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A REPORT ON THE NATIONAL WORKSHOP
HEALTH FINANCING IN THE
VOLUNTARY SECTOR
((
VOLUNTARY HEALTH
ASSOCIATION OF INDIA
9
I?
THE FORD FOUNDATION
A Report on the
National Workshop on
HEALTH FINANCING
IN THE
VOLUNTARY SECTOR
at
Wildflower Hall, Shimla
May 1 - 4, 1990
Organised by:
Voluntary Health Association of India
and
Ford Foundation
Ol 'Ho
Compiled by Priti Dave, Ford Foundation, New Delhi
Pagemaking by Macro*, Phone : 684 3251
Printed at Chitrakoot, Phone : 327 1554
1990 : Report published by :
Voluntary Health Association of India,
40, Institutional Area, South of IIT,
New Delhi-110 016
Ford Foundation
55, Lodi Estate,
New Delhi- 110 003
SUMMARY OF PROCEEDINGS
INTRODUCTION
Issues related to programme financing have been of growing concern to voluntary organisa
tions providing health care, such as the timely and sustained receipt of adequate funds. The national
workshop was convened to share the health financing experiences of voluntary organisations, and
explore means of strengthening their financial capacity.
The meeting represents a fol low up to a number of activities that have taken place over the last
two years on health financing in India’s voluntary sector, largely initiated by the Ford Foundation, New
Delhi. Case studies and other surveys have documented current financing experiences of the
voluntary sector. These showed that health programmes are usually funded from a number of different
sources, including government, donor, and community and self-generated sources. Organisations
had both positive and negative experiences with these funding sources. In particular, the studies
highlighted that the sector shows widespread use, and much innovation with community and self
financing methods. For example, sliding fee scales, community based prepayment schemes and
income generating schemes. A smaller workshop “Paying for health in the voluntary sector: experi
ences and prospects”, was then organised at the Institute of Health Management at Pachod in August
1989, to further review financing experiences and discuss issues raised by the case studies and their
wider implications. The studies and workshop both showed that financing issues are of significant
interest to the sector, and an area that is in need of further exploration and development. It was
resolved that there be an on-going process of sharing and documentation of experiences. Many
lessons can be learnt from the financing experiences of the voluntary sector, both for other voluntary
organisations as well as larger public health providers.
The national workshop was hosted by the Voluntary Health Association of India (VHAI), and
sponsored by the Ford Foundation, New Delhi. Wild Flower Hall, in Shimla, provided the venue for the
meeting. The agenda over three days covered a range of topics related to the financing of health
programmes in the voluntary sector. In addition, state health provision and financing was also
discussed to allow issues relevant to voluntary sector health financing to be viev/ed in the macro
context. It was intended that the meeting focus on both practical matters of financing, as well ethical
concerns and values. Specific workshop objectives were proposed to include:
- to share experiences of the voluntary health sector with different funding
sources
- to explore both the feasibility and desirability of increasing community and
self-financing sources
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- to identify the support needs and technical skills required by voluntary
organisations for strengthening financing activities.
- to discuss the wider role that the voluntary sector might perform in national
health financing, such as research, policy analysis and advocacy.
Participants numbered 42. The majority of participants were from the voluntary health
community. Others included representatives from government, management groups, and research
and academic institutes. In addition, there were representatives from the voluntary health movements
of Bangladesh, Indonesia and Philippines. A full list of participants is included in the workshop docu
ments, which is attached to this summary.
This paper provides a summary of workshop proceedings. Agenda timings were not strictly
adhered to. As the workshop proceeded, sessions were re-scheduled as felt appropriate. Thefirsttwo
days comprised of formal presentations of papers, followed by plenary discussions. The first day
concentrated mainly on issues of government health financing and government support of VOs.
Donor support of VOs and their implications were also discussed. The second day’s presentations
were concerned with VO experiences with community and self-financing methods. On the evening of
the second day the group divided into two working groups to discuss specific issues that emerged
from the proceedings. The first group was asked to discuss topics related to government and donor
funding, and the second group issues related to community and self-financing. Recommendations of
the working groups were presented to the plenary on the morning of the third day, and followed by
discussion. Attention then shifted to matters of a more technical nature with a discussion of information
needs and skills that might help strengthen financing activities. There were case study presentations
by VOs on different management methods and information, and their applications. In the last session,
there was a plenary discussion of possible follow up action that could be developed in health financing
and the future support requirements of the sector.
Each of the sessions are summarised in this paper. This summary is based largely on
rapporteurs notes and the personal observations of some participants. Descriptions of the presenta
tions themselves are kept brief. The main points raised in the discussion that followed each
presentation are outlined. The deliberations of the two working groups and any recommendations
made are outlined. Finally, resolutions made and proposed follow up action is documented.
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MAY 1ST, 1990
INTRODUCTION AND WELCOME
Mr Alok Mukhopadhyay, Executive Director of VHAI welcomed participants to the workshop. The
agenda was reviewed briefly and participants introduced. Rapporteurs were appointed for individual
sessions.
SESSION 1
ISSUES IN FINANCING OF THE VOLUNTARY SECTOR : CURRENT SCENARIO
Mr Alok Mukhopadhyay (VHAI) and Dr. Ashok Dyal Chand (Institute of Health Management, Pachod).
Mr Mukhopadhyay and Dr Dyal Chand both spoke of the current financing concerns of VOs.
They outlined the main sources of finance available to the sector as being government, foreign donors
and indigenous sources.
Mr Mukhopadhyaytalked at length of the “serious implications” of VOdependence on foreign
funding. He pointed out that donor agencies very often come to organisations with set priorities for
funding. This results in VOs having to fit their own programmes around these priorities, if the two do
not tally. Moreover, donor priorities often do not match the communities perceived needs. As an
example he gave the current interest of donors in funding Aids related programmes. Dr Dyal Chand
talked of the suspicious nature with which foreign funding is viewed. He said it was perceived as a dirty
word” by some. Might the receipt of foreign funds through government lessen that stigma? he asked.
He pointed out that foreign funds received through government did not require FCRA clearance and
reporting, normally a cumbersome procedure. However, receipt of funds through two bodies, the
donor and government meant having to fulfill two sets of administrative and reporting requirements.
Both Mr Mukhopadhyay and Dr Dyal Chand expressed concern with the short term nature of
foreign funding and the matter of programme sustainability after the funding period ends. They said
that donors should also be concerned that projects do not fold up when funds decline or cease. They
might assist VOs in exploring alternative sources to meet recurrent programme costs. Dr Dyal Chand
said that VOs were responsible for generating a considerable volume of foreign exchange earnings
through overseas funding, an estimated 1780 crores in 1988-89. In recognition they should be granted
import incentives.
Government support of voluntary health action tends to be scheme related, whereas the need
is for overall institutional support. Dr Dyal Ghana stressed the need for clear budgetary allocations to
the sector. Government might consider sub-contracting to VOs. But Mr Mukhopadhyay questioned
“to what extent is this desirable?” Might this increased dependence on government result in the
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voluntary sector loosing its autonomy, flexibility and ultimately its effectiveness? The question of
sustainability was raised again. Dr Dyal Chand pointed out that government funds were no more
assured in the long term then donor funds. Government funding strategies should also assist VOs in
maintaining long term financial stability. Mr Mukhopadhyay reminded us that government is not a
monolithic structure. There are many levels, higher levels have very little influence over lower levels,
which carry implementation responsibility. VOs have experienced much hostility from local govern
ment bodies. In addition, governments are not permanent structures, they also change periodically
bringing with them changed policies and priorities.
The third available source of support is that of community and self-financing methods, or
indigenous sources as termed by Dr Dyal Chand. These include user fees, prepayment and insurance
schemes, local fund raising and commercial schemes. A distinction was made between community
and self-financing of hospital based services and that of community based care. The former was
largely curative, while the latter included curative and preventive components. As a result the two types
of health care carry different financing implications, and should be considered separately in a discus
sion of community and self-financing, especially of user charges. Mr Mukhopadhyay pointed out that
imposing payment requirements may upset local systems of philanthropy. For example the payment
of traditional practitioners is currently informal and flexible, comprising of both cash and in-kind
payments.
It has been widely stated that charges have the effect of increasing the perceived quality of
services. Mr Mukhopadhyay challenged this citing the example of the British National Health Service
where services are provided free of cost at the point of use, but are clearly still valued. Increasing funds
through income generating schemes and other commercial schemes, for example schools and farm
activities was an area that might be further explored said Dr Dyal Chand. However, this would lead to
growing commercialisation in the voluntary sector, and perhaps even lead to a shift in ideology. This
financing option needs to be further debated. Mr Mukhopadhyay emphasised that mobilising revenue
through local fund raising represents an important financing source for VOs, and a hitherto under
tapped one. There are 170 million people in India that are categorised as “middle class”, this
represents a large section of the community that could be tapped for funds, he said. Dr Dyal Chand
posed the question, should VOs do their own fund raising or should an intermediary organisation take
on this role?
Mr Mukhopadhyay said that what we define as the “voluntary sector” is now becoming more
blurred. At one end of the spectrum are small Gandhian motivated groups, and at the other large
corporate trusts which also have voluntary status. Moreover these trusts receive significant indirect
government support,‘in the form of subsidies and tax exemptions. This is an area that needs to be
further investigated, he urged. Other issues that might be debated during the workshop are, the role
and effect of the private sector on health financing, and the possible role that VOs may play in the
Panchayati Raj when introduced.
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Discussion
in the discussion that followed, participants suggested additional issues that might be
addressed over the three days.
One participant stressed that matters of VO financing should not be viewed in isolation, but
within a macro perspective. For example, its implications to both government and private sector health
provision and financing should be considered. VOs, he said, should be classified as belonging to the
private sector. The voluntary sector could play a vital role in pressurising the private sector to serve
the needs of the poor. One last point raised up by this participant was that when speaking of financing
innovations in the voluntary sector, especially of community and self-financing methods that this be
viewed as a drive towards privatisation.
Health financing concerns should not only be with how to mobilise additional revenue, but
also with the efficiency and effectiveness with which current resources are used. Improved financial
planning, management and monitoring could help reap significant resource gains. Training VOs in
methods of financial appraisal and management is an important requirement and should be given due
emphasis.
Many donors, as well as VOs emphasise the importance of financial self-sufficiency. One
participant suggested that the goal of self-reliance is a myth. In the event that a organisation did have
sufficient resources (through community and self-financing sources) to meet current programme
costs, the natural tendency of an organisation would be to expand services. They would most likely
achieve expansion through government and donor support.
Government provides significant indirect support to the voluntary sector in the form of
subsidies and tax exemptions.-For example, many hospitals run by large charitable trusts receive
government aid for free beds for the poor. To what extent are these actually taken up by the poor? At
present there is very little monitoring of this. It was urged that this is an area that needed to be further
investigated.
One participant asked, is health financing only relevant to curative care, and if so then might
a discussion on health financing result in an over emphasis of curative care over preventive and
promotive?
One participant suggested that we might include a discussion of the potential role that the
voluntary sector could play in assisting government with setting priorities and schemes.
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SESSION II
BACKGROUNDiTHE PAST AND FUTURE OF GOVERNMENT FINANCING OF HEALTH CARE;
IMPLICATIONS FOR THE VOLUNTARY SECTOR
This session comprised of four presentations followed by discussion. Two of the presenters,
Dr. Rameshwar Sharma and Dr. A.K. Mukherjee were unable to attend the workshop.
Government Financing of health care from the early 50s to date by Ravi Duggal (Foundation for
Research in Community Health)
Mr Duggal traced the development of institutionalised public health care in India. He pointed
out that by independence there was already a well developed health care system, but that this had a
distinct urban bias. The Bhore committee which was established after independence recommended
that emphasis be given to rural health provision to redress this imbalance. However, successive plan
periods have not adopted the expenditure outlays and norms set out by the Bhore committee, with the
result that the rural/urban bias persists. Moreover, there has been a gradual shift of plan expenditure
from the medical head to public health and family welfare, whereas the priority of the people, he said,
is medical care. Following independence private sector provision of health, assisted by subsidies from
government has greatly expanded. He called for greater regulation of the private sector. He also called
for a review of government allocation priorities and health policy making procedures, especially of the
role of international organisations.
Government Funding of Health Care Programmes by Dr. S.C. Sharma (Directorate of Health
Services, Ministry of Health and Family Welfare)
In the first half of his presentation, Dr Sharma spoke of the present position of government
health financing. The health sector he said is accorded very low priority. In the seventh five year plan,
the percentage oftotal plan outlaytothe health sector was 3.7%, of which 1.8% went to family welfare.
This is in spite of the fact that various expert committees that have been appointed by the government
have recommended a minimum allocation to the health sector of between 5% to 15% of total outlay.
He pointed out that emphasis in the sixth and seventh plan periods was in infrastructural development
of the health sector, largely in construction of health facilities. While the focus of the eighth plan will be
on the consolidation of existing infrastructure and qualitative improvements. In the second part of his
presentation Dr Sharma talked of government support of voluntary health programmes. He outlined
the various schemes available in the departments of health and family welfare. He then went on to
describe the setting up of a steering committee, with representatives from the voluntary sector and
government to explore the possibilities of increased collaboration between the two sectors.
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Discussion
A recurring theme in the discussion was the urban/rural and curative/preventive bias in
government health spending. One participant stressed that it was inequitable to provide sophisticated
curative care to urban areas and then talk of preventive care for rural areas. There should be a
reallocation of resources away from the urban curative sector to develop health care in underserved
rural areas. It was suggested that public health spending should also include allocations to sanitation,
water supply and nutrition.
Government spending has thus far been on infrastructural development. The mere expansion
of government facilities will not ensure better health. Utilisation of health facilities is dependent on a
number of different factors, such as availability of drugs, perceived quality of care, staff attitude
towards patients, convenient hours of operation etc. These factors should also be considered by
government when developing health care services.
Medical education was a major concern. Large amounts of public money is spent on medical
training, however the bulk of graduates are subsequently lost to the private sector. Doctors are also
reluctant to serve in rural areas. Medical education needs to be reviewed and incentives developed to
counteract the private/urban attraction.
One participant suggested that VO health care provision largely served to displace govern
ment provision rather than the private sector. VO patients, on the whole, were previously using
government services.
The role and influence of international donors on government health provision and policy was
keenly debated. Some felt that both multilateral and bilateral donors wielded too much influence on
health policy formulation. Donors have distorted the development of comprehensive health care by
introducing vertical health programmes, such as the Universal Immunisation Programme. This is
cause for concern and an urgent review of donor influence in government health policy was called for.
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MAY 2ND, 1990
SESSION III
ISSUES IN FINANCING THE VOLUNTARY HEALTH SECTOR
The session started with a presentation of an overview of the issues and current experiences
of community and self-financing in the voluntary sector. This was followed by a number of case study
presentations from VOs of experiences with different financing methods. The groups represented a
cross section of the voluntary health community, including groups that provide health care alone,
health as an integrated development programme, a hospital based project and an intermediary
support organisation.
An overview of issues and current experiences by Ms Priti Dave (Ford Foundation, New Delhi)
Ms Dave presented the main findings of two papers that surveyed and documented the
current financing experiences of voluntary health programmes. The first paper “Experiences in paying
for health care in India’s voluntary sector” closely examined the costs and financing of four voluntary
groups. These organisations tap multiple sources of funding, including government, donors and com
munity and self-financing sources. Organisations, she said, had both positive and negative experi
ences with these funding sources. For example, one organisation receiving substantial donor support
was anticipating serious financial difficulties with the imminent termination of support. There were
some innovative examples of community and self-financing. One organisation running a hospital was
tapping a significant proportion of revenue from patient fees while still providing a large amount of free
care to the poor. This it was doing with a steeply progressive fee scale that charged higher income
groups above the cost of their care and subsidised non-affording patients.
The second paper that Ms Dave presented “Community and self-financing of health program
mes: experiences from India’s voluntary sector”, examined the financing experiences of a broader
array of voluntary health organisations. These included organisations that provide only health care,
that provide health care as an integrated development activity and that provide health as a support
service to economic activities. Five methods of community and self-financing were noted: user fees,
prepayment/insurance schemes, commercial schemes, fund raising activities and in-kind payment.
User fees were an important source of income for hospitals, less so for community based care. While
prepayment/insurance schemes were a major source of revenue for community care and in one case
also for referral care. The different funding methods were evaluated in terms of the following criteria,
yield, equity and risk sharing. “Yield” examined the costs covered by the financing method, “equity”
the distribution of financing burden between rich and poor patients, and “risk sharing” the degree to
which financing burdens are shared between the healthy and sick in prepayment/insurance schemes.
It was a major concern of all organisations that by charging they were not excluding the poor from
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services. Organisations resolved this by either providing services at a subsidy or totally free to those
judged too poor to pay. Means testing, however, proved difficult to do in a systematic way. Some
asked doctors or community health workers to assess ability to pay, others asked hospital clerks to
act as gate keepers, and one hospital left it to the patient to decided if they wanted treatment in a free
or paying facility. The planning, management and monitoring of these financing activities was felt to
be weak. Many of the financing methods could be improved upon with better management. For
example, the setting of fees should at least take into consideration the costs of services, and the ability
of households to pay. Organisations migh: also be more explicit about what their financing goals with
user fees are, for example, which costs they wanted to cover and the level.
Discussion
The discussion that followed centred around a number of themes: self-reliance, the desirabil
ity of community and self-financing of primary health care, the notion of equity, degree and types of
cost recovery desirable and feasible, and community participation in the planning and management
of financing activities.
On the topic of self-reliance, one participant was of the view that it was unrealistic to expect
an organisation providing welfare services to be totally self-reliant. There would always be need for
some level of outside subsidisation. Another participant suggested that income from community and
other self generated sources might be used directly to support core project costs, such as professional
staff and institutions. Donor funds tend to be for particular schemes and programmes, and are usually
only forthe lifetime of that scheme. There is need for sustained funding of core costs, community funds
could well be earmarked for this purpose.
How desirable is community financing of primary health care? this is a question that needs to
be seriously debated, said one participant. Health is not a priority of the community, therefore how can
a organisation expect that the community contribute towards health care costs? In response, another
participant felt that anything given free is not valued. For this purpose, people should be asked to
contribute at least a nominal sum towards health. Introduction of service payment might upset existing
forms of local support, warned one participant, such as the payment of traditional birth attendants
which can be in cash or in-kind. This should be borne in mind when planning financing activities.
Another participant said that the introduction of user charges was akin to opening up the market
system, and to do so without adequate controls was dangerous.
It is essential to bear in mind issues of equity when considering community and self-financing.
Firstly, it is necessary to debate on what is meant by equity, and secondly how one can promote it in
financing activities. Equity, it was agreed, implies some notion of fairness and justice. Meaning that
those not able to afford health care costs should not be excluded from services. They should be
provided either subsidised care or free care. Those judged able to pay should, at a minimum, meet
their own costs, and ideally over cost to help subsidise non-affording patients. It is important to monitor
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who is using services after introduction of community financing. Are the poor adequately represented
or are they deterred from doing so by the payment requirement? One participant reminded the group
that the cost of treatment was not the only cost faced by a service user. Costs were incurred in travel
and time (both travel and waiting time), these also carry a cost in terms of loss of earnings. This needs
to be included in a discussion of equity. The thorny problem of promoting equity in community
financing by means testing for subsidies or exemptions was raised by one participant. Means testing
cannot be undertaken in a reliable and fool proof manner, especially in the unorganised sector where
there is no formal proof of income status. The experience of Maharashtra state in attempting to
introduce user fees at hospitals was cited. Means testing for exemptions proved difficult to do, with the
result that there was an appreciable drop in utilisation. Moreover, high administration costs were
incurred in implementing the means test.
What types of health activities should community and self-financing activities support;
hospital operations? MCH care? and what costs should they cover; drugs? salary costs? The group
felt that it is important that these types of questions be considered when planning financing activities.
In addition, the level of recovery that is both desirable and feasible with a particular financing method
needs to be carefully considered.
One participant reminded us of the importance of community participation in financing
decisions. The community should be involved in both the planning and management of community
and self-financing activities. This will ensure that service users are both willing and able to pay for
services. In addition, it will ensure their commitment to the service.
Presentation of case studies: Sister Prabha (RAHA), Dr Ulhas Jajoo (Sewagram), Mr Prasanta.
Mahapatra (Andhra Pradesh Vaidya Vidhana Parishad), Mr D. P. Poddar (Community Development
Medicinal Unit)
Sister Prabha described RAHA’s experience with running a health insurance scheme which
offers coverage for both community based care and referral care. RAH A is an association of catholic
health providers. Affiliated RAHA members provide health care as well as other development activities,
such as schools. An interesting feature of the scheme is the scale of its operation. The scheme has
75,000 members, 65 affiliated community health centres and three referral hospitals located over three
districts. Members enrolled in the health insurance scheme are entitled to receive frae community
services (including services of an MCH clinic), and free referral care after payment of an admission fee
upto a ceiling of Rs. 1000. Membership fees were not the major source of income at the community
level, rather non member fee collections comprised the bulk of income. Membership fees were,
however, sufficient to cover all hospital referral costs. To ensure that members do not enroll only at the
time they are ill and in need'of services, RAHA has introduced a waiting period of two months for new
members between enrolment and their eligibility to receive membership entitlements.
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Dr Jajoo also spoke of Sewagram’s experience with implementing a prepaymeht/insurance
scheme. In the Sewagram scheme, members are entitled to receive both free community based care
and referral care. Membership collections are adequate to cover all community costs (salary of
community health worker, transportation and drugs), but not referral costs. These are covered from
other hospital sources. Membership fees are largely paid in-kind, in the form of jowar. An integral part
of the scheme is that the community participates fully in the planning and management of the health
programme and insurance scheme. He explained how it had been a community decision that
membership contribution be graded to the paying ability of households. When the village had wanted
to construct a village temple it was decided that households should contribute according to income,
why not also for health care provision? The village committee was responsible for allocating
households to income groups. To ensure that sufficient members enrol in the scheme in order to
ensure adequate risk sharing, Sewagram has made it compulsory that at least 75% of village
households enrol before services are provided. Dr Jajoo explained how he felt that community
financing of outreach care is only feasible if there is backup support of good quality referral care.
Mr Poddar from the West Bengal Voluntary Health Association (WBVHA) described how the
Community Development Medicinal Unit (CDMU) was established. CDMU is a registered private trust
which supplies low cost, essential drugs to voluntary health projects. It also promotes the use of
rational drug therapy. WBVHA felt that the pharmaceutical industry and other drug distributors were
encouraging bad prescription practices among the voluntary sector. Moreover, drugs are supplied
irregularly and are often of a dubious quality. The CDMU provides a limited range of essential, generic
drugs of assured quality. It is currently supplying over 200 voluntary organisations in West Bengal,
Orissa and Bihar states. He estimates that these voluntary agencies are achieving savings of upto 30%
on medicine costs as a result. CDMU is able to supply low cost drugs due to central, bulk procurement
and also due to the fact that it supplies only generic drugs and not brand labelled drugs. Mr Poddar
described some of the difficulties they encountered during the setting up of the enterprise, such as
hostility from pharmaceutical companies for whom they posed a threat.
Dr Prasanta Mahapatra, spoke of his experiences as the commissioner of the Andhra Pradesh
Vaidya Vidhana, a public sector body set up to manage hospitals. He outlined the major objectives of
the organisation as being: (1) to develop middle-level curative facilities (2) to broaden their resource
base (3) to enhance the control of medical facilities in the hands of the medical profession and (4) to
develop management capacity in hospitals. In his presentation, Dr Mahapatra focussed on their
experiences with fulfilling the second objective, that of broadening the resource base. This they
attempted to do in two ways, by seeking increases in the paid component of services (ie through user
fees) and by increasing the efficiency of current resource use. Dr Mahapatra recalled the dramatic
repercussions when in 1988, his predecessor attempted to introduce selected charges at public
hospitals in the state. It was intended.that approximately 10 to 15% of patients be charged, however,
this was widely misinterpreted to mean across the board charges. It proved to be politically
unfavourable, and resulted in the resignation of the then commissioner of APW, and the state minis-
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ter for Health and Family Welfare losing his portfolio. Resource mobilisation was also sought through
local appeals and philanthropy. In the first year 25 lakhs was raised through fund raising activities.
APW is now exploring the possibility of running a lottery to raise funds, and also the feasibility of
running income generating schemes in the hospitals, such as shops and a cycle stand. They plan to
devise other schemes where the public can contribute towards specific costs. For example to com
memorate the death anniversary of relative they could meet all feeding costs for one day. A banner
would be displayed to acknowledge their support.
The second strategy, that of increasing the efficiency of current resource, could be achieved
with improved methods of resource sub allocation, Dr Mahapatra said. He called for the development
of norms and guidelines for relative allocations of resources, eg of human resources and materials by
type of facility, and for budgetary classification that lends itself easily to financial analysis.
DISCUSSION GROUPS
The main issues that emerged from the preceding sessions were identified by rapporteurs
and listed. These broadly fell into two main headings, issues related to community and self-financing
of voluntary health programmes, and those related to government and donor support of the voluntary
sector. Within these broad topics further sub-issues were identified and listed. Participants were asked
to join either of two working groups, Group 1, to discuss community and self-financing issues, and
Group 2, to discuss the implications of government and donor support.
GROUP 1
COMMUNITY AND SELF - FINANCING OF VOLUNTARY HEALTH PROGRAMMES
1 he main issues that were raised in the preceding sessions under this heading were identified
as follows:
1. What is meant by community financing?
Which financing methods should it include? user charges, prepayment/insur
ance schemes, income generating schemes, fund raising activities?
2. User Charges
Who should be charged? For which services should there be charges? How
should charges be implemented?
3. Prepayment/insurance schemes
4. Income generating schemes
What are the implications to VOs of undertaking commercial activities, in terms of
ethics, mission of group and management demands?
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5. Fund raising
What is the scope for local philanthropy?
6. Sustainability of voluntary health programmes
How sustainable are different funding sources?
Dr. Amar Jesani was elected as chairperson of the group. It was agreed that each of the five
points would be discussed in turn. One group discussant urged that while discussing these separate
issues, their ideological and political implications to VOs be kept in mind.
1. What is meant by Community Financing?
The discussion started with an attempt to evolve a working definition of “community
and self-financing”. What is meant by the term community? This question was deliber
ated upon at length. It was argued that it was not only a question of semantics, but was
important to resolve in a discussion of community financing, since one had to identify who
in the community was to contribute, ancf who in the community should be involved in
making financing decisions. Should it be caste based? geographically based? numbers
based? It was not possible to come up with a precise conceptual definition, however, it
was decided that the term community, as “a group of people with a common interest” be
continued to be used, since it allowed for a flexible interpretation with which people were
familiar.
It was put forward by one participant that government provision of primary health
care could also be termed as community financing, since although provided free at point
of delivery, it was ultimately financed by the community through tax contributions.
Similarly, private sector health financing could be termed as community financing. The
general consensus, however, was that the term community financing be interpreted in a
more narrow sense. The working definition evolved was that it include;
“contributions made by members of the community towards the cost of their
health care, in part or in full, either voluntarily or as a result of a collective
decision by the community”.
It was agreed that this definition couid include all the community and self-financing
methods mentioned, ie. user charges, prepayment/insurance, income generating schemes
and fund raising, as long as the community had been involved in making financing
decisions. In particular, the decision to introduce user charges had to be made by the
community, such as what services to charge for, who should be charged and at what
level?. Financing decisions should not be imposed by either the voluntary organisation
or government. The structures and processes required for a continued dialogue with the
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community had to be developed. One participant suggested that the Gram Sabha would
provide an ideal structure for making financing decisions.
2. User Charges
The discussion on user charges centred around three questions; what services to
charge for, whom to charge and how much to charge.
The initial part of the discussion was concerned with the ethical permissibility of
charging for services. There was general agreement that people did not value a service
more because there was a charge. It was a myth that charges would imply a quality
service, and that this should not be the major reason why a fee should be introduced.
There were conflicting viewpoints about what services to charge for, primary, secondary
or tertiary service? Some believed that primary health care should be provided free of
cost, but that costs could be recovered for higher level health services. While others said
charges could also be levied for certain primary services, such as drugs and supplies, but
should be according to ability to pay. Ability to pay should be jointly decided by the
community and voluntary organisation. This linked in with the debate on what the level of
charge should be. If it was to be according to ability to pay then those judged able to meet
the full cost of care should be asked to do so, and if possibFe over cost to help subsidise
those considered unable to pay. Thus, there should be graded contributions linked to
ability to pay.
3. Prepayment/lnsurance Schemes
There was a consensus that prepayment/insurance schemes were a desirable form
of health financing, but again only if the community were involved directly in financing
decisions. For example, in deciding who should contribute towards the scheme, and in
setting premium levels. Ideally, the community should also retain management control of
the prepayment/insurance fund. The group discussed third party system of health
insurance, where the service provider and insurer are separate. It was agreed that this was
not an acceptable form of prepayment, since it favoured specialised curative care over
preventive care, and often led to cost escalation. In addition, if risks were assessed on an
individual basis, it was likely that some high risk groups would no be covered. Finally, the
concept of a national health insurance or compulsory insurance was debated, where
government is responsible for levying earmarked taxes, and regulating health provision.
It was agreed that this is an acceptable and desirable form of health financing if the entire
population is covered.
4. Income Generating Schemes
Discussion on the use of income generating activities to fund health activities were
mainly concerned with the ethical and management implications of taking on commercial
14 >
<
activities. Would taking on certain commercial activities conflict with an organisation’s
ideological beliefs or mission? eg. supplying drugs on a for profit basis, or running english
speaking schools, or even manufacturing alcohol. Clearly, different types of commercial
activities carry different ethical implications, and these have to be considered individually
by the organisation. Organisations should proceed with income generating activities with
caution, warned one participant. They carry high management demands and often a high
risk of failure.
5. Fund Raising
It was agreed that fund raising and local philanthropy could potentially represent an
important revenue source for the health sector. India has a history of local philanthropy,
for example many universities were funded by local donations. This source, hitherto has
been under tapped in the health sector. However, one participant warned that large
donations from individuals might bring with them certain demands that could go against
the philosophy of organisation. However, it was pointed out by another participant that
this is exactly what happens with foreign donations as well.
6. Sustainability
Chances of programme sustainability might be greater if VOstap multiple sources of
funds, rather than rely on only one source, especially foreign funds that are of short
d uration. There was a consensus amongst the VOs present of the need for an endowment
fund to support core project costs such as staff and institutions. Endowments.could be
built up from donors and government, perhaps through a matching requirement from the
VO. VOs could meet that through local fund raising. One participant even suggested low
interest loans. There was a discussion of what might be the prerequisites for making an
endowment deposit. These might be a long history of the agency and its activities, a
governing body together with a changing leadership.
GROUP 2
ISSUES CONCERNED WITH GOVERNMENT AND DONOR SUPPORT
The main issues that were raised in the preceding sessions under this heading were identified
as follows:
What is the role of voluntary health programmes within the national health programme and
1.
what are the implications of that with government and donor funding?
2.
What are the past experiences with government/VO relationship, and what are their implica
tions for new proposals. In what ways could the relationship be improved?
3.
What is the role of international donor funding?
Discussion on these topics was wide-ranging and animated, encompassing a variety of often
divergent opinion.
15 >
I
The role of VO’s in the national health program includes several sometimes contradictory
dimensions. VOs play an important role as innovators and experimenters, both in addressing new
problems not yet given priority in the public sector (e.g. women’s health issues) as well as in
developing new approaches to the delivery of health services. More recently, government has been
trying to integrate VO programs into its own objectives, for example in terms of reaching targets in
family planning and immunization. In some cases, government has actually handed over full
responsibility to VOs to run government programs in hard-to-reach areas or where government
services are inadequate. Another role of VOs has been as critics and health activists, providing a voice
in opposition in areas of public policy and health development.
The group felt that there was no overriding consensus about the role of VOs in health and that
perhaps there would not or should not be -- at least there was no consensus in the group. One
viewpoint sees VOs as part of the national health program, complementing and supporting social
objectives in health as voiced by the State. Another viewpoint sees VOs primary role as agents of plu
ralism in health, able to act independent of government. The former view would support VOs
integration into public programs; whereas the latter view would be wary of such co-optation.
The increasing role of government in funding health VOs was discussed in relation to this
concern about VO roles. Do government grants primarily tie VOs to State health policyand programs?
Should public support be available for VOs even if they duplicate public services, or in cases where
they even oppope public policies on the grounds that they provide a pluralistic alternative voice which
has value for its own sake? Again, no consensus was reached, but it was felt that these were important
matters for discussion between VOs and government and that much more debate and discussion was
needed. It was felt that VHAI could encourage more discussion, debate, and lobbying on these
matters.
Much of the dialogue between government and VOs was noted to take place with the central
government. There was little discussion at the state or district level. It was felt that such discussion
should be encouraged.
It was also noted that government provides much suppon tor non-governmental health care
through indirect methods such as tax benefits, subsidies in education and training, etc. Little is known
about the size of such inputs and how they are distributed in relation to State health objectives and
direct aid. Research and debate on these matters was proposed.
The role of foreign funding was also discussed. There was disagreement about how
important foreign funding is to Indian health VOs, i.e. is it the major source of support or a secondary
or tertiary source? Recent studies suggest that the role of government in financing voluntary health
action has been increasing and may now be preeminent - in other words, the view that VOs are
primarily supported by foreign funds may be outdated.
16 >
It was generally felt that VOs have an unequal relationship with foreign donors and that more
could be done to integrate their needs and concerns with donor financing policies and strategies. More
VO representation in donor organizations and attention to longer term organizational financing and
development issues were proposed as remedies.
J
6
17 >
MAY 3RD' 1990
The rapporteurs of the two discussion groups presented the main points that were raised and
any recommendations made to the. plenary.
SESSION IV
STRENGTHENING SKILLS FOR FINANCIAL SOUNDNESS IN THE VOLUNTARY SECTOR:
CASE STUDY PRESENTATIONS
This session was concerned with technical skills that might help VOs strengthen their
financing activities. In the Introductory statement to the session, Dr Peter Berman outlined how much
of the community and self-financing efforts undertaken by VOs is ad-hoc, and relies primarily on the
experiences and insights of successful programme leaders and managers. While this often provides
a sound basis for developing new approaches to program financing, a more systematic approach
including better information and analysis could lead to significant improvements in the planning of
financing activities. It could also help in evaluating and documenting the impact of financing activities.
Dr Berman prepared a background paper for the session, “Information Needs For Program Financ
ing”, this paper is included in the workshop documents.
Strategies for Development of Technical Skills Among Voluntary Organisations: Some Experiences
Dr. Prem Talwar (NIFHW)
Dr. Talwar in his presentation spoke of the general need to develop technical and manage
ment skills among the voluntary health community. Drawing from his experiences of working with the
PVOH project, a USAID/GOI joint funded scheme to assist voluntary health projects, he described
how through a process of needs assessment a number of strategies were evolved to impart management/technical skills to voluntary organisations. .Programme planning, service implementation,
management, monitoring and evaluation were identified as some of the broad areas that required
further strengthening. Skills development in these areas were imparted through training workshops.
A manual for the voluntary sector was also developed. He pointed out that a similar approach could
be adopted to identify support requirements and develop strategies for strengthening skills related
specifically to financing activities.
Following Dr Taiwar’s presentation, there were five separate case study presentations of
different types of information that may be used directly to help improve the planning, management and
monitoring of financing activities.
18 >
The Case of the URMAL Health and Development Trust: Mr Sanjoy Ghosh (URMAL)
Mr Ghosh related how the URMAL health financing strategy, a cooperative based prepay
ment scheme linked to the volume of milk produced, failed in its implementation. He then explained
how it became known to them that the reasons for this failure were linked to socio-political realities of
the community; health was not a priority of the community, the cooperatives were stratified by class
interests, eg. the poorer members were contributing less but utilising more of the trust’s services etc.
These realities were largely unknown to the trust prior to implementation. He stressed the importance
of gathering information about the community prior to planning any activity, and moreover, involving
the community in this process as well as in making financing decisions. He described their experi
ences with gathering information about the community. Firstly, workers were sent to live in villages for
a period of one month to make observations of a qualitative nature. A formal survey tool was then
devised from this qualitative information, and the survey conducted. Results of this survey were shared
4
with the community and then strategies evolved jointly.
The Use of Cost Data as a Management Tool:
Dr. Ashok Dyal Chand (Institute of Health Management, Pachod) (Paper not submitted)
Drawing on a case study that was under taken on the costs and finances of the hospital and
outreach project at Pachod, Dr. Dyal Chand provided some examples of how cost information can be
used to help make management decisions. An analysis of hospital costs and revenue showed that the
hospital was financially self reliant, ie that almost 100 per cent of costs were covered through fee
revenue. However, on closer inspection of hospital costs and revenue, it was shown that the outpatient
department was in fact subsidizing inpatient costs. That is fee income from outpatient services was
covering in excess of costs, and the surplus was helping to cover inpatient costs were fee revenue was
less than cost. This discovery had serious implications for their pricing policy, said Dr Dyal Chand.
Fees had been set without reference to cost, with the result that those inpatients who might be judged
able to meet the full costs of care were not doing so. On the other hand those outpatients that were
perhaps less able to pay were being asked to meet in excess of cost. The socio-economic composition
of both inpatients and outpatients should be analysed, together with their paying capacity, and the
4
hospital fee schedule revised accordingly with reference to service costs.
Dr Dyal Chand described the innovative model of MCH delivery that has been developed at
Pachod. It differs considerably from the government system of health delivery. Pachod employ fewer
auxilliary health workers, and use a mobile to visit villages in rotation. Dr Dyal Chand explained how
4
a comparison of per capita costs of the Pachod MCH delivery system with the present government
one, showed the Pachod system to be much more cost efficient. This was an example, he said, where
lessons could be learnt from VO experimentation and innovation.
19 >
a
Financial Planning: the Experience of the Aravind Eye Hospital:
Mr. Tulasiraj (Aravind Eye Hospital)
Mr Tulasiraj described the health financing experiences of the Aravind Eye Hospital. Initial
hospital funds were raised largely through fees charged to private patients and borrowing. He
»
described how an attempt to raise finance through fund raising was unsuccessful. Currently 92 per
cent of total hospital revenue comes from user fees. Mr Tulasiraj outlined a number of factors that were
important for financial viability - social marketing, good quality care, pricing and a referral network.
Factors affecting profitability include good financial management and cost control, productivity and
personnel management.
Management Information and Supervision: Mr. Bhagat (Parivar Seva Sanstha)
Mr. Bhagat started his presentation with a general discussion of how the adoption of
management methods can lead to greater efficiency of resource use. This has the effect of increasing
the volume of available resources, which in the voluntary sector is even more important because of the
general overall shortage of resources. He then went on to talk of some of the types of management
information collected by PSS for making programme planning and management decisions. For
example, a survey of the socio-economic status of clients is undertaken before services are provided
to help gauge their paying capacity and set fee levels. PSS use a financial management information
system to help keep a close watch on the income and expenditure of individual clinics, and their re
spective productivity. This allows them to monitor clinic deficits or surpluses, as well as the overall
financial status of the organisation.
4
In this session, although not directly related to strengthening skills for financial soundness, Mr
Raja Menon of PRADAN, described some of CINI’s experiences with fund raising. CINI stepped up
fund raising activities in response to declines in donor support. An annual sponsored walk is their main
fund raising activity. Each year this single event raises approximately 2 lakhs for project activities. Mr
Menon pointed out that fund raising requires large inputs of staff time, and can often carry large
administrative costs. However, a spin off effect of fund raising is it creates public awareness about the
organisation and its activities. CINI plan to expand their fund raising to include a number of single
&
events, such as an art exhibition cum auction.
4
Discussion
In the discussion that followed this session there was general agreement of the need to
improve planning and management of financing activities, and an acceptance that such simple tools
as cost analysis and the systematic collection of both qualitative and quantitative data could help
4
strengthen financing activities. However, the group felt strongly that such imparting of skills should be
>
kept at a level of expertise with which the organisation felt comfortable. Information should be
20 >
collected that is relevant for the organisation, and should not be gathered in a mechanistic fashion.
*
Clearly, information requirements will vary for different field situations.
The group felt that there was a need for some form of technical support and training in this
area. Training workshops could be held to impart such skills to VOs. These meetings would also
provide an opportunity for groups to exchange experiences with different financing methods, about
what works and what doesn’t. After all, lessons can be derived from failures as well as successes.
4
*
a
Of ^^0
21 >
community health cell
'3^0. V Main, I Block
^OramangaJa
bangalore-560034
India
SESSION V
4
STRATEGIES FOR THE FUTURE: DEVELOPING A PLAN OF ACTION
The plenary session was chaired by Mr Alok Mukhopadhyay. Its broad objectives were, to
discuss the future role the voluntary sector might play in national health financing, to identify the
support needs of the sector to help strengthen their financing capacity, and to discuss howthese might
be met.
The workshop has demonstrated that financing issues are of significant concern to VOs, Mr
Mukhopadhyay said. The group has debated some important issues related to health financing, and
although a consensus has not been reached on all the issues, it is important that the process of
deliberation and discussion be documented and shared widely. It was agreed that a summary of the
>
workshop proceedings be written and distributed to participants and other key people and institutes,
including government. It was suggested that a summary of the main issues touched upon in the
a
meeting should also be disseminated to a wider audience. Papers on specific topics might be written
for journals, such as “Economic and Political Weekly”, “Health for the Millions” and “World Health
Bulletin”. It was suggested that a special edition of the VHAI journal “Health for the Millions” be brought
out on the topic of health financing.
There was a felt need for on-going support and training on specific technical skills to help
strengthen financing capacity. For example, information that would be useful for planning, managing
and monitoring financing activities. Qualitative information, as well as quantitative information is
*
important for this purpose, it was stressed by one participant. It was agreed that a working group be
set up to identify the management needs of the sector and explore how these might best be met, for
example identification of institutes that might take on training responsibilities. Ten participants
volunteered to be part of the working group, these included representatives of VOs, academic and
research institutes, and intermediary support groups. Dr. Mahapatra agreed to host the meeting in
August in Hyderabad.
Further research on topics related to health financing, and documentation and sharing of
experiences of health providers with different financing methods was called for. Many lessons can be
learnt from a sharing of health financing experiences. These should include both successes and
failures with different financing methods, so that important lessons can be derived about what works
and what doesn’t under different conditions. Possible research topics identified by participants
included; a study of current VO/government relationships and how these may be improved, a study
of private sector health provision, costing studies, and a study of the financing of the broader VO
community, for example, of the large charitable trusts that receive subsidies from government.
Individuals and institutes should be identified to take on research on specific areas.
22 >
a
There was a consensus that the voluntary sector could play an important role in issues of
health financing at a macro level, and that they should take an active lead this area. For example, in
the lobbying and advocacy of government services, informing the public and creating awareness of
current deficiencies, etc. The voluntary health community could also play a similar role in issues
related to international donor support. Donor support, both multilateral and bilateral are areas of great
concern, said Mr Mukhopadhyay. There is a urgent need for further analysis and review of funding
policies. There should also be on-going dialogue of some of the ethical concerns with health financing
that were raised during the workshop, such as charging the poor and the effectiveness of different
methods of means testing.
Finally, it was agreed that the Indian voluntary health community should provide support to
neighboring asian countries in health financing. A support network could be established. Research
findings and financing experiences should be shared widely, so that lessons can be learnt from the
Indian experience. Participants from Bangladesh, Indonesia, and the Philippines resolved to initiate
health financing activities in their respective countries. Dr Nasiruddin from Bangladesh requested
assistance for organising a workshop in Dacca, latter this year.
It was agreed that there should be a follow-up national meeting on health financing to review
the year’s activities and progress to date. The meeting was scheduled for May 1991. The national core
group on health financing which was established to help organise this meeting should continue to play
a coordinating role. The core group agreed to have their next meeting on August 31st in New Delhi.
WRAP-UP
Mr Mukhopadhyay summed up the main points of the meeting and proposed follow-up action.
He thanked the participants and organisers for their contributions.
23 >
PLAN OF ACTION : A SUMMARY
1. Workshop Proceedings
A summary of workshop proceedings to be written immediately and disseminated widely. A
special edition of “Health for the Millions” to be brought out in August 1990. Papers to be written on
specific workshop topics for various journals, such as “Economic and Political Weekly”, and
“WorldHealth Bulletin”.
2. Working Group on Management Skills for Health Financing
To establish a working group to identify the management and technical support needs of
voluntary health groups, and to explore the means of meeting those needs. The working group was
formed in the plenary, and is comprised of the following participants:
Dr. P. Mahapatra (WPS) - Convener
Dr. Peter Berman (Ford Foundation)
Ms. Priti Dave (Ford Foundation)
Prof. D. Nagabrahman (IRMA)
Dr. Gouri Gupta (Delhi University)
Dr. Prem Talwar (NIFHW)
Mr.. Raja Menon (PRADAN)
Mr. Sanjoy Ghosh (URMAL)
Dr. Ashok Dyal-Chand (IHMP)
Father John V. (Catholic Hospital Association)
The group will have its first meeting on August 24th-26th in Hyderabad.
3. Research Agenda
To undertake on-going research on specific financing issues. To further document and share
VO financing experiences. Proposed areas of research are; VO/government relationships, cost
studies, donor support, and the broader voluntary health community, including large charitable trusts.
4. Policy Analysis and Advocacy
Policy review and analyses of government health financing, and international donor funding.
Lobbying and advocacy work in both of these areas. To maintain an on-going debate about ethical
concerns of community and self-financing.
24 >
5. Regional Support Network
To provide support to neighboring asian countries in health financing, and establish a regional
support network. To share widely experiences and developments in health financing in India.
6. Follow-up National Meeting
To have a follow-up national meeting on health financing in May 1991. The National Core
Group on Health Financing to play a coordinating role for the above proposed activities.
Core Group Members:
Mr. Alok Mukhopadhyay (VHAI)
Dr. Peter Berman (Ford Foundation)
Ms. Priti Dave (Ford Foundation)
Dr. Prem Talwar (NIFHW)
Dr. Ashok Dyal-Chand (IHMP)
Mr. Sanjoy Ghosh (URMAL)
Mr. Ravi Duggal (FRCH)
The Group will next meet on August 28th, 1990. □
25 >
AGENDA FOR HEALTH FINANCING WORKSHOP
Day 1 : May 1, 1990
Session I
Introduction
09.30-10.30
Opening remarks - Mr. Alok Mukhopadhyay
Introduction of participants, review of agenda,
organisation of discussion groups, appointment
of rappoteurs.
10.30-11.00
TEA BREAK
Session II
:
Issues in the Financing of the voluntary sector.
11.00-13.00
Current Scenario - Dr. Ashok Dayal Chand
Issues - Mr. Alok Mukhopadhyay
Plenary discussion
13.00-14.00
LUNCH BREAK
Session III
Background : The past and future of Government
Financing of Health Care;
Implications for the Voluntary Sector.
14.00 -14.30
:
Government Financing of health care from the
early 50s’ to date, Paper presented by Dr. Ravi
Duggal
14.30-15.00
:
Health Finance in the Sth plan;
What we in the Voluntary Sector can expect,
Paper presented by Dr. Rameshwar Prasad.
15.00 -15.30
Plenary discussion of papers
15.30-16.00
TEA BREAK
16.00 -16.30
:
Government funding of health care programs of
the Voluntary Sector
Dr. AKMukherjee & Dr. S.C.Sharma
16.30-17.30
Group discussion of issues raised by
Drs. Mukherjee and Sharma
20.30
DINNER
Restricted trip to Shimla - Mall
26 >
Day 2 : May 2, 1990
Session IV
Issues in Financing the Voluntary Health Sector.
09.30-10.10
An overview of issues and current experience Ms. Priti Dave
10.10-10.30
Discussion
10.30-11.00
TEA BREAK
11.00-13.00
Presentation of case studies :
Integrated health development project
Purely health project
Hospital-based health project
Umbrella organisation
13.00-14.00
LUNCH BREAK
14.00-15.00
Discussion and listing of issues brought out in case
studies.
Small group discussion of above issues.
15.00-17.00
(15.30
:
Tea - Lounge, Bar and Main Hall)
19.30-20.30
DINNER
20.30 - 22.00
Plenary presentation of group reports.
27 >
Day 3 : May 3, 1990
Session V
Strengthening Skills for Financial Soundness in the
Voluntary Sector.
09.30-10.00
Opening statement outlining session plan : Skills
needed and Strategies for skill development -
Dr. Peret Berman.
10.00-10.30
Skills development strategies for Voluntary
Organistion’s experience in India -
Dr. Prem Taiwan
10.30-11.00
TEA BREAK
11.00-13.00
Case presentations of applications of specific skills
Assessment Methods - Mr. Sanjoy Ghose
Costing - Dr. Ashok Dayal Chand
Management information and Supervision Ms. Sudha Tiwari
13.00-14.00
LUNCH BREAK
Session VI
Strategies for the future : developing a plan of
action.
14.00-16.00
Group discussions to develop specific proposals
for future activities including research, training,
documentation, policy etc.
Identification of problems and priorities.
(15.30
Tea - Lounge, Bar and Main Hall)
16.00-18.30
Plenary to discuss future strategies/develop
resolutions.
18.30-19.00
TEA / SNACKS
19.00-21.00
Cultural Programme
21.00
SPECIAL DINNER
28 >
LIST OF PARTICIPANTS
ANDHRA PRADESH
Fr John Vattamattom
Catholic Hospital Association
Post Box No 2126
Gunrock Enclave
Secunderabad 500003
Dr H Sudershan
Honarary Secretary
Vivekananda Girijana Kalyana Kendra
B R Hills, Post Office
Secunderabad 571313
Dr D N Rao
Bhagvatulla Charitable Trust
Yellamanchilli
District Vishakapatanam
PIN 531055
P Mohapatra
Director
Andhra Pradesh Vaidya Vidhana Parishad
Sultan Bazar
Hyderabad
GUJRAT
Nimita Bhatt
Honarary Secretary
Gujurat Voluntary Health Association
21 Nirman Societv
Alkapuri
Baroda 390005
Prof D Nagabrahmam
Institute of Rural Management
Post Box No 60
Anand 388001
29 >
HIMACHAL PRADESH
Subhash Mendapurkur
Director. SUTRA
Jagjit Nagar
District Solan
KARANTAKA
Sujatha de Magry
International Nursing Services Association
2 Benson Road
Bangalore 560046
Dr N Devadasan
ACCORD
14/1 North Road
St Thoamas Town
Bangalore 560084
Dr P V Rao
Manipal Industrial Trust
Valley View
Manipal
Dr B S Paresh Kumar
Department of Sociology
University of Mysore
Menasa Gangotri
Mysore 570008
MAHARASHTRA
Dr U N Jajoo
Department of Medicine
Mahatma Gandhi Institute of Medical Science
Sevagram 442102
Dr Ravi Duggal
The Foundation for Research in Community Health
84-A Thadni Marg, Worli
Bombay 400018
30 >
MAHARASHTRA.continued
. DrAmarJesani
The Foundation for Research in Community Health
84-A Thadni Marg, Worli
Bombay 400018
Dr Charles Yesudian
Head, Department of Health Services Studies
Tata Institute of Social Sciences
Sion, Tromboy Road
Deonar, Bombay 400088
Dr Ashok Dayal Chand
Ashish Gram Rachna Trust
Pachod, District Aurangabad
PIN 431121
Ajay Dua, IAS
Divisional Commissioner
Nasik Road, Nasik
MADHYA PRADESH
Fr Joseph Thayil
Bishop’s House
Post Box No 168
Indore
Sr Prabha Varghese
Executive Director
RAHA
C/O Bishop’s House
Post Office Kunkuri
PIN 496225
NEW DELHI
Dr S C Sharma
Assistant Director General
Ministry of Health & Family Welfare
Room No 556, ‘A’ Wing
Nirman Bhawan
PIN 110011
Dr P K Goswami
Health Consultant
Catholic Relief Society
Community Centre
East of Kailash
OR
31 >
NEW DELHI...continued
Dr Prem Taiwar
National Institute of Health & Family Welfare
New Mehrauli Road
Munirka
PIN 110016
Dr B B L Sharma
National Institute of Health & Family Welfare
New Mehrauli Road
Munirka
PIN 110016
Dr A K Bhagat
Parivar Seva Sansthan
28 Defence Colony Market
PIN 110024
Dr Gouri S Gupta
Faculty of Management Studies
Delhi University
ORISSA
Paras Bhai
Executive Secretary
PRDATA
G Udayagiri
Phulbani 762100
RAJASTHAN
Dr Dinesh Agarwal
Department of Community Medicine
B NT Medical College
Udaipur
Sanjoy Ghosh
URMUL
Post Box No 55
Bikaner
TAMILNADU
Dr Venkateswara Rao
Additonal Director
Voluntary Health Services
Adyar, Madras 600113
32 >
TAMILNADU..continued
R D Thulsiraj
Administrator
Arvind Eye Hospital
1 Anna Nagar
Madurai 625020
WEST BENGAL
Raja Menon
Child in Need Institute
Post Box No 16742
Calcutta 700027
Nikhil Nasker
Child in Need Institute
Post Box No 16742
Calcutta 700027
N K Mukherjee
Elmhirst Institute of Community Studies
Nababithika, Andrewspalli
Santinikan 731235
D P Poddar
Executive Secretary
West Bengal Voluntary Health Association
Surya Tara, Flat # 1A,
48, Gorachand Road
Calcutta 700 014
BANGLADESH
Dr Nasir Uddin
VHSSS
273/274 Baitul Aman
Housing Society
Road 1, Adabar
Shyamoli
Dhaka 1207
INDONESIA
Dr Felix Gunawan
Executive Director
PERDHAKI
JI, Kramat V'/7
Jakarta 10430
33 >
PHILLIPINES
Nenita Crescini
BUKAS
9 Cabanatuan Road
Philam Homes
Quezon City
VOLUNTARY HEALTH ASSOCIATION OF INDIA, NEW DELHI
Alok Mukhopadhyay
Executive Director
Madeline Hirschland
Manvinder Mamak
Finance Officer
FORD FOUNDATION, NEW DELHI
Dr Peter Berman
Programme Officer
Priti Dave
Consultant
34
4
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The Voluntary Health Association of India (VHAI) is a secular,
non-profit organisation. The main objective of the association is to
strengthen health programmes by creating awareness about the
health situation in the country. Its major activities are : production
and distribution of books, pamphlets, flash cards, flannel graphs,
film strips and slides on basic health care for the use of various
health functionaries at the village level; campaigns on issues such
as drugs, tobacco, baby foods etc., documentation of relevant
material for the use of activists, and training workshops and pro
grammes for Community Development and Community Health
Workers.
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VOLUNTARY HEALTH ASSOCIATION OF INDIA
Tong Swasthya Bhawan
40, Institutional Area, South of IIT,
New Delhi -110 016
Tel.: 652953, 655871,668071,668072. Fax :011 -676377
Grams : "VOLHEALTH"
NEW DELHI -110 016
Position: 753 (6 views)