is as per capacity and services according to the needs, makes it
accessible. The culture of hospital is not alien to villagers. They can catch hold of the
people responsible for the management of the scheme (Dr. Jajoo & Sister Bagade), at
any time. Moreover, the villages are well connected to the hospital and transport facilities
are conveniently available, such that some VHWs accompany almost every referred
patient.
3. Acceptable – The bargaining power of the jowar scheme shows acceptability of the
services. No more do villagers need to be coaxed about sterilization or vaccination.
4. Affordable – contribution is essential but is limited to one’s paying capacity. However
services are not determined by one’s contribution.
5. Appropriate – innovations in sanitation, immunization strategy and introduction of
numerous developmental activities have all risen from the needs of people.
6. Adaptable – The scheme does not aim at replicability but is based on the fundamental
principles aiming to achieve its objective through adaptation. The emphasis on varied
activities like Prabhodan, male self help groups, well construction for drinking water is
evidence to this.
7. Accountable – Social financing, democratic decision making and appropriate training
makes all those responsible for the service delivery, accountable.
8. Credible – Credibility is an intangible asset which is visible in the villages. The respect
commanded by the team, the readiness of people to co-operate is evidence to this.
104
9. Effectivity – Improved health status apparent through improved health indicators,
vanishing apprehensions amongst the villagers to cater health services shows the
effectivity of the health program. Community organization, improved level of
organization reflects the effectivity of other programs.
10. Holistic – The scheme has evolved from people’s health needs with their efforts
gradually seeping to social, developmental and spiritual activities being sensitive to the
changing milieu.
From an Insurance perspective –
A community based health insurance scheme is any not for profit insurance scheme that is aimed
primarily at the informal sector and formed on the basis of collective pooling of health risks and
in which members participate in its management.
- Chris Atim.
The Jawar Scheme satisfies all the above (underlined) criteria. However the definition embodies
the concept of self reliance which in turn implies financial sustainability. If health services have
to cater preferentially to the poor, it cannot be economically self reliant. The scheme does not
aim at financial self reliance and hence cannot fit into any structured definition of insurance. It
can be rather termed as ‘health assurance to the poor’.
Health Assurance – The Concept –
The essence of assurance is ‘an affirmation of just health care service’, in contrary to insurance
which ensures ‘financial aid’ only for health contingency. Hence jawar scheme can be termed as
an assurance scheme rather than an insurance scheme.
Primary health care is the fundamental right of the people and hence should be available,
acceptable, accessible and affordable to them. The poor however spend considerable amount on
medical care to unregulated and exploitative private sector, primarily due to low credibility of
public hospitals. The maldistribution of centrally pooled resources is what primarily ails our
system. The distribution of government funds is lop-sided favors “Haves” and neglects “Have
Nots.”
105
Primary health care services must provide free curative care for its acceptability to the poorest of
the poor. The egalitarian health services can never be economically self reliant, if they have to
preferentially serve the poor.
It is possible to offer a just primary care to all, within existing government resources provided
funds are locally governable in effectively managed decentralized set up. It cannot sustain on a
vertical model and empowerment of the poor is the key towards an accountable system. Power
emanates through the control of public funds and its management. And conferring such a power
to the people would mean empowering Gram sabha. This requires a strong political will.
Charity corrupts people and so beneficiaries should essentially contribute towards health care
services as per their capacity though enjoy services as per needs. However social financing of
such a kind can never meet the expenses towards medical cost and hence such a financial
mechanism must be utilized to generate demand for quality care.
The spin off benefits of social financing are –
•
It increases accessibility of health services.
•
It promotes operators concern for health in the community.
•
It generates the concept of right to demand a quality health care by the beneficiary
population.
•
It responds to priorities as judged by the community.
•
It ensures that services are acceptable.
•
It keeps service providers on toes.
•
It stimulates organizational self confidence and paves way for participatory culture at
community level.
It is obligatory for the welfare state to offer health care services to all. This can be achieved by
appropriate resource allocation. The vertical approach towards medical care needs to be
horizontalized to penetrate the proletariat of the proletariat. Social health insurance is an
effective means of percolation to the marginalized which can never be served by the profit
yearning private companies!
106
Health insurance in Sewagram evolved to develop an egalitarian and just health care delivery
system which must be acceptable, affordable, available and accessible to all. Scrutinizing the
scheme –
Issues
Conventional Insurance Schemes
Jawar Assurance Scheme
Size and diversity Larger and diverse the group Though it covers diverse population in
of membership
terms of age and area, the geographical
lesser is the risk of loss.
As it aims at financial security the spread is limited to ensure access to
limited
geographical
coverage services.
could rather be perceived as a The assurance of services can only be
financial threat, especially in cases given to accessible areas.
of epidemics.
Financial
Insurance
ensures
financial However this scheme ensures financial
protection to the protection against the paying protection irrespective of the paying
beneficiary
Cost
capacity.
recovery It
from the scheme
is
capacity.
indispensable
for
the It is just used as information to assess
sustainability of the scheme.
the level of contribution through
public funds and other private bodies.
Rates of utilization An increase in this indicates As
health
care
is
guaranteed
moral hazard, morale hazard or irrespective of the ability to pay an
adverse selection.
increase indicates change in the trend.
Lack of awareness The bureaucratic structure and A strong tie with the community by
of the scheme in low penetration leads to this constant interface with them over the
the beneficiaries
problem.
past
few
years
overcomes
this
problem. Infact, the hospital is more
known to the people because of the
scheme.
Moral hazard
It is a threat and tried to be As the scheme is managed through the
[The tendency to controlled by employing terms hospital moral hazard is avoided. The
superfluously
and conditions.
other measure adopted to avoid moral
utilize the services;
hazard is a system of co-payment,
both
the
wherein the patient has to bear some
of
proportion of the payment.
by
providers
107
health care by over
prescribing
or
overcharging and
by
the
beneficiaries
by
over utilizing the
services.]
Morale hazard
Though close scrutiny of cases do Every insured is required to produce a
[Fraudulent act to reveal it, a well knit plan generally receipt signed by the VHW and at
reap benefit from evades.
times the VHW accompanies the
the scheme]
patient thereby ruling out morale
hazard.
Adverse Selection
Various conditionality are laid to The scheme does face a problem of
[Inclusion of high avoid this.
adverse selection as all pre-existing
risk group]
conditions* are covered and there is
no waiting period.
(* all the ailments extant before the
inception of the coverage)
It
requires
a A lot of resources are drained in Appropriate and optimum resource
support system
manpower and infrastructure to allocation coupled with affordability of
support the scheme as it does not the scheme has offered revenue
involve
the
community
in stability and community co-operation.
management.
Benefit
package Schemes
not compromised
offer
flexibility
with
very
limited The scheme has evolved through and
numerous for the need of the people and hence
limitations like upper limit on has undergone numerous changes to
services.
befit the changing needs with changing
time.
All the services are provided except
that for un forseeable events a copayment is initiated.
Financial stability
It is a priority
It is not a priority.
Salability of the It is not easy to sell
Since the scheme evolved from the
108
product
people it does not have to be sold.
Coverage
Covers only a proportion of There are no sub limits to care except
payment.
More
for foreseeable hospitalization.
oriented Benefits the community more Scheme having evolved from people
towards
community
than individuals, there may be managed by people there is no
than reluctance to participate
reluctance
individuals
among
people
to
participate.
SWOT Analysis – from an Insurance perspective.
Strengths
Opportunities
•
•
Weaknesses
Health care services are largely
•
Though such schemes can
inaccessible to the poor. A
aid in providing need based
unique scheme like this can
and effective services to the
penetrate to such masses and
marginalized,
cater their needs.
operationalized through the
Segmented approach to health
hospital cannot extend the
leads to disease control and not
services to geographically far
promotion of health. Need
placed regions.
based
diversified
it
being
effort
employed through this scheme
can aid in achieving health in its
true perspective.
Threats
•
None of the schemes whether
health
or
others
can
•
The health insurance scheme
be
sustains on government and
replicated. All initiatives in all
private aid. If this oxygen
the villages convey this and
supply is cut the scheme
serve as a model of adaptability
would succumb.
rather than duplicity.
109
Financial Analysis14 –
Number of schemes are being managed by employing innovative means which are run through
MGIMS. In order to understand its implications and learn from its experience, an exercise has
been carried out to analyze the financing and cost of care.
The broad aim of this study is to decipher the complex picture of financing and cost of care
provided through the hospital.
The analysis has been broadly classified into two sections, viz. the hospital data analysis which
includes the income and expenditure details besides the changing trends; the analysis of jawar
insurance scheme.
Background –
Kasturba Hospital is a medical college hospital and is utilized for training undergraduate and
post graduate students, nurses and paramedics; besides rendering medical services to the
patients. It therefore has to satisfy the norms with regard to staff pattern and facilities laid down
by the MCI for a teaching medical college and for research activities. Thus the cost incurred is
apparently more than that in a pure service providing hospital. Moreover, it serves as a referral
hospital catering to the needs of patients from all over the state and from other states too.
The different health insurance schemes run through the hospital are as follows –
•
Jawar Insurance Scheme
o Pre payment according to capacity but services according to the needs.
o 50% subsidy is given for OPD, while the total bill is waived off for
unexpected/unforeseen IP admissions, except for few planned hospitalization.
•
14
Subsidized family insurance scheme
Refer to Annex II for the statistics.
110
o Rs. 15 to be paid per person per year, provided 75% of the villagers contribute.
o Both IPD and OPD services are subsidized by 50%
•
Indoor Insurance scheme
o Rs. 15 per person per yer.
o Only IPD services are subsidized by 50%.
o 75% coverage of the village population is not obligatory.
•
Hospital run family insurance scheme for semi urban/urban population.
o Rs. 150 per family of five persons per year.
o 50% subsidy in IPD & OPD services.
•
Staff insurance scheme
o This is benefit provided to all the staff and their family members.
o The premium is deducted at source, which is 0.5% of the basic pay and DA per
month.
o All hospital services are available free of cost, except food and appliances.
o If the patient is referred to any other hospital, the additional cost of treatment is
reimbursed up to a limit of Rs. 5000/-
•
Referral insurance scheme for the staff offered by the credit cooperative society of the
employees.
This scheme is deposit linked scheme provided only to the staff and their family
members on payment of a stipulated deposit as premium which is refundable. It will
be dealt in details later.
The objective of this exercise is to estimate how much does the hospital spend in provision of
services vis-a vis the contribution made under insurance scheme, to assess to what extent a
community based health assurance/insurance scheme can meet the hospital expenditure.
111
Sources of Information–
1. Income/Expenditure –Annual Budget.
2. Hospital Statistics, Data on Insurance Scheme – Annual Report.
3. Statistics pertaining to Jawar Scheme and the non insured from the villages eligible for
the scheme – Hospital Register.
Methodology –
A systematic method has been adopted to present the income and expenditure obtained from
the Annual Budgets following which the cost recovery through different financial mechanisms is
estimated.
1. To compute the income of the hospital, the contributions made by the patients and the
premium paid for various insurance schemes are taken, which includes recovery both for
indoor and outdoor services. However, computerized data for only indoor bills has been
maintained since the year 2000, which has been utilized to assess the income under both
the categories, viz. indoor & outdoor services.
2. To compute recurring expenditure, expenses only under some major heads are analyzed,
it being a medical college hospital number of activities pertaining to training and
research are not directly related to delivery of medical services. The major heads under
which the expenses are taken for computation of hospital annual recurring expenditure
are –
-
Salary of the staff; including doctors, nurses, interns and other non clinical
hospital staff and wages paid to class IV workers.
-
Expenditure on food, materials and equipment.
-
Expenditure on repair and maintenance.
Note – The expenditure under the following head is excluded
Pay allowances for the nursing school staff, for Provident fund and Gratuity, traveling
expenses, office expenses, nursing training expenses, and under materials and supplies
required for rural centers and other additional activities.
112
3. The jawar scheme was evolving from 1979 to 1985. Hence data from 1986 to 1994 was
considered in the first phase. The scheme further evolved from 1995 to 1999, wherein
multiple schemes were offered to the same villages, till in the year 2000 a uniform
pattern was implemented. Hence in the second phase scheme has been analyzed from
2000 onwards.
Average Expenditure/Capita (Jawar Scheme) =
Total hospital expenditure on jawar scheme
_______________________________________
Total beneficiaries covered under Jawar scheme.
Cost recovery = Total in hospital collection/ insurance contribution
________________________________________ X 100
Total expenditure
Section I – Hospital data analysis
Revenue Structure –
The various sources of income for the hospital are as follows –
Graph 1: Pie chart showing the sources of income for the hospital.
113
Sources of Income for the hospital
KHS
25%
Govt of India
50%
Govt of
Maharashtra
25%
1. 50% of the total expenditure is received from the Govt. of India, Ministry of health and
family welfare, Department of health as grants-in-aid.
2. 25% of the total expenditure is obtained from Govt. of Maharashtra, medical Education
and drugs department as grants-in-aid.
3. 25% of the remaining expense is met by Kasturba Health Society.
a. Receipts from college.
b. Receipts from hospital*.
* This study examines only this aspect of income generation, as the income generated through
other sources are either received as grants from the government or are met from the medical
college.
i.
Patient payment – These are payments made by the patients at the time of seeking
service, including co payments15 of the insured population. This comprises payments
made for both indoor and outdoor services.
ii.
Income from health insurance – These include the premium collected through various
insurance schemes, both from the hospital and the college, as all the staff & students
avail to the services rendered by the hospital, besides the other insured population.
(a) The graph clearly shows that the recovery of the cost is more from the patients, while it is
negligible from the insurance schemes. This can be attributed to the huge expenditure incurred
by a medical college and referral hospital, in contrary to the minimal premium collected through
15
25%(up to 2001) or 50% of the bill is paid by the insured person at the time of seeking services.
114
various insurance schemes. The cost recovery through jawar insurance scheme will be discussed
later, which will throw more light on this.
Graph 2: Line diagram showing the income generated from the hospital.
Income generated from the hospital
25
Cost recovery in
percentage
20
15
10
5
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
0
Year
From all the insurance schemes (%)
From the patients contribution (%)
(b) Of the total expenditure, 10.7% (1986) (Graph 2) is met with, from the hospital receipts,
which has shown an increase to 22.4% in 2002. This includes the recovery from the out patient
fees also besides that from in patient care. Though this is nearly close to 25%, which the Trust is
expected to generate every year, the above analysis does not include the other costs incurred by
the hospital like administration, expenses on training, etc. Hence the actual cost recovery is
expected to be lesser than aforementioned value.
Graph 3: Composite Bar diagram showing the cost recovery from the indoor and outdoor
services
115
Proportion of expenditure
recovered in percentage
Cost recovery for indoor and out door services
30
25
20
20
15
27
26
16
11
13
10
5
0
2000
2001
2002
Year
Proportion of the indoor
expenses paid
Total cost recovery
(c) From the indoor bills record, it is seen that the cost recovery from indoor charges is 11%
(2000) which has risen to 16% (2003). The corresponding figures for the cost recovery from
both indoor and outdoor charges are 20% and 27%, respectively. Thus the cost recovery from
only outdoor charges is estimated to be 9% and 11% respectively for the two years. Thus, a little
than 50% of the total cost recovery is from outdoor charges (Graph 3).
Fee Structure –
The pricing is ad hoc with no reference to the actual cost. The charges are determined from the
market prices and based on annual expenditure, they are increased at random based on the
decision taken by the Medical Superintendent. Due to increasing cost of materials and drugs the
hospital is unable to provide it at free of cost and hence most of the drugs and accessories are
now prescribed to the patients thereby adding to his/her out of pocket expenditure. Even the
insured patients have to buy medicines from outside!
Changing trends –
Over the years the number of admissions has shown a considerable increase which is consistent
with the increase in the bed occupancy. This reflects in decline in the average length of hospital
stay.
Graph 4: Line graph showing annual bed occupancy ratio
116
Year
Graph 5: Line diagram showing trend in average length of stay.
Trend in average length of stay
20
02
20
00
Year
19
98
19
96
19
94
19
92
19
90
19
88
19
86
Number of days
10
9
8
7
6
5
4
3
2
1
0
Graph 6: Line diagram showing the ratio of outdoor vs indoor admissions
Ratio of Outdoor vs Intdoor admissions
Year
117
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
Number of outdoor patients
treated for every indoor
admission
10
9
8
7
6
5
4
3
2
1
0
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
100
90
80
70
60
50
40
30
20
10
0
1986
Proportion in percentage
Annual bed occupancy
The ratio of the number of out patient services sought vis a vis the indoor admissions has shown
a decline from 9:1 in 1986 to 7:1 in 2004. This implies that the rate of increase in indoor
admissions is more than that of out door patients. This could be considered as an evidence of
the increasing popularity of health services provided at MGIMS.
Expenditure –
The focus of the study being on rural community based health insurance scheme, an attempt was
made to calculate all the costs pertinent to provision of essential care. As the provider hospital is
a medical college hospital with large capital expenditure, which is less likely in service oriented
hospital the capital costs were not taken into consideration for computation of the hospital
expenditure.
1. The major chunk of expenditure is on salaries engulfing around 62% (in 1986) to 64% (in
2003) maximum being 73% in the year 1989. The allocation of fund on drug food and other
materials has shown a decline from 30% (1986) to 28% (2003) with the mode being around 28%
over the years. Thus a very large amount is spent on salaries while the fund allocated for the
essential products viz. medicines and equipment indispensable for the treatment, has shown a
rise in late 90s which has again declined after 2000.
Graph 7: Line diagram showing the trend in the hospital expenditure
118
Trend in the hospital expenditure
Proportion of funds
allocated in percentage
80
70
60
50
40
30
20
10
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
86
19
88
0
Year
Staff salaries
Drug/food & materials
2. The hospital data on expenditure includes the expenses made on both indoor and outdoor
services. Thus the average expenditure per admission includes expenditure on n number of
outdoor patients also. The number of outdoor patients for every indoor admission is shown in
the graph above (Graph 5). The average number of outdoor patients treated for every one
indoor patient over the years is 8.
Graph 8: Line diagram showing the trend of average expenditure per indoor admission.
Trend of the average expenditure per admission
4500
Amount in Rs.
4000
3500
3000
2500
2000
1500
1000
500
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
0
Year
The average expenditure per admission (which also includes approximately 8 outdoor patients)
has increased from Rs. 803 (1986-87) to Rs. 4078 (2003-04). As already mentioned the hospital
being a referral and medical college hospital, the expenses are too high which is reflected
119
through the aforementioned figures. This is also attributable to inflationary changes and
technological advance.
Section 2: Analysis of the Jawar scheme
The members covered under the Jawar scheme (100% subsidized) are covered for all hospital
services including both inpatient and out patient care with no conditionality. However the
insured is required to bear 50% of the hospital expenses arising due to any foreseeable event,
which was 25% of the total bill till 2001.
The insurance scheme was conceived in 1979, which went through a phase of evolution till 1985.
From 1986 to 1994 the entire village was offered the scheme i.e. all the villagers from the
selected villages, were eligible for the scheme. From 1995 onwards more than one scheme was
offered to the villagers and from 2000 onwards the scheme was open to selected families
satisfying the eligibility criteria. As the scheme was in evolutionary phase till 1986, and as it was
difficult to separate the data of Jawar scheme from the pooled data from 1995 to 1999, the data
from 1986 to 1994 has been analyzed. Further the data from 2000 to 2002 has been analyzed to
estimate the difference in the billing pattern of the indoor admissions from the insured villages
with those from the general hospital admissions.
Acceptability The scheme gradually evolved out of the needs of the people and expanded from handful of
villages to nearly 40 villages. The below graph shows the trend in enrollment over the years,
under different categories based on the socio economic status.
Category I – Families who employ labourer on yearly contract (Saldar) for agricultural
work.
Category II – Families who own irrigated land and a pair of bullocks, but do not employ saldar.
Category III – Family who own unirrigated land and a pair of bullocks but do not employ
saldars.
Category IV – Families who own dry land but neither employ Saldar nor have bullocks.
Category V – Landless labourer.
Any other additional occupation raises the economic grade by one.
120
Thus the villagers from category I, II & III can be considered from comparatively higher socio
economic status as compared to those from category IV & V.
Graph 9: Line diagram showing the trend in enrollment under the jawar scheme.
Proportion insured in
percentage
Trend in enrollment under Jawar Scheme
90
80
70
60
50
40
30
20
10
0
1986 1987 1988 1989 1990 1991 1992 1993 1994
Year
Overall insured
I+II+III
IV+V
The increase in overall enrollment shows increased acceptance of the scheme. However few
villages were dropped out intermittently due to non adherence to the conditions laid. The level
of enrollment from the lower economic strata has always remained more than that from the
upper strata, till the year 1992, after which both categories equal.
Nagapur was first adopted in 1979 as a role model and continued to receive the service and
hence the acceptability of the jawar scheme in this village is examined. Villagers from another
village Nandora, having learnt from Nagapur’s experience also got enrolled subsequently. As this
village has remained insured for a number of years uninterrupted, it has also been taken into
consideration for analysis on acceptability.
121
Graph 10: Line diagram showing the trend of enrollment in two selective villages
Trend of enrollment in two selective villages
Proportion of insured in
percentage
120
100
80
60
40
20
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
0
Year
Nagapur
Nandora
The scheme was incepted in Nagapur and as mentioned in the evolution of the scheme, the
villagers readily agreed to contribute as seen in the graph showing 88% enrollment. However in
subsequent years as the villagers, especially the rich did not benefit as much as the poor did,
some stopped contributing. This is seen through the falling curve of the graph. Around 1982 the
enrollment again showed an upsurge, which increased further in 1986 after a drastic fall in 1984.
Thus after an initial fall in enrollment, the rate of enrollment has remained consistent around 75
to 85%. It took five years for the scheme to earn credibility in the role model village!
Nandora was included in the scheme in 1983 and the enrollment is high from the first year after
which it has remained almost consistent. The villagers from Nandora had observed benefits that
Nagapur had reaped; hence it did not take time to gain acceptability.
Changing trends –
The number of persons against which there is one indoor admission amongst the beneficiaries of
Jawar scheme has remained almost consistent around 11 in 1986 to 9 in 1994.
However, only one patient got admitted for every 30 non insured members from the same
village in 1986, this figure reducing to 13 in 1994 (Graph 10). This shows that even from the non
insured population more and more people are now getting hospitalized. It reflects the increasing
credibility that hospital services enjoy even in non insured population.
122
Graph 11: Line graph showing the trend in the indoor admissions in insured and non insured
population.
Trend of Indoor admissions in Insured and non
insured population
Number of people against
which one person gets
admitted
40
35
30
25
20
15
10
5
0
1986
1987
1988
1989
1990
1991
1992
1993
1994
Year
Insured under jaw ar scheme
Non insured
With increased enrollment the number of admissions have also increased over the years.
Cost Recovery –
Cost recovery can be expressed as the proportion of the amount recovered in percentage, of the
expenditure made. For this study to determine the cost only recurring expenditures from the
hospital have been taken into consideration and on the income side the premium paid under
insurance and the payment made by the patients at the time of seeking care has been taken into
account.
As already mentioned, the cost recovery from Jawar scheme is assessed to elucidate as to what
extent the cost of health care can be met by such insurance schemes.
123
Graph 12: Line graph showing the cost recovery from the insured and non insured.
Cost recovery from insured and non insured
Percentage of cost
recovered
14.0
12.0
10.0
From
copayments
8.0
6.0
From insurance
contributions
4.0
2.0
Total from
insured patients
0.0
1986 1987 1988 1989 1990 1991 1992 1993 1994
Year
From non
insured patients
1. The premium collected from the beneficiaries under the scheme is deposited in the
village fund which is utilized for providing only outreach services. This amount is not
pumped back to the hospital and hence cannot be considered as a source of income to
the hospital. However, if this amount was to be used for provision of hospital services,
the probable cost recovery would have been 2.2% in 1986 of the total hospital recurring
expenditure, which has remained constant to 2.4% in 1994.
2. However, the amount collected from co-payment system for foreseeable hospitalization
under jawar scheme is utilized by the hospital. The cost recovery from only the copayment allowed under jawar scheme has remained below 2% in the overall years. Thus
copayment system can be seen only as an effective tool to avoid moral hazard16 and not
as a source of income.
3. The cost recovered from the non insured patients’ contribution from the villages
covered by jawar scheme has fallen from 13% in 1986 to 7% in 1994, thereby implying
that as they could not pay the hospital bills, some portion of it had to be waived off.
16
The tendency to superfluously utilize the services.
124
Graph 13: Line graph showing the trend in the payment made by the insured and the non
insured population.
Trend in the payment made by the insured and the
non insured population
350
Amount in Rs.
300
250
200
150
100
50
0
1986
1987
1988
1989
1990
1991
1992
1993
1994
Year
Avg. bill paid
Avg. bill made
The above graph shows that irrespective of the bill amount, the amount paid by the non insured
has remained almost consistent i.e. they cannot pay beyond a certain paying capacity and hence
the bill amount has to be waived off. As patient exhausts his pocket money in getting drugs and
material by the time he/she gets discharged he/she does not have enough money to pay the
hospital bill.
Per capita average expenditure –
Graph 14: Line diagram showing the trend of per capita expenditure in the villages under jawar
scheme.
Trend of per capita expenditure in the villages under
jawar scheme
250
Amount in Rs.
200
150
100
50
0
1986
1987
1988
1989
1990
Year
125
1991
1992
1993
1994
The average expenditure per person under jawar scheme has shown an increase from Rs. 75
(1986) to Rs. 213 (1994). This amount is expected to be more due to the following reasons –
•
The hospital is a medical college hospital and has to satisfy certain norms laid by MCI in
terms of facilities available and in terms of manpower. As seen from Graph 4, the
expenditure on the staff salaries contributes to more than 60% of the fund allocation.
Thus the overall expenditure is expected to be high.
•
It also serves as a referral hospital with complicated cases being referred here from other
hospitals. In order to meet the increasing demand of patients and to enable deal with
complicated cases the expenses are further bound to be more.
From the data available it is seen that the average length of hospital stay is comparatively
more in the overall admissions than those of the insured population. This could be
because the hospital caters to referrals and complicated patients. Hence, the expenditure
on these patients is expected to be higher than the admissions under jawar scheme.
Above facts have reflected in the billing pattern – From the data available from 2000 to
2002 and the hospital computerized data, it is seen that the average bill per indoor
admission is Rs. 700 against Rs. 484 for the patient from the insured village in 2000,
thereby amounting to 69%, which has remained constant for three years. This implies
that the average per capita expenditure would be necessarily lesser than the computed
figure by around 30%.
Though billing is uniform for all the hospital patients, it is seen that it is lesser for those
from the insured villages. This could be because the later group represents the general
population while the former group comprises of more of referred (complicated) patients
thereby requiring more expensive intervention and longer hospital stay. This apparently
leads to more average expenditure per admission and hence amounting to higher bill.
•
With increased utilization of beds the cost of care is bound to fall.
Observations & Suggestions In a service providing hospital the budgetary allocation on salaries are not expected to exceed
40% of the total fund allotted. Thus considering a hypothetical situation where, if the allocation
of funds on salaries were reduced to 40% keeping every other variable constant, the average per
capita expenditure comes to Rs. 59 (1986) to Rs. 104 (1994) and to R 146 (2000) and Rs. 244
(2002) .
126
Graph 15: A hypotheses giving the adjusted per capita expenditure against the computed value.
A comparison of per capita expenditure
600
Amount in Rs
500
400
300
200
100
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
0
Year
As computed under Jawar scheme
After reducing for the billing pattern by 30%
After adjusting for the staff salary by 40%
By Govt. of India
Though there are various factors affecting the billing pattern, from the above analysis it is clear
that on an average the bill made for the indoor patients from the insured village is around 30%
less. If this were to be considered in computing the average per capita expenditure it is bound to
reduce to Rs.100, Rs. 152 and Rs. 171, in the year 2000, 2001 and 2002 respectively.
Further considering all the aforementioned factors influencing the cost the actual per capita
expenditure would further be reduced. The average per capita expenditure by government being
Rs. 41, Rs.91, Rs. for the years 1986 & 1994, respectively. Considering this it would be possible to
provide quality service to the patients with the current budgetary allocation if the resources are managed efficiently.
Conclusion –
In India with huge misallocation of resources, community based initiatives which aid in
channelizing the resources, addressing larger issues behind health and relentless pursuit in
achieving the goal towards holistic development and sustenance is required. Most of the
activities in Sewagram are undertaken with this enlarged perspective and have shown relative
success.
Inspired by Gandhian ideologies most of the initiatives started by Dr. Jajoo are aimed at
strengthening community, creating interdependence and taking them closer to nature. The threat
127
of environmental degradation was poignantly highlighted by Gandhi in his response to a
question on Indian economic development. “It took Britain half the resources of the planet to
achieve prosperity. How many planets will a country like India require?” Thus technology has
been used to revolutionize – use for locally relevant, feasible and affordable techniques. Various
such schemes were initiated to promote self sufficiency. To sustain programs people were
inspired to a higher level of commitment ignited by sincerity of expectations.
From Sewagram experience one gains a wisdom that the poor are willing to contribute for health
needs but only to the extent that they can afford. As justified by Dr. Jajoo that when the
government allocation on health is less than 1%, why do we expect the poor to pay more?”
Primary health care is a fundamental right of people and hence they should have easy access to
health care at any point of time. This can be achieved by a well managed pre payment system
with risk pooling. However to achieve this, the CBHI scheme should be sensitive to the needs of
people and accordingly assume different forms depending on their health profile and health risk.
95% of all useful remedies that science and human experience has discovered whether in curing
or prevention can be provided at a cost that even the poorest countries can afford for their
population. The remaining 5% is also crucial as it is this cost that the poor has to meet at the
time of emergency.
The findings of this study support this statement. Primary health care services to all, is an achievable goal with the
existing resources. This however calls for a strong political will to decentralize to the level of Gram sabha.
Private companies aiming to target rural segment must be prepared to invest in their health,
bearing in mind that almost 87% of external aid is required. Health activities served as a nodal
point of entry into the villages and gain their confidence. Deprofessionalization of medical
practice and active involvement in community activities enhanced their credibility. Their sincere
efforts nurtured deep linkages with people to bring a remarkable and holistic change over the
years by ‘walking an extra mile’
Sewagram experience depicts a true picture of the initiatives that makes a difference to the
society at the national level by catering to the needs of people – beyond the realms of health!
128
CHAPTER 15
An Insurance Scheme for Referral Services provided by the Mahatma
Gandhi Institute of Medical Sciences Employees’ Credit Cooperative
Society.
Objective
To examine the referral scheme managed by the Credit cooperative society, in order to assess its
viability and feasibility.
The Premises All the staff of MGIMS except the contract labourers are covered under the hospital insurance
scheme, which is extended to their family members also. The premium is deducted at source,
which is 0.5% of the basic pay and DA per month. All hospital services are available free of cost,
except food and appliances and if the patient is referred to any other hospital, the additional cost
of treatment is reimbursed up to a limit of Rs. 5000/Thus most of the health problems were being addressed through different insurance schemes at
MGIMS hospital. The only health contingency which escaped the bracket was of super specialty
services which could not be handled at the hospital and required referral to major hospitals in
major cities! Though the hospital insurance scheme covered up to Rs. 5000, this amount was
found to be insufficient. This not only increased the unnecessary trepidation of referral but also
of making financial arrangements to meet the cost.
In the year 1997, the MGIMS Emp. Credit Cooperative Society having had already covered
some members of the society under Group Personal Accident policy, thought of extending the
medical insurance exclusively for referral care. The premium quoted by the insurance companies
was however, exorbitant with limited services, disclaimer and above all a non refundable annual
premium. Who would agree to shell out around Rs. 2250 to Rs. 2500 every year for no
guaranteed benefit?
The Cooperative Credit Society being principally involved in financial business is concerned with
granting loans to the members and taking loan on credit from the bank. The Credit Society
129
received loans from bank @ 18% and granted loans @ 20% (1999-2000). It was thought
therefore, by some members that if the amount is collected at the interest rate offered by the
bank i.e. 12% and a margin of 8% is maintained, instead of transferring the risk to the insurance
company, they could not only manage the scheme with lower contribution but could also ensure
guaranteed benefits, besides a good referral check. This would serve everyone’s purpose, as the
Credit Society could now look upon the hospital staff as lenders under the scheme who in turn
would get the entire amount reimbursed with an interest of 12% (interest rate which concords
with that given by bank) on cancellation of the membership and would also be eligible for
reimbursement up to Rs. 1 lakh for any referral care.
Following a brainstorming session, a scheme was conceptualized which would benefit everyone
and befit everyone’s needs. Based on some preliminary assumptions and forecasting, an amount
of Rs. 50 was arrived as a monthly deposit per member the scheme being open to the staff of the
hospital and their family members. This amount would be refundable with a stipulated interest
on the cancellation of the membership caused due to the termination of the service.
The scheme is a credit linked scheme which is linked to loan benefit scheme, providing complete
exemption from any loan taken from the society in case of death of the member. It is also linked
to Personal Accident policy the premium for which is paid by the society.
The conditions of the scheme are as follows –
•
It is a voluntary scheme and for permanent staff.
•
Benefit is available to all the family members, irrespective of their age and pre-existing
conditions.
•
Any member wishing to continue after retirement is required to make an annual
payment of the premium at the beginning of each year.
•
Any member withdrawing from the scheme receives 50% of the stipulated interest on
the deposited amount and shall loose his/her right to become member of the scheme in
future.
•
Any member who has claimed the benefit provided by the scheme and institution within
five years of membership the entire sum (premium and interest) will be forfeited. He
however continues to be a member and builds up the deposit afresh.
130
•
The referral service entitled for the reimbursement must be necessarily for an
intervention which cannot be done at MGIMS*.
(* All the staff covered under this scheme are insured with the hospital under hospital staff
insurance scheme and are also entitled to a reimbursement up to Rs. 5000 from the hospital
for referral care. The referral scheme reimburses only above Rs. 5000)
Benefits under the scheme –
•
The insured is eligible to treatment in any referred hospital upto a maximum of Rs. 1
lakh.
•
There is no limit to the number of claims that can be made by any insured.
•
If no claims are made, the entire amount deposited is refundable with the stipulated
interest.
Operational Aspects –
•
The member can choose amongst the following options for payment of premium –
1. Monthly deduction from salary
2. Annual payment
3. Deduction from annual MGIMS workers co-options society dividend.
•
Depending on the changes in the rate of interest on the amount granted by banks, the
interest rate earned over the premium is also revised.
•
On availing the benefit of the scheme the refundable amount is reduced based on the
amount claimed.
•
The society preserves the right to investigate the referral claim from a medical board
appointed for the purpose.
•
On producing all the requisite documents, payment is directly made to the hospital by
the society or the amount is directly paid to the claimant if the bills are submitted.
•
In case of a pre-existing condition proven thereof, 50% of the claim amount not
exceeding Rs. 50000 will be paid by the cooperative society, while the remaining 50% is
required to be paid to the cooperative society by the insured such that the entire amount
is directly paid to the hospital by the society.
131
Some Facts –
•
There are around 900 staff members of which only 448 are enrolled. As enrollment was
not too encouraging in the initial two years and some employees started enrolling only
on the prospect of claiming, a new condition was introduced. All those getting enrolled
after 2003 will have a waiting period of 3 years. This will however not be applicable to
new entrants (employees).
•
The simple interest of 12% (1999-2000) compounded yearly fell to 10% (2000-2001,
2001-2002) and at present is 6% (2002-2003). The interest offered by banks has also
shown a dip to 15%, the margin now being 9%.
Analysis –
The objective of the financial analysis of this scheme is to assess its viability and utility so as to
propose a scheme that can be managed by such cooperative society for their members.
Methodology –
The data obtained from the past five years i.e. from the inception of the scheme are analyzed. In
order to simplify the analysis and to achieve the objective of proposing a referral insurance
scheme linked to credit society, the study focuses only on the amount deposited for the purpose
of referral insurance and the claims made; excluding all the interlinked benefits like personal
accident and loan benefit.
Firstly only the deposits made by the members is taken into consideration to compute
the interest accrued on it.
Income is computed taking the interest earned by the society on the deposit, the
forfeited amount of the claimant and the interest earned on it.
Assuming no money would be withdrawn claims are taken as expenditure thereby shown
as liability for the society
This claim amount has then been adjusted against the deposited amount.
132
Findings & Observations17 The total amount in the deposit by the end of the second year is Rs. 334824. After adjusting the
claims against the income earned the society still has a liability of Rs. 40349. On paying this claim
the balance remaining with the society is Rs. 294475. Thus over the years, the experience shows
that each year the claim has been met with from the corpus.
From the 4 years experience, the net claim expenditure is Rs. 432561 with an average of Rs.
108140. Though the claim each year could vary, for simplicity taking 1.08 lakhs as an annual
estimated claim, assuming the claim pattern would continue, the fund is required to have
minimum of Rs. 1.10 lakhs with some amount for the management of the scheme. From the
four years experience, it is seen that the balance amount remaining by the end of the year 2003 is
Rs. 1226522. Deducting the liability, Rs. 110387 is obtained @ 9%. Thus by the end of the
fourth year the scheme has reached a state of breakeven. However considering that the fund
would receive an additional deposit the scheme can be termed as self sufficient. However it must
maintain either the margin of interest a 9% or must increase the enrollment to achieve this. Each
year with the present number of members remaining same, the deposit will be built by around
Rs. 4 lakhs. Interest earned on it will fill up the existing gap in the corpus and meet bigger claims
in the coming years.
On the other hand the deposit that can be withdrawn from the members is considered to be a
liability for the society. However there are no chances of withdrawal in the initial few years as the
amount deposited is less and would reap no benefit to the member. Increasing risk of health
hazards with age will be covered by the insurance up to Rs. 1 lakh, which if the deposit amount
is expected to meet will take numerous years. Moreover he/she is not allowed to take the
membership again which is another disincentive for withdrawal. The benefit is available to even
the retired staff provided he/she makes an annual payment of the premium. This further acts as
an additional incentive to increase enrollment and reduce drop outs. Even if there are
withdrawals made it would be spread over time and of negligible amount. The society is
expected to meet this expense over a period of time.
17
Refer to Table I, II & III in the Annex for the data and calculations.
133
At the same time the margin of interest serving as income to the society needs to be maintained.
However over a period of time with fluctuation in the economy and the overall interest rates
offered by the banks the margin might have to be altered. Envisaging this possibility, in order to
sustain the fund the number of enrollment must be increased. The current number of members
covered is 633 (including family members) of around 900 staff (families with approximate family
size of 2.5). This amounts to around 2250. Thus the estimated current enrollment is only 28% of
the total potential members. Even if those individuals covered under the scheme are convinced
to get their family members included the total membership would increase to 943 (Table IV),
thereby providing a greater pool of fund to manage big claims, if any arise! It is seen that the
enrollment for the family members from Class III & IV is relatively less. In order to encourage
more individuals for extension of the cover to a wider group, the premium could be reduced
with corresponding reduction in the limit of benefit.
Table IV: Members enrolled under the scheme
Individua
l
Expected
Total
Famil
total
Category
Families members
members y size
members
I, II
21
10
73
3.00
136
III
83
142
342
2.41
542
IV
11
169
193
2.18
217
10
2
25
2.30
48
Credit
Soc
Staff
633
943
Claim analysis –
Table V – Claim details
Year
Nature of illness
Amount claimed Total amount in
in Rs.
Rs.
50075
1999-2000
2000-2001
Cardiac ailment
50075
2001-2002
Orthopedic case
500
Cardiac ailment
100000
134
2002-2003
2003-2004
Brain Hemorrhage
57781
Investigation
7400
Brain Hemorrhage
9750
Spinal injury
4122
Ophthalmic
7000
Orthopedic case
1307
Ophthalmic
1125
Cardiac ailment
50000
158281
27200
197005
432561
As seen from the above table the expenditure is more for cardiac ailments, while the expenditure
on the other ailments is negligible. It is seen that in few claims the claim amount was lesser than
the current deposit amount of the member. This being a welfare scheme, as the deposit gets
forfeited on the payment of any claim the claimant must be informed about the current status of
his account. To facilitate this, a pass book could be maintained for each member for periodic
updating, which will also gain credibility to the society besides aiding in proper account keeping.
135
Chapter 16
Composite Package Insurance for tribals of Gudalur taluk
Introduction –
It is a tripartite venture between the insurance company the NGO i.e. ACCORD and the tribals
of the Gudalur taluk, represented by the Adivasi Munnetra Sangam (AMS). After negotiations
with the three partners the ‘Composite Package Insurance for tribals’ was started on 26th Feb
1992. The New India Assurance Company (NIAC) offered a package whereby the tribals were
required to pay a premium of Rs. 15 per individual per year for a period of five years. This made
them eligible for hospitalization benefits up to Rs. 1500/- per individual per year. However the
organization (ACCORD) reimburses the total hospitalization expenditure.
Besides each family was also expected to pay an additional premium of Rs. 7/- per family per
year for the following benefit1. Coverage against any damage to their huts and contents (including cattle) up to Rs. 1500/2. Coverage against any personal accident to the head of the family up to Rs. 2500/Thus a family of four had to pay Rs. 67/- as annual premium.
However even this was a burden for the tribal community especially when they had to pay five
years premium in one installment. Thus ACCORD offered to pay the premium on behalf of the
tribal community. The community through the AMS repaid a part of this premium to
ACCORD in installments. Similarly ACCORD offered to process the claims and receive the
reimbursements on behalf of the community provided they were admitted to ACCORD’s
hospital – the Gudalur Adivasi hospital (GAH)
Objective of the scheme – The objective of the scheme forms a part of the objective of
ASHWINI the health program.
To establish a health system which is accessible and acceptable to the tribals and effective. It
should be managed by the tribals themselves and should be sustainable.
Exclusions under the scheme (provided by the insurance company)–
1. Pregnancy and pregnancy related illness.
136
2. Domiciliary treatment, i.e. Out patient charges which did not require hospitalization.
3. Any expenditure above Rs. 1500/-
Review of the scheme –
At the time of renewal i.e. by the end of 1995, the scheme was reviewed by ACCORD to make it
more expedient for all the concerned partners.
Number of patients admitted, claims made and reimbursed. (April 1992 – Feb 1996)
Year Total number Total number Total number Total number Proportion Proportion
of tribal
of insured
of claims
of claims
insured reimbursed
patients18
patients19
reimbursed
1992
516
302
264
264
59
100
1993
870
556
459
458
64
100
1994
685
422
331
300
62
91
1995
689
417
282
261
61
93
Though around 96% of the claims are reimbursed, of the total tribal admissions only 46.5% are
reimbursed. The low reimbursement rate could be attributed to the following reasons –
1. 40% of the patients are not insured due to various reasons especially the red tapism involved
in insuring them.
2. More than 20% of the insured patients’ claims are not made because they are pregnancy
related.
3. About 4% of claims are not reimbursed because they are ‘common diseases’ or chronic
diseases.
Amount of claims made and reimbursed (April 1992 – Feb 1996)
Year Premium Total
claim Total
paid
amount in Rs. reimbursements
in Rs.
1992 386318 82674
81556
1993 44296
149400
136077
1994 20372
119478
106384
1995 10513
128946
105060
1996 3905
NA
NA
18
Percentage
reimbursed
98.6
91.1
89
81.5
-
This includes insured as well as non-insured tribals. All tribals are not insured by ACCORD.
These are the AMS members on whose behalf ACCORD makes the payment. They in turn pay the
organization.
19
137
Though 96% of the number of claims were reimbursed only 89% of the amount was reimbursed
by the NIAC. This could be because of the maximum limit of Rs. 1500/- per claim. About 4%
of the total claims exceeded the Rs. 1500 limit.
Strengths of the scheme as stated by ACCORD
It was seen more as a social obligation providing service to the downtrodden community of
the tribals and not as a profit making venture.
It was not seen as ‘free treatment’ by the tribal community and they actively contributed
towards the repayment of the insurance premium.
ACCORD manages the scheme and hence spares the tribals from this major headache.
Besides the problems of moral hazard is also avoided as the premium is first paid by the
organization, which also covers all the conditions, excluded under the formal scheme.
By removing the financial burden for the tribal this scheme has ensured that they can avail
to good quality medical care.
Some weaknesses of the scheme as stated by ACCORD –
Though pregnancy related maternal deaths are unacceptably high in many of the villages, the
scheme did not address this problem as such conditions were excluded.
Around 4 to 5% of all the admissions need referral to a higher medical centre, requiring
specialized health care. As the cost of referral care ranges from Rs. 5000/- to Rs. 10000/and the reimbursement is only up to Rs. 1500/- by the insurance company the remaining
amount is borne by ACCORD.
The cost of domiciliary treatment is not covered.
Though an additional amount of Rs. 7/- was collected per family for insurance against
accident and huts, no family could avail to this coverage. It was therefore decided to
discontinue this cover.
Thus the scheme was renewed for another five years i.e. from 1997 to 2002 from which the
home and accident insurance were excluded. The premium was increased to Rs. 20 per head. No
other changes were made in the coverage though maternity cover was desired.
138
The total premium paid from 1992 to 2002 is Rs. 594566/Total claims sent by ASHWINI to NIAC is Rs. 1363371/Total reimbursements made by NIAC is Rs. 1268051/- i.e. 93% of the total claims.
The claims ratio is 213% i.e. more than twice the premium is reimbursed by the insurance company.
Current scheme –
As the claim ratio was high NIAC refused to renew the policy. An analysis was done to assess if
the fund could be managed by the organization without transferring the risk to any insurance
company. As it was found unfeasible to self manage the fund, the state government was
approached to bear some proportion of the premium. As any such provision could not be
extended to one NGO run hospital, the proposal was turned off. It was realized that as the
insurance company had been reimbursing more than the premium collected, the best option
would be to get the scheme managed by some insurance company. Various insurance companies
were approached and finally RSA agreed to the deal.
From May 2003 the tribals are covered by Royal Sundaram Alliance Insurance Company ltd. and
they offered to cover first three pregnancies in a family. The premium was increased to Rs. 30
per head with sum insured increased to Rs. 2000 per hospitalization. Maternity claims are
confined to maximum of Rs. 500/- per case.
Sir Ratan Tata Trust has supported the scheme by paying the premium on behalf of the
organization. The premium amount collected by the tribals is pooled into a saving account,
which can be used after the cessation of any grants.
Particulars
19.5.03 - 18.5.04
Claimed
Nos.
amt. In Rs. Claimed
Premium Paid
244520
0
Insured Bill Amount 522314
107446
Amount Claimed
333268
0
Amount
309379
0
Reimbursed
139
Around 93% of the total amount claimed is paid and the claim ratio is 127%. The scheme is
proposed to be renewed under the same conditions with no limits on maternity claims per
family.
Operationalisation of the scheme –
The amount collected by the insured in the form of premium and from the patients (non tribals
& non insured tribals, i.e. non sangha patients) in the form of fees are pooled into a corpus. The
donations granted by different donor agencies and recently the SRTT funds are used to pay the
premium for the insured population. The amount reimbursed by the company are collected by
the hospital and pumped into the corpus. The money from this corpus and all the other
donations are collectively utilized for running of the hospital.
However as the SRTT fund to support the premium is soon expected to cease a separate corpus
of Rs. 200 crore is proposed to be formed @ 5% and all the patients’ contributions will be
pooled into this.
Analysis of the Scheme –
The premium amount is paid by ACCORD on behalf of the community, which is subsequently
collected from the community. The organization pays the premium from the corpus for which it
gets contribution from different donor agencies. Since the past two years this premium amount
is met from SRTT donation.
Affordability –
Given the living conditions though the premium of Rs. 15 now increased to Rs. 30 per person
per annum, seems to be nominal it is imperative to know if it is actually affordable to the triabls
who cannot afford two meals per day. One of the indicators to assess affordability is to examine
the proportion of tribals paying the premium and the trend in payment of the premium by the
community.
140
Trend in the payment of premium by the
community
Proportion of
members paid in
percentage
60
50
40
30
20
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
From the graph it can be seen that the contribution from the community has remained almost
constant ranging from 55 % to 35% of the total members. From 2000 it has shown continuous
decline. This implies that the affordability of the tribals to pay the premium is low and is on
decline.
A new mechanism has been adopted on a pilot basis. In the year 2004, a premium of Rs.22 was
collected in five out of the eight Areas (clusters). In one area it was Rs.10 per person + Rs. 10
per family. In another, it was different premium for different villages, i.e., Rs.10, 15, 20 and 22
per person. In the third, it was a fixed amount per family. It was seen that more number of
people were willing to pay the premium.
Enrollment pattern –
The tribals have to pay an annual membership fee of Rs. 15 (1993), Rs. 30 (2003) for the sangha
(Adivasi munnetra Sangha). All the members are eligible for the insurance cover and ACCORD
pays the premium on their behalf. Depending on their affordability the members pay the
premium anytime during the year. However irrespective of this payment they remain eligible to
claim under the scheme.
Trend in enrollment
Number of members
14000
12000
10000
Insured
persons
8000
6000
Premium
paid
members
4000
2000
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
0
Year
141
The number of AMS members have increased over the years, but the number of members
paying the premium have remained almost constant. This implies that the number of members
affording the premium is almost the same over the years.
Proportion of insured
tribals
Utility of the scheme –
90
80
70
60
50
40
30
20
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Of the total tribal patients having sought treatment from the adivasi hospital most of the tribal
patients are those covered under the scheme. This shows that the proportion of tribal population
not covered under the scheme who have to pay the expenses from their pocket, seeking service
is less.
Utilization of services by the tribal and non-tribal population –
100
80
Tribals
60
Insured tribals
40
Non Tribals
20
0
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
Proportion of people in
percentage
Trend in hospitalization in different categories
Year
142
The number of non-tribal people getting treated in the hospital is relatively less. It however does
not mean that the non-tribals do not prefer this hospital. Preference is given to tribals for
admission. It is evident from the graph the proportion of non-tribals’ admission is more in the
years 1996 and 1997, when correspondingly the proportion of tribals’ admission has shown a
dip. As stated by Dr. Shyla the non-tribal patients being more outward than the tribals, they use
unfair means to get preference in the treatment and in getting admitted to the hospital. As a
result of this non-tribal patients are seen in the OPD only once a week. Moreover, the number
of beds is restricted and as no other hospital is inviting to the tribals the tribal patients are given
preference. It also needs to be remembered that it is adivasi hospital owned and managed by
them.
The expenditure per admission in the non-tribal population is seen to be consistently more than
the per admission expenditure in the tribal population. This implies that the non-tribals are
admitted for relatively more complicated cases thereby leading to higher expenditure and longer
length of stay in the hospital. As mentioned before it being an adivasi hospital preference is
given to tribals. However non-tribals are not denied treatment or admission, though they have to
pay for the services. The cost of the treatment for the non-tribals is just the same as that charged
in any private hospital.
Expenditure per admission in the tribal and the non tribal
population
Amount in Rs.
1600
1400
1200
1000
800
600
400
200
0
Tribals
19
9394
19
9495
19
9596
19
9697
19
9798
19
9899
19
9900
20
0001
20
0102
20
0203
20
0304
Non tribals
Year
Health insurance is seen as a mechanism to generate demand in the tribal community for health
care. The hospital authorities have stated that despite of insurance coverage to all the sanga
members only those who have paid the premium seek services more often. This can be
143
quantified only by comparing the hospitalization rate of the people who have paid against those
who haven’t paid their premium. However such a data was not available.
Financial viability of the scheme –
The adivasi hospital is managed with the aid of the following sources–
Grant from Paul Hamlyn foundation.
Grant from Skillshares International.
Grant from Tata trust.
Other donations and grants.
Fees charged from non insured patients.
Premium collection
Other indirect sources for various resources are –
Diabetic medicine reimbursement from a German based NGO.
Government sickle cell program.
Receipts from ambulance and balwadis.
Government family planning program.
Besides a corpus fund is managed and interest is earned on it.
The premium collection from the insured tribals comprises of around 2% of the total income
(with an exception of 8% in 2000-01). It thus forms a negligible component in terms of income
generation.
The expenditure on only insured patients is estimated to be almost 5 to 11 times more than the
premium collection. Thus the scheme is not viable in terms of financial sustainability. On having
a closer look at the scheme, the funds are merely processed through a cycle called insurance but
the cost of care is met directly through funds. The Tata trust donation is made available to pay
the premium, which is paid to the insurance company. The insurance company in turn
reimburses the claim amount, which is almost 200%, more than the premium paid. Thus in short
almost 50% of the cost is provided by the insurance company and remaining 50% is provided by
the grant from Tata trust of which the actual contribution from the community forms a very
negligible part.
144
From 2003-2004 data –
Premium paid
by tribals
19%
Insurance
reimbursemen
t
53%
Tata trust
28%
The contribution from the tribals in the form of premium constitutes 40% of the total premium
paid. Out of the actual expenditure on the insured only 64% is claimed from the insurance
company, of which 92% is reimbursed. Thus of the total expenditure on insured patients 19% is
met by premium contribution from the community members, another 28% is met from the
balance insurance premium (i.e from Tata trust). The remaining 53% of the expenditure is paid
by the insurance company.
Conclusion –
The scheme is unquestionably not a viable scheme where most of the cost is met by the
insurance company and other donor agencies. However, it serves the following purposes – it
makes a private insurance company pay for the medical care of the tribals, it provides a learning
experience to the tribals to finance and manage a scheme on their own and necessitates the
maintenance of a good information system.
To make the scheme more acceptable and affordable for the community some innovative
measures need to be adopted like the flexible premium structure as seen in the pilot project.
145
Chapter 17
Supplementary Social Health Insurance Approach
Part I - For Chattisgarh
Need for the Scheme – Though the infrastructure for referral and secondary health care is provided
by the state, the recurring costs are to be generated internally. In the process of ensuring cost
recovery the basic health care services have become inaccessible to the most vulnerable section.
However it is not possible for lowering operational costs further. Even as of now the fact that
the doctors have to forgo fees for seeing beneficiaries leads to low returns for medical personnel
and distortions in utilization. However, it is imperative to make the health care facilities available
and accessible to the poor. The proposed scheme is an approach to achieving this.
The scheme will be initially tried on pilot basis in 8 to 10 selective towns for a year. If the
programme runs successfully, Phase I as proposed in Annexure II could be implemented in the
subsequent year or else by the end of the second year, the scheme could be phased out of the
pilot project towns.
The three major variables affecting the scheme are –
1. The range of benefit, i.e. the package offered.
2. The premium charged to the patient and
3. The extend of coverage i.e. for whom will it be mandatory and for whom it will remain
voluntary.
The Beneficiaries –
The entire population may be classified into three groups as follows –
Class I – General – those with an annual salary of 1 lakh or more.
Class II – Poor – Beneficiary.
Class III – Vulnerable – as identified by the ULBs. (This category would include migrants, rag
pickers, street children, CSWs, slum dwellers, etc.)
The scheme will be mandatory for Class II & III and the government will partly pay the
premium for Class II & will pay the entire premium for the beneficiaries under Class III. The
146
scheme will however be discretionary to Class I as they are required to pay for their premium
themselves.
The target for the first Phase I (first one year) would be as shown in the table below (Refer to
Table 1). Based on the experience gained from the fist year the scheme may then be extended to
the other population.
Definition of family – A family covers four members viz. the proposer, his/her spouse and three
unmarried children. To extend the benefits of the scheme to other members a premium of Rs.
150 (for all the Categories) needs to be paid by the proposer for an annual cover.
The average family size is 5.
Class
I
Total beneficiaries to be Number of households
covered in Phase I
that could be covered in
Phase I
600000
120000
II
300000
60000
III
100000
20000
1000000
200000
I
240000
48000
II
120000
24000
III
40000
8000
400000
80000
I
120000
24000
II
60000
12000
III
20000
4000
200000
40000
I
60000
12000
II
30000
6000
III
10000
2000
Total
100000
20000
Grand Total
1700000
340000
Category A
Total
Category B
Total
Category C
Total
Category D
147
Benefits –
The insured is eligible only for certain categories of hospitalization expenses where treatment can
be provided by the Secondary Centers including the township hospitals and the Mitanin kendras,
'designated accredited rate fixed clinics' under the following two categories
Category
Benefits covered
Major procedures/surgeries
Minor procedures
Approximate cost
for procedure in
Rs.
• Shall include Caesarean Sections, 5000/Hysterectomies
and
other
gynaecological and obstetric
procedures.
• Common surgical procedures like
that
for
hernia
repair,
appendicitis, etc.
Shall include Normal deliveries, Day care 1000/procedures,
short
duration
hospitalizations and minor surgical
procedures like I & D, haemorrhoids,
hydrocele,
circumcision,
RTI/STI,
Family planning services, etc.
ContributionFor Class III the total premium shall be paid by the government, while it will bear only 50% of
the premium for Class II. The scheme is thus mandatory for these two classes while it is
voluntary for Class I who are required to pay their premium.
Category A:
Class
Contribution in Rs.
Total in Rs.
from the beneficiaries
from the government
II
Per family
Total
Per family
600
72000000
300
0
0
300
18000000
0
18000000
600
36000000
III
Total
Per family
Total
0
12000000
12000000
I
148
72000000
Total
90000000
30000000
120000000
Category B:
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
28800000
300
0
300
28800000
II
Total
Per family
7200000
0
7200000
600
14400000
III
Total
Per family
Total
0
36000000
4800000
12000000
4800000
48000000
Total
Total in Rs
Category C:
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
14400000
300
0
300
14400000
II
Total
Per family
7200000
0
7200000
600
14400000
III
Total
Per family
Total
0
21600000
2400000
9600000
2400000
31200000
Total
Total in Rs.
Category D:
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
7200000
300
0
300
7200000
II
Total
Per family
1800000
0
1800000
600
3600000
III
Total
Per family
Total
0
9000000
1200000
3000000
1200000
12000000
Total
Total in Rs.
149
Grand Total –
Category
A
B
C
D
Total
Contribution in Rs.
from the beneficiaries
90000000
36000000
21600000
9000000
156600000
from the government
30000000
12000000
9600000
3000000
54600000
Total in Rs.
120000000
48000000
31200000
12000000
211200000
The contributions to be collected from Class I & Class II can be deducted at source i.e. in the
form of health tax of Rs. 600 and Rs. 300 per family, respectively; thereby ensuring the collection
of the premium from every household.
The government contribution accounts for only 26% of the total contribution and the total
contribution expected is Rs. 211.2 million. The government contribution for Class II & Class III
is Rs.34.2 million & Rs. 20.4 million, respectively.
However as the scheme is optional for Class I the actual number of beneficiaries might be less
than the expected numbers. Thus if we consider only 60% of the target figures from Class I
assuming that they would willing to subscribe for the policy, the premium collection will be as
follows –
Category
A
B
C
D
Total
Contribution in Rs.
from the beneficiaries
61200000
24480000
15840000
6120000
107640000
from the government
30000000
12000000
9600000
3000000
54600000
Total in Rs.
91200000
36480000
25440000
9120000
162240000
Thus the premium collection would come down to Rs. 162.2 million. In this case the
government contribution would be 34% of the total amount collected.
Viability of the scheme
150
(A.) CBR being 25/1000, we can expect 42,500 lakh births in a population of 17 lakhs. Only
10% of these are expected to undergo Caesarean Section.
Therefore, total expenditure on
1. Normal deliveries = (Expected births – Expected Caesarean Section) X Reimbursement per
normal delivery.
= (42,500–4250) X 1000
= 38,250 X 1000
= Rs. 38.25 million
2. Caesarean Section = Expected Caesarean Section X Reimbursement per section
= 4250 X 5000
= Rs. 21.25 million
(B.) Of the total population 1% require any surgical intervention out of which only 15% would
require any major surgical intervention.
Therefore the expenditure on
1. Minor Surgical interventions = (Expected total minor surgeries – Expected total major
surgeries) X Reimbursement per case.
= (17000 – 2550) X 1000
= 14450 X 1000
= Rs. 14.4 million
2. Major Surgical interventions = Expected total major surgeries X Reimbursement per case.
= 2550 X 5000
= Rs. 12.75 million
Thus the total claims expected in one year is Rs. 86.7 million.
Administrative costs @ 20% - Rs. 17.34 million
Total Expenditure = Rs. 104.04 million
Profit = Rs. 107.1 million
151
Govt. contribution = Rs. 54.6 million
Net profit = Rs. 52.56 million
In effect therefore the program can expand to the whole state area with no burden on state system
but a transfer of resources to the poor.
If to this we add that the poor (beneficiaries and the vulnerable beneficiaries) will get first
contact curative care at the door step through HHWs, the profit projections appear adequate to
cover their remuneration and services also.
However as the scheme is optional to Class I the actual enrolment might be lesser than this. The
scheme is believed to breakeven at a point where the enrolment from the non-poor class i.e.
Class I is 60% of the total. This implies that for the scheme to be self sustaining the enrolment
from the non poor should be around 60% and if this falls down the scheme needs to be
subsidized.
Conditions –
1. A prerequisite for the implementation of the scheme is that the PPP policy and the Mitanin
Kendra must be already in place.
The payment made under this scheme is a third party payment which is directly paid to the
health care providers and no beneficiary is entitled to cash reimbursements. The third party
payments are made to Rogi Kalyna Samiti in case of hospitalization to CHC or district hospital
or to the Mitanin Kendra, Mitr Chikitsalaya for private providers.
2. For the Class III beneficiaries a prerequisite is to enrol in a SHG.
Complementary Scheme: The Role of the SHGs.
Complementing this scheme to meet the indirect costs which are also estimated to be high a
deposit linked scheme functional through SHGs could be devised.
152
A monthly contribution of Rs. 10 per family is paid into an SHG from which loans can be
prioritised for the purpose of meeting the indirect costs, viz. the transport charges, food charges,
wages lost by the patient and the relative accompanying the patient to the hospital, etc. this is
mandatory for Category III but optional for Category II. The banks would be called in to give
matching grants to the SHGs, so that they have an adequate corpus for the purpose. Their
membership in an SHG makes the family eligible for the social insurance.
The scheme could be possibly handled by an insurance company for efficient risk management,
to ensure continual monitoring and for effective settlement of the claims with no loss of time.
Part II - PILOT PROJECT
The project will be first tested in few towns especially the company towns. Depending on the
success of the scheme it would be extended to other areas in Phase I i.e. covering 17 lakhs
population in the first year.
Assuming the around 8 to 10 towns would be selected for the pilot project, the distribution of
the beneficiaries from different Categories and Classes would be as follows –
The Beneficiaries –
The entire population may be classified into three groups as follows –
Class I – General – those with an annual salary of 1 lakh or more.
Class II – Poor – Beneficiary.
Class III – Vulnerable – as identified by the ULBs. (This category would include migrants,
ragpickers, street children, CSWs, slum dwellers, etc.)
Definition of family – A family covers four members viz. the proposer, his/her spouse and three
unmarried children. To extend the benefits of the scheme to other members a premium of Rs.
150 (for all the Categories) needs to be paid by the proposer for an annual cover.
The average family size is 5.
Class
Total beneficiaries to be Number of households that
covered in Phase I
could be covered in Phase I
153
Category A
Total
Category B
Total
Category C
Total
Category D
I
II
III
100000
50000
16667
166667
40000
20000
6667
66667
20000
10000
3333
33333
10000
5000
1667
16667
283333
I
II
III
I
II
III
I
II
III
Total
Grand Total
20000
10000
3333
33333
8000
4000
1333
13333
4000
4000
667
6667
2000
1000
333
3333
56667
Contributions for the scheme –
Category A:
Class
Contribution in Rs.
Total in Rs.
from the beneficiaries
from the government
II
Per family
Total
Per family
600
12000000
300
0
0
300
3000000
0
3000000
600
6000000
III
Total
Per family
Total
0
15000000
2000000
5000000
2000000
20000000
I
Total
Category B:
154
12000000
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
4800000
300
0
300
4800000
II
Total
Per family
1200000
0
1200000
600
2400000
III
Total
Per family
Total
0
6000000
800000
2000000
800000
8000000
Total
Total in Rs
Category C:
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
2400000
300
0
300
2400000
II
Total
Per family
1200000
0
1200000
600
2400000
III
Total
Per family
Total
0
3600000
400000
1600000
400000
5200000
Total
Total in Rs.
Category D:
Class
Contribution in Rs.
from the beneficiaries
from the government
I
Per family
600
0
1200000
300
0
300
1200000
II
Total
Per family
300000
0
300000
600
600000
III
Total
Per family
Total
0
1500000
200000
500000
200000
2000000
Total
Grand Total –
Total in Rs.
155
Category
A
B
C
D
Total
Contribution in Rs.
from the beneficiaries
15000000
6000000
3600000
1500000
26100000
from the government
5000000
2000000
1600000
500000
9100000
Total in Rs.
20000000
8000000
5200000
2000000
35200000
Thus the total income is Rs.35.2 million and the government contribution accounts for only
26% of the total contribution. The government contribution for Class II & Class III is Rs. 57
lakhs & 34 lakhs, respectively.
The contributions to be collected from Class I & Class II can be deducted at source i.e. in the
form of health tax of Rs. 600 and Rs. 300 per family, respectively; thereby ensuring the collection
of the premium from every household.
Benefits –
The insured is eligible only for certain categories of hospitalization expenses where treatment can
be provided by the Secondary Centers including the township hospitals and the Mitanin kendras,
'designated accredited rate fixed clinics' under the following two categories
Category
Major procedures/
surgeries
Minor procedures
Benefits covered
Approximate cost
for procedure in
Rs.
• Shall
include
Caesarean
Sections, 5000/Hysterectomies and other gynaecological
and obstetric procedures.
• Common surgical procedures like that for
haemorrhoids, hydrocele, hernia repair,
appendicitis, etc.
Shall include Normal deliveries, Day care 1000/procedures, short duration hospitalizations and
minor surgical procedures like I & D circumcision,
RTI/STI, Family planning services, etc.
Viability of the scheme
(A.) CBR being 25/1000, we can expect 7000 births in a population of 2.8 lakhs. Only 10% of these
are expected to undergo Caesarean Section.
156
Therefore, total expenditure on
1. Normal deliveries = (Expected births – Expected Caesarean Section) X Reimbursement per
normal delivery.
= (7000-700) X 1000
= 6300 X 1000
= Rs. 6300000/2. Caesarean Section = Expected Caesarean Section X Reimbursement per section
= 708 X 5000
= Rs. 3541667/(B.) Of the total population 1% require any surgical intervention out of which only 15% would
require any major surgical intervention.
Therefore the expenditure on
1. Minor Surgical interventions = (Expected total minor surgeries – Expected total major
surgeries) X Reimbursement per case.
= (2833-425) X 1000
= 2408 X 1000
= Rs. 2408000/2. Major Surgical interventions = Expected total major surgeries X Reimbursement per case.
= 425 X 5000
= Rs. 2125000/Thus the total claims expected in one year is Rs. 14.37 million.
Administrative costs @ 20% - Rs. 2874933/Total Expenditure = Rs. 17.25 million
Profit = Rs. 17.95 million
Govt. contribution = Rs. 9100000/Net profit = Rs. 8850400/-
157
In effect therefore the program can expand to the whole state area with no burden on state
system but a transfer of resources to the poor.
If to this we add that the poor (beneficiaries and the vulnerable beneficiaries) will get first
contact curative care at the door step through HHWs, the profit projections appear adequate to
cover their remuneration and services also.
For Class III however a prerequisite to be covered under the scheme is membership in a Self
Help Group, by contributing Rs. 10 per month. This amount would be utilized in meeting the
indirect costs borne by the beneficiary at the time of seeking health care.
The scheme therefore benefits all the stakeholders – the vulnerable gets the health services free
of cost while his contribution takes care of the indirect cost; the poor get quality service for a
nominal premium with equal contribution from the government, the middle class can seek
service without having to pay at the time of seeking the service for a nominal premium and the
providers get volume of patients. This mechanism ensures cross subsidization so as to meet the
cost of health contingencies of the poor and the vulnerable.
158
Chapter 18
Cost Analysis of Rogi Kalyan Samiti in Chattisgarh.
Introduction –
The private sector in health primarily caters to the needs of the affordable class making the
services inaccessible to the poor. While public health service is the only facility available to them,
the decades old decaying public hospital and health care centres are unable to serve their needs.
As an alternative to provide quality health care services to the needy, the concept of ‘Rogi kalyan
Samiti’ evolved during the catastrophic plague event of Surat in 1994. People’s contribution was
utilized for providing services that were initially unavailable to them. Following the success of
the Maharaja Yeshwantrao hospital, it was replicated to other hospitals gradually. The scheme
spread to more than 1000 hospitals in 61 districts with an objective of providing different health
care system (public) resources and autonomy to function at their best.
The scheme is operational in MP, Chattisgarh since mid-nineties. It assumed the form of
Medical Relief Societies in Rajasthan in 1995 which was followed by 68 more societies. In March
2003, Chikitsa Prabhodan Samiti (formerly known as ‘Chikitsa Sudhar Samiti) covering district
and combined and base hospitals was formed in Uttaranchal.
The basic objective of all these initiatives is to improve and strengthen the Public System
through people’s participation. It thus requires a nominal contribution from the people in the
form of user fees at the time of seeking health care services from the government hospitals. The
fund collected is used for improving the hospital infrastructure and provision of other related
services. In such a scenario it is found imperative to know how the fund is utilized, if it actually
meets the needs of the people. For effective implementation it is important to know the cost of
the services, the cost to the government and by the people. This would also aid in assessing the
efficacy of such a scheme and in examining different alternatives.
What is Rogi Kalyan Samiti?
Rogi Kalyan Samiti are the registered societies constituted in the hospitals as an innovative
mechanism to involve the peoples representatives in the management of the hospital with a view
to improve its functioning through levying user charges3.
159
Instead of assuming a zero-sum relationship between Government involvement and private cooperative efforts, some social capital theorists argue about the possibility of state –society
synergy. They hold the view that an active government and mobilised communities can enhance
each other’s developmental efforts. In the construction of synergy, micro level social capital has
an important place. The Rogi Kalyan Samiti scheme in the health department is an example of
how this synergy can be harnessed at the micro level.
Inception –
Maharaja Yeshwantrao hospital a 750 bedded hospital, established in 1955, known to be a
premier institute was gradually deteriorating ----- it had become a home for the rodents! The
plague scare of Surat in 1994 raised an alarm and soon attention was driven towards the
appalling condition of hygiene in the hospital. The then collector S. R. Mohanty with the district
administrator took up the task of revamping the system to change the condition of the hospital.
An appeal was made to the people for their cooperation and in turn would also ensure
transparency and accountability. Donations started pouring in, patients were shifted to the
neighbouring government and private hospitals, the complex was cleaned, tons of rubbish,
truckloads (around 150) of junk, furniture were removed and deweeding, external and internal
baiting, sealing of the sewerage system were undertaken to trap the rodents. Finally the rodents
were killed by using poisonous gas and disposed off in electronic crematorium. The general
public was involved at every stage of planning. Though the physical facilities were restored there
was still a general apprehension that the system might again collapse unless an administrative
structure is inbuilt within the system to ensure its permanency. It was thus decided to adopt the
following strategy
•
Undertake a scientific reallocation of available space to improve efficiency.
•
Redefine administrative responsibilities.
•
Introduce user charges to strengthen resource base.
•
Establish a management structure to ensure smooth running of the hospital.
This was named as ‘Rogi Kalyan Samiti.’
In the first year, a handful of districts, especially those close to medical colleges adopted the
scheme. In 97-98 almost all the district in the state adopted it, while in most districts the initial
work was done in the district level hospitals, there were several smaller hospitals where local
160
officials started the scheme. After a review in 1999, the government issued instructions that gave
sweeping powers to the Samitis and the objectives and the duties were expanded1.
Highly impressed with this novel programme, Chief Minister Digvijay Singh issued directive for
the implementation of this program in all the district level public hospitals in the state. The RKS
was reportedly formed in “more than half of the nearly 1,200 public hospitals in the state” and
“an estimated Rs. 37 – 40 crore” was raised across undivided Madhya Pradesh in the five years
and spent on the improvement of the hospital (India Today, January 8, 2001)
“We see decentralisation as the strategic architecture for democracy to become articulate in our
country. It is essential architecture to make democracy full-blooded and full-throated.
Decentralisation has intrinsic merit as an enabler of democracy by maximising participation.’
- Digvijay Singh.
The poor patients who could not afford to pay for the services were exempted from paying the
user fees and treated free of cost. They were not required to bring any testimony to prove their
poor state of being.
‘Rogi Kalyan Samiti.’- Structure1–
The basic structure of the Rogi Kalyan Samitis is as follows –
•
RKS would be a registered society and be set up in all medical colleges, district hospitals
and community health centres.
•
It would have people’s representative, health officials, local district officials, leading
members of the community, representatives of the IMA, members of the urban local
bodies and Panchayat Raj representatives as well as leading donors as their members.
•
For its functioning it shall be deemed not as a government agency, but almost as an
NGO.
•
It could utilize all the government assets and services to impose user charges. It would
be free to determine the quantum of charges on the basis of the local circumstances.
161
•
It could raise funds additionally through donations, loans from financial institutions,
grants from government as well as other donor agencies.
•
It could utilise surplus land available in the hospital for commercial purposes or to
construct shops and lease them out.
•
It could take over and manage canteens, rest houses, stands, ambulance services and
other facilities within the hospital complex owned or managed by the government.
•
Private organizations offering high tech services like Pathology, MRI, CAT Scan,
Sonography etc. could be permitted to set up their units within the hospital premises in
return for providing their services at a rate fixed by the RKS.
•
The funds received by the RKS will not be deposited in the state exchequer but will be
available by the executive committee constituted by the RKS.
•
As a result of the RKS system coming into effect, the government would not reduce its
budgetary allocation traditionally received by the hospital.
Objectives of RKS2 –
1. Improve the management of the hospitals with community participation.
2. Up gradation of health institution, modernisation of health facilities and purchase of
equipment for institutions. Effect a continual up gradation of facilities.
3. To ensure discipline and monitor accountability.
4. Provide assured ambulance services for emergencies and during accidents.
5. To establish public private partnership for betterment of the institution.
6. Maintenance & expansion of hospital building.
7. To develop the unused extra land of the hospital for commercial purposes as per the
guidelines of the state government for strengthening the financial condition of RKS.
8. Increase community participation.
9. Organise training & workshops for staff members.
10. Ensure adequate and safe disposal of hospital wastes.
11. Arrange for good quality diet and drugs and stay arrangements for the relatives of the
patients. Ensure equity through provision of free treatment to patients below poverty line.
12. Ensure proper maintenance of hospital, wards, beds, equipment, cleanliness of premises.
13. Monitoring & supervision of National Health Programs.
162
14. To obtain loans from banks & financial institutions for development & up gradation of
medical facilities in hospitals.
Constitution of RKS2–
Rogi Kalyan Samiti have been set up at various level of hospital
1. District hospital.
2. Civil hospital.
3. Community Health Centre.
4. Primary Health Centre.
Rogi Kalyan Samiti at each level has two bodies for its effective functioning, General body and
Executive body.
District hospital
General body –
I/C Minister of the district
Chairman
President Jila Panchayat
Member
Mayor of Municipal Corporation
Member
Collector
Member
Superintendent Police
Member
Chief Medical Officer
Member
MLAs of district
Member
President of Health Committee
Member
Municipal Corporation/Municipality
Senior MO of hospital
Member
Municipal Commissioner
Member
CEO Zila Panchayat
Member
Ex. Eng. PWD & PHED
Member
Secretary Red Cross
Member
President IMA
Member
Two Donors (donated Rs. 50,000)
Member
Nominated by Chairman
163
Two social workers nominated by the chairman
Member
Civil Surgeon cum Hospital Superintendent.
Member
Executive body –
For managing day to day functioning of the Rogi Kalyan Samiti Executive Committee have been
given certain powers. The composition of executive body is as follows –
Collector
Chairman
Municipal Commissioner
Member
CEO Zila Panchayat
Member
Chief Medical Officer
Member
Senior MO of hospital
Member
Ex. Eng. PWD
Member
One Donor (donated Rs. 50,000)
Member
Nominated by Chairman
Civil Surgeon cum Hospital Superintendent
Member
Tehsil & Block Level Hospital Rogi Kalyan Samiti
The Community health centres, Civil hospitals and other hospitals at the tehsil & Block level
come under this category. The composition is as follows –
MLA of the area
Chairman
S.D.M.
Member
President Janpad Panchayat
Member
President of Municipality
Member
President of Health Committee of Municipality
Member
CEO Janpad Panchayat
Member
One parshad of area
Member
S.D.O., PWD, PHED
Member
Two Donors (donated Rs. 80,000)
Nominated by Chairman
Member
Senior MO nominated by CMHO
Member
Block MO I/C MO Hospital
Member Secretary
164
Executive body –
SDM
Chairman
President Janpad
Member
CEO Janpad Panchayat
Member
S.D.O., PWD
Member
Senior MO nominated by CMHO
Member
Block MO I/C MO Hospital
Member Secretary
Other Health Institutions/Dispensary/PHC
General Body –
Janpad Panchayat member of area
Chairman
President Nagar/ Gram Panchayat
Member
President of Municipality
Member
President of Health Committee of Nagar/ Gram Panchayat
Member
Nagar/ Gram Panchayat female member
Member
Sub Eng. PWD & MPEB
Member
Two Donors (donated Rs. 10,000)
Member
Nominated by Chairman
Tehsildar/Nayab Tehsildar
Member
I/C MO Hospital
Member Secretary
Executive body –
Tehsildar/Nayab Tehsildar
Chairman
President of Health Committee of Nagar/ Gram Panchayat
Member
Sub Eng. PWD & MPEB
Member
I/C MO Hospital
Member Secretary
District Level Rogi Kalyan Samiti2
165Executive
Chairman
Committee
Collector
ZP President Mayor
President Health
Committee MC
MLA 2 Non Govt.
Member 2 Donors
Sec. Red Cross
President IMA
Chairman
Minister
I/C of
the
Suptd. Police
EE PWD
EE MPEB
CEO ZP
Municipal Comm.
CMHO
1-Senior doctor
Member Secretary
Civil Surgeon cum
Hosp. Suptd.
Powers and responsibilities of General body of RKS–
1. The general body shall meet at least twice in a year. However the Executive Committee or
1/3rd members on request can call meetings of RKS.
166
2. The newly constituted RKS shall hold its meeting within 3 months and shall elect its office
bearers.
3. The Executive committee can call the special meeting of the old RKS General body and this
body can amend objectives, membership, change in rules and regulations or it can approve
the removal of the left out members from the list.
4. The chorum of the General body shall be 1/3rd of the members.
5. The General body shall take the policy decisions and it will be implemented by Executive
Committee under rule 10 of the constitution of RKS.
6. General body can authorise the Executive Committee for implementation of functions, it
can delegate financial powers to members of Executive Committee and also approve
financial proposals that are that are beyond the powers of the Executive Committee.
7. The General body shall review the financial account at least once in a financial year, review
the income & expenditure statements and shall approve the budget for the next year.
8. General body shall have powers to appoint chartered accountant and can constitute sub
committees for specific purposes such as new construction and commercial use of land.
Powers and Responsibilities of Executive Committee –
1. The Executive Committee will meet at least once in two months. The chorum will be of
50% members. The presence of the Chairman will be essential.
2. Executive Committee will perform its day to day functions with existing manpower.
3. Executive Committee will implement the decisions taken by GB and will function within its
powers invested by GB.
4. Executive Committee can delegate its financial powers to the member secretary.
5. Executive Committee shall have authority of raising the funds for the activities approved by
GB e.g. new construction, equipment purchase, and modern investigative facilities. It shall
have the authority to take loan from banks.
6. The Executive Committee can appoint cleanliness staff, para medical staff, and security
guard and part time employees on contract.
7. Executive Committee will levy user charges from the patients and facilities given for their
relatives.
8. Executive Committee can purchase equipment, drugs, furniture, pathological reagents, XRay films in consultation with the Sr. MO for quality purchase.
167
Devolution of powers –
The government authorised the RKS to manage the existing facilities and assets of the
concerned hospital. RKS has been given the freedom for operations, management and
investment to meet service requirements. The RKS is empowered to mobilise resources through
levy of user charges.
It allows commercial use of assets like land of the institution, donations in cash or kind from the
public at large and allotments/Grants from the government or non-government bodies & loans
from financial institutions.
Levy of user charges –
User fees are considered not only a tool for ensuring efficient use and equitable financing of
public services, but also as an investment, guide, because consumers’ willingness to pay for
services in many instances is considered to be the only way in which the benefits of a service can
be ascertained and compared with the cost of providing the service.
The guidelines for user charges are as follows –
Charges must be levied for all facilities provided in the hospital including the outdoor patient
ticket, pathological tests, indoor beds, specialised treatment, operation, etc.
The economically weaker sections of the society and other groups as determined by the
government (for e.g. persons below the poverty line, freedom fighters, etc.) would be exempt
from the levy. Identification would be based on self-certification. The charges for general ward
would be nominal while those for private wards would be higher. Funds so received would be
deposited with the RKS and not in the government exchequer.
Implementation –
The Executive Committee acts as a watchdog to oversee the day to day functioning. People’s
representatives on the RKS facilitate social audit. The activities of RKS are monitored by the
members of the district government and the Minister In-charge of a district is also the President
of district level RKS which ensures effective supervision.
168
Other studies on Rogi Kalyan Samiti –
A study conducted by Girish Kumar3, for the 18th European Conference on Modern South
Asian Studies, is based on data collected from 9 hospitals in selected five districts of Madhya
Pradesh which is primarily a documentation of the innovative reform scheme critically
examining the decision making process and sharing of responsibilities by the different
stakeholders. It also aims at assessing the strength of institutional arrangements, transparency
and accountability of the new management structure. The study shows that the scheme has
heralded a major initiative to reform the near defunct government hospitals in Madhya Pradesh
by enforcing accountability of the staff, transparency in the use of available resources, and above
all providing more facilities to the patients without putting financial burden on the state
exchequer. However the patients interviewed in few hospitals were not content, monitoring is
limited as it is more attuned to observing procedures than an exercise in ushering dynamism in
the functioning of the RKS. The main actors of the scheme seem to be complacent, even
saturated with their performance as if they have reached the end of the journey. There is hardly
any organised effort to bring about a change in the behavioural pattern, work ethics, inject the
sense of duty and mould the traditional mindset of the health functionaries in order to make
them de facto agents of change. However it has been able to demonstrate that the huge
infrastructure created in 1970s and 1980s could be saved from going waste in the face of ever –
shrinking budgetary allocation if reforms in these lines are introduced with little innovation.
An article on Rogi Kalyan Samiti1 states that a total of Rs. 350-400 million have been collected
by the various districts through donations and user charges, MPs and MLAs have earmarked
funds out of their discretionary local area development funds for improvement of the health
institutions. The district Red Cross Societies have been functioning in tandem with RKS and in
fact been more active of late with the expenditure jumping to Rs. 70-80million in 94-99 from 4
million in 1990-1994. Daily collection in each of the hospital depending on the location is
around Rs. 500 to 25000 and a conservative estimate of monthly collection of Rs. 25 to 30
million which is still on increase. It states that the social benefits due to the implementation of
RKS is both direct and indirect, improving both the quality of service the acceptance and the
willingness to pay. However there is no evidence of any study showing the willingness to pay or
for the acceptance of service and satisfaction. It has been assumed that it is acceptable, as there
have been no protests in the entire state over the introduction of user fees. The study states that
169
there has been improvement in the efficiency of the doctors, arresting the deterioration in the
hospitals and increase in the number of patients coming to the government hospitals after the
introduction of user charges reflecting their willingness to pay.
Similarly some hospitals have been adopted by Rajasthan State to provide better services in
medical field which has been documented by Dr. A.S. Bapna in a Handbook for General
guidelines for Rajasthan Medicare Relief Societies4. It states that to improve resources to primary
health care it is necessary to evolve a process by which state resources can be conserved at
secondary and tertiary level of health care and hence RMRS was constituted. However the irony
is that to improve primary health care, resources are being generated and utilised at secondary
and tertiary level. It aims to provide autonomy and convenience in utilisation of resources.
However all the requirements to utilise the resources is reserved with the community composed
of technocrats thereby breeding hierarchy and systemic approach.
An exhaustive study2 on the RKS in Madhya Pradesh since the time of inception to 2001,
suggests that once the management of the hospitals improved, the MPs and the MLAs too came
forward in earmarking funds out of their discretionary local area development funds for
improvements of health institutions. District Red Cross Societies too started functioning in
tandem; and around Rs. 40 lacs were spent on the hospitals. Various ancillary services like
Pathology, Sanitation, MIS, Security and Canteen services have been introduced in phased
manner. The net gainer being the consumer as the rates are almost 30% lower than elsewhere.
On an average Rs. 10 lakhs have been generated per district per year. The pattern of resource
mobilisation does not indicate sustainability as the major amount of funds were generated from
non medical sources like donation. The resource mobilisation is only up to 50% from medical
resources. It is stated that there is a need to augment the resource mobilisation from medical
sources like special investigations, surgical procedures, ambulance services & pathological
investigations. There is a mis match in income generation and expenditure pattern. The study
shows an improvement in the utilisation as the number of patients from middle class have
increased, though there is no direct evidence of increase in below poverty line patients. As the
below poverty line patients are exempted from user charges, the number of BPL patients is
believed to not have reduced.
170
Analysis of the report shows the positive evidence of increase in the specialised investigations
like ECG, X-Ray, number of blood transfusions but there is a decline in the routine blood test in
many districts.
Aim of the study –
To estimate the cost effectiveness of the Scheme.
Objective of the study –
To analyse the costing pattern of the government health care providers (district
hospitals/CHCs) vis-à-vis the collections made under the Rogi Kalyan Samiti.
To study the utilization of the funds from Rogi Kalyan Samiti.
Sampling –
For the purpose of the study three CHCs from three different districts- Raigarh (Pusaur),
Jhanjgir (Baloda) and Kanker (Charama) were selected and district hospital of Raigarh and
Jhanjgir were selected. This is a purposive sampling based on the criterion of availability of
information and accessibility.
The CHC is conceived as a 30-bed secondary referral centre, the most important component of
secondary referral along with the district hospital. though the norm expects a CHC to cover one
lakh population, on an average 1.5 lakh population are covered per CHC in Chattisgarh. There
are 121 CHCs in 16 districts of the state.
Methodology –
The following information was obtained from the health centres –
1. The salary of the overall hospital staff and those specially appointed by RKS.
2. The staff pattern and the different units in the hospital and the number of hours spent
by the staff especially the doctors in different activities.
3. The tariff rate for the different services provided under RKS.
4. A statement of the income earned and the expenditure made under RKS.
171
5. The number of OPD patients, IPD patients, Operations conducted (both major and
minor)
6. The number of deliveries conducted and number of L.S.CS.
7. The total number of injections administered to the Out patients and the number of XRays, USGs and CT Scans conducted.
8. The details from the stock register as to the number of equipments purchased, the
medicines purchased and dispensed, etc.
With the aid of the aforementioned data, and making the following assumptions the cost for the
different services were computed–
1. The annual capital expenditure by the hospital in the form of depreciation for its assets is
assumed to be 10% of the total, while that for the staff salary is assumed to be 60% and the
expenses on water/electricity/maintenance/repair and consumables is estimated as 5 and 25%
respectively. Though this is not expected to be same for all the institutions especially the district
hospitals and the CHCs, the assumption has been kept uniform.
Based on the aforementioned assumptions, the total expenditure made by the hospital has been
estimated.
2. The total number of patients having sought services from different units is multiplied with the
rate of service to obtain the total income in the respective units. This figure has been further
discounted by around 60% (43% for BPL and remaining for other waive off) to estimate the net
income under Rogi Kalyan Samiti. This figure is very close to the income mentioned in the
statement of income and expenditure of RKS, though not the same.
The computation of the income unit wise was essential to estimate the cost recovery per unit and
to compare with the actual allocation of the fund to the respective units.
3. The data was available for different periods and hence has been adjusted to obtain the annual
figure to allow comparison.
4. The expenditure has been apportioned for different units as follows –
172
OPD
IPD
OT
LAB
PHR
INJ
X-RAY
ADMIN
Total
25%
22%
16%
6%
6%
10%
7%
8%
100%
1. Jhanjgir Premises As mentioned before based the Jhanjgir district hospital was selected on the geographical
accessibility and availability of information. The district Jhanjgir-Champa is situated in the center
of Chattisgarh and so it is considered as heart of Chattisgarh and the district hospital is situated
at the heart of the district around 2 kms. from Naila station which is around 175 kms from the
state capital Raipur. The district covers 13,16,140 population in 9 blocks, of which 43% are
below poverty line (Article by Myra MacDonald – New Indian State Pioneers free market
reforms – Internet). The health care facilities available to the people are around 10 PHCs, 6
CHCs, 211 SCs and one district hospital besides other private services.
District HospitalThe building was constructed in 1956 to serve the primary health care needs of the people. It
was converted to district hospital in 1998 and is manned by 45 employees. The remuneration for
3 staff viz – 1 radiographer and 2 sweepers is met through Rogi Kalyan Samiti and hence they
are called contractual employees under Rogi Kalyan Samiti. The staff pattern has been given in
the Annexure I. As per the existing staff both the manpower and the infrastructure are far below
the requirements of the hospital.
It is a 28 bedded hospital with the following units under the control of the Civil Surgeon. The
different departments in the hospital –
Outdoor services, Indoor facilities, Laboratory services, Operation Theatre, Labour room,
Pharmacy, X-Ray Centre, Dressing room, Injection room, Ophthalmic centre, Administration.
As mentioned before in the general description of RKS, the charges for different services are
fixed by the Committees.
The tariff for different services in Jhanjgir district hospital is as follows –
Sr. No.
Unit/Service
Current rates in Rs.
173
Revised rates in Rs
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
1
2
3
4
Haemoglobin
Total & Differential counts
ESR
Urine-Sugar/Albumin
Urine-Routine/Microscopic
Blood Grouping
UPT
Urine Bile salt pigments
Blood- B.T.C.T.
Blood sugar – Calorimeter
Blood sugar – Glucometer
Serum bilirubin
Blood urea
Widal
V.D.R.L.
Australian Antigen ‘B’
Hepatitis ‘C’
X-Ray charges
12X15
10X12
8X10
6X8
5
5
10
5
10
10
30
10
10
10
30
15
10
10
10
45
5
10
10
5
10
20
40
10
10
20
30
20
20
20
20
60
140
45
45
25
25
35
35
20
20
Unit wise Cost analysis –
OPD Clinic –
The OPD services are provided in two rooms, one in which the Civil surgeon sees his patient
and the other larger one in which 4 Medical Officers examine their patients. None of the rooms
have an examination table and there is a lack of privacy for the patients. However, while the
larger room is well illuminated and ventilated the smaller room lacks appropriate light supply.
There is only 1 small 4 feet long bench for the patients to be seated, while waiting to be seen by
the doctors.
The OPD timings are 8.00 am. to 14.00 pm. and from 16.00 pm. to 18.00 pm. thereby
amounting to 8 hours. However the clinic starts not before 10.00 am and closes around 17.30
pm.
174
The total number of patients seen in nine months (April to Dec, 03) is 37523. The average
number of patients seen in a month is around 4169. Thus the average number of patients
examined/treated in a day is around 175.
Assuming that of the total expenditure 25% is spent on OPD services the annual expenditure on
OPD is Rs. 1743049. Thus expenditure per patient comes to Rs. 35. This however excludes the
cost for pathology and X-Ray. The cost of these services would be taken separately. As the data
for Indoor and Outdoor patients getting services in the aforementioned units is not separately
available, it is not possible to estimate the separate cost for these services (X-Ray, pathology,
etc.) for Out door patients. Rs. 35 per patient is inclusive of the staff salary, maintenance &
repair, cost of consumables and the capital cost.
The registration charge per patient is Rs. 2 for out patient service. This amounts to around Rs.
1,00,061 in a year. If 60% of the total patients were given free treatment (BPL, pensioners, etc.)
the income through OPD would be Rs. 40024. Thus of the total expenditure on Out patient
services around 2.3% is recovered from the patients.
Indoor Services –
It has two wards one for the male patients and the other of the female patients. In all there are
28 beds, the average bed occupancy being ----- The average length of stay is around 3 to 4 days.
The total number of patients admitted in 9 months (April to Dec, 03) is 154. The average
number of admission per day is either one or nil while the monthly admission is around 17.
Assuming that of the total expenditure, 22% is spent on IPD services the annual expenditure on
Indoor patients is Rs. 1533883. Thus expenditure per patient comes to Rs. 1643. This is inclusive
of only the staff salary, building cost, maintenance & repair cost and cost of consumables. The
recovery from the patient’s contribution is 0.21%. This excludes the cost of X-Ray, lab
investigations, surgical procedures & delivery (including L.S.C.S).
Laboratory –
The laboratory is located in a small room close to the entrance and is congested. The laboratory
can conduct normal tests like blood, sputum, urine, malaria, etc. but microbiological cultures and
175
histopathology are not available. The total number of investigations done in seven months (Jan,
04 to July, 04) is 12651, the details being available in the Annexure. The total income generated
through the laboratory could be around Rs. 96119. If 60% of the patients being either
pensioners or BPL were waived off the fees, the income from pathological tests would amount
to Rs. 98865.
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes to Rs.
418332. Thus the cost recovery from the patients contribution amounts to 15.76%.
[As the detailed profile of the Pathological tests is not available, to estimate the collections from
the lab facility the following assumptions have been made.
1. If around 350 ANC cases are seen, and assuming that at least 80% of them would have done
UPT, the actual number of UPT done in a year would be around 280.
Assuming that the remaining 60% would be for Routine/Microscopic Urine. 20% for bile salt
and remaining 13% for blood sugar the total collection from Urine examination sums to Rs.
38744
2. For blood investigations assuming that the cost of each test could have been Rs. 10, the total
income from blood investigations could be taken as Rs. 44600.
3. From other blood investigations considering that only around 5% would have undergone
Australia Antigen test for Hepatitis ‘B’, and around 20% for Serum bilirubin, the income under
this head amounts to Rs. 11615. ]
X-Ray –
The X-Ray department is manned by a radiographer appointed under Rogi Kalyan Samiti on
contractual basis. He therefore does not enjoy other benefits like pension, provident fund, etc.
Moreover his salary is lower than the other technicians.
The total number of X-Rays done in a year is 2320. The detailed classification of X-Rays done in
the month of Oct, 2004 is available in the Annexure. The estimated income from X-Rays for a
year after discounting for the free patients is Rs. 41520. The total expenditure on the patients for
X-Ray being Rs. 488054, the cost recovery is 8.51%.
176
Operation Theatre –
There is only one OT in which both minor and major surgeries are conducted. The total number
of Major surgeries conducted in 2003- 2004 is 30, while only 28 minor surgeries have been
conducted. The total number of Caesarean Sections done is 3.
The minor surgeries are not charged and for major surgeries Rs. 25 is charged. For 30 major
surgeries this sums to Rs. 750 which on discounting for waive off comes to Rs. 300.
Allocation of funds for different units from RKS –
Unit
Fund Allocation in Rs.
Estimated fund generation in Rs.
Medicines
X-Ray
51716 (30%)
33001 (19%)
41520 (27.49%)
Lab
2467 (1%)
65910 (43.64%)
Labour
32884 (19%)
-
2837 (22%)
-
Advertisement/Publication
38057 (1%)
NA
Hospital Exp and Meetings
1720 (2%)
NA
BPL
3784 (2%)
NA
Other Exp
3477 (4%)
NA
The fund allocation is independent of the fund generated by each of the units. The hospital was
converted from a community health centre to a district hospital around 5 yrs. ago and the
requisite number of manpower and infrastructure are yet to be increased. Provision of
medicines, which is primarily government’s responsibility, is met by the fund collected from
RKS.
With the expansion of services more facilities are required to handle the additional caseload,
especially in the provision of Lab services. However over the past five years no attempt has been
made either to provide more technicians or to improve the infrastructure.
Total income generated under the scheme is Rs. 172867 while the amount spent from this fund
is Rs. 169943, which is 98% of the total. The estimated overall hospital expenditure is Rs.
177
6972196 and hence the cost recovery is estimated to be 2.5%, i.e. of the total expenditure only
2.5% is met through the RKS fund.
The cost recovery from different units is as follows –
Cost Recovery from user fees
Cost recovery from
percentage
20
15.76
15
8.51
10
5
2.3
0.21
0
OPD
Indoor service
Laboratory
X-Ray
Units
The estimated cost recovery is more from Laboratory services and X-ray. This implies that the
number of investigations suggested to the patients is more. These are supportive services and
though aid in diagnosis and hence in treatment, they do not directly benefit the patients in terms
of relief from diseases. These departments can also be seen as revenue generating units!
Community Health CentreOn an average 1.18 lakh population are covered per CHC in Jhanjgir. Baloda CHC is located
around 50 kms. from Naila station. The RKS was constituted here in 1996.
It is a -- bedded hospital with the following units - Outdoor services, Indoor facilities,
Laboratory services, Operation Theatre, Labour room, Pharmacy, X-Ray Centre, Dressing room,
Injection room, Administration.
Note- As the number of indoor patients is par less than the out door patients and the number of
minor surgeries conducted are also less, the expenditure apportioned for different units in a
CHC are as follows –
OPD
IPD
OT
LAB
PHR
INJ
X-RAY
ADMIN
Total
40%
5%
5%
10%
10%
10%
10%
10%
100%
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OPD Clinic –
The total number of patients seen in a year (April 03 to March 04) is 33172. The average number
of patients seen in a month is around 2764. Thus the average number of patients
examined/treated in a day is around 92.
Assuming that of the total expenditure 40% is spent on OPD services the annual expenditure on
OPD is Rs. 3947625. Thus expenditure per patient comes to Rs. 119. This however excludes the
cost for pathology and X-Ray. The cost of these services would be taken separately. Rs. 119 per
patient is inclusive of the staff salary, maintenance & repair, cost of consumables and the capital
cost.
The registration charges per patient is Rs. 2 for out patient service. This amounts to around Rs.
66344 in a year. 14% of the total patients were given free treatment (8% BPL, pensioners and
others 6%) the income through OPD would be Rs. 57056. Thus of the total expenditure on Out
patient services around 1.4 % is recovered from the patients.
Indoor Services –
The total number of patients admitted in a year (April 03 to March 04) is 76. Assuming that of
the total expenditure 5% is spent on IPD services the annual expenditure on Indoor patients is
Rs. 493453. Thus expenditure per patient comes to Rs. 6493. This is inclusive of only the staff
salary, building cost, maintenance & repair cost and cost of consumables. The recovery from the
patient’s contribution is 0.21%. This excludes the cost of X-Ray, lab investigations, and surgical
procedures.
The details on income expenditure are as follows –
RKS - Expenditure
Ambulance-Maintenance
Equipment-Repair & Maintenance
Medicines
Hospital Maintenance
Eye Camp
Staff salary
2001-02
2002-03
1315
2340
380
9589
2400
37358
200
179
2003-04
14813
1415
Total
14813
3655
1795
Percentage
14.29
3.53
1.73
2100
17800
49047
20400
47.30
19.68
Other expenses
Total
4778
43651
4063
18772
5133
41261
13974
103684
13.48
100
RKS-Income
2001-02 2002-03 2003-04 Total
Percentage
Donation
16556
2220
18776
9.83
OPD Registration
23836
42148
45768
111752
58.51
IPD Registration
450
500
950
0.50
Delivery charge
150
750
1300
2200
1.15
Other income
20
850
870
0.46
X-Ray
1170
2780
340
4290
2.25
Blood Investigation
175
640
440
1255
0.66
Urine
65
510
350
925
0.48
Other Investigation
300
2285
3650
6235
3.26
Eye Exam
860
1420
1540
3820
2.00
Eye camp
10000
10650
4725
25375
13.29
Ambulance charge
11050
11050
5.79
Others
408
3096
3504
1.83
Total
53112
62061
75829
191002
100
The maximum income is from OPD patients while the maximum expenditure is on eye camp.
A generator has been purchased from the contribution of patients. However during power cut it
could not be used as it was out of order. The accountant was very displeased with the system
and stated that though a scheme like this is operational for patient’s welfare, even despite of
frequent power cut the officials do not grant permission to buy even inexpensive candles.
Trend in Income Vs. Exp
250000
Amount in Rs.
200000
150000
Income
Expenditure
100000
50000
0
2001-02
2002-03
2003-04
Total
Year
The income through RKS has shown consistent increase over the years, which is not congruous
with the expenditure pattern. A huge amount is left unspent.
Raigarh -
180
Premises –
Situated on the eastern border of Chattisgarh, Raigarh district covers an area of around 6,836 sq
km. It covers a population of 12,65,084 and is around ---- kms. from the state capital Raipur.
There are 7 CHCs covering on an average 1.8 lakh population per CHC.
District Hospital –
It was started as a 117 bedded hospital, which was further, expanded to 190 beds in 1995.
Facilities of delivery, eye, child, surgical, medical, T.B. and burn unit are available here. Dental
treatment facilities are also available in this Hospital along with those of X-Ray, Blood Bank,
Pathology and I.C.U. Ward. District Rogi Kalyan Samiti at district hospital, Raigarh for the
welfare of the patients was established during the month of October, 1995 with public
contribution. The Samiti with the help of public collected Rs. 42,92,969.00 for different facilities.
In 1998-99, the District Rogi Kalyan Samiti made available an amount of Rs. 2,45,392.00 for
construction of two I.C.U. Rooms.
Indian Red Cross Society, Raigarh branch was established during the year 1991-92 and with the
help of public Rs. 1,27,53,952.00 was collected till 2002 of which Rs. 91,14,869.00 was expended.
During the year 1997-98 an amount of Rs. 12,09,023.00 and during the year 1998-99 an amount
of Rs. 11,43,337.00 has been expended for different types of works.
Unit wise costing
OPD Clinic –
The OPD timings are 8.00 am. to 14.00 pm. and from 16.00 pm. to 18.00 pm. thereby
amounting to 8 hours. However the clinic starts not before 9.30 am and closes around 17.30 pm.
The total number of patients seen in a year (Jan to Dec, 03) is 136555. The average number of
patients seen in a month is around 11380. Thus the average number of patients
examined/treated in a day is around 438 in different departments.
Assuming that of the total expenditure 25% is spent on OPD services the annual expenditure on
OPD is Rs. 6730984. Thus expenditure per patient comes to Rs. 49. This however excludes the
181
cost for pathology and X-Ray. The cost of these services would be taken separately. As the data
for Indoor and Outdoor patients getting services in the aforementioned units is not separately
available, it is not possible to estimate the separate cost for these services for Out door patients.
Rs. 49 per patient is inclusive of the staff salary, maintenance & repair, cost of consumables and
the capital cost.
The registration charges per patient is Rs. 2 for out patient service. This amounts to around Rs.
2,73,110 in a year. Around 53% of the total patients were given free treatment (BPL, pensioners,
etc.) thus the net income from out patients is Rs. 129440. Thus of the total expenditure on Out
patient services around 1.9% is recovered from the patients.
Indoor Services –
Assuming that of the total expenditure 22% is spent on IPD services the annual expenditure on
Indoor patients is Rs. 5923266. Thus expenditure per patient comes to Rs. 365. This is inclusive
of only the staff salary, building cost, maintenance & repair cost and cost of consumables. The
recovery from the patient’s contribution is 5.41%. This excludes the cost of X-Ray, lab
investigations, surgical procedures & delivery (including L.S.C.S).
Laboratory –
The total number of investigations done in a year (Jan, 03 to Dec, 03) is 15581, the details being
available in the Annexure. The total income generated through the laboratory is Rs. 67790.
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes to Rs.
1615436. Thus the cost recovery from the patients contribution amounts to 4.19%.
X-Ray –
The total number of X-Rays done in a year is 9492. The detailed classification of X-Rays done in
the month of Oct 2004 is available in the Annexure. The estimated income from X-Rays is Rs.
345475. The total expenditure on the patients for X-Ray being Rs. 1884676, the cost recovery is
18.33%.
182
CT Scan –
This service is charged even for the BPL population and the pensioners. The charges are Rs. 800
for general category with an additional Rs. 200 for the plate and computerised report, while for
BPL population Rs. 400 plus Rs. 200 is charged. For contrast media another Rs. 400 is charged.
Around 852 patients underwent CAT scan and the total revenue generated through this is Rs.
767800. Assuming that of the total hospital expenditure if 10% were utilised for providing this
service, the estimated expenditure is Rs. 2692394. Thus the cost recovery for the hospital from
the patients contribution is 28.51%.
The cost recovery from different departments are as follows –
Cost recovery from the user fees
28.52
30
Cost recovery in
percentage
25
18.33
20
15
10
5.41
5
4.19
1.9
0
OPD
IPD
Laboratory
X-Ray
CT Scan
Units
The cost recovery is more from CT Scan & X-Ray department while that from Indoor patients is
also considerable. This implies that a lot of patients are suggested investigations like X-ray &
scan.
The statement of income from Rogi Kalyan Samiti for the year 2003 (Jan, 2003 – Dec, 2003) is
as follows –
Unit Head
OPD
IPD
Pvt. Ward
ICU
Labour chg.
Plaster chg.
Investigations
X-Ray
ECG
Pathology
Blood Inv.
Amount collected in Rs.
129440
400510
229220
79365
67790
3825
Proportion in percentage
4.24
13.13
7.51
2.60
2.22
0.13
345475
18320
11.32
0.60
665349
21.80
183
Other Inv
Cycle stand
Ambulance
Attendant Entry
CT Scan
Rent-Shop
ARV
Others
Interest
10050
59666
83108
88868
767800
58747
7195
11652
24999
3051379
0.33
1.96
2.72
2.91
25.16
1.93
0.24
0.38
0.82
100.00
In
te
re
st
AR
V
EC
G
Pa
th
ol
og
y
O
th
er
In
Am
v
bu
la
nc
e
C
T
Sc
an
900
800
700
600
500
400
300
200
100
0
O
PD
Pv
t.
W
La
ar
bo
d
ur
c
In
hg
ve
s.
st
ig
at
io
ns
Amount in Rs. (,000)
Income generated through RKS
Units
The maximum income is made through CT Scan, following which is blood investigation and XRay. Thus it is seen that maximum income is through investigative procedures, which aid in
diagnosing and not in treating the patients. (Though it indirectly aids in treatment.) However the
irony is that in many cases even after the ailment is diagnosed the hospital is not equipped
enough to handle the case and provide appropriate treatment. For instance though the Raigarh
district hospital has high tech diagnostics like CT Scan it is not equipped to handle L.S.C.S.
The fund collected through RKS is utilised for various purposes like new construction,
maintenance and repair and purchase of medicines, which is as follows –
Unit Head
Maintenance/New
construction
Repair
Medicines
Equipments/materials
Amount in Rs.
Proportion in percentage
1516374
195867
393762
97220
68.73
8.88
17.85
4.41
184
Labour chg
Others
Total
Eq
ui
pm
O
th
er
s
hg
La
bo
ur
c
en
ts/
m
at
er
ia
ls
ed
ic
in
es
M
Re
pa
ir
co
ns
N
ew
M
ai
nt
ai
ne
nc
e/
0.14
100.00
Expenses under RKS
1600
1400
1200
1000
800
600
400
200
0
t
Amount in Rs. (,000)
3053
2206276
Units
A huge proportion of the amount collected through RKS is spent on New construction and
maintenance of the building and major equipment.
The sanitation and hygiene conditions of the hospital is appalling with the infective and the non
infective wastes being dumped in the open space at the centre of the hospital building which is
flanked by wards on all its sides. On enquiring the justification given for the poor sanitary
condition was that the Class IV staff were on strike for a hike in the salary. Though the hospital
is able to collect a considerable amount through user fees a huge chunk of around Rs. 10 lakh is
earmarked for the maintenance of CT scan machine. It is well known that not many patients
need to undergo this investigation and while the general state of the hospital in terms of
manpower and basic sanitation is so poor, it seems ridiculous to hold back such a big amount of
people’s contribution which is meant to serve people’s needs. Moreover the charges for CT Scan
though is less than market price is not subsidised to a great extent.
185
Monthly trend of Inc vs. Exp
Amount in Rs. (in lakhs)
3.50
3.00
2.50
2.00
Income
1.50
Expenditure
1.00
0.50
Ja
n
Fe
b
M
ar
Ap
ril
M
ay
Ju
ne
Ju
ly
Au
g
Se
p
O
ct
N
ov
D
ec
0.00
Month
72% of the total contribution is utilised though the utility of the services for which the amount is
spent could not be assessed. The income generated from the patients has never been less than
Rs. 2 lakhs while in almost 4 months the expenditure has been maintained less than Rs. 1.5 lakhs.
The expenditure surpassed the income in the month of Sep & March. However the gap between
income and expenditure has been consistently maintained, despite of the fact that the staff is
discontent with the pay package, the hospital is unkempt.
In some hospitals every unit enjoys the autonomy with respect to utilisation of resources
generated by it. However in Raigarh hospital the resource generated through different units are
pooled and utilised for different purposes based on the decision of the committee. It was
therefore not possible to compare the unit wise resource utilisation.
Community Health Centre –
Pusaur CHC is located around 35 kms. from Raigarh station. The RKS was constituted here in
1997.
The tariff chart for the user fees as decided by the committee –
Sr. No.
1
2
3
Unit/Service
Haemoglobin
Total & Differential counts
ESR
Current rates in Rs.
5
5
5
186
4
5
6
7
8
9
10
11
12
13
14
15
16
Urine-Sugar/Albumin
Urine Bile salt pigments
Serum bilirubin
Widal
V.D.R.L.
Major surgery
Minor surgery
OPD
IPD
X-Ray
Sickle cell
RA
Serum Cholesterol
5
5
20
30
15
50
25
2
10/day
40/50/60
15
15
20
OPD Clinic –
The increase in the number of out patients has been consistent from the time of inception of
RKS in 97, which is around 20% increase every year. However in 2001-2002 the number of
patients fell by 11% in comparison to the preceding year and in 2002-2003 the number of out
patients increased by 47% which showed a mere increase of 8% in the subsequent year.
Currently on an average around 60 patients are treated each day. Assuming that of the total
expenditure 25% is spent on OPD services the annual expenditure on OPD is Rs. 813810. Thus
expenditure per patient comes to Rs. 49. This however excludes the cost for pathology and XRay. The cost of these services would be taken separately. Rs. 49 per patient is inclusive of the
staff salary, maintenance & repair, cost of consumables and the capital cost.
The registration charge per patient is Rs. 2 for out patient service. The total number of patients
seen in a year (April 03 to March 04) is 16776. 59% of the total patients i.e. 9904 patients were
given free treatment. The revenue generated through OPD in 2003-2004 is Rs. 12182. Thus of
the total expenditure on Out patient services around 1.5% is recovered from the patients.
Indoor Services –
The total number of patients admitted in a year (Jan 03 to Dec 03) is 801. Assuming that of the
total expenditure 22% is spent on IPD services the annual expenditure on Indoor patients is Rs.
716152. Thus expenditure per patient comes to Rs. 894. This is inclusive of only the staff salary,
building cost, maintenance & repair cost and cost of consumables. The recovery from the
187
patient’s contribution is 2.17%. This excludes the cost of X-Ray, lab investigations, and surgical
procedures.
The income from 801 indoor patients being Rs. 15520 the average fees per patient can be
estimated to be Rs. 19, which means that the average length of stay could be 2 days (Indoor fees
per patient per day is Rs. 10).
Laboratory –
The total income generated through the pathological investigations in 2003-2004 is Rs. 2455.
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes to Rs.
195314. Thus the cost recovery from the patients contribution amounts to 1.26%.
X-Ray –
The revenue generated from X-Rays in 2003-2004 is Rs. 26890. As per the assumption the total
expenditure on the patients for X-Ray is estimated to be Rs. 227867, and hence the cost recovery
is 11.8 %.
The details on income expenditure are as follows –
Income
OPD
IPD
Labour
Investigation
X-Ray
Pathological
Blood
Others
From other
sources
Total
97-98
98-99
1460
1180
500
00-01
1970
565
200120022003Total
2002
2003
2004
2888
2438
6380
12182
25348
3070
2680
5140
15520
29560
870
1190
1180
1660
5965
20280
26890
47170
15
335
500
980
345
212
535
810
238
1395
875
1061
1180
1275
999
4440
3805
2510
3155
3370
8365
7891
36311
59706
118798
Expenditure 97-98
Medicine
99-00
98-99
99-00
00-01
475
20012002
20022003
560
188
20032004
Total
1035
Consumables
Total
Balance
1145
1620
1535
3046
3046
5319
3370
3682
4242
3649
11026
11026
25285
44614
44614
15092
63513
64548
54250
Income from various units
Pathology
4%
Others
2%
OPD
20%
X-Ray
45%
IPD
26%
Labour
3%
The maximum income is from X-Ray while the contributions from Indoor patients is the next
higher revenue generating unit.
Cost recovery from different units –
Cost Recovery
14
11.8
Cost Recovery in
percentage
12
10
8
6
4
2
2.17
1.5
1.26
0
OPD
IPD
Laboratory
X-Ray
Units
The cost recovery through X-Ray department is maximum as implied even from the previous
graph showing maximum income from the same department. However though the income
generated from Indoor wards is more the expenses are also more on the indoor patients and
hence the cost recovery is substantially reduced to 2%.
189
Trend in Income Vs. Expenditure
70000
Amount in Rs.
60000
50000
40000
Income
30000
Expenditure
20000
10000
0
1997- 1998- 1999- 2000- 2001- 2002- 20031998 1999 2000 2001 2002 2003 2004
Year
No income & expenditure is shown in 1998-1999, the reason is not known. In 97 though some
amount has been spent it is negligible, while in 1999-2000 no money has been spent despite of
contribution from the patients. The gap between income & expenditure is considerable in all the
years, i.e. a huge amount is left unspent though the patients are in dire need of services.
No one is exempted from fees as it is felt that everyone should pay for health care services*. This
decision is reached at unanimously by the committee as it is felt that if the BPL population is
exempt from the levy everyone will try evading payment on the same pretext and there will be
no source of income. It is also felt that by paying the people will be able to demand for services.
Though patients are compelled to pay for the service around Rs. 62495 from their contribution
is left unutilised.
The doctors are indulged in private practices and pick up medicines from sample packets as is
known to many. Though the CHC is spacious there is no separate room allotted for injection
administration and a corridor outside the female ward is utilised for the same. A table which is
loaded with register, syringes, needles and swabs and a bench adjacent to it to make the patient
lie down while administering the injection are allotted for the purpose.
This is not only
unhygienic but also does not allow privacy to the patients both indoor and outdoor.
Charama – Community Health Centre –
*
Some patients are treated free on a special consideration from the Medical Officer.
190
Kanker has a population of 651333 in 7 blocks. It has 6 CHCs with each CHC covering on an
average a population of 1 lakh.
OPD Clinic –
Assuming that of the total expenditure 25% is spent on OPD services the annual expenditure on
OPD is Rs. 743800. The number of patients seen in 6 days (a week) is 446. If this is extrapolated
the total number of out patients examined in a year can be estimated to be around 21408. Thus
the expenditure per patient will be Rs. 35.
The registration charge per patient is Rs. 2 for out patient service. The revenue generated
through OPD after discounting for the free patients can be estimated to be Rs. 36672. Thus of
the total expenditure on Out patient services around 4.9% is recovered from the patients.
Indoor Services –
Assuming that of the total expenditure 22% is spent on IPD services the annual expenditure on
Indoor patients is Rs. 654544. Thus expenditure per patient comes to Rs. 2081. This excludes
the cost of X-Ray, lab investigations, and surgical procedures.
Laboratory –
Assuming 6% of the total expenditure would be on laboratory the net expenditure comes to Rs.
178512.
As some important information was not available like the charges for various services, this
section is left incomplete.
A Comparative Analysis –
The CHCs and the district hospitals selected for the study being highly varied in terms of
infrastructure, evolution, facilities, etc. serving populations of varied background in terms of
191
socio-economic conditions and demography they are not comparable. However a general
impression gathered about the functionality of the scheme shows that the scheme has its pros
and cons.
Cost recovery in percentage
Comparative Cost Recovery
30
25
20
Pusaur
15
Jhanjgir
10
Raigarh
5
0
OPD
IPD
Laboratory
X-Ray
CT Scan
Units
1. The cost recovery for the hospital is more from the investigative procedures like pathological
tests X-Ray and Scan. This is suggestive of more patients being sent for diagnosis. Thus it can be
considered as a good revenue-generating unit.
2. Not more than 72% of the contribution has been utilised in any of the hospitals, though the
hospital does not seem to be self-sufficient. In the year 2003-2004, in Raigarh, Baloda and
Pusaur 72%, 54% and 72% of the total contribution from the patients have been utilised.
Moreover the income in all these centres are generated from patient contribution, as there is no
record of any donation being received.
Proportion spent in
percentage
Trend in the expenditure
90
80
70
60
50
40
30
20
10
0
Baloda
Pusaur
2001-02
2002-03
Year
192
2003-04
In the two CHCs the amount spent from the total collection dropped to mere 30% in 2002-03,
which again increased in the following year.
Conclusion
The user fees are fixed on ad hoc basis by the committee/trust without considering affordability,
accessibility to the service and the indirect cost incurred by the people. Some studies3 also show
that decentralization is in turn centralized at the hands of few like the dean of the hospital or the
CMO and thereby leading to improvement in selective services confined to few departments
which in true terms might not benefit the patient, like provision of CT Scan in a place where
there is no facility for provision of basic services. A large amount of the fund collected is
earmarked for maintenance of some major equipment or service, which in turn is blocking the
money for some definite purpose not actually taking into consideration the immediate and the
urgent needs of the poor patients.
The cost recovery from each the unit is minimal and the chief stated objective of introducing
user fees is to encourage people’s participation in the management of the hospital and to create a
demand for fair services from the hospital. However since the power of allocation rests with few
it still manifests the problems of implementation.
As there is a shortage of staff some are appointed as RKS staff but are employed on contractual
basis and are paid less than others and also are devoid of other additional benefits. This has led
to dissatisfaction among the staff appointed under RKS.
A list of activities2 undertaken in a handful hospitals are commendable, but these are in few
hospitals as compared to the total number of hospitals and more amount is seen to have been
spent on infrastructure development, and investigative procedures which do not address the
immediate needs of the patients.
As stated in one of the studies1 the increase in the number of middle income class patients and
lack of protest is seen as an evidence for acceptability & willingness to pay. This could also be
attributed to the fact that people have no other option and in the time of crises they are
193
compelled to pay. It is also to be noted that the study shows increased utilisation by middle
income patients and not by poor patients which implies that either even the poor are charged or
the quality of treatment given to the poor is unaffordable. One must also be cognisant of the
indirect cost to the patient, which could be another cause of not seeking service, which the
scheme fails to reckon.
Some studies2 suggest augmentation of revenue from ambulance, pathological and Investigative
services. Most of the hospitals are seen doing the same, without strategizing on how these
resources could be effectively spent for the benefit of the patient. It seems to be more of a
revenue generation mechanism.
One of the main objectives of establishing RKS was to provide autonomy to the hospital so as
to increase the efficiency. However the constitution of the committee is a clear evidence of
hierarchical structure. The Executive Committee meets quarterly and the decisions have to be
stalled until then. The CMO has limited power, which he/she utilises for vested interest, like
lakhs of rupees are earmarked for the maintenance of CT scan in a hospital where basic
sanitation is absent, and there is virtually no waste management.
Due to lack of strong civil society presence, there is no pressure for the funds to be spent for the
benefit of the poorer patients or even the hospital development. A sizeable collection of user
fees is used even for petty things like paying of electricity, water and telephone bills. In most of
the hospitals the collected amount has been spent in buying cooler and generator which might
not benefit the patients directly.
Though it was not possible to elicit minute details about the implementation of the scheme, the
findings of similar schemes5 in other states suggest–
It increases the accountability of the hospital staff but in the absence of ‘real powers’; it
unnecessarily increases the burden of the staff.
Though the resources generated are supposed to be utilised for hospital development, in
bigger hospitals they are used for paying electricity bills and in smaller hospitals to buy
medicines.
194
There is very little public awareness of the functioning of the scheme and politicisation of
the scheme.
Suggestions for further study –
To analyse the utility of the services from the time of inception of the scheme.
Detailed analysis of trends of expenditure.
Detailed analysis of trends of user fee collection.
Client satisfaction studies.
References –
1. RKS
2. Rogi Kalyan Samiti – A detailed report on RKS in Madhya Pradesh
3. Girish Kumar: Public Hospital Reforms in Madhya Pradesh (India)- Perceptions and trends.
Paper prepared for the 18th European Conference on Modern South Asian Studies Lund
University, Sweden.
4. Dr. A.S. Bapna: A Handbook for General guidelines for Rajasthan Medicare Relief Societies.
5. Initial assessment of Chikitsa Prabhadhan Samiti (CSS) in Uttaranchal.
6. Ramesh Bhat, Harshit Sinha, Dileep Mavalankar: Cost Analysis of government hospital
services at block level. Case study of Community Health Centre at Sanand Taluka in
Ahmedabad district, Gujarat.
7. Edited by Andrew Creese & David Parker: Cost Analysis in Primary Health Care- A training
manual for program managers.
195
Institutional Agenda of FRLHT
3 Major Thrust areas of FRLHT
Conserving natural resources used by ISM
through institutional and community involvement
C1 Conservation Research
1.
2.
3.
4.
Botanical & Ecological surveys in
different forest types & regions.
Threat assessment of species of
conservation – concern.
Species recovery.
Sustainable harvest studies.
Demonstrating contemporary relevance of theory and practice
of ISM.
D1 Participatory Documentation, Research & Assessment
of Local health practices.
D2 Modern methods & tools for interpreting traditional
knowledge.
1.
R2 Promotion of self-help
women groups for revitalization
of household health care
practices.
1. Home herbal gardens in rural
& urban areas.
2. Home doctor multi lingual
web site.
D3 Databases on traditional, medical knowledge focussed
on materia medica & diagnostics.
R3 Promotion community owned
enterprises engaged in cultivation
collection & processing of
medicinal plants.
2.
1.
3.
2.
C3 Conservation Databases
4.
1.
1.
2.
3.
Medicinal plant databases.
Trade bulletins for users on prices &
pharmacognosy.
User oriented databases, ENVIS,
Meta database, FRLHT website.
C4 Biocultural Herbarium & Raw drug
library of ISM plants
1.
Virtual Herbarium & R.D. Library.
R1 Promotion of taluk level natti
vaidya associations.
Application of chemistry, genetics, microbiology &
botany for quality, standardization & evaluation of
raw drugs.
Use of modern tools for development &
standardization of products & processes.
Development of pharmacognosy referral database on
medicinal plants.
Database on metals & minerals used in ISM.
C2 Conservation Action
In-situ conservation of wild
populations & habitats of natural
resources used in ISM.
Community gardens in district &
taluks & towns via local institutions.
Revitalizing Social processes
(institutional, non-institutional
commercial) or transmission of
traditional knowledge of health care.
Referral databases for assessment of LHTs.
D4 Cross cultural Research on strategically chosen aspects
of traditional knowledge in order to build bridges of
understanding between Indian & Western systems of
medicine.
1.
2.
3.
4.
5.
Assessment of bone setting traditions in south India.
Studies on malaria.
Ethno botanical nomenclature program.
Database on traditional collection standards.
Studies on ethno-veterinary practices.
D5 Manuscripts Conservation & Research Centre.
R4 Creation of Ayurveda & Yoga
research hospital, pharmacy &
training centre.
R5 Policy studies.
R6 Publications, Education &
Training.
Annex II
Hospital Statistics
Total Hospital (Recurring) Expenditure (in Rs.)
Exp on salaries
Exp on non clinical staff
Net exp on salaries of the hospital staff
Exp on drug/food & Materials
%age exp on salaries
%age exp on drug/food & materials
Net recurring exp on the hospital
Total Indoor Adm.
Average length of stay
Total OP
Annual bed occupancy (in %)
Avg. Exp/Admission (in a ratio of 1 IP:nOP)
Avg. Exp/Admission/day
Number of OP cases every Inpatient case (n)
Total bill made in Rs.
Total bill paid in Rs.
Billing pattern for the hospital (in %)
Proportion paid
1986-87
1987-88
1988-89
1989-90
1990-91
11778979 13659395 15657684 20174342
6486499 8667032 9587067 14853003
1991-92
1992-93
1993-94
Hospital Income from the patients and insurance
Health insurance - only from hospital
From patients
Total income
Total cost recovery from all the hospital patients
Health insurance - hospital + college
Cost recovery from all the insurance schemes
1986-87
1987-88
1988-89
1989-90
1990-91
1991-92
1992-93
1993-94
1994-95
1995-96
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
167619
184656
281354
352439
311864
413557
417331
576460
686445
908197 1201421 1657903 1958657 2590920
4064610
4420356
4241535
1167355 1601414 1807101 2051512 2308700 2590183 2748525 3360841 4355619 6342060 7227403 8241586 9521835 14223825 16903960 21409144 23781868
1365645 1822722 2129825 2456612 2682776 3074022 3245443 4024740 5137252 7350969 8539303 10025576 11626270 17036106 21187296 26059793 28532167
0
11.6
13.4
14.2
12.0
11.5
10.4
10.0
12.9
14.0
18.0
19.3
21.6
20.1
23.3
21.1
27.1
27.0
0.0
198290
221308
322724
405100
374076
483839
496918
663899
781633 1008909 1311900 1783990 2104435 2812281
4283336
4650649
4750299
1.7
1.6
2.2
2.0
1.6
1.6
1.5
2.1
2.1
2.5
3.0
3.8
3.6
3.9
4.3
4.8
4.5
0.0
7543157 8793409 9648328 15211598 16378641 17641191 20446289 21998447
3255719 2331837 4226261 4185029 5355059 7197537 7941211 8288331
64
65
64
74
70
60
63
70
28
17
28
20
23
24
24
27
11775857 13627943 15000075 20513312 23407192 29621902 32511917 31221150
13542
15274
15813
14433
15450
16543
15801
16598
9.1
9.1
8.9
9
8.9
8.9
9.2
8.8
119674
129784
133789
116329
127760
131333
133417
149647
67.4
75.7
76.4
71.3
75
80.4
79.9
80.1
870
892
949
1421
1515
1791
2058
1881
96
98
107
158
170
201
224
214
9
8
8
8
8
8
8
9
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1994-95
1995-96
1996-97
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
43357817 47096029 53099414 61429549 76421671 110833821 100626988 111089631 133603411
25564619 31007992 34444903 40900626 54732951 85399007 71434584 75568503 85494653
2548513 2879981 6689497 3524319 3456816 10302186
4306445
5536311
6764121
23470086 23016106 28128011 27755406 37376307 51276135 75096821 67128139 70032192 78730532
8812656 14501202 15002319 17193001 18470793 19268099 22812049 24423177 26398518 35295908
64
56
64
60
65
70
75
70
66
62
24
36
34
37
32
26
23
25
25
28
36756301 40809304 44216048 46409917 57905230 72964855 100531635 96320543 105553320 126839290
17412
18823
18742
19989
22297
26755
26511
26797
27926
30476
8.5
8
8.2
8.2
8.2
7.7
7.5
7.2
7
7
145238
149518
164528
152556
163466
181112
185135
187624
187330
199866
80
74
82
80
89.2
86.1
84
89.3
82.5
89.6
2111
2168
2359
2322
2597
2727
3792
3594
3780
4162
248
271
288
283
317
354
506
499
540
595
8
8
9
8
7
7
7
7
7
7
18015953 20397458 24825885 27751398
10986153 12568791 16533323 18320963
0.0
0.0
0.0
0.0
0.0
0.0
17.9
21.2
23.5
21.9
61.0
61.6
66.6
66.0
Annex III
Jawar Scheme
Total Beneficiaries
1986-87 1987-88 1988-89 1989-90 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-00 2000-01 2001-02 2002-03
7555
9349
10414
8770
14080
11812
12345
11988
11605
5892
12101
12026
9294
7759
4122
7839
6125
100% waive off
Total Indoor Admissions
Total Bill made in Rs.
Total Exp
Exp. Per head under jawar scheme
Contributions collected from JS - Cash
Billing pattern for Jawar scheme (in%)
Number of people against which there is 1 adm.
Probable Cost recovery from JS
488
604
595
365
481
39847.6 80271.6 71996.6 59729.8 80299.2
423920 538551 564791 519193 729032
56
58
54
59
52
17465
31952
34681
39496
51693
9
15
13
12
11
15
15
17
24
29
4.1
5.9
6.1
7.6
7.1
533
597
574
700
304
675
552
547
499
106639 114247 103894 158001 82365.8 219833 205640 219226 191673
954032 1228379 1079705 1477683 659089 1592457 1281619 1421336 1361392
81
100
90
127
112
132
107
153
175
45093
70828
60533
58488
90695 105773
70277 148681 352928
11
9
10
11
12
14
16
15
14
22
21
21
17
19
18
22
17
16
4.7
5.8
5.6
4.0
13.8
6.6
5.5
10.5
25.9
Co-payment for foreseeable event
Total Indoor Admissions
217
322
286
233
337
288
Total bill made
34048
42973
31541
34992
54487
47234
Total Amount paid
9657 11752.8 10916.1 10123.1 15470.4 13136.4
Total expenditure
188786 286942 271297 330731 510868 515693
Cost recovery from copayment (This does not
include the contribution amount)
5.1
4.1
4.0
3.1
3.0
2.5
Total probable cost recovery from Jawar sch (100%+50%)4.4
5.3
5.5
5.8
5.4
4.0
Non insured
Total IPAdmissions
Total Bill made
Amount paid
Cost recovery from non insured pop (in%)
92
13281
9248
11.5
162
22561
10462
7.2
183
34549
17637
10.1
161
26959
11987
5.2
156
25596
14858
6.3
156
29203
15151
5.4
354
45985
12214
728385
212
462
485
229338 120369 344799
803919 1660637 1832801
195
212
299
130353 256156 105781
29
7
19
19
17
13
16.2
15.4
5.8
363
636
547
591
594
676
922
203
950
1123
48714 116136
79209 180636 207238 218660 245821 380891 614176 580338
12653 32806.2 35371.6 46564.7 53149.2 59385.3 67212.6 96447.4 161721 349881
682810 1342580 1185926 1394285 1379133 1755570 2513613 769791 3416168 4245416
1.7
4.2
1.9
4.2
2.4
3.2
3.0
6.8
3.3
5.1
3.9
4.6
3.4
6.5
2.7
10.8
12.5
14.4
4.7
8.2
8.2
7.5
260
48465
25385
4.7
275
58391
27757
5.4
484
476645
64872
6.3
604
136916
100564
7.7
421
151116
95629
9.6
394
135752
94633
10.3
568
159843
113796
7.7
411
162887
119274
10.6
458
323750
57856
3.3
238
232876
152747
17.9
281
161818
140553
13.2
Annex IV
Table I
Total number of Amount Total amt. c.f. from Amt.
Bal
Interest accrued on Rate of
Total deposit amt. Liability- From Deposit bal after
Deposited the preceeding yr
forfeited remaining the bal amt. i.e G
interest
with interest
Table III
paying the claim
Number of members members
Class I,II,IIIClass IV
A
B
C=A+B
D
E
F
G=E-F
H=G*I
I
J=D+E+F
I
J=H-I
1999-2000
184
118
302
102500
2000-2001
277
163
440
213350
102500
1272
101228
20246
20%
334824
40349
294475
2001-2002
401
188
589
242807
294475
4345
290130
52223
18%
585160
136086
449075
2002-2003
461
193
654
362244
449075
8179
440896
70543
16%
873683
3144
870539
2003-2004
447
191
638
389805
870539
9063
861476
129221
15%
1380502
153981
1226522
Year
Table II - Exp/Liability
Premium Rate of
Deposited interest
Year
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
102500
213350
242807
362244
389805
12%
10%
10%
6%
Total Liability
12300
31585
55866
55254
Table III - Income
Total
Deposit
Interest Income earned Deposit
Interest accrued on Rate of
income
Year
Amt.
margin on the deposit forfeited the forfeited amt.
interest
earned
Claims
1999-2000
102500
2000-2001
213350
8%
8200
1272
254
20%
9726
2001-2002
242807
8%
17068
4345
782
18%
22195
2002-2003
362244
6%
14568
8179
1309
16%
24056
2003-2004
389805
9%
32602
9063
1359
15%
43024
Liability
50075
158281
27200
197005
432561
40349
136086
3144
153981
333559
Position: 2234 (3 views)