Sadhana bose

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RURAL HEALTH ASSURANCE SCHEME: A JOURNEY Prof Ulhas Jajoo Head of Internal Medicine Dept MGIMS, Sevagram, India & Dr Sadhana Bose Consultant in Public Health Medicine Oxford, UK

Transcript of Sadhana bose

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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

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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.

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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)

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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

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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.

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BACKGROUNDFigure 1. Map of Vidarbha, a region in central

Maharshtra

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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

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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

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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

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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)

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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

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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).

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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

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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.

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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.

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CONTACT US

Professor Ulhas Jajoo Department of Medicine

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

Website: www.gandhisvision.com

Email: [email protected], [email protected] [email protected]