RURAL HEALTH ASSURANCE SCHEME: A JOURNEY

Prof Ulhas JajooHead of Internal Medicine Dept

MGIMS, Sevagram, India&

Dr Sadhana BoseConsultant in Public Health Medicine

Oxford, UK

INTRODUCTION

Presentation focus: Describe an initiative implemented to Improve access to affordable rural healthcare, available to all those in need of care

Examine the role of communities in tackling socio-economic barriers to equitable access and in voluntary, health assurance schemes.

INTRODUCTION

• Universal Health Cover (UHC): access should be based on individual need, without forcing the user to spend money one does not have or preventing access because of inability to pay

• Jowar Health Assurance Programme (JHA): - introduced in 1980

- in villages, Wardha district (Maharashtra)

UNIVERSAL HEALTH CARE• Availability - Address financial barriers to access

• Accessibility – pro-poor, universal

• Affordability - Address financial barriers to access

• Sustainable - Limited resource; reduce dependence

• Holistic - social, economic and environmental • determinants of ill health

JOWAR HEALTH ASSURANCE PROGRAMME (JHA)

• Holistic approach to Universal Health Care

• Reach most-needy at affordable, no additional cost

• Community participation, local partnerships and use of alternatives to hard cash.

• Initiatives to address wider, socio-economic factors influencing inequitable access to essential health services.

BACKGROUNDFigure 1. Map of Vidarbha, a region in central

Maharshtra

BACKGROUND: VIDARBHA

• Contributes significantly to Maharashtra as India’s leading cotton producer (2/3rd of the annual output)

• 3.4 million cotton farmers from Vidarbha

• Holds 2/3 rd of Maharashtra’s mineral resources

• Holds 3/4 th of Maharashtra’s forest resources

• Is a net producer of power

BACKGROUND: VIDARBHA

• 31.6% of total state land

• 21.3% of state’s total population

• 95% of Vidarbha’s cotton farmers struggle with crippling debt - Chronic poverty often pushes a farmer to commit suicide

• Absence of basic necessities – mortgage farmland to meet family needs is common practice

VIDARBHA’S STORY OF INEQUITY

Multifactorial and interlinked •Environmental (below average regional rainfall)

•Agricultural practices: Rising cultivation costs; Lack of small irrigation projects; Falling returns from crops (result of change in farming practices/focus on maximising output)

•Poor infrastructure: Heavy load-shedding; Ignorance of role of ancillary occupations to raise income

VIDARBHA’S STORY OF INEQUITY

• Chronic poverty: Inability to repay debts following crop loss; Inability to afford basic medical care for self and family; Pressure of private moneylenders and banks; Children inherit family debts and poverty

• Spatial disadvantages arising from harsh climates and lack of geo-political influence in policy leverage

• Genetically modified BT (Bacillus thuringiensis) resistant cotton seeds - terminator seeds (2002)

INEQUITY IN ACCESS TO BASIC HEALTH CARE: VIDARBHA FIGHTS BACK

A number of government-aided and voluntary sector initiatives are in place to address above mentioned multifactorial causes of health and socio-economic inequities in Vidarbha’s farming communities

INEQUITY IN ACCESS TO BASIC HEALTH CARE: VIDARBHA FIGHTS BACK

• Address health inequalities arising from inequitable access to health care:

1. MGIMS led initiative 2. Initiated in 19803. Engaged with resident families using the village

council (Gram sabha)4. Evolution of the concept of Jowar Health Assurance

programme (JHA).

JOWAR HEALTH ASSURANCE (JHA): VIDARBHA FIGHTS BACK

• An experiential journey - Started with ill-health - evolved over time to address issues beyond health but with impact on health outcomes

• Use ‘Samanvaya’- co-operation across societal strata – JHA extended scope to include wider socio-economic factors precipitating suicides

JOWAR HEALTH ASSURANCE (JHA): VIDARBHA FIGHTS BACK

• Embrace whole families (‘Sarvodaya’ - betterment of the larger society) of villages

• Down to the most needy, most neglected and excluded (‘Antyodaya’- betterment of the most downtrodden)

• Path breaking journey of enriching local relationships

and partnership working.

JHA: NUTS AND BOLTS

• Every participant village is an active partner in the assurance scheme

• Annual Harvest - each family in village contributes Jowar (Sorghum) based on family size/ land holding

• Families contribute based on economic ability but receive health services based on need

• Collected harvest is sold to generate a base fund

JHA: NUTS AND BOLTS

• Base fund is deposited into the JHA account in a local bank (Sevagram, Wardha)

• At year end, unspent funds are transferred to a corpus, under the aegis of the MGIMS

• The interest accrued from unspent funds is used to procure drugs, organize agricultural education and development activities for participant villages

JHA: NUTS AND BOLTS

• Base fund is used to provide health assurance:1. Strengthen primary care services within the village2. Subsidise (by 50%) hospital bill for users of planned

medical care provided by MGIMS

• MGIMS provides free in-patient medical care for unforeseen illnesses

• Co-payment from indoor hospitalisation and the village annual contribution together account for 10% of total expenditure to participating villages

JOURNEY MILESTONES (1980- 2014)

• Journey started: in 1980 to tackle health inequalities arising from inequitable access to healthcare services

• Enroute: 1. Realized need for social transformation 2. Transcended beyond medical care to comprehensive village development activities like Dairy farming, Lift irrigation, sanitation, others

• Journey continues............. Into 2014

JOURNEY MILESTONES

• Journey continues:........in 2014

• JHA: foundation for programmes addressing social, economic, ecological determinants of ill-health

• JHA: adds to evidence on UHC in middle income countries grappling with socio-economic inequities

RESULTS

• Realization that health issues do not become the vehicle for social transformation

• Realization that acts of common faith are as important as economic development for an egalitarian political structure (Figure 2)

• Self-reliance (swavalamban) in felt needs like food, clothes and finances had the potential to empower communities by inculcating acts of common faith.

CONCLUSIONS

• Micro-financing a health insurance scheme (JHA):

1. Allows entire villages to benefit from universal health coverage

2. Allows direct access to additional public health resources from the central and state governments through MGIMS through a mere 10% equity

CONCLUSIONS

• Micro-financing a health insurance scheme (JHA):

3. Design and implementation is an example of proactive people participation in health care decision making at local level

4. Key players: respected community leaders, successful engagement between villages and healthcare provider, culture of decision making by consensus

SUMMARY: JHA• Affordable and accessible primary and secondary

care services of high quality to entire villages

• Direct participation by end user i.e.people’s participation and community engagement

• Buy-in by district’s largest not-for-profit provider hospital (MGIMS)

• Three way engagement between provider, end user, participating villages - delivery of UHC to rural poor

SUMMARY: JHA

• Equity in access between poorest and rich villages

• Local ownership of the assurance programme and one’s health i.e. decentralized social unit with voluntary participation

• Effective healthcare - absence of maternal mortality, measles, polio, tetanus, whooping cough

• Addressing ill-health with non-health determinants.

CONTACT US

Professor Ulhas Jajoo Department of Medicine

Mahatma Gandhi Institute of Medical Sciences, Sevagram (Wardha), Maharashtra, India-442102

Website: www.gandhisvision.com

Email: gandhisvision.mgimsalumni@gmail.com, ulhasjajoo@gmail.com sadiebose@gmail.com