BUILDING HOLISTIC HEALTH SYSTEMS IN RURAL INDIA Introduction Mahatma Gandhi, the Father of our Nation had written

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 ones 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 (peoples 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 1930s, 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.

The investor-led economy and the political system have gleefully capitulated into describing the medical services as Health Care Industry, automatically giving the noble medical profession, 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, computers, mobiles, laptops, etc. have reduced prices progressively, medical costs continue to spiral and rise skywards! In the words of a British educationist, 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, that medical schools would design doctors who would meet societal obligations and serve the rural villages, providing viable health services for the people who needed them the most. Unfortunately, as in several other fields, the medical profession too paid scant attention to Mahatma Gandhis thoughts and vision. But exceptions do turn up and the pioneering work of Dr. Ulhas Jajoo in providing comprehensive health services to 40 villages (year 2012) near Wardha, Maharashtra , ensures the well-being of the rural people, physically, mentally and spiritually. This is what holistic health systems should be offering in rural areas, services that are affordable, appropriate and accessible. A Giant Leap in Faith The Kasturba Hospital, Wardha was founded by Mahatma Gandhi in 1945, in memory of his wife who died in detention in 1944, with 15 beds for women and children. It grew to 50 beds and after Gandhijis assassination in 1948, the Gandhiji Smarak Nidhi, which managed the hospital, found the expenditure to be too high and resolved to hand it over to the Government. 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. To ensure funds for the hospital, Dr. Ranade and Smt. Manimala Chowdhary went around the villages with a bullock cart collecting sorghum (jowar) at harvest time and everyone gave, as much as they could afford. The concept of Health Insurance was born and the insured villages were charged 25% of the modest hospital charges. 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. 10 lakh, interest of which was to meet the annual deficit of the hospital at Rs. 1 lakh per year. The Kasturba Health Society extended to the villages, comprehensive health care that was preventive, promotive and curative by evolving the concept of insuring entire villages, and charging Re. 1 per person per year. Services included a through health check-up, advice and help in health promotion, prevention of disease and medical treatment for illnesses, as necessary. An insured village needed 75% of the inhabitants to be medically insured at the low cost of Re.1 per year. Later on, cash contributions were fixed at Rs. 15 for the year and gradually increased to Rs. 35 per year (1984), for a family of five. In 1969, the Kasturba Hospital was upgraded into a teaching hospital with 500 beds, and became the Mahatma Gandhi Institute of Medical Sciences (MGMIS). Health insurance for all students, nurses, staff members and their families were started. Dr. Jajoo joined the hospital in 1977 and with some of his enthusiastic medical students (Medico Friend Circle), started visiting the villages, either walking or on bicycles, arranging meetings of villagers to ensure their own health which was low priority for these rural people. 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, as they could not afford to lose daily wages for labor and afford costly hospital fees. This led to the 1984 scheme of Health Insurance for the 15 nearby villages.

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. From this village fund, an honorarium was paid to a village health worker and an Auxiliary Nurse Midwife (ANM) and some common drugs were kept for use, with the village health worker. Every village was visited on a monthly basis, 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, if they were insured. As more and more poor villages opted to join the Health Insurance Scheme, it can be termed a success but the better-off villagers dropped off, as they expected more services for the larger annual premium paid by them. Dr. 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, Wardha where MGMIS is situated and fill in the critical gaps, with designed interventions. Village Fund for Medical Treatment A common village fund was mooted to assist medical treatment and for meeting unforeseen illness costs, each villager decided to contribute 2.5 kgs. of Jawar (Sorghum) per acre of landholding. The landless contributed as per capability to pay. 90% of the villagers paid up in the 1st year and a dispensary was set up with minimal equipment as also a kindergarten school. The villagers were divided into 5 grades as under: 1) 2) 3) 4) 5) Grade-I: Families employing labor on annual contract basis. Grade-II: Families with irrigated land, pair of bullocks but not employing annual labour. Grade-III: Families with unirrigated land, pair of bullocks but not employing annual labour. Grade-IV: Families with land, without bullocks and not employing annual labour. Grade-V: Landless Labourers.

Any other additional occupation increases the economic grade by one. Village contributions as per socio-economic grades for 3 years at Nagapur village dispensary:

The lesson learnt as contributions reduced, 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. The poor villagers could not easily communicate with the educated medical students and medical problems were not a priority. Poverty issues and socio-economic factors were major obstacles. The

medical education system did not enable students to help the rural people. Self-reliance in health care was a myth and community participation in health care was another. 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. The village dispensary had to be linked to a central hospital for treatment of serious ailments. Also, such a scheme could not be self-reliant. Many changes were made in the hospitalisation scheme due to misuse and in the village dispensary by providing a mobile health team, visiting once a month. The villagers took some time in trusting the new scheme. Hospital admission cases increased due to increased coverage in Nagapur and Mandavgarh villages, as was expected, and the average period of stay in the hospitals was 6 days. The details of health insurance coverage are given below:

The cost analysis given for 1983-84 given below is instructive: 1) Grain contribution provided 86.3% of the money required to fund the village health workers, drug kits, antenatal assistance and the fuel expenses of the mobile health team. 2) Each hospital admission was subsidised by the health insurance scheme by Rs. 18.50. 3) The rural health service (excluding hospital expenses) cost Rs. 2 per capita, which was low. 1983-84 Costs Analysis Total population covered in 12 villages: 10,297 Total no. of hospital admissions: 425

Balance with Hospital: Rs. 7,864

Average Subsidy per Hospital admission: Rs. 7,864 For 425 admissions: Rs. 18.50

Supported by a group of dedicated medical students who were fired by Dr. Ulhas Jajoos selfless idealism, a system was put into place which linked primary healthcare with a hospital-based tertiary care system. Trapped in a vicious cycle of crushing poverty and their daily struggle for survival, the village people were least interested in preventive health measures which did not figure on their priority list. Instead of a prescriptive top-down approach, Dr. Jajoo tried to understand the villagers point of view as regards health issues and spent much of his free time, arguing, debating and discussing with the villagers. He realised that to be effective, the community-based interventions had to be designed on the premises that when rural communities access reliable curative services, they would be more amendable to preventive health care issues. Thus, an affordable and accessible hospital must also ensure good curative services along with prevention of an entire spectrum of common medical disorders. Improving Health Delivery Systems Realising the importance of the village health workers, he redefined their roles, rights and responsibilities and gave them adequate power to ensure that appropriate healthcare is actually brought to the doorstep of the villagers. He trained them, 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. With high motivation and empowerment levels, the village health workers and ANMs where inspired to seamlessly bond the strong referral support system of the hospital with the village community, for all health-related issues. With the help of obstetricians an effort was made to ensure that no mother in the nearly villages, died from preventable causes. In 1982, door-to door vaccination visits which were too costly, was replaced by the cluster immunisation strategy which ensured 100% vaccination coverage, at far lesser costs. To minimise pregnancy-related deaths, he identified, trained and posted village health workers who would pick up high-risk pregnancy cases and arrange for safe delivery of children, at the hospital. He advocated participatory processes in health care delivery at the grassroots levels and encouraged women and people from weaker sections of society, to participate in decision- making processes and take an active part in local governance issues. He felt that the top-down approach for delivery of healthcare was faulty and he introduced the Gandhian concept of self- governance or swaraj which included several concepts like self-sufficiency and self-reliance in respect of food, cloth, shelter, employment, education, health, knowledge and skills. The Gandhian concept of gram-swaraj may be very Utopian but he did instill the importance of self-sufficient villages with local administrative structures, planning and catering to local needs! India has a long history of governance by discussions, with people sharing common interests debating and consulting and arriving at solutions by consensus. The concept of local self government is indigenous to the India soil and helped to preserve the democratic traditions in social, cultural, economic and political issues. Transforming Local Initiatives Dr. 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, at the planning, implementation and monitoring stages of development. He encouraged the medical students and local communities to experiment, innovate and adjust to realities at the grassroots level. He was aware of the deep-rooted poverty and developed non-profit, non-political and secular structures in the villages to sustain the rural health delivery systems. He believed in CHANGE! He emphasised income-generation programs and social uplift of rural women, by organising and training rural communities to critically plan and implement sustainable development activities for enhancing incomes and enhance social awareness. Another achievement was to ensure that the local community leaders were honest, sincere, and committed to collective decision making.

A Village Education and Development Fund for micro-economic empowerment of villages, was set up (details at Annexure-II) Due to poverty, many of the villages did not have toilets and open defecation was a cause of health hazards. 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. Another campaign was taken up for lift irrigation systems , 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. The participatory watershed development strategy has helped the villages to conserve and manage land and water resources. Harnessing the enthusiasm of village folk for change and bettering their lot, ensured that the people-led initiatives, were given due priority. Safe drinking water was a major challenge as most water-borne diseases occur, due to its non-availability especially in the hot summers. Watershed development schemes could ensure rise in water tables as also safe drinking water availability during summer. Community Based Health Insurance (CBHI) A good health system for rural people has to be accessible, affordable and appropriate. The community based health insurance scheme was started long back at Wardha. But healthcare costs and cost of in-patient care, is a major cause of rural indebtedness and impoverishment among the rural people. Dr. 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. The rural community decided about contribution levels and the collection mechanism, the contents of the benefits package and allocation of the financial resources. In 2011, the CBHI scheme had 58000 villagers as members, of which 55,000 were members of self help groups (1500 village-based organisations) also joined the scheme. Details of the Scheme are set out at Annexure-I. 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. As the hospital was fully supported by Govt. funds, the scheme became structured around: 1) Accessible hospital services of optimum quality. 2) Accountability of the health care system to the consumers 3) Affordability of services to the poorest by involving external funding. 4) Focus shifted from curative care to preventive/promotive healthcare. In addition to 75% of the villagers participating as the main eligibility clause, more active social participation was needed by the family, 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. 4) Village Panchayats elected by consensus unopposed.

The various medical schemes now available to 40 villages with 58,000 members are: 1) Jawar Insurance Scheme- 50% subsidy for outpatient care, 100% subsidy for all indoor care (except for selective admissions@ 50% subsidy). 2) Subsidised Family Insurance Scheme- Rs. 35 per person per year with minimum 75% villagers participating. No outpatient subsidy and 50% subsidy for hospital patients. 3) Indoor Insurance Scheme- Rs. 35 per person per year, no outpatient subsidy,50% subsidy for hospital patients. 4) Hospital Health Insurance Scheme- Rs. 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. 75 in 1986 to Rs. 420 in 2002. The average bill per indoor admission is Rs. 700 as against Rs. 484 for insured villages (about 70%). This is said to decrease with increased bed utilisation in the hospital. In a service providing hospital, budgetary salary allocations should not exceed 40% of total expenses (60% at MGMIS, Wardha). The average per capita expenditure by the Govt. increased from Rs. 41 in 1986 to Rs. 189 in 2002. It is possible to provide quality services to patients with current budgetary allocations, if resources are managed efficiently. Financial Data for 2008-2010 1) Average for indoor patients under Jawar Insurance scheme was 85.6%, 81.5% and 82.2% of the average hospital expenditure for 2008, 2009 and 2010 respectively. This reduces hospital expenditure per indoor patient by 15-18%. 2) The ratio for 1 hospital patient to the entire population covered under the Jawar Insurance Scheme was 8.2, 8.4 and 12.9 in 2008, 2009 and 20120 respectively. 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). 4) Villages contribution to insurance premia (pre-payment) and by co-payment per capita was Rs. 57 in 2008, Rs. 79 in 2009 and Rs. 57 in 2010. Primary healthcare is a fundamental right and can be managed with a prepaid system with risk pooling. 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. Women Self Help Groups In rural households, women rarely have the opportunity to voice their opinions or the power to take decisions. Theirs is a subdued world and they rarely are able to take part in family financial decisions! Dr. 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 micro-loans as required and learn to take financial decisions. The Women Self Help Groups have enabled rural women to maintain accounts, take financial decisions for their SHGs and their families. These

empowered women have picked up financial literacy skills and are now challenging existing societal norms. Perspectives The versatile Dr. Ulhas Jajoo is a man of many talents, a physician, a teacher, a researcher, community health worker, besides being a friend, philosopher and guide to the village folk around Wardha, and equally at home at an ultra-modern medical lab or in a field, talking with the farmers. The issues peculiar to rural health and the gaps in various rural health programs cannot be ignored any further. Will telemedicine fit the bill and will the rural people take medicines as prescribed? He believes in working together with the simple rural people, ensured closing gaps in health-care systems with low-cost medicines and avoiding unnecessary tests and needless surgeries. The self-supporting community- based medical insurance scheme is the outcome of interaction with the village folk and is operated by them. Designing a community-based medical assurance scheme, which is sensitive to their unmet demands and appropriate for the common man, was a big challenge and through largely met by Government aid and private contributions, this people-designed scheme is unique and meets the local peoples health needs. The prospect of sharing Health and Prosperity with the villagers is unique and in keeping with Mahatma Gandhis advice You must be the change you want to see in the world. The Wardha (Sevagram) Experiment is a Unique Holistic Health Model fit for replication in developing countries, as it combines elements of a community-based Health Insurance Scheme along with a comprehensive rural development Program. 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.

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. 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. There are two arms, 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; 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, Rs. 35 lakhs has been collected. To this fund MGIMS Alumni 1985-1984 batch tied their knots by donating 7 lakhs. 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

Threat

holistic health delivery mechanism 1) None of the schemes can be replicated unless initiative from village arises. 2) Model for adoptability not for duplication.

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, lesser is the risk of loss Limited geographical coverage would be a financial threat esp. for epidemics Financial protection as per paying capacity Must for Scheme sustainability Jawar Assurance Scheme Though diverse population, limited area covered to ensure medical service access. Services assurance only for accessible areas. Financial protection irrespective of paying capacity Benchmark to assess contribution levels from public funds Does not aim at cost recovery, considers it a social security measure. Ensures healthcare guarantee irrespective of ability to pay; Increase indicates change in trends Due to strong community ties to the hospital ,awareness of hospital is central to Scheme As operated through hospital the over prescribing is avoided, threat is minimal. Also, system of co-payment is imposed for chronic illness, so over-utilization 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, the adverse selection problem is minimize because of co-payment wherein the patient has to bear some proportion of cost. Appropriate/optimum resource allocation and scheme affordability offers revenue stability and client support Evolved over period of time+ flexibility. all services provided except when co-payment charged Not a priority, 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- 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

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 peoples scheme, no selling required No sub-limits , except for foreseeable hospitalization As scheme has evolved as per peoples needs, there is no reluctance