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INTERVENTION
IN THE CIVIL
SOCIETY
sanjayDOCTOR
Project Mentor
mikrofields
A strategic exploration
to face the challenges
of a changing
healthcare paradigm
in India
June 2007
ver 1.0
HEALTHCARE INTERVENTION
IN THE CIVIL SOCIETY
A strategic exploration to face the challenges
of a changing Healthcare paradigm in India
~ TABLE OF CONTENTS ~
Introduction............................................................................................................................................................. 1
PART ONE
1
PART TWO
6
X
Introduction
Sanjay Doctor
|1
PART ONE
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CH A PTER 1
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REFLECTIVE / LIVING-SYSTEMS
The evolutionary consciousness of our species has led us to a paradigm shift about
our World reality. Science makes great discoveries about our worlds - mapping the
Human Genome in our internal world and going deeper into the Cosmos in our
external world. The Cartesian-Newtonian view, built on a mechanical world view, is no
longer able to explain the mysteries of Life. We are left with many unanswered
questions. There is a great revival to seek out ancient knowledge. Fritjof Capra, in the
'Web of Life' observes:
Since industrial society has been dominated by the Cartesian split between mind and
matter and by the ensuing mechanistic paradigm for the past three hundred years, this new
vision that finally overcomes the Cartesian split will have not only important scientific and
philosophical consequences, but will also have tremendous practical implications. It will
change the way we relate to each other and to our living natural environment, the way we
deal with our health, the way we perceive our business organizations, our educational
systems, and many other social and political institutions
The planet is looked upon as Gaia, mother earth goddess. The Gaia hypothesis is an
ecological theory that proposes that living and non living parts of the earth are viewed
as a complex interacting system that can be thought of as a single organism. Named
after the Greek earth goddess, this theory postulates that all living things have a
regulatory effect on the Earth's environment that promotes life overall. Stephen
Schneider and Penelope Boston in "Scientists on Gaia" (MIT Press) describe:
"James Lovelock and Lynn Margulis coined the phrase the Gaia hypothesis to suggest ...
that life serves as an active control system. In fact, they suggest that life on Earth
provides a cybernetic, homoeostatic feedback system, leading to stabilization of global
temperature, chemical composition, and so forth.
To see the the Earth (and even the cosmos) as interconnected, living systems has led
to the "reflective/ living-systems" paradigm.
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Each person takes responsibility for the wellbeing of the world, enabling high levels of
decentralization and freedom at the local level,
and a sustainable harmony at the global level.
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PEACEFUL CO-EXISTENCE
Global security and peace are linked to a productive life for all. The report, Investing
in Development, referring to West-led international developmental goals,
'The Goals not only reflect global justice and human rights, they are also vital to
international and national security and stability'.
And so as consciousness evolves, it begins to conceptualise the human being and
the value of balance and harmony for peace. Professor Panicker, scientist and
Gandhian philosopher explains the logic in his article, Evolution of Humanity :
Aum Shanti: These two words express the aspiration of humanity for evolution towards
harmony and peace. They denote an attitude of life and a way of living. Aum represents
harmony harmony among creation, sustenance and dissolution; harmony among body,
mind, intellect, harmony among individuals, neighbourhoods and the world. Harmony,
from Greek 'harmos' (= joint), is literally yoga. Yoga is which joins (Sanskrit yujyate
anena yogah).
Yoga leads to Shanti. Shanti means peace peace with oneself or inner peace, peace
within community and universal peace. Peace from Latin ' pacisci' (= to agree), is a state of
tranquillity. From harmony to peace is literally an evolution from joint to agreement, from
congruence to unity.
Peace comes to individuals from harmony in living, to communities from living in harmony
with neighbours.
Political thought is headed towards a neoliberal outlook, where the Left has
partnered with the Right wing. Again Edir Salami observes:
With the fall of the USSR and the 'socialist bloc', capitalism was once again sole ruler of the
world scene. The remaining post-capitalist countries reinvented themselves. China opted for
a form of market economy as in all likelihood will Vietnam. Cuba sought to defend the
basic gains of the previous period rather than advance towards socialism. The radical shift
in the balance of forces reverberated through the social and political movements. With
growing unemployment in Europe, unions were thrown onto the defensive, mounting at
best a partial resistance to flexibilization while rapidly losing members. In the increasingly
informal and heterogeneous world of labour that was emerging, traditional methods of
organizing had ever less effect. Parties had to confront the universalization of neo-liberal
policies. European social democracy adapted to this at the very moment when, for the first
time, the Centre-Left was in power in nearly every EU state; the Communist parties of the
region shrivelled, or vanished altogether. A similar scenario was enacted in Eastern Europe,
where former Communist parties took up a radicalized neoliberalism or local versions of
the Third Way.
It was in this context that local and sectoral forms of resistance ecological, feminist, ethnic,
human rights, municipal democracy combined to form the movement that, together with
union organizations and anti-WTO groups, would surface so explosively in Seattle in
November 1999. If they represent an advance, in creating new spaces in which opposition
forces can come together, many of them also implicitly renounce any attempt to construct
an alternative society: as if our indefinite confinement within the limits of capitalism and
liberal democracy was accepted as fact.
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CH A PTER 2
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The Individual
The Community
Government
Business
Voluntary Sector
From a liberal right perspective, Sara Evans and Harry Boyte in Free Spaces: The
Sources of Democratic Change in America, locate the primary territory of civil society in:
the public spaces, in which ordinary people become participants in the complex, ambiguous
engaging conversation about democracy: participators in governance rather than
spectators or complainers, victims or accomplices.
They further elaborate:
particular sorts of public places in the community, what we call free spaces, are the
environments in which people are able to learn a new self-respect, a deeper and more
assertive group identity, public skills, and values of cooperation and civic virtue.
Civil society exists at the intersection where the various elements of society come
together to protect and nurture the individual and where the individual operates to
provide those same protections and liberating opportunities for others.
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CH A PTER 3
Religious and cultural societies put together have a clear edge over other forms of
voluntary sectors in India. Government sponsored voluntary sector in India in the areas of
social sector, such as health and education etc. may, however, soon come to have a larger
share.
In regard to mobilization of resources, moreover, it is stated that half of all 72 sources of
receipts (51%) is self-generated through fees/charges for the services rendered.
This is followed by grants and donations (29%). Amongst the various sources of raising
funds, donations and charity are mostly adhoc and irregular. Private fund raising is,
furthermore, more time consuming. Similarly, while collection of funds from fees and user
charges are market determined, grants-in-aid are rule bound and more dependable
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INDIA SHINING
After 60 years of independence, there is a trickle down effect of the development
work done by the actors and India appears to rated high in the growth rate scorecard.
Key parameters, as stated by the Finance Minister P. Chidambaram in his Feb 2007
budget speech, are as below:
Manufacturing has become the main driver of growth.
Per capita income has increased by 7.4%
Savings rate is 32.4% and investment rate is 33.8%
Foreign exchange reserves $180 billion
SECTOR
AGRICULTURE SECTOR
2004-05
2005-06
AVERAGE
2.3
.7
3.9
22.2
20.8
19.9
6.2
7.4
7.6
19.6
19.5
19.3
8.1
10.2
10.3
58.2
59.7
60.7
6.4
7.5
8.4
2006-07
Q1
Q2
3.4
1.7
9.7
10.5
10.5
10.7
8.9
9.2
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The civil society will be dominated by players at two scales. One will be corporate
entities working with the state on mega projects like the 4 lane highway, airports,
ports and other infrastructure projects. They enter the theatre of developmental work
for the purpose of economic development leading to larger markets in the long run.
Others will continue their work at the micro scale; more ideology based or just plain
legacy. It is these we focus on.
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CH A PTER 4
ORGANISATION RENEWAL
Firstly, they must undergo a change management exercise. Change is all around us.
Remaining static, subscribing to dogmas and living in an antiquated business model is
the bane of most of the actors grasping for breath. It implies movement.
Secondly, they must create a revenue generation model. Funding is transformed into
a revenue model. Non-profits must become social enterprises.
These enterprises must tune themselves to global consciousness. They must became
shapers rather than adaptors of globalisation. Programs must originate from the filed
data rather than merely implementing international aid agency agendas. Indigenous
knowledge must be harnessed to find solutions.
The 3 Ps
Being a civil society actor is not them same as being employed in social service or in
a part time 'feel good' hobby. Membership to the club requires competence. At an
organisation level, it means lfrom the Strategy - Structure Systems model to a
harmonious model built around the 'Purpose Process People'. as proposed by
Sumantra Ghoshal. In an article 'A New Manifesto for Management ' (1999), Sumantra
Ghoshal, Christopher A. Bartlett, and Peter Moran explain:
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CH A PTER 5
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5 of the 8 goals specifically address health issues. It draws us to the conclusion that
in the race for global economic development, a large part of the human community
struggles with existence itself. The goals are so basic that for the developed world and
elite class, they are presumed to be available by default. A large part of of the human
race stands a very narrow chance of survival in the coming decades if these issues are
not addresses. Also if this was to be the case, global security and well being would be
severely compromised.
Table 4: Millenium Development Goals
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Responding to this urgent need, a macroeconomics and health process helps place health
at the centre of the broader development agenda in countries. It engages Ministries of
Finance, Planning and Health to act in tandem with development agencies, civil
society, philanthropic organizations, academia, and the private sector. Together, they
can take forward a shared agenda for addressing financial and systemic constraints to the
equitable and timely delivery of quality health and social services. This work will contribute
toward achievement of the Millennium Development Goals, global objectives such as "3 by
5", and national health targets.
Countries are driving the macroeconomics and health process, which takes into account
countries' unique health and macroeconomic variables. WHO, working closely with
governments and their partners, advocates for a more prominent role for health within
countries macroeconomic agendas. It also offers technical expertise to support country
efforts for developing long-term multi-sectoral investment plans. The work is carried out in
line with three themes:
Achieving better health for the poor
Increasing investments in health
Progressively eliminating non-financial constraint
The WHO works in India through its India Office. Its intervention strategy is
explained by it as:
The Country Cooperation Strategy (CCS) is a medium term, adaptable country specific
strategy that provides the framework of cooperation between WHO and the country. It
articulates a vision and selective priorities for the work of WHO for health development
that are based on systematic assessment of country needs and expectations as well as a
countrys commitment and capacity. The CCS is, in turn, translated into operational plans
that are linked to regular budget and extra budgetary funding.
The CCS is more than a document and it reflects the values, principles and corporate
directions of WHO as one organization and is developed in a spirit of partnership and
mutual respect in the context of the countrys overall efforts for health development. It is a
tool that helps in the process of placing health at the centre of sustainable development,
articulating the linkages between poverty and health, and calling for greater equity in
health.
WHO South East Asia Office
Macroeconomics and Health: India , 2004 set its agenda for India:
Indias total health expenditure as a percentage of GDP was 4.9% in 2000. Government
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KEY PARAMETERS
Measure
26.1 %
6.2 %
44.3 %
93
407
42
40
75.9 %
54.2 %
29.6 %
84 %
28 %
Health, led by P. Chidambaram, Union Finance Minister and and Dr. A. Ramadoss,
Union Health Minister. The report published in 2005 became a well planned strategy
document under the stewardship of the technically competent ministers. It sets a
strategy for India's public health system:
Indias health system: The delivery of health care services
The principal challenge for India is the building of a sustainable health system.
Selective, fragmented strategies and lack of resources have made the health system
unaccountable, disconnected to public health goals, inadequately equipped to address
people's growing expectations and inability to provide financial risk protection to the poor.
Access to medical care continues to be problematic due to locational reasons, bad roads,
unreliable functioning of health facilities,transport costs and indirect expenses due to wage
loss, etc. making it easier to seek treatment from local quacks. This explains the gross
underutilization of the existing health infrastructure at the primary level contributing
to avoidable waste.
The reasons for this failure can be attributed to three broad factors: poor governance and
the dysfunctional role of the state; lack of a strategic vision; and weak management. The
structural mismatch in the institutions at the Centre and State levels, with many
departments and agencies duplicating work or working at cross-purposes make
governance in health ineffective. Contributory factors for a dysfunctional health system are
unrealistic and nonevidence- based goal-setting, lack of strategic planning and inadequate
funding.
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health;
(4) investing in technology and human resources for a more professional and
skilled workforce and better monitoring.
These concerns need to be addressed by stimulating the process of reform. Reforms should
aim to overhaul the existing system that is dominated by low-quality health care, is costly
and unaffordable for the majority of the people, and where the public sector is underfunded, poorly equipped and constrained by bureaucratic procedures. If India is to stay
committed to achieving the National Health and Population Policies in 2010 and the
Millenium Development Goals in 2015, this Commission recommends that public spending
be increased from the current level of 1.3% to 3% of GDP in the next few years. The
additional resources can form the building blocks for implementing the Commission's
recommendations for a strong and viable health care system in India.
Further it makes an important statement regarding the future role of the state in
public health:
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Achieving MDG goals and the Tenth Plan objectives in India, in this scenario, will be
possible only if there is a significant increase in resources, targeting areas and population
groups with low health indicators and focusing on the upgradation of the health system
through a well sequenced process of reform.
Our estimates indicate that public investment for provisioning of public goods and primary
and secondary services alone will require about Rs 74,000 crore or 2.2% of GDP at current
prices.
In a next logical sequence the government decided that instead of a new health
policy, last published in 2002, it would come out with a thrust program, funded in part
with international funding. Also it would dovetail its program with Millennium Goals
so that India stands a chance of showing some achievement in its report.
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PART TWO
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CH A PTER 6
GOALS
Reduction in Infant Mortality
Rate (IMR) and Maternal
Mortality Ratio (MMR)
Universal access to public
health services such as
Womens health, child health,
water, sanitation & hygiene,
immunization, and Nutrition.
Access to integrated
comprehensive primary
healthcare,
Population stabilization,
gender and demographic
balance.
ACTION PLAN
Strengthen Sub-Centres,
Primary Health Care
Centres and Community
Health Centres
Disease Control
Programs
Public Private
Partnerships
Health Financing
Mechanisms
Reorient Medical
Education
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BUDETARY SUPPORT
In his budget speech 2007, the Finance Minister has made the following provisions:
Table 7: Key Budgetary Allocations in Union Budget 2007
India's Gross Domestic Product
Share of expenditure
Rs.
9,947 crores
(increase is of 21.0%)
7.6%
4.8%
47%
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THRUST AREAS
And so this is the story of India's healthcare. Poised with an acute understanding of
the environment, the mission is a blueprint without the public finance to put into
action. The plan has 3 main thrust areas:
(1) Building a cadre of voluntary health workers (ASHA)
(2) Upgrading standards of existing health facilities to meet the specifications of
Indian Public Health Standards (IPHS)
(3) Encouraging indigenous and local health traditions (AYUSH) as alternative
alternative medicinal systems to allopathic medicine.
Without an influx of resources from the third sector, the mission is unviable. And
so the interim action calls for a creating / upgrading actors in the civil society to fulfil
the Millennium Goals. The need for voluntary actors to enter and participate with the
state in PPP partnerships is needed more than ever before.
It is not that India does not have the financial resources to meet the expense. The
priorities are different. Defence takes away 47% of the budgetary allocation. A mere
10% diversion of funds to meet the fundamental living standards lacks the political
will. Until corrective action takes place, the People must seeks the solution with their
own resources.
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CH A PTER 7
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Typically, a private sector consortium forms a special company called a "special purpose
vehicle" (SPV) to build and maintain the asset. The consortium is usually made up of a
building contractor, a maintenance company and a bank lender. It is the SPV that signs the
contract with the government and with subcontractors to build the facility and then
maintain it. A typical PPP example would be a hospital building financed and constructed
by a private developer and then leased to the hospital authority. The private developer
then acts as landlord, providing housekeeping and other non medical services while the
hospital itself provides medical services.
The government has successfully tendered partnerships with the private sector
under the agesis of 'Public Private Partnerships' also known as P3 partnerships. The
Planning Commission in its report, 'Public Private Partnership' by the PPP Sub-Group
on Social Sector (Nov 2004) conceptualises P3 as:
2.1 Public-Private-Partnership - The Concept
...The term private in PPP encompasses all non-government agencies such as the corporate
sector, voluntary organizations, self-help groups, partnership firms, individuals and
community based organizations, PPP, moreover, subsumes all the objectives of the service
being provided earlier by the government, and is not intended to compromise on them.
Essentially, the shift in emphasis is from delivering services directly, to service
management and coordination.
It is further explained that the responsibility of delivery remains with the
government. It is an out-sourcing of service deliverables. The potential benefits would
be:
1. Cost-effectiveness- since selection of the developer/ service provider depends on
competition or some bench marking, the project is generally more cost effective than
before.
2. Higher Productivity- by linking payments to performance, productivity gains may be
expected within the programme/project.
3. Accelerated Delivery s ince the contracts generally have incentive and penalty
clauses vis-a-vis implementation of capital projects/programmes this leads to
accelerated delivery of projects.
4. Clear Customer Focus - the shift in focus from service inputs to outputs create the
scope for innovation in service delivery and enhances customer satisfaction.
5. Enhanced Social Service- social services to the mentally ill, disabled children and
delinquents etc. require a great deal of commitment than sheer professionalism. In
such cases it is Community / Voluntary Organizations (VOs) with dedicated volunteers
who alone can provide the requisite relief.
6. Recovery of User Charges- Innovative decisions can be taken with greater flexibility
on account of decentralization. Wherever possibilities of recovering user charges exist,
these can be imposed in harmony with local conditions.
The model for the partnership, in 3 roles, is explained;
The government may collaborate with the private developer/service provider in any
one of the following ways:
Funding agency: providing grant/capital/asset support to the private sector engaged
in provision of public service, on a contractual/noncontractual basis.
Buyer: buying services on a long term basis.
Coordinator : specifying various sectors/forums in which participation by the private
sector would be welcome.
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Contractual Framework:
The contract mirrors the basic objective of the programme /project, the tenure of
agreement, the funding pattern and of sharing of risks and responsibilities. The need to
define the contract very precisely, therefore, becomes paramount under PPP.
Projects/programmes under PPP may, however, broadly be classified under three heads
namely; service contract, operations & maintenance (management) contract and capital
projects, with operations & maintenance contract.
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PPP
Service Provider
Sterilisation (for
Private Practitioners/NGOs
having medical facilities.
Population
Stabilization)
Mother NGO
(MNGO) Scheme
Contractual
appointment of
Addl. ANM,
Public Health
Nurse , Lab
Technician.
Hiring of Safe
Motherhood
Consultant
Vande Mataram
Scheme
Social Marketing
of Contraceptives
(viz. Condoms / OCPs)
through social
agencies SMOs /
NGOs
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CH A PTER 8
Indicators. (1) Under-five mortality rate (2) Infant mortality rate (3) Proportion of 1 year-old children
immunized against measles
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Indicators. 1. Maternal mortality ratio (2) Proportion of births attended by skilled health personnel
Indicators. 1. HIV prevalence among pregnant women aged 15-24 years 2. Condom use rate contraceptive prevalence rate 3. Condom use at last high-risk sex 4. Percentage of population aged 15-24
years with comprehensive correct knowledge of HIV/AIDS
Target 1 Indicators. (1) Proportion of land area covered by forest (2) Ratio of area protected to maintain
biological diversity to surface area (3) Energy use (kg oil equivalent) per $1 GDP (4) Carbon dioxide
emissions per capita and consumption of ozone-depleting CFCs (ODP tons)
using solid fuels . Target 2 Indicators. (1) Proportion of population with sustainable access to an improved
water source, urban and rural (2) Proportion of population with access to improved sanitation, urban and
rural Target 3 Indicators. (1) Proportion of households with access to secure tenure
Indicators. Market access: (1) Proportion of total country exports (by value and excluding arms) to
developed countries admitted free of duty (2) Average tariffs imposed by developed countries on
agricultural products and textiles and clothing from developing countries (3) Agricultural support estimate
fas percentage of GDP (4) Proportion of ODA provided to help build trade capacity
Other Indicators: (1) Unemployment rate of young people aged 15-24 years, each sex and total (2)
Proportion of population with access to affordable essential drugs on a sustainable basis (3) Telephone
lines and cellular subscribers per 100 population (4) Personal computers in use per 100 population and
Internet users per 100 population.
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The CHCs were designed to provide referral health care for cases from the
primary level and for cases in need of specialist care approaching the centre
directly. 4 PHCs are included under each CHC thus catering to approximately
80,000 population in tribal / hilly areas and 1, 20,000 population in plain
areas. CHC is a 30- bedded hospital providing specialist care in medicine,
Obstetrics and Gynaecology, Surgery and Paediatrics.
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Goal 5:
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Ensure
Primary Health
Care at Family
Household
level
Target 1. Induct and train Voluntary Village Women Health Worker called ASHA ( Accredited
Social Health Associate) as first community health interface animator.
[3,20,000 ASHAs recruited. 2,40,000 have received formal induction (2006)]
Matrix
Selection
Training
MICRO
1.A1
A2
MID-LEVEL
STRUCTURAL
Shortlist candidates
1-B1
Recruitment agency
C1
B2
C3
Competency mapping
trainers)
Program
Sub-Centres,
Primary Health
Care Centres
& Community
Health Centres
as per Indian
Public Health
Standards
(IPHS)
Program
Plan, forecast
and develop
District level
Public Health
Delivery
Operations
A3
B3
C3
Pharmaceutical Co-ops
Mentoring
A4
B4
C4
Survey, assessment
Logistics
A5
B5
C5
Benefits
A6
Monthly Stipends
B6
C6
CSR funding, P3
partnerships
Target 1. Strengthen Sub-Centres, Primary Health Care Centres and Community Health Centres
Matrix
Infrastructure
MICRO
MID-LEVEL
STRUCTURAL
2A1
2B1
3C1
2A2
2B2
Workshops, Courses
2C2
Operations
2A3
On-line support
2B3
2C3
Equipment
2A4
2B4
2C4
Supplies
2A5
Provide in kind
2B5
2C5
Manufacture supplies
Staffing
2A6
Financial Support
2B6
2C6
Training
MICRO
3A1
MID-LEVEL
STRUCTURAL
3B1
IT support
3C1
Analysis
3A2
Village assessment
3B2
3C2
Planning
3A3
3B3
3C3
Training of Facilitators
Consensus
3A3
2B4
District stakeholders
3C4
Research Methodology
roundtable
Program
Preventive
community
health
measures to
combat
disease
Preparation
3A4
2B5
3C5
Awareness
2A5
2B6
3C6
MICRO
4A1
4A2
MID-LEVEL
4B1
4B2
STRUCTURAL
4C1
Watersheds, Sewage
Treatment Plants
Multi-media
4C2
CSR Funding
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Program
Theme based
control
intervention
Program
Revitalise
Local Health
Traditions
Program
Societal
Interventions
MICRO
MID-LEVEL
STRUCTURAL
Awareness
5A1
5B1
5C1
Training
5A2
5B2
Delivery Agency
5C2
Operations
5A3
ASHA Mobilisation
5B3
Task Force
5C3
Monitoring
5A4
Village Reports
5B4
Periodic Reports
5C4
Advocacy
P3 partnerships
MICRO
Awareness
6A1
Training
MID-LEVEL
6B1
6A1
Operations
6A1
Staffing
6A1
STRUCTURAL
6C1
6B2
6C2
6B3
6C3
AYUSH Paramedics
6B4
6C4
MICRO
HIV
7A1
Nutrition
7A2
P3
7A3
Gender
7A4
7B1
Develop PRI
7B1
SHG to be active
7B1
7B1
STRUCTURAL
7C1
Organic farming
7C2
7C3
7C4
Leadership Training
7C5
intermediaries
Equality
Insurance
MID-LEVEL
7B1
7A5
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CH A PTER 9
The funds required for a comprehensive public health program are not
available through public funding.
(2)
Qualified medical staff including doctors not willing to work at PHC level
(3)
Statistical base for providing health services is not realistic and the ratio of
capacity to population ratio is too high leading to a collapse of public health
services.
(4)
PRIs and panchayats are severely affected by politics and will lead to
diversion of funds.
(5)
(6)
The role envisaged for private agencies is not participatory and there are no
plans to build competencies in third sector.
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Self Help Groups (SHG): Today there are more than SHG groups in India with
an estimated of Rs.
to their members on an auction basis and have become thrift societies. The
time has come for these funds to be used in productive investment cycles. For
many of the village level activities Social enterprises can be formed which will
not only serve the health requirements but also earn a modest profit for its
members. For example, the village can invest in an ambulance which would
charge an affordable fee for its services.
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Women power: Vinobaji had termed this latent power as Stree shakti. The
rural women can come together as a collective and overcome their individual
shortcoming. Stil driven by strong maternal family drives, this stree shakti can
vercome all social economic and social barriers by their collective.
CONCLUSION
The challenges ahead may be listed as:
Self Reliance
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