This action might not be possible to undo. Are you sure you want to continue?
extensively on various issues which confronted the making of modern India. In ‘Harijan’ (15 June 1947) his perception and vision for the medical profession was penned as under! “I would like to know what the medical men and scientists are doing for our country. One finds them readily going to foreign lands to learn new modes of treating special diseases. I suggest that they should turn their attention towards the seven lakhs of villages in India. They would immediately discover that all the qualified men and women are required for village service, not after the manner of the West but after the manner of the East”. In another perceptive paragraph, his thoughts on holistic treatment have been put forth, as under: “My quarrel with the medical profession in general, is that it ignores the soul altogether and strains at nothing in seeking merely to repair such a fragile instrument as the body. Thus ignoring the soul the profession puts men at its mercy and contributes to the diminution of human dignity and selfcontrol”. Holistic Health conjures up a vision of a human body pepped up by the right food/ exercise / medicines/ meditation all converging on a self- centered view of health. Our Indian traditions (with the Bhagwad Gita and Mahatma Gandhi), have often reiterated the irrelevance of material gains in the absence of a backdrop of spirituality, decency, societal consciousness, the appreciation of one’s duties to Society and to Humanity. Health Issues in Rural India In Indian society, families and communities are important contexts for relationships and there is more emphasis on duties than rights! The reason is that Indian culture tends to be more holistic rather than analytical and wisdom-oriented rather than science- oriented. The driving forces of this wisdomoriented learning are: i) ii) iii) iv) v) The Humanism of the Bhakti (devotion) movement Swarajya (self-rule) and Lokneeti (people‘s policy) The Sarvodaya (well-being of all) movement Socialism meaning Antodaya (poorest of the poor, first and always) Ideologies that have shaped modern India-Secularism and Democracy
Gandhian philosophy is based on all the above principles. How is the vision for a holistic health system to be realised? Dr. Alexis Carrel, the Noble prize winner and author of the classic ‘Man the Unknown’ has pointed out in the 1930’s, that medical science pays too much attention to this much of proteins, that much of vitamins, forgetting all the while that frequent doses of spirituality and meaningful prayers, are even more vital. Quasimodo Salvatore, another Noble prize-winner, summed up modern man (Homo modernus et scientificus) as Heartless, Loveless and Christless. Given, the extreme clout of money and media, crass commercialism prevails and economic gains get rapidly matched by social decay. This is difficult to digest and even Mahatma Gandhi tried to reverse this trend and failed.
This led to the 1984 scheme of Health Insurance for the 15 nearby villages. Ranade and Smt. 35 per year (1984). services that are affordable. interest of which was to meet the annual deficit of the hospital at Rs. nurses. 1 lakh per year. the Kasturba Hospital was upgraded into a teaching hospital with 500 beds. Manimala Chowdhary went around the villages with a bullock cart collecting sorghum (jowar) at harvest time and everyone gave. etc. The Kasturba Health Society extended to the villages. ensures the well-being of the rural people. This is what holistic health systems should be offering in rural areas. arranging meetings of villagers to ensure their own health which was low priority for these rural people. advice and help in health promotion. in memory of his wife who died in detention in 1944. cash contributions were fixed at Rs. The concept of ‘Health Insurance’ was born and the insured villages were charged 25% of the modest hospital charges. physically. mentally and spiritually. laptops. and became the Mahatma Gandhi Institute of Medical Sciences (MGMIS). It grew to 50 beds and after Gandhiji’s assassination in 1948. providing viable health services for the people who needed them the most. A Giant Leap in Faith The Kasturba Hospital. as much as they could afford. . 15 for the year and gradually increased to Rs. medical costs continue to spiral and rise skywards! In the words of a British educationist. Wardha was founded by Mahatma Gandhi in 1945. The Kasturba Health Society was registered in 1964 and the management of the Kasturba Hospital was passed onto it by the Gandhi Smarak Nidhi along with an endowment of Rs. computers. the medical profession too paid scant attention to Mahatma Gandhi’s thoughts and vision.1 per year. Services included a through health check-up. automatically giving the noble medical profession. But the devoted hospital workers were uncomfortable with this idea and held consultations with the leaders of the nearby village communities whom they served and this idea was vetoed. comprehensive health care that was preventive. Health insurance for all students. Unfortunately. with 15 beds for women and children. Dr. mobiles. have reduced prices progressively. as necessary. Jajoo joined the hospital in 1977 and with some of his enthusiastic medical students (Medico Friend Circle). the Gandhiji Smarak Nidhi. Ulhas Jajoo in providing comprehensive health services to 40 villages (year 2012) near Wardha. prevention of disease and medical treatment for illnesses. started visiting the villages. 10 lakh. the modern medical curriculum could be summarised as putting false pearls before real swine! Medical colleges give degrees but do not shape character! It was felt after 1947. But exceptions do turn up and the pioneering work of Dr. staff members and their families were started. either walking or on bicycles. appropriate and accessible. as in several other fields. that medical schools would design doctors who would meet societal obligations and serve the rural villages. found the expenditure to be too high and resolved to hand it over to the Government.The investor-led economy and the political system have gleefully capitulated into describing the medical services as Health Care Industry. 1 per person per year. which managed the hospital. Dr. In 1969. promotive and curative by evolving the concept of insuring entire villages. Maharashtra . for a family of five. as they could not afford to lose daily wages for labor and afford costly hospital fees. the right to seek dollars-in-disease and view all patients-as-profit! The kickbacks and commissions in the medical system have ensured that while all other commodities and consumables such as TVs. To ensure funds for the hospital. Later on. An insured village needed 75% of the inhabitants to be medically insured at the low cost of Re. and charging Re. Health care for the common man meant treatment of the very sick people and villagers came for treatment only when it became impossible for them to carry on daily work.
was that those who paid more wished to be treated as more than equals while the landless contributed in increasing numbers as they perceived benefits. Wardha where MGMIS is situated and fill in the critical gaps. Grade-III: Families with unirrigated land.The Power of One The village insurance payment was collected at harvest time (December) in kind (jowar/sorghum) according to the individual paying capacity judged as per the land-holdings. Village contributions as per socio-economic grades for 3 years at Nagapur village dispensary: The lesson learnt as contributions reduced. if they were insured. Grade-II: Families with irrigated land. each villager decided to contribute 2. with the village health worker. Poverty issues and socio-economic factors were major obstacles.5 kgs. Dr. pair of bullocks but not employing annual labour. as they expected more services for the larger annual premium paid by them. Grade-IV: Families with land. by a team of doctors and students from the MGMIS and patients referred to the hospital were given free treatment for any unforeseen illness and at 25% cost for chronic long standing illnesses. As more and more poor villages opted to join the Health Insurance Scheme. The poor villagers could not easily communicate with the educated medical students and medical problems were not a priority. Grade-V: Landless Labourers. it can be termed a success but the better-off villagers dropped off. pair of bullocks but not employing annual labour. Village Fund for Medical Treatment A common village fund was mooted to assist medical treatment and for meeting unforeseen illness costs. The . with designed interventions. without bullocks and not employing annual labour. of Jawar (Sorghum) per acre of landholding. 90% of the villagers paid up in the 1st year and a dispensary was set up with minimal equipment as also a kindergarten school. Jajoo made efforts to reach the unreached and MGMIS offered him the opportunity to analyse the ills of the health care delivery system in villages around Sevagram. From this village fund. Every village was visited on a monthly basis. Any other additional occupation increases the economic grade by one. The villagers were divided into 5 grades as under: 1) 2) 3) 4) 5) Grade-I: Families employing labor on annual contract basis. an honorarium was paid to a village health worker and an Auxiliary Nurse Midwife (ANM) and some common drugs were kept for use. The landless contributed as per capability to pay.
of hospital admissions: 425 Balance with Hospital: Rs. 18. which was low. 1983-84 Costs Analysis Total population covered in 12 villages: 10. 2) Each hospital admission was subsidised by the health insurance scheme by Rs.864 For 425 admissions: Rs. drug kits. Self-reliance in health care was a myth and community participation in health care was another. 7. The villagers took some time in trusting the new scheme. such a scheme could not be self-reliant.50 . Also.3% of the money required to fund the village health workers. and the average period of stay in the hospitals was 6 days. The village dispensary had to be linked to a central hospital for treatment of serious ailments.medical education system did not enable students to help the rural people. 18. The details of health insurance coverage are given below: The cost analysis given for 1983-84 given below is instructive: 1) Grain contribution provided 86. Hospital admission cases increased due to increased coverage in Nagapur and Mandavgarh villages. Many changes were made in the hospitalisation scheme due to misuse and in the village dispensary by providing a mobile health team. 7. visiting once a month. 3) The rural health service (excluding hospital expenses) cost Rs. 2 per capita. as was expected.297 Total no. antenatal assistance and the fuel expenses of the mobile health team.864 Average Subsidy per Hospital admission: Rs. The cooperation of the villagers fell off year by year and as 95% of the diseases treated at the dispensary was limited to respiratory diseases due to infections. viral fever and gastrointestinal infections.50.
the village health workers and ANMs where inspired to seamlessly bond the strong referral support system of the hospital with the village community. Thus. sincere. Another achievement was to ensure that the local community leaders were honest. an affordable and accessible hospital must also ensure good curative services along with prevention of an entire spectrum of common medical disorders. door-to door vaccination visits which were too costly. he redefined their roles. He realised that to be effective. Transforming Local Initiatives Dr. the village people were least interested in preventive health measures which did not figure on their priority list. at the hospital. was replaced by the cluster immunisation strategy which ensured 100% vaccination coverage. With the help of obstetricians an effort was made to ensure that no mother in the nearly villages. non-political and secular structures in the villages to sustain the rural health delivery systems. The concept of local self government is indigenous to the India soil and helped to preserve the democratic traditions in social. He felt that the top-down approach for delivery of healthcare was faulty and he introduced the Gandhian concept of self. for all health-related issues. by organising and training rural communities to critically plan and implement sustainable development activities for enhancing incomes and enhance social awareness.making processes and take an active part in local governance issues. He encouraged the medical students and local communities to experiment. he identified. education. at far lesser costs. Improving Health Delivery Systems Realising the importance of the village health workers. innovate and adjust to realities at the grassroots level. The Gandhian concept of gram-swaraj may be very Utopian but he did instill the importance of self-sufficient villages with local administrative structures. .governance or swaraj which included several concepts like self-sufficiency and self-reliance in respect of food. arguing. economic and political issues. debating and discussing with the villagers. cultural. trained and posted village health workers who would pick up high-risk pregnancy cases and arrange for safe delivery of children. knowledge and skills. died from preventable causes. Ulhas Jajoo’s selfless idealism. He was aware of the deep-rooted poverty and developed non-profit. a system was put into place which linked primary healthcare with a hospital-based tertiary care system. He advocated participatory processes in health care delivery at the grassroots levels and encouraged women and people from weaker sections of society. with people sharing common interests debating and consulting and arriving at solutions by consensus. Jajoo tried to understand the villagers’ point of view as regards health issues and spent much of his free time. Dr. He believed in CHANGE! He emphasised income-generation programs and social uplift of rural women. motivated them and inspired them to be not only responsive to the villagers’ problems but also creatively engage in issues of rural health and illness in rural communities. and committed to collective decision making. health. Trapped in a vicious cycle of crushing poverty and their daily struggle for survival.Supported by a group of dedicated medical students who were fired by Dr. In 1982. employment. they would be more amendable to preventive health care issues. With high motivation and empowerment levels. planning and catering to local needs! India has a long history of governance by discussions. implementation and monitoring stages of development. the community-based interventions had to be designed on the premises that when rural communities access reliable curative services. cloth. Instead of a prescriptive top-down approach. at the planning. He trained them. to participate in decision. shelter. To minimise pregnancy-related deaths. rights and responsibilities and gave them adequate power to ensure that appropriate healthcare is actually brought to the doorstep of the villagers. Jajoo redesigned home-grown systems instead of transporting best practices from other areas/alien concepts and motivated rural communities and developmental agencies to work together harmony.
the CBHI scheme had 58000 villagers as members. of which 55. the contents of the benefits package and allocation of the financial resources. affordable and appropriate. Villagers were invited to join hands with a NGO to build toilets for every household and this helped all villages to acquire toilets for their houses. But healthcare costs and cost of in-patient care. In addition to 75% of the villagers participating as the main eligibility clause. Safe drinking water was a major challenge as most water-borne diseases occur. the scheme became structured around: 1) Accessible hospital services of optimum quality. Ulhas Jajoo showed that pooling of financial resources could cover the cost of unpredictable health-related problems and protect rural households against the uncertain risk of catastrophic medical hospital expenses. due to its non-availability especially in the hot summers.A Village Education and Development Fund for micro-economic empowerment of villages. As the hospital was fully supported by Govt. Details of the Scheme are set out at Annexure-I. many of the villages did not have toilets and ‘open’ defecation was a cause of health hazards. is a major cause of rural indebtedness and impoverishment among the rural people. for eligibility consideration as per the scheme: 1) One house-one Latrine scheme with 100 % coverage. 2) Lift Irrigation scheme for all village families. 3) Milk Co-operative for all village families. were given due priority. The community based health insurance scheme was started long back at Wardha. The participatory watershed development strategy has helped the villages to conserve and manage land and water resources. Another campaign was taken up for lift irrigation systems . was set up (details at Annexure-II) Due to poverty. The rural community decided about contribution levels and the collection mechanism. 4) Focus shifted from curative care to preventive/promotive healthcare. Community Based Health Insurance (CBHI) A good health system for rural people has to be accessible.000 were members of self help groups (1500 village-based organisations) also joined the scheme. 4) Village Panchayats elected by consensus unopposed. Harnessing the enthusiasm of village folk for change and bettering their lot. Dr. Expansion of Village Insurance Scheme into Community Action Scheme Ninety percent of hospitalisation costs were being met by MGMIS Hospital. . Wardha and only 10% came from the village insurance scheme. more active social participation was needed by the family. funds. using the labor of the villagers who toiled hard to lay pipes in the rock-hard soil and leveled sloping lands for more groundwater retention. 2) Accountability of the health care system to the consumers 3) Affordability of services to the poorest by involving external funding. Watershed development schemes could ensure rise in water tables as also safe drinking water availability during summer. ensured that the people-led initiatives. In 2011.
4 and 12. Financial Data for 2008-2010 1) Average for indoor patients under Jawar Insurance scheme was 85.Rs. 100% subsidy for all indoor care (except for selective admissions@ 50% subsidy).50% subsidy for outpatient care.6%. 150 per year per family of 5 and 50% subsidy for (For Urban Poor) hospital expenses (inpatient/outpatient). Analysis of the Scheme from Villagers’ Point of View The average per person expenditure under the Jawar Insurance Scheme increased from Rs. The community based health insurance scheme is designed to meet the needs of the village people with existing resources but keeping in mind that 87% of external funding is required. The average bill per indoor admission is Rs.9 in 2008.Rs. 2) Subsidised Family Insurance Scheme. 35 per person per year with minimum 75% villagers participating. 81. 700 as against Rs.2. No outpatient subsidy and 50% subsidy for hospital patients. This reduces hospital expenditure per indoor patient by 15-18%. 57 in 2010.Rs. 484 for insured villages (about 70%). 79 in 2009 and Rs. The Women Self Help Groups have enabled rural women to maintain accounts. 8. In a service providing hospital. 2009 and 2010 respectively. Primary healthcare is a fundamental right and can be managed with a prepaid system with risk pooling. women rarely have the opportunity to voice their opinions or the power to take decisions. 57 in 2008.50% subsidy for hospital patients. 420 in 2002. 4) Hospital Health Insurance Scheme.5% and 82. 41 in 1986 to Rs.000 members are: 1) Jawar Insurance Scheme. Wardha). 35 per person per year. The average per capita expenditure by the Govt. 2) The ratio for 1 hospital patient to the entire population covered under the Jawar Insurance Scheme was 8. These . 2009 and 20120 respectively. It is possible to provide quality services to patients with current budgetary allocations. 189 in 2002. Rs. 4) Villages’ contribution to insurance premia (pre-payment) and by co-payment per capita was Rs.2% of the average hospital expenditure for 2008. 3) Budgetary allocations for hospital salaries ranged from 75% to 80% and could be brought down to 40% (without computing expenditure on drugs/food costs borne by patients). 75 in 1986 to Rs. budgetary salary allocations should not exceed 40% of total expenses (60% at MGMIS. no outpatient subsidy. Women Self Help Groups In rural households.The various medical schemes now available to 40 villages with 58. 3) Indoor Insurance Scheme. take micro-loans as required and learn to take financial decisions. This is said to decrease with increased bed utilisation in the hospital. Jajoo took positive steps to empower rural women by launching women-led microfinance programs and encouraged them to save regularly from their household budgets. take financial decisions for their SHGs and their families. Theirs is a subdued world and they rarely are able to take part in family financial decisions! Dr. increased from Rs. if resources are managed efficiently.
a researcher. which is sensitive to their unmet demands and appropriate for the common man. talking with the farmers. a teacher. This is to remind the rural poor people that they have to work hard to ensure a better future for themselves and their families with the assistance of the community. . and equally at home at an ultra-modern medical lab or in a field.empowered women have picked up financial literacy skills and are now challenging existing societal norms. The issues peculiar to rural health and the gaps in various rural health programs cannot be ignored any further. philosopher and guide to the village folk around Wardha. a physician. Designing a community-based medical assurance scheme. as it combines elements of a community-based Health Insurance Scheme along with a comprehensive rural development Program. The self-supporting community.based medical insurance scheme is the outcome of interaction with the village folk and is operated by them. Ulhas Jajoo is a man of many talents. Will telemedicine fit the bill and will the rural people take medicines as prescribed? He believes in working together with the simple rural people. was a big challenge and through largely met by Government aid and private contributions. this people-designed scheme is unique and meets the local people’s health needs. community health worker. The prospect of sharing Health and Prosperity with the villagers is unique and in keeping with Mahatma Gandhi’s advice “You must be the change you want to see in the world. Perspectives The versatile Dr. besides being a friend.” The Wardha (Sevagram) Experiment is a Unique Holistic Health Model fit for replication in developing countries. ensured closing gaps in health-care systems with low-cost medicines and avoiding unnecessary tests and needless surgeries.
processing of manure (vermicompost/biogas) 6) One dal processing unit in village Empowerment 1) Milk collection and distribution system 2) Organic farming and cultivation methods 3) Women self help groups 4) Self Reliance in clothes 5) Educative trips and issue based conferences As on date. To this fund MGIMS Alumni 1985-1984 batch tied their knots by donating 7 lakhs. This fund arose as a felt need of the village folk to enable rural socio-economic empowerment. It is a fund built on the insurance contributions of the rural people and is used for educational and development activities. with villages as active participants. This holistic approach is aimed at ensuring a positive effect on improving health and living standards in surrounding villages. Rs. Annexure-II Jawar Health Assurance Scheme of Sewagram (A) SWOT Analysis Opportunities Strengths 1) Quality Health service available to Masses 2) Need based diversified effort level achieves Weaknesses 1) A good hospital providing quality care is mandatory . 35 lakhs has been collected. basic needs and empowerment: Basic Needs 1) Health Assurance Scheme 2) Lift irrigation schemes 3) Potable water storage tanks 4) One toilet per house 5) Manufacturing cattle-sheds. There are two arms.Annexure-I The Village Education and Development Fund (2006) This fund was raised out of surplus amount that accumulated over years in village fund (every village has a bank account in which the insurance contribution is deposited) and is kept in trust with Kasturba Health Society.
considers it a social security measure. the adverse selection problem is minimize because of co-payment wherein the patient has to bear some proportion of cost. considered a social 2) Financial protection to beneficiary 3) Cost recovery from scheme 4) Rates of Utilisation 5) Lack of Awareness about Scheme 6) Moral Hazard by over prescribing and over-charging and over-utilising of Scheme 7) Morale Hazard. limited area covered to ensure medical service access.awareness of hospital is central to Scheme As operated through hospital the over prescribing is avoided. Village Health Worker has to sign a receipt for admittance to hospital Though all pre-existing conditions are covered and no waiting period. Financial protection irrespective of paying capacity Benchmark to assess contribution levels from public funds Does not aim at cost recovery. system of co-payment is imposed for chronic illness. for epidemics Financial protection as per paying capacity Must for Scheme sustainability Jawar Assurance Scheme Though diverse population. so over-utilization is avoided. Services assurance only for accessible areas. Increase indicates change in trends Due to strong community ties to the hospital . 1) Needs government social security 2) Not self-sustaining (Health care out reaching the poor can not be self sustaining) (B) Comparison with conventional Insurance Schemes: Issues 1) Size +diversity of membership Conventional In Schemes More diverse the membership.fraudulent use of scheme 8) Adverse selection due to inclusion of high risk group Increase indicates moral hazards or adverse selection Bureaucratic structure and low penetration A threat and is controlled by employing stiff terms and conditions and by monitoring Difficult to stop though close scrutiny + monitoring done Various conditions are imposed to avoid such problems 9) Support system needed High manpower cost as community not involved in scheme management Limited flexibility of schemes with limitation + upper caps It is a priority 10) Benefit package not compromised 11) Financial Stability . Appropriate/optimum resource allocation and scheme affordability offers revenue stability and client support Evolved over period of time+ flexibility. threat is minimal. Ensures healthcare guarantee irrespective of ability to pay. 2) Model for adoptability not for duplication. Also. all services provided except when co-payment charged Not a priority.Threat holistic health delivery mechanism 1) None of the schemes can be replicated unless initiative from village arises. lesser is the risk of loss Limited geographical coverage would be a financial threat esp.
except for foreseeable hospitalization As scheme has evolved as per peoples’ needs. no selling required No sub-limits .12) Product sales 13) Coverage 14) Community orientation and not individual Not easy to sell Small segment of population If individual does not benefit there is reflectance to participate responsibility As people’s scheme. there is no reluctance .
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.