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In Search of Self-Sufficiency the Field Experience of a
Department of Community Medicine
RAVI NARAYAN,
PARESH KUMAR
supervision and posted interns to
up/with the discovery of a ‘model’
assist the health team to various
approach. In each area we tried to
activities. It also supplied some
build
the
best
possible
approach
Medical College Bangalore, has
equipment through courtesy of
been involved with the development with the resources available
UNICEF.
following an informal process of
of community health projects in
The
health cooperative was man­
analysing the local situation.
many villages of Karnataka. The
aged by a committee consisting of
primary purpose of the depart­
representatives of the milk coop­
Case studies
ment’s involvement in health care
erative, the department of commu­
delivery was the establishment of
nity medicine and the government
Village M: The first venture was
health centres for training intern
health department. This met every
an attempt to tag on a health
doctors who have a compulsory
month to plan the activities of the
function to an existing successful
three months rural posting during
centre.
milk cooperative. Village M had
their rotating internship. This is a
Fifty five per cent of the families in
responded enthusiastically to the
university and curriculum regula­
the village were not members of
promotion of dairying by the gov­
tion.
the cooperative. These were
ernment. Forty five per cent of the
From the very beginning it was
families that were involved in
families owned milch animals and
decided that health projects would
sericulture (25 per cent) and
were members of a registered milk
be planned and evolved in such a
landless labourers and harijans (30
cooperative. The production of
way that the community would be
per cent). In order to ensure an
milk ranged from 2500-3000 litres
encouraged to participate in the
equitable and just availability of
per day. The milk cooperative
financing and management of the
health services to the member and
committees agreed to a health cess
centres. This decision arose from a
non-member sections of the
of three paisa per litre of milk to
pragmatic assessment of many
village,
the following policy was
be deducted at source when the
other programmes that had been
evolved.
payment to farmers was made. A
externally funded.
sum of Rs 2500-2700 would thus be Preventive and promotive services
Whether the fund was governmen­
which included immunisation,
available every month for a basic
tal or voluntary, private or foreign,
vitamin and iron supplements,
health care system.
it was found that the process of
The health fund collected was used ante-natal and post-natal check up,
external funding resulted in the
chlorination of wells and so on was
to employ a doctor and a nurse.
super-imposition on the local com­
made available free to all members
Three villagers were selected for
munity of a system planned,
of the community. Curative
on the job training as dai, dis­
organised, budgeted and executed
services were free for members but
penser and records clerk. Apart
for the community through deci­
non-members had to pay. A
from staff salaries the fund was
sions taken outside the community.
section of the village through this
also used for drugs, rentals,
Such systems were often irrelevant,
cooperative endeavour, were con­
travelling allowance and
and consisted of structures that
tributing the total costs of non­
other materials.
were too costly, too unwieldly and
curative primary health care
Resources like vaccines, vitamin
unrelated to local reality.
services available to all. This was
and iron supplements, contracep­
From 1973-1983, the department
tives, surveillance of communicable an added and unusual benefit of
was involved with the development
the scheme.
diseases and health education files
of three health care programmes in
The
leaders of village M showed
and pamphlets were tapped from
three different areas. While each
government health centres to avoid great foresight, entrepreneurship
project drew inspiration and
and ability to .handle crisis. This
duplication. The college depart­
caution from the previous experi­
was
very &uch evident in some of
ment provided supportive technical
ence, we tried NOT to get caught

Pil he Department of CommuJL nity Medicine of St John’s

32

HEALTH for the Millions June 1990

the decisions they took as the
programme evolved.
Six months after starting the pro­
gramme the village leadership
boldly decided to sell milk to a
private party rather than the
government dairy because of the
government’s indecision to change
procurement prices in spite of
increasing costs. This was done in
spite of the risk involved in the loss
of certain subsidies promised by
the government dairy. Even more
remarkable was the decision to
raise the health cess from three to
five paise per litre in view of the 25
paise increase in returns per litre.
In later years there was a shift in
the economy of village M from
dairying to sericulture due to a
massive World Bank supported
programme in that district. Milk
production decreased to 900 litres
per day and the health cess had to
be increased to 15 paise per litre to
maintain committed costs. Sericul­
ture boomed in that area but
efforts to cooperatise it had failed.
The options available to the centre
were to either close down or start
charging for services irrespective of
membership. Some money had
been saved over the years for
investment in a chilling plant. With
decrease of milk production this
had become unnecessary and the
leaders with their usual foresight,
unanimously decided to invest the
money in a health endowment for
the centre in fixed deposits in one
of the local banks. The health
cooperative thus became a health
endowment.
Nine years later, the village leaders
once again put aside some coop­
erative savings and tapped addi­
tional funds from a government
scheme to invest in the construc­
tion of a permanent building for
the health centre as well as a
medical officer’s quarter. Till then
the centre had functioned in a a
rented building. It is to the credit
of the village committee that even
ten years after involvement, the
department of community medi-

cine was not called upon to invest
in a single brick in the village !
The relationship which evolved
between the villagers and leaders
of village M and the professional
staff of the centre and department
was one of respect and partnership.
The professionals had to change
their patronising and superior

there was little dairy or sericulture.
The church was an important
feature of this village and had over
the years responded to the needs of
the people through sponsored
charity and distribution program­
mes.
It was decided to start a health
programme funded initially by

Every new investment, whether it was forpolio vaccines,
refrigerator or even health education materials,
could be made only after the health committee was convinced
of the need. This sometimes took weeks or months.
In the years to come this patience resulted in a confident,
active and sound local leadership ...
grants from the Women’s League
and a foreign funding agency. A
committee consisting of local
leaders, the parish priest, the
Medical Officer of the project and
representatives of the Women’s
League and the Community
Medicine Department was formed.
This committee, in addition to
managing the centre, was required
to initiate development program­
mes in the village which would
gradually contribute to the health
fund and take over some of the
costs of the programme.
Over the years the committee and
more specially the medical officer
and her husband, a social scientist
(both resident in the village)
initiated a poultry, a women’s
handicraft centre, a dairy and other
programmes. They organised a
youth club and a women’s club to
plan and run the development
programmes. The health pro­
gramme which was initiated con­
currently concentrated on maternal
and child health and two village
Village S: At the request of a
girls
were trained informally as
Women’s League, the Department
health
workers io assist the
adopted village S to organise a
medical
team.
health programme. Unlike village
However,
all attempts at tapping
M, the economy of village S was
local
financial
support for the
very different. Most of the villagers
health
programme
failed. It was
_______
were wage earners who had jobs in
the city. They commuted to and fro neither possible to put a health
cess on development activities nor
through a government bus service.
convince the villagers to pay for the
Very few families owned land and

attitudes, often the result of
‘professional education’, and get
used to discussing with the leaders
and villagers as equals and coworkers. The health team’s role
changed from the traditional one
of ordering, advising and prescrib­
ing to a new way of sharing and
awareness building.
Since the community was paying
for the whole scheme, another
important learning experience
which the team had was on the
need for patience with representa­
tives of the community. Every new
investment, whether it was for
polio vaccines, refrigerator or even
health education materials, could
be made only after the health
committee was convinced of the
need. This sometimes took weeks
or months. In the years to come
this patience resulted in a confi­
dent, active and sound local
leadership which was neither subservient nor dependent.

June 1990 HEALTH for the Millions

33

-A

donations were collected from the
village families: others made col­
lections during festival time, put a
health cess on a milk cooperative
collection, tapped, panchayat
funds, got a water diviner to
contribute his earnings during a
season, or contributed the pro­
ceeds of a village drama to the
fund, and so on.
In addition to financial resources, a
The village leaders participated in village committee meetings host of other non-monetary re­
sources were also contributed to
enthusiastically, offering advice, providing frank feedback
the centres. These ranged from
and criticism, registering protest, offering support and
repair and maintenance of clinics
encouragement when necessary, sharing perspectives and
and residences with materials
obtained locally; hospitality for
ensuring execution of decisions.
visiting staff and specialists during
camps; assistance in the organisa­
tion of formal and informal health
was to be refused treatment. Since
Villagers from neighbouring
education programmes as well as
there was a sizable proportion of
hamlets were ready to make
village
dramas and street theatre;
the community who could not
contributions, including fee for
prizes
for
baby shows; village vol­
services but in___
the_ absenceafford
of anyeven the minimal costs, supunteers
for
camps and clinics; par­
partidpadon from the two primary plementary collections were vital to
ticipation
of
school teachers, dais
ensure the viability of the centres,
villages attempts at self-sufficiencyr
and
youth
clubs
and women’s clubs
were
A nationalised bank was tapped by
were given
given up^
up. To
To this
this day,
day, the
the
in organising programmes and so
centre continues to be funded from the department for basic infras-^
on.
tructural costs for initiating such a
external sources.
The
village leaders participated in
programme. These included'costs
village
of a jeep, a social scientist’s salary,
- «=»■ committee
_ . meetings
“ enthu...
Villages of A-Block: In 1978, the
intemship stipends and seed1grants s.ast.cally offering adsnee providing
State Government affiliated a
frank feedback and criticism,
per health programme for equip­
government primary health (situ­
registering protest, offering
ment and initiating a rolling drug
ated in Community Development
support and encouragement when
bank of Rs. 3000 per centre.
Block A) to the community medi­
necessary, sharing perspectives and
In about a year’s time villages
cine department. This centre
ensuring execution of decisions.
B,G,Y and H were identified and
catered to a population of 72,000
This
active involvement in decision
four small programmes initiated.
spread over 101 villages. For two
making
and management of the
Village health committees were
years the Department had a pro­
centre
turned
out to be an impor­
gramme of supportive participation formed in all of them. These
tant
component
of the dynamic
committees found accommodation
in all the activities of the health
totality
of
self-sufficiency.
No
for the doctors (interns from the
centre especially its maternal and
doubt
political
wrangles,
personal
­
medical college) and the clinic. The
child health arid family welfare
ity
clashes
and
differences
of
types of accommodation were a
programmes. Then it was decided
opinion were part of the process
village
cottage, a room of the
that the department team would
but the overall experience was
village school, an unused parish
try and establish health care proquite positive. Three village centres
grammes in the sub-centre villages spriest’s quarters and a village
continue to function to date. Only
teacher
of the block using a strategy
’ ’’s quarters. Rules for
payment of services were drawn up one centre was closed down and
evolved from the experience in
this due to local politics which pre­
and a committee member was put
villages M and S. These program­
in charge of supervising collections vented the committee from func­
mes would tap village resources
tioning effectively.
and maintaining accounts. Follow
and enlist community participation
These
three case-studies (seven
up of defaulters was the responsi­
in their organisation. They would
centres)
represent a small attempt
bility of the committee.
also complement/supplement the
in
the
search
for self-sufficiency of
Supplementary income was raised
extension work of the government
community
health
programmes. It
by each village committee in
health centre auxiliaries.
is
important
to
clarify
that these
different ways. In one village
Villages were identified, which

services. Years of church spon­
sored welfare had created a
stubborn dependence. In the past,
appeals to the Bishop routed
through proper channels had
provided most of their needs food, jobs, education and medi­
cines. They failed to be convinced
of any need for self-support.

34

were keen to establish local health
centres. In each of them, village
health committees were formed to
manage and supervise the centre,
operate local bank accounts,
supervise funds. The assumption
made was that payment for service
even on a no-profit, no-loss basis
would run up a deficit if no patient

HEALTH for the Millions June 1990

*

*>

were evolving processes with
phases of smooth functioning and
points of crisis. More important
than the micro-level study and
analysis of these projects, is the
derivation of broad conclusions
based on the reality of these field
experiences which pertain to the
relevance and rhetoric aspects of
this whole quest for self-suffi­
ciency.
Self-sufficiency: Relevance and
rhetoric

We are convinced that given an
open, informal, decentralised
approach, it is possible to initiate
and sustain processes of selfsufficiency in health care program­
mes. Such processes can help take
over a substantial part of the
recurring costs of a programme.
Wider definition
of self-sufficiency

Self-sufficiency as a goal should
not be visualised in its narrow
definition of local finances or
monetary resources but must
include a host of non-monetary
material resources and human
resources in the community. In its
broadest sense, active participation
by representatives of the local
community in decision making in
the programmes should be a
crucial component of the goal of
‘self-sufficiency’.

Funding ‘process’ not ‘structures*
In the present socio-political
reality, funding from external
sources, be they government or
private, industrial house or foreign
funding agency will continue to
remain a starting point for health
care intervention programmes,
even those in quest of self-suffi­
ciency. however, if such external
funds were used cautiously to fund
process rather than constructions’
or ‘structures’, then self-sufficiency

would make some headway. Large
buildings hot only raise expecta­
tions in villagers but convince them
of the vested interest that project
personnel will have in the continu­
ity of an externally funded pro­
gramme. Both these put a stamp
on future dependence and stimu­
late local initiative to extract
advantage and exploit the project
rather than contribute to its future
support or development. In the
Indian experience, buildings are
quite often available for use in the
village. In our experience, invest­
ment in brick and mortar is not
only unnecessary but also counter
productive to the quest of selfsufficiency.

Tapping government sources

Even when non-governmental or­
ganisations are involved with.
health care programmes that aim
at self-sufficiency, our experience
has shown us the importance of
tapping all the available govern­
ment resources as part of the
strategy. Apart from preventing
overlap or duplication of efforts,
tapping government resources,
especially if it is done through
generating pressure groups or
some degree of social activism in
the community, is almost always a
good policy. It ensures that the
NGO realises its catalyst role and
does not get carried away with in­
stitutional on>projcct development
nor the pursuit of an unrealistic
parallel services.
Maintaining status quo

Our experience evaluated from
the perspective of social justice for
the under-privileged and poorer
sections of the community raises
serious concern about the pursuit
of self-sufficiency as an end by
itself. If financial self-sufficiency
becomes a primary goal of the pro­
gramme then this will ensure that
the main contact of the programme
will be with the existing leadership

of the village which in the Indian
situation consists of land owners
and rich farmers.
Two experiences clearly taught us
the subtle but definite way in which
this aspect of village reality
operates:

* When harijans and landless
labourers began to invest in milch
cattle, because jobs in sericulture
provided alternative green fodder,
the village leadership intervened by
closing cooperative membership
and forcing prospective members
to sell milk to the cooperative
rather than participate in it - thus
effectively keeping out the lower
sections and affecting the availabil­
ity of .health services to them.
* Another case in point was that
village leaders had agreed that Rs.
200 would be set aside every month
from the cooperative fund for
concessional or free treatment of
poorer sections in village M. When
there was an economic crisis due to
shift in economy from dairy to
sericulture this subsidy was slashed
making health services once again
inaccessible to the poorer sections.
Unethical Medical Practices

With the escalating cost of drugs,
health teams committed to quests
of self-sufficiency are often pres­
surised to balance the budget by
resorting to practices such as
administering of unnecessary injec­
tions and tonics, selling of physi­
cians’ samples, pi escribing unnec­
essary drugs. These practices help
to increase the returns. However
even though these practices may be
directed towards the affluent
sections of the community, they are
in principle unethical in both a pro­
fessional and a social sense and not
compatible with the principles of
community health.

(Continued on page 44 )

June 1990 HEALTH for the Millions

i

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35

J
■

What next? A plan of action
At the end of four days, out of
the floating, colliding, and explod­
ing of issues, a plan of action
somewhat miraculously emerged.
It addressed the workshop’s many
recurring themes. First, a commit­
tee was formed to pursue the
acquisition of management skills
and the documentation of health
financing experience.
Second, a commitment was made
and a committee formed to
increase the sector’s advocacy role
in policy making; particular priority
was placed on regulation of the
private health sector.
Finally, the importance of of
continuing the debate over the
sector’s future directions was
asserted.
To this end, a second annual health
financing meeting was scheduled.

-- Madeline Hirschland has been a
consultant with VHAI on health
financing. Her background is in the
financial management, administra­
tion and politics of voluntary
organisations.
(This report is based on the work­
shop papers listed below, presenta­
tions, and give and take during
animated and often fast-paced
discussion. As the presenters alone
are explicitly referred to in the text,
we would like to acknowledge and
thank all the workshop participants,
many of whose ideas are included
above, for their contributions to this
evolving assessment of health
finance in the voluntary sector.)

Dave, Priti, “ Community and Selffinancing of Health Programmes;
Experiences from India’s Volun­
tary Sector”
Duggal, Ravi, “State Health
Financing and Health Care
Services in India”

Ghosh, Sanjoy, “The Case of
Urmul Rural Health and Develop­
ment Trust”

Jajoo, UN, “Financing of Health

Projects; Mahatma Gandhi
Institute of Medical Sciences; The
Scvagram Experience”

Mahapatra, Prasanta, “The Need
for Developing a System of Sub­
Allocation pf Resources for Health
Institutions in Developing Coun-

iriesZ
Menon. Raja, “Income Generating
Project or Health Financing”
Menon, Raja, “Health Financing -

Mukherjee, A.K., “Government
Funding of Health Care”
Kumar, Paresh and Ravi Narayan,
“In Search of Self-sufficiency; The
Field Experience of a Department
of Community Medicine”
Poddar, D.P., “Financing pf Health
Projects: WBVHA CDMU Experi­
ence”
Prabha, Sr., “Financing of Health
Care - The Experience of RAHA

Berman, Peter, “Information
Needs for Programme Financing”

Rao, K. Venkateshwara, “Financ­
ing pf Health Care - The Experi­
ence of Voluntary Health Services”

Berman, Peter and Priti Dave, “
Experiences in paying for Health
Care - India’s Voluntary Sector”

Sharma, S.C., “Government
Funding of Healthcare Program­
mes”

Bhagatt, A.K., “Management In­
formation and Supervision”

Talwar, Prem P., “Strategies for
Development of Technical Skills
Among Voluntary Organisations;
Some Experiences”

44

(Continued from page 35 )

The goal of arriving at some sort
of a model project in one village
which can then be replicated in
every other village has plagued the
organisers of community health
programmes all over the world.
Our experience has clearly shown
that this pursuit of model ap­
proaches is nonsense in reality.
In the final analysis, self-sufficiency
in terms of generating local
community resources, be they
monetary or material, should be an
important but not exclusive objec­
tive of a community health pro­
gramme. When it is exclusive it will
ultimately keep out the poorer and
under-privileged groups in society.
For self-sufficiency to meaiftfruch
to people and particularly the poor,
the good should be reappraised
and strengthened in its human
sense of participation in planning
and active decision making.
Community health programmes
would then strengthen the people’s
own ability to plan and organise
programmes for maintaining their
own health. These would mean an
increasing commitment to demysti­
fying medicine, health education,
skill transfer, promoting autonomy
and improving group relationships.
Only such a process would make
the pursuit of self-sufficiency
‘relevant’ rather than ‘rhetoric.

I

I

- Ravi Narayan and Paresh Kumar
are both at the Department of Com­
munity Medicine, St John's Medical
College, Bangalore.
(This paper was first presented at
the A CHAN workshop on “Selfsufficiency in financing community
health programmes - rhetoric or
reality" held at ECC, Whitefield,
Bangalore, in January 1983. )

HEALTH for the Millions June 1990

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