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“RURAL HEALTH EMPOWERMENT”

BY

GOPALKRISHNA MALLYA
SHRIKESH
SOUMI DEY

Organizational Traineeship Segment


PRM 2004-2006

Submitted to
PRAYAS

June-July, 2005

Institute of Rural Management, Anand


Acknowledgements

At the outset, we would like to thank IRMA and the OTS coordinator at IRMA,
Prof. Jayant Negi for providing us with the opportunity to work with an organization and
have a feel of the organizational life for the two months. This has been an invaluable
experience. We are also grateful to our faculty guide, Prof. G. Krishnamurthy for being
not just our guide, but also our philosopher.

This brings us to our next philosopher, Dr. Narendra Gupta, the secretary of
Prayas. The Doctor from Devgarh brought the discussions out from the meeting rooms
and firmly rooted our basics in the lives of the rural poor of Chittor and Udaipur. We
scarcely had to look further for inspiration.

M/s Pallavi Gupta and Ms. Anjali Sharma have been our very patient mentors for
the traineeship. Both of them have been extending their help and support to us during the
entire period of our traineeship. We would like to extend our apologies due to both of
them, specially thanking them for their patient mentoring, guiding and assisting us with
the requisite.

Our special thanks for words of wisdom are due to Mr. Khemraj Chaudhry.

On the list of people without whom this report could not have been completed, we
would like to thank Mr. Govardhan Yadav, Mr. Lalu Ram Gameti, Mr. Vijaypal Singh,
Mrs. Vijaylakshmi, Mrs. Ishrat Jahan, Mr. Dinesh, Mrs. Maya for their help, support and
inputs during our visit to Mungana and Devgarh.
EXECUTIVE SUMMARY

I. Title : Rural Health Empowerment


II. Organization : Prayas, Chittorgarh
III. Reporting officer : Ms. Anjali Sharma
IV. Faculty Guide : Prof G. Krishnamurthy
V. Student’s Name : Gopalkrishna Mallya (25016), Srikesh (25099), Soumi Dey (25101)

The project begins with an exploration of the meaning of “Rural Health Empowerment” from the
perspectives of the host organization (Prayas) and the beneficiaries. The convergence of the views of the
concerned helped define Health empowerment as the availability of rational health care system which is
accessible to the rural people at reasonable cost in the hour of their need. The objective of the study was to
find alternatives to reduce the burden of morbidity or mortality so that destitution resulting from exorbitant
expense on availing health care facilities can be reduced effectively.

To achieve this objective a detailed analysis of the households in the tribal belt of Dhariavad cluster was
undertaken. The analysis consists of the morbidity profile of the area, health care services available and also
those availed commonly by the people, average expenses depending on the nature of disease, prevalent
practices in the area regarding maternal and child health care, awareness about preventive care measures and
the maternal and child mortality profile. The findings of the analysis can be summarized as follows:

The morbidity profile of the area shows a high degree of incidence of TB, malaria, cough, asthma,
orthopedic complications both among men and women. The incidence of diarrhea and ear infection is high
among the children. The state of government health care facilities available to the rural people is ineffective in
terms of reach and also insufficient in terms of the spread of population that is under its command area. Under
these circumstances, people prefer to go to traditional faith healers for quick recovery. They refer to the govt.
PHCs and quacks only in case of serious complication. In the absence of rational treatment, the expense on
treating common disease like stomach ache and body ache assumes an unusually high proportion. Also lack of
detection of fatal diseases like malaria and TB cough in early stages increases the cost of treatment at a later
stage and diminishes the chances of recovery. The root cause analysis of the high incidence of stomach related
ailments highlights the lack of safe drinking water and hygienic personal practices.

In view of the above findings several alternatives aiming at attaining the objective of rural health
empowerment were evaluated. The alternative of having institutional health insurance to insure these people
against health risks was rejected as a first means of intervention keeping in view the non monetized economy
in the tribal areas and the inadequate availability / access to rational health care facilities. Based on the
findings of the survey and focus group discussions, the non-availability of medicines at the early stages of
disease was found to be the major reason of high treatment costs.

The proposed plan was instead to implement health service provision. The proposed organization is
expected to be a three tier health service consumer cooperative. This would be expected to cut down the
morbidity rate to manageable levels. In addition, the awareness creation regarding rational treatment is also
expected to improve the responsiveness of the existing health care services of the government. The
cooperative is also expected to generate a small surplus which can be used for purposes of provision of
medical benefits in cases of maternity etc. In case this proposed change can be seen within the target
population, then the possibility of health insurance can become a reality.
Table of Contents
Acknowledgements...............................................................................................................i
Table of Contents.................................................................................................................a
List of Tables........................................................................................................................c
Abbreviations and Local Phrases Used:...............................................................................i
Introduction..........................................................................................................................1
A rural case study of health service at Bavrikheda..............................................................3
About Prayas........................................................................................................................6
Objectives of the Prayas Health Programme.......................................................................7
Objectives of the Study:.......................................................................................................9
Methodology:.......................................................................................................................9
The methodology adopted included a detailed analysis of the households using the
baseline data collected by Prayas, Focus group discussions with the community,
interview with the health services providers, review of available health insurance
packages...............................................................................................................................9
Analysis of the Data Collected:...........................................................................................9
Objectives of the Survey:.................................................................................................9
Methodology:.......................................................................................................................9
Sampling Method ..............................................................................................................10
Statistical Analysis.............................................................................................................10
Household Size..............................................................................................................11
Income Sources..............................................................................................................11
Sex Ratio........................................................................................................................12
Age Wise break up of family.........................................................................................12
Literacy..........................................................................................................................12
Access to Water..............................................................................................................13
Garbage Disposal Site Access and Distance..................................................................13
Fertility...........................................................................................................................13
Health Risks and Expenses................................................................................................14
Diseases that have occurred in the past one year:..........................................................15
Age wise categorization of the diseases that have occurred over the past year.........16
Probability of Disease Occurrence.................................................................................17
Diseases that have occurred within the three previous months of the survey...............17
Special Focus on Malarial Treatment............................................................................18
First Round Treatment Only: ........................................................................................19
Preference in Second Malarial Treatment Centre .........................................................19
Details of Focus Group Discussions .................................................................................20
Review of Health Insurance Packages...............................................................................23
VimoSEWA, a community based insurance approach...................................................23
The Operations and Mechanism of SEWAVimo:...........................................................25
Drawing Lessons from VimoSEWA’s experience for Prayas15, 16 .................................29
Rural Health Empowerment..............................................................................................30
Financial Vulnerability.......................................................................................................32
Lack of Awareness.........................................................................................................33
Lack of Facilities............................................................................................................33
Lack of Liquidity...........................................................................................................34
Objective of the Study.......................................................................................................34
Criteria to be met...............................................................................................................34
The Alternatives to achieve the Objective.........................................................................35
Detailed Design and evaluation of the proposed plans of Risk management Techniques. 36
Increasing the responsiveness of the Government Health Services...............................36
First Aid Kit containing medicines for common ailments.............................................36
Non Institutional schemes to minimize health expenditure risk....................................38
Institutional Insurance Coverage...................................................................................39
Mobile Health Service...................................................................................................40
Choice of Alternative.........................................................................................................41
Implementation Plan..........................................................................................................42
Rationale for the formation of a cooperative.................................................................42
Activities to be undertaken for Implementation ...........................................................44
Conclusion.........................................................................................................................49
APPENDIX 1: Weightage calculation using Census 2001 data:..........................................i
APPENDIX 2: Treatment Expenses Calculation on Population of 20 villages.................iii
Interview with the P.H.C. Doctor........................................................................................iv
Interview with the quack (Bangali Doctor).........................................................................v
References:...........................................................................................................................a
List of Tables

Table 1: Split up of income generation activity...................................................................a


Table 2: Access to BPL and Swasth Card............................................................................a
Table 3: Statistics on Water Source......................................................................................a
Table 4: Coding of distance of water source........................................................................b
Table 5: Village wise split up of Chronic diseases...............................................................b
Table 6: Cost incurred on chronic diseases..........................................................................c
Table 7: Age wise occurrence of chronic diseases...............................................................c
Table 8: Split up of first round treatment of Malaria...........................................................c
Table 9: Average cost of treatment of diseases that have occurred in 3 months preceding
the survey.............................................................................................................................d
Table 10: Cost Incurred on common diseases: Split up.......................................................e
Table 11: Probability of occurrence of diseases...................................................................e
Table 12: VimoSEWA Insurance Schemes...........................................................................f
Table 13: Costing of First Aid Kit for 139 Households.......................................................g
Table 14: Cash Flow Statement for the Cooperative for 4 years.........................................h
Table 15: Balance Sheets of the Cooperative for the first four years..................................h
Abbreviations and Local Phrases Used:

Bhopa Faith Healer


BPL Below Poverty Line
Dai Traditional Mid Wife
Fala Hamlet
Haat Rural Market
Jadi-Buti / Jangli Dawa Local / Traditional Herbal Medication
Kuccha House House of Short term durability, made with earthen material
Mala-D Oral Anti-Pregnancy tablets
OBC Other Backward Caste
PHC Primary Health Centre
Pucca House House made from modern materials like Reinforced concrete
RTI Reproductive Tract Infection
SC Scheduled Caste
SHG Self Help Group
SPSS Statistical Package for Social Sciences
ST Scheduled Tribe
STD Sexually Transmitted Disease
Swasth Card A Government issued card for subsidized/free Health Service
WEIGHT The value of weights given to each village (APPENDIX 1)

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Introduction

The tribal people of Chittorgarh have long refrained from monetizing. Their
relations with the jungles were symbiotic. They protected the jungles and the jungles fed
and sheltered them and provided them the various simple requirements that they had.
With massive deforestation after the late 1960’s the reliance on the jungles receded with
the jungles themselves receding.

Most of the tribals in the jungles still are not able to come to terms with “saving”
or having more than what is required.15 There have been advances that have reached
them. Their reliance on a hunting gathering life has receded and agrarianism has
increased. The agriculture is primarily subsistence. Most of the fields do not even have
adequate bunding resulting in top soil erosion and exposure of the rocky substrate.

They still depend upon the forests for fuel wood, fodder for the animals as well as
a few fruits and drink (a local brew called Mahua). Animal husbandry has caught on since
the wild animal population receded with the forests. They have Bulls which are used for
agriculture, cows and buffalos for the milk, goats for milk and meat and chicken for the
meat. The water for the animals come from nearby streams which are plenty in the region
around Mungana although not all of them are perennial.

For their agriculture, their tools are simple ploughs made from the wood of the
forest, the metal parts are all purchased from Mungana market. The agriculture is rain fed
for one season and canal/river fed for the winter crop. The land is not as fertile. Most of
the land is not bunded and hence after the rains, a lot of small rocks are exposed and this
is the land that is tilled for cropping. The fertilizers are purchased against loans. A
Rs.250/- bag of fertilizer is purchased at Rs 350/-.

The way in which this works is that the bag of fertilizers and seeds are purchased
from the preferred money lender come trader. The person then makes a contract that the
farmer should pay Rs.350 per bag of fertilizer at the end of 3 months. This money is not

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directly given to the trader. Instead, the trader takes back a part of the produce at a price
below that of the market and ends up making large profits even on the produce. Leaving
aside the profits from under-evaluation of the produce, the stated interest rate on the bag
of fertilizer alone comes to 120% PA.

The main source of income (since agriculture is more for subsistence) is labour.
The tribals seek manual labour in the nearby cities or through government drought relief
and employment schemes. However, all is not well even in the employment domain.
Even here, in case of non-governmental labour, there are contractors who set up the job
for the people and are the middlemen when making the payment. Quite often, the
contractors make a down-payment to a family in need and then fix the contract of the
person. There is no direct payment made to the person. Instead, only his food will be
given and the person needs to work. Prayas has been working for the enforcement of the
bonded labour act and has been the organization that has freed the largest number of
bonded labourers in a single year.

Expenses in the markets too are not too many. In the focus group discussions
conducted among the tribals, their response was that whenever they need money, they
would sell some of the grains and then use the money. Most people do not have large
number of material possessions. They mostly keep two sets of clothes each per year and
wear it out, only to buy new ones the succeeding year.

However, the health problems faced by these tribal people is not different from
that faced by any of us, although the intensity of sickness may vary. There is however, a
great gap in the health care facilities that these tribal people get at the hour of their need
as compared to what is available to us. To elaborate the condition of health care facilities
available to these people the following case study may be the most appropriate one.

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A rural case study of health service at Bavrikheda

Kejribai is a woman in her early forties. She, like most others in the area is not
sure of her age. She and her husband Dhulaji have three sons, two of whom are married
and have children. Like the other people in the area, they belong to the Meena tribe.

The name of the hamlet (“fala”) is Bavrikheda which is slightly offset from its
village, Hajariguda. Over half a decade ago, Prayas had organized the tribals to plant
trees and regrow the forests which had been earlier razed. The jungles are now back. The
fala is surrounded by a thick forest of teak which the villagers protect through their forest
committees.

The agricultural lands surround their houses. On the other edge of the lands are
the forests. The agriculture practiced is entirely manual with no amount of
mechanization. There is no electricity in the village or sources of water for lift irrigation.
There are no tractors. Although one can be hired for around 250/- a day, none are
employed and tilling is done with bullocks which most households have. They have two
crops a year, one is rain fed and the other is canal fed with water from the Jakhm dam.

The drinking water in the village is taken from a hand pump. Although the river
Mahi flows close by, it is usually used for bathing/washing clothes and seldom for
drinking.

In order to reach the fala, one has to get off the main tarred road that connects
Mungana (one Panchayat) with Boria (another Panchayat). The mud road then takes one
through undulating land with rocks, pebbles and forests of teak. After a walk for over an
hour and a half (around 5 to 6 kms), the jungle clears up at Bavrikheda which is on and
around a small hillock. The mud road has been widened to provide accessibility for a
medium sized four wheel vehicle.

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However, even now, there are no preset modes of transportation from the fala.
Only providence could provide one with a tractor on the mud road, or of all the chances,
if someone has pre-hired a jeep for transport to Mungana or Boria. The main road too
may not provide solace as there may be private transport systems (overcrowded jeeps)
plying irregularly every hour to two hours between seven in the morning and five in the
evening.

This, when viewed from the perspective of medical services, poses a serious
difficulty. There are no means of transport in case of medical emergencies. The nearest
PHC which is at Mungana has no facilities for treating in patients.

Dhulaji had borrowed Rs. 10,000/- from a moneylender in Mungana at 50%


interest PA in order to trade goats. He had no previous experience in the business. Most
businesses in the area are traditional family businesses. The money lending business is
run by Jains who can only be found in Mungana and not in the nearby villages. The other
dominant caste in Mungana is that of the Tailors. Almost every household has people who
are working in Kuwait. The tribal people in the area come to sizeable village/towns like
Mungana, Tehsil Headquarters Dhariavad or Pratapgarh in order to make purchases/sales
in the market etc.

Kejribai, started developing some pains in the stomach, which she put up with for
a few days. Once the pain worsened, it could not be put off. Kejribai was taken to a
“private doctor”. The private doctors are usually quacks and not registered practitioners.
She had to be treated thrice before she no longer had the problem. The total cost of
transportation for the three trips was around Rs. 500. Another 1000/- was spent on
medication and consultation.

Upon interviewing a couple of “private doctors”, the doctor at the PHC and
conducting focus group discussions in the villages, there emerges a clearer picture. The
locals have the sense that they will be cured only upon administering glucose drips
intravenously. The requests for IV drips, colloquially called “botal Chadana”, are a

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common phenomenon here. Any medical service provider who does not do so, will not be
considered a doctor. The doctors too recognize this. But they are also slightly defensive
with regards to this practice. They say that the conditions in which the patients arrive, the
diseases are in an advanced stage, and the patients are quite weak. The IV drips
rejuvenate the patients. Also the delivery of injections over tablets is also a common
phenomenon. This too was defended, albeit weakly, by talking of the advance stages of
diseases.

The cost of administering the IV drip in the area is between 150/- and 300/-
depending on the patient, the disease and the injection which is delivered through the IV
drip. Compounded with the problem of graft in the PHC, this comes up to a considerable
amount for the poor tribal of the areas who have largely refrained from being monetized
and are more subsistence oriented

The medicines and treatment that is supposed to be available free of cost to the
people are also being charged. The medicines that need to be dispensed are shown to be
out of stock. The prescription for the same is given to the patients who get these
medicines from the local medical shop which dispenses the drugs that have been supplied
in connivance with the operations of the PHC. The medicines bear a “not for sale” on the
label which is inadequate considering the low literacy rate even in the local languages.
Most of the medicines bear labels in English.

For people like Kejribai, availing healthcare facilities can become an ordeal. Her
husband failed to make any profits from his 8,500/- of loan left over after paying 1,500/-
for a simple stomach related illness. The debt burden he now carries is Rs. 15,000
considering the interest rate of 50%. For this he has mortgaged his land. The one thing
that may save his land is the fact that the tribal land cannot be owned or transferred to/by
a non tribal. But as with everything else, the laws of the land may only be paper tigers.

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About Prayas

“For every thousand hacking at the leaves of evil there is one striking at
the root”
-Thoreau

Prayas is a Non-Governmental Organization (NGO) based in Devgarh in


Chittorgarh district of Rajasthan. It works primarily among the tribal and dalit populace
of the Chittorgarh district. It believes that only revitalization of self-esteem of the poor
can bring about an everlasting improvement in the quality of their lives.

The objectives of the organization are described as follows.

• To enable the poor to have opportunities to their social, economic, physical and
cultural growth
• To create alternative knowledge and mechanisms for community development
• To lobby to secure social, economic, political and cultural rights of all
• To respond to contemporary poverty related community needs
• To campaign for gender sensitive conduct and equity

The activities of Prayas are primarily in the field of healthcare. The NGO is
funded among others by Novib of Netherlands, Action Aid, OXFAM, UNICEF, UNFPA,
CRY, SRTT and Swiss Development Committee.

The work of Prayas is spread among dalit, adivasees and other poor in more than
400 villages of Chittorgarh district and about 100 villages of Udaipur district. All these
villages fall in Chittorgarh, Pratapgarh, Nimbahera, Bhadesar, Bhadsoda, Chhoti Sadri,
Badi Sadri, Kapasan, Dungla and Arnod blocks of Chittorgarh District and the
Dhariyawad block of Udaipur district.

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Since its inception in 1979, Prayas has been working in the field of healthcare.
The area of activity was primarily the Devgarh block of Chittorgarh. However, Prayas
expanded into other blocks of the district. Its head office is at Chittorgarh, the district
headquarters, due to the importance of proximity to the decision making in Government,
although the registered office and a large strength of the organization is still in Devgarh.

In the early 1980s, Prayas was operating a PHC with special request from the
Government of Rajasthan in Devgarh. However, it no longer delves into service delivery
and its activities are primarily in the awareness, activism and advocacy.

Prayas has also been working in the Mungana block of Udaipur district since
1997. The initial activities (until June 2004) were restricted to Microfinance Self Help
Groups (SHGs). Since June 2004, healthcare was included into the list and currently, the
SHGs are the village level platforms for the organization to carry out its activities.

Objectives of the Prayas Health Programme

The stated objectives of Prayas’ “Tribal Women and Child Health Awareness
Programme” are as follows.

• Improvement in the general health of women and children


• Educating men and women on the health systems and procedures
• Increasing scientific awareness about the causes of disease and disease specific
preventive measures which can be taken to prevent diseases among the rural populace
• Creating a mutual health fund for sudden and serious diseases through which at times
of need, there would be help at hand
• Advocating the provision of safe, effective and free medical services available
through Government health services.

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Among the objectives, the fourth one which is underlined indicates the
importance attached to the economic impact of health problems. Through the focused
group discussions in the villages, interviews with PHC personnel, quacks and medical
practitioners, it became apparent that health issues within the households are usually
ignored and the immunity system is let to take its own course most of the times. Only
when the symptoms become severe and there is a considerable degree of pain does the
target population approaches the health services. The government health services are not
readily accessible to the people.

The typical condition of the area can be sketched as follows6

“Low living standards, barely subsistence incomes, poor housing, widespread


undernourishment, a great deal of ill health and contagious disease traceable among other
factors to environmental conditions, poor sanitation, inadequacy of diet and insufficient
education; a severe shortage of medical personnel made worse by their uneven
geographical distribution, resulting from a widespread tendency of doctors to concentrate
in large cities or towns; and inadequate transport facilities further limiting access to
medical and non-medical personnel to the rural areas. As a rule these conditions were
accompanied by an inadequate and scarce infrastructure in all respects, including short
supply of out-patient facilities, lack of hospital beds, equipment and therapeutic
technology. Low standards of public administration, weaknesses and instability in the
economy, completed the picture.”

Although the above is a description of England in the 1940s and 50s, it pretty
much sums up the conditions in rural Dhariavad in 2005.

Prayas works in Mungana with a team of six people. Prayas, Mungana runs
several Self Help groups and have had the groups operating in the ten villages. These ten
villages were taken up as a part of the baseline health survey conducted by Prayas for the
Mungana region. The data collected was transcripted into SPSS and the analysis was
conducted using both SPSS and MS Excel Data Analysis.

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Objectives of the Study:

The objective of our organization action component was to devise a mechanism to


provide health insurance to the tribal population in the Mungana region.

Methodology:

The methodology adopted included a detailed analysis of the households using the
baseline data collected by Prayas, Focus group discussions with the community,
interview with the health services providers, review of available health insurance
packages.

Analysis of the Data Collected:

Objectives of the Survey:

The primary Objectives of the analysis of the survey are

a) Ascertain the validity of the sample data collected


b) Describe the demography of the sample.
c) Analyze the health related issues and expenditures within the population through
the sample data in order to design an insurance / health assurance product/s

Methodology:

The surveys were conducted in ten villages, in the households of the SHG
members. These SHGs were instituted by Prayas. The questionnaire used in the survey
was developed by Prayas. Two thousand four hundred one respondents from four hundred
four households were the part of the survey conducted. Extensive training was imparted

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to the surveyors before the survey commenced as to the methodology of conducting the
survey and also to sensitize them about the need of conducting the survey. Training was
essential due to the sensitive questions (e.g., information regarding sexual health, etc.) in
the questionnaire.

Sampling Method

The type of sampling method adopted was convenience sampling. The sampling
size was also not representative. Hence, by appropriately weighing the scores for each of
the villages, the sampling can be considered as Quota Sampling. However, the size of the
sample ranged between five to ten percent of the entire population. Hence any deviation
from the population may not be significant.

The sample size surveyed from each village was compared to the actual
population of the given villages using the 2001 Census data. In order to make the sample
representative, weights were attached to the data collected in proportion of the
discrepancy between the population representation of each village in the sample and the
same in the census data. The weights against each village are given in APPENDIX 1.

Statistical Analysis

The number of observations carried out encompasses all the SHG households
falling under the Mungana cluster. However, the 2001 census data was used to make the
sample population representative.

The entire survey covered the tribal households only, who constituted
approximately ninety percent population in each of the surveyed village.

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Household Size

The household size in the area varies between 1 and 14, with 65% (1 σ) of the
household size falling between 3.73 and 8.16 (at a confidence interval of 98%). The
median size of the household is 6.

Income Sources

The activities that individual households are involved in for income generation
are mainly agriculture and labour. There is also a small percentage of households who
have members practicing some artisan skills like basket weaving etc. as well as another
small number being employed.

The split-up is given in Figure 1 and percentages are available in Table 1. The
overall split up of the 404 households is that 401 households have members depending on
agriculture, 369 households with members involved in manual wage labour and eight
households have members who are employed. Seven households have additional income
coming from artisan products and three households in the “others” category including
having shops. Agriculture is more of a means of subsistence rather than source of income.

The land is undulating and rocky. However, there are no systems of bunding
which results in frequent loss of top soil. Also the agriculture extensively uses Fertilizers
which are procured from the towns. The payment for the fertilizer is done in kind with a
part of the produce being returned to the lender. The interest on the Rs 250 bag of
fertilizer is Rs 100 in the three months of the agricultural season. This brings about an
effective interest rate of 160% Per Annum. This is not the only situation of exploitation as
the returns collected in terms of grain, is treated as that of lower cost than what is
available in the market and there is some amount of exploitation in terms of the weighing.

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The labour is usually that in the marble quarries and mines of limestone around
the region. The payment here is around Rs 60 per day. In case of the seasonal farm
labour, it is Rs 50 per day.

The agriculture however is done more from the point of view of subsistence rather
than as a source of cash generation. Despite this, the percentage of households with BPL
cards is only 17.57% and those with Swasth Card are 11.88%. The breakup of the access
to these government certifications is given in the Table 2.

Around 82.9% of the 2401 members in the sample are covered neither by the BPL
card nor by the Swasth Card. In terms of households, 81.4% are not covered. Among the
10 villages surveyed, the most remote to access village, Chunpa, did not have a single
household among the respondents which was covered by the BPL card.

Sex Ratio

The sex breakup of the sample households (n = 404) is 1,201 females and 1200
males. The associated sex ratio of the population is 1001.

Age Wise break up of family

The age wise break up of the family is taken as a means of adjudging the disease
instances. Hence the breakups are given in Figure 2.

Literacy

The literacy levels of the sample households are 50.23%. However, the number of
literate females is lesser than that of the male. As a percentage of the total literates,
women represent 43.7% of the literates and men cover 56.3%. The percentage among

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women who are literate is 43.88% and that of men is 56.67%. Therefore, in the sample,
more men tend to be literate as compared to women in the sample.

Access to Water

In the sample surveyed, the access to water breakup is shown in Figure 3. In terms
of the absolute sample taken, 50% of the population has access to water from Hand
pump, around 49% from open well and 1% from stream (This is mostly in the village of
Chunpa).

The distance traveled by the people in order to access drinking water has an
average distance of 157 meters. The distances have been shown in Figure 5 with the
coding of the distances given in Table 3.

Garbage Disposal Site Access and Distance

Of the households surveyed, 2.5% of the households do not have a specific site to
dispose garbage. Among the other households, the mean distance from the house for
disposing the garbage is 57 meters.

Fertility

Of the total married women in and above the reproductive age, 91.5% (484/529)
of the women are valid samples for pregnancy. The distribution of total pregnancies
including miscarriages is given in Figure 7.

As can be seen from the distribution, the highest frequency of pregnancy is three
pregnancies (16.9%) and the median number of deliveries is four per woman. If we take a

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Designing of Health Insurance for Rural Poor in Mungana Prayas

weighted measure of the sample as per the sampling plan, then, the distribution is as
given in Figure 8.

The age at the time of the first delivery has a median of eighteen years and the
mean is 18.6 years. However, the major issue of concern here is that over thirty five
percent of all pregnancies occur before the age of eighteen (i.e. seventeen and lesser)
which is the minimum age of marriage by law (as is shown in Figure 9).

In terms of the Infant Mortality, the study is fairly limited. The mortality rate has
been captured based on data collected from five hundred thirty married women surveyed.
Hence the method of calculating mortality rate per thousand births may differ from that
adopted by National Health and Family Survey. The thousnad births should be considered
over a smaller duration of time (the births that occurred in the area over the last year etc).
In the survey however, the births covered have dated back to the 1960s. Hence the
findings are shown only for the purpose of understanding rather than being a basis for
concrete analysis. The number of still born children per thousand births is 21.7. The
number of children who do not survive beyond their fifth year of birth numbers one
hundred and seventy five children per thousand children. From the focus group
discussions, it was found that the children usually die after a bout of diarrhea or malaria /
fever.

In terms of the assistance obtained for delivery, 87% of the births were Dai (local
midwife, untrained) assisted (Table 25). This is usually a woman member of the family or
a local woman who has assisted

Health Risks and Expenses

The survey conducted covered the following three specific parts regarding health
problems :
1. Chronic diseases that have persisted since last one year before the survey,

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Designing of Health Insurance for Rural Poor in Mungana Prayas

2. Common diseases that had occurred in past three months preceding the survey
3. Reproductive tract infection and Sexually transmitted infection (RTI/STI)
cases.
The details of the common diseases and chronic diseases covered in the survey
are detailed below.

Diseases that have occurred in the past one year:

Among the respondents, majority of the diseases (over 76.4%) was not
categorized into pre-coded diseases. The split up of the diseases (by percentages) in terms
of a pie-chart is given in Figure 10. The “Other” category (3.3%) includes cancer,
paralysis, disability, lunacy and stone. The unclassified diseases are categorized into the
“Others” (76.4%). If the “Others” category is filtered out of the total disease responses
(458), the split up of the disease is given in Figure 11. The diseases categorized as
“Other” in the figure 11 are cancer, paralysis, disability, lunacy and stone which are less
than 3% of the total number of diseases. The split up of the diseases in number terms are
given in Table 5.

The cost incurred on the diseases excluding that of “Others” are given in Figure
12. Only in one case has the disease expense been recorded at over Rs.25, 000. This was
later found out to be towards treatment for infertility which was unsuccessful.

If we exclude the others, the diseases for which expenses were borne by the
households are related to the respiratory diseases (10.57%). Arthritis, at 7.92%, forms the
second largest occurring disease for which expense was borne for the households. In
terms of expense too, excluding the “Others”, Ashtma, Arthritis and TB cough dominate
the spending for disease. The percentages are given in Table 6.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

In terms of the sex-wise split up of diseases for which expenses are borne for
treatment, Arthritis dominates for both the sexes with the instances being more frequent
among the women as compared with men as shown in Figure 13.

T.B./Cough is more dominant among the men as compared to the women.


Instances of disability, stone and asthma and TB cough combine are prevalent only
among men as compared to women among the diseases on which there have been
expenditure in the households.

Age wise categorization of the diseases that have occurred over the past year

The disease occurrence for each of the age groups has been split up by diseases to
give a clearer view of the breakup. The first of the graphs (Figure 14) show the
occurrence of TB/Cough , Asthma and both these occurring together.

As can be seen from Figure 14, the occurrence of these diseases is prevalent in the
people of higher age groups. Asthma has also been recorded among the children in the
age group of 6 to 11.

The occurrence of Arthritis and related bone problems and disability shown in
Figure 15 is across the age groups. Incidences of bone problems are highest among the
age groups of 31 to 45.

The only instance of Cancer is found in the age group of 31 to 45. Both Paralysis
and lunacy is found in the age groups of 46-90 as shown in Figure 16. The instances of
ear disease, ovarian infection, swelling as well as stone are given in Figure 17. The
comprehensive age wise statistics are given in Table 7.

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Probability of Disease Occurrence

The commonly occurring (common) diseases that have occurred in the


respondent’s household over the last year are detailed below. Table 11 gives the
occurrence of the common diseases that had occurred within the three months preceding
the survey. As can be seen in the table, the highest instance of any disease is that of
Malaria which occurs in ten and a half percent of the population. As has been analyzed,
this also is a reason for serious expense among the households.

The percentage of the sample which is affected by Malaria as well as other


diseases or only standalone instances of Malaria is actually 13.33%, of being affected by
stomach related diseases (including diarrhea, malnutrition, acidity and ulcers) is 10.87%
(Which is the second most commonly occurring disease: Standalone stomach related
problems occur in 7.87% of the people).

The average cost incurred for the treatment of these diseases is Rs. 182. There
was only one reported case of mental illness and epilepsy, the expenses made by the
household (Rs. 7700) on the same is not included. The highest average expense incurred
for a disease is Rs. 639 incurred for skin related diseases which is followed by Rs. 565
being spent on an average for Malaria. The detailed figures are given in Appendix 2.

In terms of exploring the various rural insurance schemes and products for
implementation in Mungana, one that was looked into in depth was that of VimoSEWA.
This scheme is described in detail below.

Diseases that have occurred within the three previous months of the survey

The survey had categorized the disease occurrence for the last 3 months and for
the previous year. Given in the Figure 18 is the split up of the diseases by cost. The

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Designing of Health Insurance for Rural Poor in Mungana Prayas

diseases for which more than 500 Rs was expended upon are given in Figure 19. The split
up of the diseases by Percentages is shown in the pie chart given in Figure 20. In the
graph, the “others” category includes Non-Infectious: Diabetes, BP, cataract, cancer /
Animal Bite / Mental Illness, epilepsy / Swelling in Body / Stomach & Respiratory /
Stomach & Skin / Stomach & Malnutrition / Respiratory & Malaria / Skin & Malaria /
Malnutrition & Skin / Malnutrition & Malaria / Stomach, Respiratory & Skin / Stomach,
Skin & Malnutrition

Excluding the malaria related diseases as well as the commonly occurring


diseases, the remaining diseases broken up by percentages is shown in Figure 21. In
terms of the expenses incurred on the diseases, we get a clearer picture if we exclude the
disease instances with expenses of less than Rs 100, as has been done in Figure 22.

From the graph, it is apparent that even a disease such as Malaria for which the
Government health services are to provide free medication is not treated freely. The cross
tabulation of the disease and total expenses on the disease is shown below.

More than half the diseases treated, for which expenses were incurred by the
people, were treated for less than Rs. 100. The case of Malaria is dealt with in further
detail below.

Special Focus on Malarial Treatment

With regards to Malaria, the treatment is to be provided at PHCs and Government


Hospitals free of cost. However, from the data, we can understand that there is some
degree of expense involved in terms of the sample getting treatment for Malaria.

Below is a slightly detailed analysis of the sample population’s treatment of


Malaria.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

A total of 320 instances of Malaria were reported during the survey of which there
were 269 standalone instances of Malaria. Of these, 133 reported spending some amount
of money. Among the 133, only 33 went in for a second round of treatment, 12 for a third
round and 5 for a fourth round.

The mean expense incurred for all the 133 instances of Malaria that were treated
is Rs. 512. The mean expense for the 160 people treated with Malaria and additional
problems was down slightly at Rs.468 .

First Round Treatment Only:

Of the 120 instances of treatments being made only in the first round, the Table 8
gives the breakup of the numbers.

From the figures it is apparent that the Private treatment is the most preferred first
place of treatment for Malaria and the cost of the treatment at private practitioners is also
lower than that at government health centers.

Preference in Second Malarial Treatment Centre

Of the people who went in for 2 rounds of treatment, (23), nine went in for
treatment through the government service provider and ten through private healthcare.
Only one went in for bhopa and three opted for the local medication for the Malarial
treatment.

Of those who went in for government treatment in the second round, their mean
cost of the second treatment was Rs. 1,063 with the total cost coming to Rs 2,430. Those
who had opted for both rounds of treatment at the government centre had their costs
marginally up at Rs 2,536. The range of costs incurred varied from Rs. 80 to Rs. 5,700.

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Compared to this, those who opted for both rounds at private practitioners (10
people) incurred a mean cost of Rs.173 with the cost ranging from Rs. 50 to Rs. 730.

From the above statistics it can be seen that the cost of treatment at the PHC /
CHC is much higher than the cost of treatment at other service providers’. A possible
explanation is that the payment to the other service providers includes payment in kind
whose worth is not accounted for while recording the treatment expenses. Also while the
counsel of traditional faith healers and quacks are sought at the preliminary stages of the
disease, the same is done much later when the PHC is concerned. This is due to various
factors like accessibility, faith in the service provider etc.

In general the trend of expenses for the treatment for those who went in for 4
rounds of treatment is given in detail in Figure 23.

Details of Focus Group Discussions

Focus group discussions were carried out in various villages under the Mungana
unit as a part of the exercise to access the need of health insurance products. In each of
these villages there are women SHGs which form the primary unit of analysis in this
report. The topics discussed in these focused group discussions were as follows:

1. The incidence of common and specific ailments among the members of the SHG
and their family members
2. The health care facilities available to the members both from the organized and
the unorganized sector
3. The distance of service providers.
4. Expense breakup as per diseases in medicine, consultation, transportation,
opportunity cost (if any)
5. Expenses incurred on pregnancies and child birth

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Designing of Health Insurance for Rural Poor in Mungana Prayas

6. Kinds of disability and incidences of the same.


7. Type of healthcare providers (Bhopa, Quack, PHC)
8. Average income level and family size
9. Current sources of credit availed for healthcare purposes
10. Mapping probable needs of credit which could lead to financial difficulties
11. Assessing the ability and the willingness to pay for a health insurance products

The SHGs which were formed by Prayas in the area have member strength
ranging from ten to twenty members. The average age of the SHGs was three years. Each
SHG had a team leader (“Adhyaksh”), a treasurer (“Koshadhyaksh”) and a secretary
(“Sacheev”).

The health care facilities available in each village were similar. However, the
nature and state of disease in which professional medical help was sought varied from
member to member. For instance, people tend to prefer the traditional healers (“Bhopa”)
above any other kind of medical assistance and they go to PHC’s or Govt. hospitals only
on the recommendation of these Bhopas to do so. They have little faith on the PHCs
which is both due to lack of awareness as well as due to lack of proper care in these
institutions.

On an average the expenditure on any disease like stomach ache or fever amounts
to Rs. 500 if approved professional medical care is sought. This is because of the fact that
they have to purchase all the recommended medicines from private medicine shops. Each
time the cost of their treatment becomes unusually high because they insist on being
administered IV drips, as they believe that it is the medicine that will cure them of their
ailments.

The incidence of stomach related ailments was particularly high in case of


children (diarrhea) as well as adults. The health care service providers ranged from
traditional faith healers (Bhopas), quacks (Bangali doctors) and PHCs. However, if the

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service providers are mapped according to the easy availability and the faith of the
members, the bhopas far outweighs the PHCs.

The distance of PHC from the villages varied according to the location of the
villages and the cost of transportation varied according to the distance from the motor
able road. In the distant villages, tractors or motorcycles of fellow villagers form the
primary mode of transportation. In the absence of any of these modes of transportation,
the patient has to cover the distance on foot. Among the expense incurred on being ill,
one of the most significant is the opportunity cost of the effected person and the person
who accompanies him/her to the PHC. The cost becomes significant as most of these
people are subsistence level farmers and in the non agricultural season, they work as
wage labourers. The daily wage of Rs. 60 (if they happen to work in mines) of the patient
as well as that of his companion is lost on the day they go to the PHC for treatment.

Another major concern of the members was that in their non monetized economy,
it becomes extremely difficult for them to pay in rupees the expenses of medicines and
treatment in PHC. As compared to this, the Bhopas are closely integrated in the society of
these tribal people. They charge them not in term of cash but in kind. They ask for grains
and / or livestock as their fees for treatment. When the villagers need to pay for treatment
in cash, they sell some of their stored grains or they borrow money from the local money
lenders. These moneylenders usually charge 24% rate of interest on the amount credited
but on occasions when villagers need money urgently (like for medical treatment), the
interest rate could be up to 60% per annum.

Since the tribal areas are not monetized, this rate of interest translates to sacks of
grains stored for self consumption. In the event of inability to pay back the loans thus
taken under various circumstances, the moneylenders pick up as many sacks of grains as
they feel would suffice as repayment, by force. The other reasons for which these people
need credit is agricultural inputs, farm implements, cattle / livestock, house repair,
vehicle purchase, other businesses (if any) and in a few cases, school fees for their
children.

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The level of awareness about maternal care during pregnancies as well as during
child birth is abysmally low. Even after repeated education by the health workers (of
Prayas), they tend to follow the old practices and customs blindfolded. Traditional dais
still acts as birth attendants. This is in spite of the fact that there are ANMs (auxiliary
nurse mid-wife) available in each of these villages. The reason being stated for the
inability of the ANMs to be present at the time of child birth is that if the birth takes place
during night or any other wee hour, the ANM is not available in the village.

Due to repeated efforts by the Prayas health workers, iron tablets are being
accepted by pregnant women as an important constituent of their diet. Repeated
pregnancies starting from very early age leads to several STI and RTI related problems
which in these parts are known as “purda rog”. Ignorance about the facilities of treatment
available and the culture of silence prevalent among women restricts their approach to
medical assistance.

Review of Health Insurance Packages

VimoSEWA, a community based insurance approach

“I saw constant illness…- frequent pregnancies, high mortality, both of


the infants and mothers and widowhood. All these have emerged, at one
time or another, as reasons for a financial crisis in a woman’s life,
leading to her high vulnerability”
-Elaben Bhatt, Founder, SEWA

As a part of the exploration for various alternatives for insurance, Upassana Joshi
from VimoSEWA, Ahmedabad explained the intricacies of the SEWA approach to
insuring the poor.15

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The Self-Employed Women’s Association (SEWA) is a labour union of over


500,000 women workers of the informal economy and is based in Ahmedabad in Gujarat.
It was started in 1972 by Ela Bhatt and is spread over six states in India: Madhya
Pradesh, Uttar Pradesh, Delhi, Bihar, Kerala and Gujarat. The combined strength of the
SEWA movement is over 700,000 in India.

In the course of organizing the poor women, some of the learnings of SEWA were

• Women and their families face multiple and frequent risks which result in huge
economic leakages and losses, keeping them in poverty
• The poorest and most vulnerable of communities and especially women are
disproportionately affected by exposure to risks.
• Risks and crises result in de-capitalization and asset loss and consequently women
and their families slip deeper into poverty
• Risks may be chronic or acute; chronic risks include: poverty and unemployment and
acute ones include drought, floods, sickness and natural disasters like earthquakes
• Poor women want support to tackle as many risks as possible at a time, thereby
reducing their vulnerability. An insurance package is one way to do so.
• Poor women are willing to give premium for insurance, thereby protecting themselves
against risks

Social Security, which is what SEWA views the insurance as, it believes, is an
integral part of full employment. Without it, women workers cannot obtain work security
and vise-versa, and without both, workers cannot achieve their goal of self reliance.

SEWA hence holds that all workers need a minimum level of social and economic
security through health care, childcare, insurance and housing. This is all the more
required for women of the informal economy, the poorest of workers in the country.
SEWA’s belief is that social security services for poor women workers can best be
provided by member-owned institutions. These institutions also must become financially
viable in the long-term, with contributions from workers, employers and government.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Hence SEWA has developed cooperatives and associations to provide social security
services.

SEWA initiated an integrated insurance scheme in 1992 where each insured


member pays a premium for a comprehensive insurance cover of life and non-life
products. SEWA members use and manage their own insurance service which is called
VimoSEWA (after the Gujarati word for insurance, Vimo)

This is based on the core principles of Mutual help, self help, integrated approach,
financial viability and sound insurance principles.

As of January 2005, SEWA insurance had a membership of over 133,000 women,


their husbands and children with over 25,000 insured members having received claims
worth over Rs. 5 Crores. The Vimo SEWA is headed by Mirai Chatterjee.

The Operations and Mechanism of SEWAVimo:

The renewal rate (the number of people who renew their insurance) for the
insurance is 40%. Although it is a very low figure, the overall insurance renewal rate in
India is very poor, and this is one of the largest experiments in terms of micro insurance.
The mechanism for renewal is that of door to door “campaigns” which are made three to
four months before the last date of paying the premium.

The organization structure till the level of supervisors is as follows. At the


village/grassroots level are the members. They are “managed” by a “aagewaan” who is
the village level / local level person who works on piece meal daily wage basis. The
“aagewaan” is trained on the insurance concept and SEWA’s insurance products and then
has a field level training by being attached to a senior experienced “aagewaan” who is to
mentor the new person. Several “aagewaans” report to the organizer who is a paid

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Designing of Health Insurance for Rural Poor in Mungana Prayas

employee of the organization and the organizers at a cluster level report to the Cluster
Supervisor.

VimoSEWA has a unique approach in the sense that the same agency
(VimoSEWA) handles both the agency part (sales of the insurance product) as well as the
claims part of the insurance.

In terms of the claims, all the claims are processed at the head office level in
Ahmedabad. The only exceptions to this are two districts of Anand and Kheda. The
claims committee which has a Registered Medical Practitioner on the panel meets once
every week to scrutinize the claims and reject or accept the claims. The scrutiny is
essential due to a sizeable number of fraudulent claims. Around 14% of the claims were
rejected for the year 2002-2003. The then rate of claims was 15/1000 members per year
for the health insurance. 11% of the claims did not involve admission to hospital, most of
which were fractures. Preventable illnesses comprised most common causes of
hospitalization e.g.: injuries, gastroenteritis, malaria. The average cost of hospitalization
was Rs. 4500 and the average rate of reimbursement was 47%. The average time to
reimbursement was 3 months because of delayed submission of claims by members. The
details of the scheme are given in the Table 12.

The insurance scheme of SEWA is conceived as a cooperative and hence


incorporates several features and beliefs. Among these are
• The workers themselves manage the services through local teams of grass-root level
women leaders (“Aagewaans”)
• The workers promote insurance by educating and disseminating information on
insurance. Most SEWA aagewaans and members need intensive education on
insurance as it is an entirely new concept for them.
• The workers decide on the claims and ensure rapid disbursements
• Decide on the premium, new products and coverage to be offered, based on the data
prepared by the in-house technical staff
• Begin to negotiate with the commercial insurance companies like ICICI Lombard etc.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

The aagewaans, through their training learn and experiment with the ways to
convey information to other women workers in a comprehensive and effective way.

In terms of the learnings of SEWA through the insurance arm, it lists the
following as the most important learning. A few of these are very important in general
cases for micro-insurance since these can be seen as generic.

• Insurance is an essential economic support to women in crises. It prevents de-


capitalization and indebtedness and hence promotes self-reliance. Thus insurance
should be part of poverty alleviation programmes. It should be specially linked to
livelihood and employment generation programmes.
• Financial services like savings and credit encourage women to save for insurance.
Insurance coverage, in turn, promotes savings and credit and long term financial
planning among poor women. Thus, insurance must be linked to other financial
services (savings and credit) for poor women. It is part of microfinance and should be
integrated with asset building programmes.
• People’s insurance programmes can be viable since people are ready to contribute.
Government and employers too must contribute towards financial viability. Further,
contributory insurance programmes for the poor must be developed and managed by
them.
• The poor prefer coverage of multiple risks through an insurance programme.
Coverage for sickness is the top priority, followed by life and accident insurance.
Thus a “package” of risks should be covered in which health and life insurance must
be essential components.
• Health insurance including reproductive health coverage complements the public
health system and creates demand for better quality services. This is because when
insured persons are hospitalized, they use the health system, both public and private.
The latter is increasingly unaffordable for the poor. Thus, health insurance must be
developed to complement the public health system

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Designing of Health Insurance for Rural Poor in Mungana Prayas

• Education on insurance accelerates membership and expansion. Persistent efforts are


required to explain the concept of insurance to poor women for whom it is a new and
unfamiliar form of risk pooling
• Insurance should be developed in a decentralized manner by and with local women
and their own organizations. This not only promotes economic self-reliance of
individual women, but also their empowerment as a group. This, then, in turn
encourages women workers to further organize.

In terms of sustainability of the insurance arm, the lessons learnt, as documented by


the SEWA team is as below.

• Promotional, marketing and claims – The servicing costs are high when insuring the
poor
• Expansion of insured members helps spread costs
• Increase in premiums must be gradual. Premiums can be increased gradually so that
at all times they are affordable and accessible to the poorest.
• Government and private equity is required for overall sustainability
• If workers, government and employers and/or donor agencies contribute a third each,
the entire programme can be sustainable. Currently (2003), SEWA’s members, the
workers contribute 50% of all running costs. The government’s contribution is 17%
and the employers and private sector have not yet given any contribution via equity.
Some funds for capacity building are currently available from private donors
• Investing in the poor, especially women, through social insurance is viable.
• Linking with preventive health programme is both necessary and helpful to reduce the
burden of illness among the poor. And, of course it has the impact of reducing health
claims, and thus contributing towards sustainability.

In terms of the challenges faced by VimoSEWA, as documented by the SEWA


team in 2003, there are two major challenges. The first is the statutory requirement of
Rs.100 Crores to set up an insurance company/cooperative. This means that only

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Designing of Health Insurance for Rural Poor in Mungana Prayas

organizations with sufficient amount of capital can set up an insurance company.


VimoSEWA needs to be capitalized by workers, government and employers through
equity. Alternatively, SEWA will have to press for a special policy to reduce the capital
requirement in insuring the poor.

Secondly, there is a high technical requirement to set up an insurance company,


including hiring of trained insurance personnel. VimoSEWA would have to build up its
technical competency and a team of persons well-versed in insurance.

Drawing Lessons from VimoSEWA’s experience for Prayas15, 16

Keeping in view the background of the people of the region, the specific points
put forward by VimoSEWA in terms of reduction of risk can be seen to be applicable.

The fact that the tribal people around Mungana face multiple and frequent risks
which can change their economic status drastically and lead to poverty can be seen from
the instances that have occurred in the villages. The vulnerability of the peoples of the
region is also quite high as a crop failure or limited employment at the mines where they
work can mean the difference between relative security and poverty. De-capitalization
and asset loss are already a part of the life in these areas. In cases of acute risks like
drought, floods, sickness or natural disaster, the people do not have any succor.

The need for social security is apparent and yet not available in these
communities. There are community based social security approaches. In some of the
villages, there are local customs and traditions which provide some sort of a social
security. In these schemes, if any household is in need of money for treatment, they keep
a box and a book and announce the same in the village. All households then contribute
the amount of money they can and record the same on the book. The money could be
anywhere between Rs50 and Rs300. The collected money is used for treatments. The
custom works since, if members in another household need money, the household which

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Designing of Health Insurance for Rural Poor in Mungana Prayas

had earlier collected money by custom have to contribute more money than what they
received from the household in consideration.

This help is quite limited considering the indebtedness of the people due to
reasons of ill health. However, saving money for a rainy day is not a trend that is
commonly followed here. Due to lack of monetization, monetary thrift is a concept which
seems nearly alien to the people here. Hence, the VimoSEWA learning that financial
services like savings and credit encourage the people to save for insurance also is quite
applicable.

Though there is a system of traditional pooling of money, the concept of insurance


is relatively new. On being explained how the scheme works, the tribal people have only
one reservation, that of non-refundable nature of the health insurance. The need for
creating awareness on the intricacies of insurance is apparent due to the situation
regarding the expenses incurred, the vulnerability as well as the lack of awareness about
insurance schemes.

However, as can be seen from the experience of VimoSEWA, the infrastructural


problems, lack of adequate health service providers as well as other factors could
contribute to high servicing costs, especially in terms of claims servicing. While the
distances of the village from the government PHC is large, treatment costs are high. Even
in cases of diseases like Malaria, for which the Government is to provide free services
through the Primary health care services, the average cost of expenditure in the Mungana
area through the PHC is around 330/-.

Rural Health Empowerment

The health risks faced by the rural people in the study area have been identified
using both primary and secondary sources of data. The various loss exposures associated
with loss of health can be classified under three broad categories:

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Designing of Health Insurance for Rural Poor in Mungana Prayas

1. Expenses incurred on account of availing medical care. The expenses include


transportation costs, cost of medicines and cost of food.

2. The opportunity cost due to loss of employment during the period of illness. This
cost in case of mine labourers is Rs. 60 per day for an adult. The cost in the case
of agricultural labourers is Rs.50 per day. In case of a person working on his/her
own field it becomes difficult to estimate the opportunity cost as everyone in the
household contributes labour.

3. The opportunity cost of person accompanying the ill person due to loss of
employment. The opportunity cost of this person includes the transportation cost,
loss of income (Rs. 60 in case of mine labourer) as well as the cost of food.

The above expenses depend mainly on the disabilities caused by the illness. The
disabilities caused can be the total disability resulting in complete incapability of gainful
employment during the time of disability or partial disability resulting in decreased
ability to earn a living. The risk exposure pertaining to losses due to disabilities can be
further analyzed under the following headings:

1. Causes of disability: The causes of disabilities due to illness vary according to


sex, age and other factors like, personal hygiene, environment etc. For instance,
the incidence of asthma and TB cough is more in the case of males as compared
to females who are more prone to cancer. The senior members (age group of 46
years and above) are more prone to arthritis whereas the incidence of ear infection
is more in the case of children (age group of 6 to 11 years).

2. Duration of disability: The duration of illness is another significant factor in the


total medical expenses as prolonged / repetitive illness tends to increase the cost
of treatment.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

The diseases have been categorized as chronic and common diseases on the basis
of their length occurrence and severity of effects. The chronic diseases are those from
which a person has not fully recovered and have been in existence since at least 3 months
from before the survey. In other terms, these are the diseases which require prolonged
medical treatment. TB cough, arthritis, asthma are some of the diseases categorized as
chronic diseases.

Common diseases in comparison are diseases whose rate of occurrence is higher,


but it effects the person for shorter duration and the expenses incurred as a result of this is
also lesser than those incurred for chronic diseases. Stomach related problems like
diarrhea, stomach ache, ear infections, fever have been classified as common diseases.

3. Severity of the disease: With advancement in the stages of the disease the medical
expense tends to increase manifold. Thus, the stage of disease at which medical
help is sought becomes a deciding factor in the expenses incurred. It was observed
in many cases that medical help from Govt. hospitals or PHCs were sought only
after repeated expenditures as fees to traditional faith healers and/or quacks.

Financial Vulnerability

The reasons for financial vulnerability due to illness are primarily three.

• Lack of Awareness
• Lack of Facilities
• Lack of Liquidity

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Lack of Awareness

Most people in the area tend to ignore the symptoms of the diseases at the
preliminary stages. Unless the disease becomes severe, they do not try to seek any sort of
medical help. Hence the instances of diseases that are treated are quite severe and people
who avail the same are quite weakened and stricken physically.
Compared to this, under the same circumstances, persons residing in urban or
semi urban areas would usually consult the local pharmacist and consume medicines at
the very outset of the disease. This early medication often cures the disease and/or
reduces the instances of severity.

Lack of Facilities

One of the reasons why diseases are ignored in the preliminary stages is due to the
lack of infrastructure: both that of health services as well as for transportation. The non
monetized nature of the tribal economy also means that the travel to the local market
centers and haats are quite few and far apart. Hence even a visit to the doctor would be a
specific reason for travel rather than being a part of a bundle of activities that require
traveling to the market/town.

The average time taken to reach a PHC from the ten villages studied is about two
and a half hours. This would mean an entire day would be spent to get treatment. The
PHC at Mungana too is not very responsive in terms of the services. The PHC does not
stay open beyond its scheduled time of 8AM to 12PM and 5 PM to 7 PM. The medicines
which have to be dispensed freely, like that of Malaria, too are only prescribed. The same
needs to be purchased from medical shops nearby which have a nexus with the PHC and
dispense the free medicines at a price. Prayas, through its “People’s health initiative
programme” is trying to spread awareness among the tribal population about their right to
get free treatment from the PHC. However, due to infrastructural problems and people’s
faith in traditional system of healing, the demand on the PHC for free treatment is low.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Lack of Liquidity

Since the tribal economy is largely non-monetized, the amount of money that
exists with any household is quite low. Hence in case of Illnesses, the cost of transport
and treatment is usually met with borrowed money. The rate of interest paid for this
money in most places is around 50%. This leads to serious financial difficulties for the
tribal population.

Objective of the Study

Looking at the various problems, we can see that there is no single root cause. The
objective of “Rural Health empowerment” can be elaborated as

“To devise and implement a mechanism that improves the general health of the tribal
population around Mungana”

Criteria to be met

The criteria to be met while trying to achieve the objective are

• To reduce the cost incurred for curative medicine


• To promote preventive medicine / reduce instances of disease occurrence to provide
preventive care for reducing the instances of disease.

In terms of cost reduction, the criteria would imply lesser cost being incurred to
treat a disease as compared to the cost being incurred to treat the same disease at present.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

The Alternatives to achieve the Objective

Preventive healthcare can be split up into three types.

• Primary Preventive Care


• Secondary Preventive Care
• Tertiary Care

Primary preventive care would include: Messages for personal hygiene, clean
water, sanitation at home, smoking and correct nutrition. Secondary preventive care
would include: early detection of disease which would provide relevant information
about chronic disease. Tertiary preventive care would ensure, prevention of progression
of a chronic disease

Each of the alternatives may not be mutually exclusive. Each one will be
evaluated on its own merit and non-merit

1. Increasing the responsiveness of the Government Health Services.


2. Providing a first aid kit containing medicines for common ailments at the village
level.
3. Providing paramedical training.
4. Non Institutional schemes to minimize health expenditure risk.
5. Providing insurance cover to members of SHG and their family members through
institutional insurance coverage.
6. Providing health services through mobile units.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Detailed Design and evaluation of the proposed plans of Risk management


Techniques

Increasing the responsiveness of the Government Health Services

The PHC at Mungana have personnel who indulge in unfair practices like selling
the “free” medicines through the nearby medical shops. The doctors and nurses also urge
the patients to consult them privately rather than through the PHC thus making extra
income and quite often ignore the patient’s needs when the person arrives at the PHC.
However, changing this is major problem.

In case the nexus of PHC-Medical shops is broken with Police help, then the
doctors and nurses at the PHC may no longer be able to practice and may be jailed. There
is no guarantee of resumption of services if the PHC closes down due to the changes.
Even if the staff are changed or transferred, there is no guarantee that the services will
become more responsive or better.

Keeping in view the above constraints, Prayas is trying to make people more
demanding about the health services that the PHC ought to deliver, through their
awareness campaigns.

First Aid Kit containing medicines for common ailments

During the study of the health profile of the target villages, it was identified that
the villagers tend to neglect commonly and frequently occurring communicable and/or
non-communicable diseases till it assumes the penultimate stage of severity (These
diseases typically are stomach ache, fever, vomiting, diarrhea, skin infection, headache,
body ache, common cold). Till this stage is reached, the villagers prefer their traditional
faith healers / quacks over PHCs/ Govt. hospitals.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Once the medication of these faith healers and quacks fail to produce any result
and the person is bodily very weak, the villagers seek the consultation of the doctors in
PHCs or hospitals. In this manner, the loss of income and expenditure on medical care
accumulates and assumes a considerable amount. Thus, the average expenditure on
account of any common disease turns out to be Rs. 500 or greater (this includes all costs
of medication, transportation, food etc.). The expected normal expenditure on any of
these diseases would typically have been possible well within Rs.50, which is ten percent
of the usual expenditure incurred by these villagers.

Also, it is envisioned that through this scheme, the reach of medicines to the
needy would be better. With the availability of medicines made easier, the dependence on
traditional faith healers/quacks would reduce. The decrease in cost of treatment would
also reduce the load of loan taken on the account of health care expenditures & interest
burden thereof on the household members. This translates to lesser dependence on the
moneylenders and would probably reduce their vulnerability.

Keeping in view the above facts, it seems probable that if generic drugs (non
Schedule H drugs) could have been made available at the onset of the disease, the burden
of illness both in terms of loss of health and money could have been averted. In order to
make these drugs easily available in the village at a reasonable cost, a community health
fund needs to be created. With this fund, the common medicines, as detailed later, can be
bought in bulk and distributed in the villages on a monthly basis.

A community based organization can take over the role of being the aegis under
which the first aid kit can be delivered within a village. The SHGs presently functioning
in the village can hence have a leading role to play. The institutions have to

a. Collect money from its members towards building this community health fund.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

b. Identify one member among all who would be the custodian of the medicine kit.
The criteria to be adopted for choosing such person is her easy accessibility to all,
central location of residence and the willingness to assume the responsibility of
extra work for maintaining the records of medicine consumption and stocks.

Although SHG would act as the service providers, the distribution of medicines
monthly and the control over indiscriminate usage of the same has to be assured by the
NGO. It would act as a facilitator in building the community fund, choosing the
volunteer, training her about the usage of medicines as per disease, dosage and about
maintaining records. Also, it would be task of the NGO to negotiate with the PHCs for
providing the SHGs with medicine which are otherwise distributed free of cost. For
instance, the medicine for treating diarrhea, malarial fever, TB cough is distributed freely
by the Govt. of India.

The list of common diseases and the cost of medicines and the financial projections for
the scheme is given in Table 13.

Non Institutional schemes to minimize health expenditure risk

If a mutual health fund is established, where people contribute their funds to the
scheme which they can access in case of medical needs, it can provide some benefits to
the members. The salient features of such a fund should be

• Mechanism to ensure timely collection of the fund


• Mechanism to monitor and disburse the funds with mutual agreement and trust
• Mechanism to monitor the expenditure incurred per treatment

Among the three, the last is the most difficult to achieve. The single most
important benefit that the scheme offers is the liquidity. The scheme can ensure timely
access to money.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

However, the major drawback of the scheme is that it would be very difficult to
make the scheme sustainable, as shown in Appendix 2. Considering the target population
size (between thirty five and forty thousand in forty villages) and the rate of occurrence
of the diseases, the size would not reach the critical mass required to be sustainable. The
cost of monitoring the expenditure would be quite high.

In order to overcome a few of these problems, the nature of the fund can be
changed from one of a reimbursement of the expense to that of loan for the expenses
incurred for treatment. The rate of interest charged on the loan could be low, but the
period of repayment should be shortened. However, this will lead to several problems
regarding collection of loan amount, maintenance of records etc.

Institutional Insurance Coverage

Among the health insurance schemes available commercially, some of the


products that have been evaluated are those of Oriental Insurance and ICICI Lombard.
The VimoSEWA package which has been detailed in the report has also been studied.

Among the schemes, those of Oriental and ICICI have coverage available to a
larger amount. However, the premium per person is quite high, with Oriental charging Rs
130 per annum which is still lower than that of ICICI Lombard.

The merits of the institutional insurance are

• Coverage of large expenditures


• Sustainability of the scheme is not an issue as compared to those of non-institutional
schemes

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Designing of Health Insurance for Rural Poor in Mungana Prayas

However, the demerits in terms of applicability to the requirements of Prayas


which are given below may outweigh the merits

• Only In Patient charges can be reimbursed


• Cost of premium is quite high
• Claims redressal is not always speedy
• No maternity benefits are offered. Caesarean section is not covered
• Reproductive Tract Infection / Sexually Transmitted Infections are not covered
• The schemes assume the availability of a robust formal health services
• The schemes and procedures are quite inflexible

The SEWA scheme though, differs and has quite a few merits

• The premium is affordable in the schemes on the lower end, the family coverage costs
less than a rupee a day
• The scheme is sustainable considering the large number of members as well as
institutional tie up
• The claims processes are handled by SEWA. Hence there is flexibility and speed in
terms of claims
• Maternity is covered under the scheme

Another feature of the SEWA scheme is that other than health, life, accident and
assets are also covered under the scheme.

Mobile Health Service

As described earlier, health empowerment in the tribal area around Mungana can
be possible only if there is provision of medical service in and around the area. This can
be seen as a necessary condition before thinking of any insurance or health fund.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

The main strengths of the service provision approach are that diseases can be
tackled at an earlier stage. This could reduce the number of instances of serious
occurrences of the diseases and the need to visit a hospital.

The main drawback is the cost associated with providing health services in remote
and relatively inaccessible areas.

These can be overcome by conceptualizing a mobile health service unit.


Employing the services of a fully trained medical practitioner can cost up to a lakh of
rupees a year. To reduce this cost, the paramedical worker can replace the doctor. The
costing and requirements associated with paramedical worker training has been given in
this report.

However, even the paramedical worker’s expenses may be quite high to be borne
by a single village. A more cost effective strategy in terms of integrating several villages
under the services of one mobile unit could be a solution, but due to the difficult terrain
of the area concerned, the feasibility of this alternative becomes doubtful..

Choice of Alternative

No single alternative can be effective. However, a combination of some of the


alternatives could be a solution.

This is because each plan’s merits could be taken up considering the need. The
implementation plan given below considers the features of mobile service provision,
paramedic training, village medical kit, improving responsiveness of government services
and non-institutional schemes over various points of implementation.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

Implementation Plan

The plan given in Figure 24 assumes a start date in the first week of September
2005. The plan is detailed to make operational a Health Service Consumer Cooperative
with resources from the village level, although a startup grant would help the Cooperative
in attaining financial stability.

Rationale for the formation of a cooperative

The choice of institution with regards to the medical service was that of a
consumer cooperative.. The rationale for being a cooperative was dual. Prayas has a
conscious ideology of not providing health services and only trying to make the existing
government services more responsive. Also, by making it a cooperative, at least on paper,
the services provided by the organization is the raison d’être for it. This means that the
service provision will be accountable to the owners (members) of the organization. This
accountability to the clients of the service is missing in the government system at the
moment. By keeping the organization distinct from Prayas, this accountability can be
systematized and built in. . With the Government debates of privatizing health service
provision in rural areas, (if such a move comes subsequently,) a robust Cooperative
would be a better solution than either of Private services or Non-Governmental Services.

However, the formation of cooperative is not an easy task. There are several
problems which needs to be addressed in order to make the cooperative feasible. Since
cooperation becomes difficult beyond a critical group size, SHGs containing on an
average fifteen members are envisaged as the basic units. SHGs (women as well a men
SHGs ) are already existing in ten of the villages, rendering the process of SHG
formation an added impetus as SHG is not a new concept which requires introduction.
The representatives from the SHGs (at least one representative from each village) are to
be elected to form the governing body of the cooperative.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

The major concern after the formation of a cooperative is to evolve the


monitoring mechanism. This includes elaboration and formalization of rules and
procedures regarding the activities of the cooperative. The procedural part involves the
detailed specifications of the duties and responsibilities of the employees of the
cooperative like, the field level workers and the paramedical staff, as well as, the
executive members of the cooperative. Evolution of rules include the documentation of
the Bye law and also performance evaluation method for the employees. The system for
recording medicine consumption and stock keeping activities are also required to be in
place.

Regarding the formation of the board Prayas can play an active role in terms of
conducting the elections for board members and also being a part of the governing body.
This is required to help build the capacity of the cooperative at the nascent stage and also
help stabilize the operations. It is also recommended that the PHC doctor is a member of
the governing board. This will serve the purpose of making the PHC more responsive to
the community in an engaging manner. The cooperative needs to engage the PHC in order
to avoid confrontation and also invite participation in providing the health care services
which are not covered by the cooperative.

In terms of financial considerations, although the cooperative can be sustainable,


any grant from donors can help the organization in terms of establishment. A professional
manager in charge of the project can deal with the details in terms of implementation and
also help formalize and systematize the organization. The institution would also be on a
sound financial footing if there could be a grant that builds a partial corpus or funds the
initial expenditure related to setup. The rationale behind the grant is that since the funding
agencies are interested in the general health of the population in the area, any initiative in
terms of provision of medical care could generate interest in the funding community that
can result in a surplus in the organization. The one time membership fee paid by the
households can also be reduced. This can also lead to an increase in membership from
each village resulting in stronger financial measures for the organization. The monthly

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Designing of Health Insurance for Rural Poor in Mungana Prayas

service charge and the cost of medicines however are best left unsubsidized. The stake of
the members in the organization would be greater if the services are paid for. This would
lead to an increased accountability from the service provision point of view.

Activities to be undertaken for Implementation

The breakeven number of villages per cluster for this plan is twenty villages. The
tasks are detailed only for the pilot first cluster. Several such clusters could then be
federated under the Cooperative. The first task would be that of appointing a village
assistant. The duties of the village assistant would comprise of the following

• To maintain the Inventory of the medical first aid kit and to record medicine
distribution and money collection.
• To maintain the Household files for people who avail the services. Against each
household member’s page to whom a tablet was issued from the medical kit, the
amount taken as well as the dosage is to be recorded.
• To conduct monthly community health self help group meetings and to collect
membership fees / service fees
• To diagnose basic health problems like gastric problems, malarial fevers, fever,
diarrhea, to treat cuts and wounds etc., and to provide the required medicines
• To advise and monitor the use of medicines as well as collect payment for the
medicines.
• To refer doubtful problems to Paramedic.

The Village assistant needs to be identified as a person with relatively good


educational background (8th / 10th standard), with the ability to maintain records, basic
mathematical skills etc. S/he will be from the village for which the selection is done and
paid an amount of Rs 350 per month.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

As given in the Gantt chart, the estimated time to identify twenty Village
Assistants is three weeks. The training for the persons would be split up into trainings on
Operations and training on Practices.

The training on operations would essentially comprise of developing familiarity


with the proposed forms and medicines with which the assistant is supposed to work. The
training on practices includes sensitization of the person to various means of interaction
with the patients to elicit information regarding sicknesses that the person may not be
really comfortable revealing (e.g.: RTI / STI / Other problems that people think are
“insignificant” to report). Also, in the course of sensitization, the problems with
allopathic medicine like natural immunity development suppression etc. need to be
pointed out. The person should also be able to create awareness on the importance of
timely medication as well as consumption of the full course of the medication.

The second major task is to create awareness in the targeted twenty villages. The
design of the curriculum is expected to take one week. This task is to be undertaken by
Prayas, as it has the required knowledge and experience about the community and the
dynamics therein. The work could be outsourced to training specialists. The same
principles as the ones given above have to be structured. Once this is through, then
Prayas field staff and the village assistants can be given the course in a Training of
Trainers. Considering the field staff of ten being available and twenty village assistants,
the estimate is on the higher side, one week. Conducting training in the villages is
expected to take two weeks. This is because each Prayas field staff would have two
village assistants attached to them. This training should not be seen to be a one time
effort. There needs to be regular set of activities to increase the awareness as well as
periodic evaluation of the Knowledge, Actions and Practices.

The field staff and the village assistant would spend around a week in the villages
creating awareness and constituting health SHGs. The expected membership of the
Cooperative (used for calculation) is 60% of the tribal population. The average number of
ST households per village is two hundred and thirty one of which the expected

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Designing of Health Insurance for Rural Poor in Mungana Prayas

membership would come to around one hundred and thirty nine households. Hence an
average of nine health SHGs could be constituted per village with each SHG having an
average membership of around fifteen.

These trainings and SHG creations would be also have a simultaneous or


successive activity, that of registering the Households of the members of SHGs and
creating a health activity file per household with a separate sheet for each member of the
Household. Each member’s sheet would have her/his name, date of birth, relation to head
of household, marital status etc. Below that would be a table with four columns, one for
the date, symptoms and medicines given (with number) and amount charged for the
medicines. The membership fees of fifty rupees per household would also be collected.
The total expected time for these activities is about three weeks after the initial awareness
education.

The medical first aid kit would simultaneously need to be procured and installed
in each of the twenty villages.

The identification of a paramedical officer should also be done in the mean time.
The person should preferably be one willing to work in rural areas and a graduate
preferably from biology / nursing background. The person could be from either of
Udaipur or Chittorgrah districts. S/he should be paid a monthly amount of around
Rs.5,404. The salary component of this is Rs 4,000, with the rest being the petrol costs of
the bike provided and maintenance of the bike.

The reasons that the salary is higher than the normally “acceptable” levels of
payment around the area are several.

The rationale for payment of Rs.4,000 to the paramedical worker are several.
He/she would be trained for a period of over 2-3 months or would be a trained nursing
professional. Hence the person should not be considered as just another field personnel.
Most of the field workers and supervisors in the area receive a salary that is less than the

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Designing of Health Insurance for Rural Poor in Mungana Prayas

payment proposed in this case. This is because of the reason that the person is expected to
be covering 4 villages in a day spending an hour and a half in each village. Such a person
should not be made to worry about other personal problems concerning finances. Also
such a person would value this designation as no other similar job in the region would
pay in the scale offered hence reducing the chances of attrition and drawing the return on
the training investment carried out by the cooperative. The provision of the vehicle is also
for the reason of coverage of the villages within the given time. A high salary would
reflect the position of the person in the organization’s hierarchy. The paramedic would
also feel that her/his job is quite important to the organization and thus increases the
stake of the person. This would mean that, if the person is held accountable through
various systems and processes to the members, then the quality of service provided would
also improve.

The identified paramedic could then be trained for a month with private
practitioners near Chittorgarh or Udaipur. The main tasks of the Paramedic would be

• Identification of commonly occurring diseases through rudimentary diagnosis.


• Provision of Antibiotics in cases of infections etc.
• Rudimentary diagnosis including BP, temperature check
• Collection of blood , urine, stool sample for testing
• Maintenance of Cluster level records
• Reviewing of village level records, checking on patients and recommending visit to
PHC/Hospital in case of necessity
• Delivery of drug whose stock has run out within a village

The Paramedic visits a village once a week. A set of 20 villages in a cluster where
the paramedic operates means that the person would visit 4 villages a day for 5 days. The
6th day would be for any office related activity etc at the cluster level.

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Designing of Health Insurance for Rural Poor in Mungana Prayas

A bike and a cold box kit for the bike would be procured and given to the
paramedic. The cold box is to enable the paramedic to store and transport blood samples /
urine/ stool samples collected from the village to the pathology laboratory at the PHC. If
these services require cash payment, then the paramedic would also collect the cash for
the same from the member (External service will have to be paid for by the member).

In terms of fully operationalizing the activities, the one week given is not to start
the operations. The operations would be fully started in all 20 villages once the training
of the Paramedic is complete. However, this would be to develop systems, processes and
mechanisms to have accurate, timely and adequate feedback.

Since the proposed system is that of a Consumer Health Cooperative, the board
would constitute of 3 external members, preferably from Prayas and a Doctor from the
PHC other than the members from each village. The Chairperson of the board should be
rotated once every three years. The internal membership to the board should be by voting
every year. Extraordinary Board Meetings should be called only when all SHGs within a
village agree to it (This could be modified to 2/3rd of the SHGs).

The onus of performance evaluation of the Village Assistant should lie with the
community, since he is responsible for providing service to the community. The
recommended procedure for performance evaluation is a quarterly evaluation based on
360o feedback mechanism. This can be done by weighing the feedbacks given by the
members, paramedic and Prayas personnel who visit the village once a month with 60%
or more Weightage attached to the feedback of the SHGs (which should be done by the
Secretary of the SHG with consultation with members). this will ensure participation
from the members of the cooperative and also make the employees more accountable to
the people they serve. Yearly review of the performance may be done by the executive
board of the cooperative

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Designing of Health Insurance for Rural Poor in Mungana Prayas

For the Paramedic, a half yearly appraisal in the similar format needs to be carried
out. Timely production of the balance sheet of the Cooperative would also be a prime
consideration.

The surplus generated by the sale of medicine after deducting the operating
expenses, can be retained so as to fund some future plans like maternity benefits,
insurance subsidization of federating into a small hospital / dispensary or pathology
laboratory.

Conclusion

The possibility of introducing commercial insurance products or a pooled


insurance in the region around Mungana would be difficult due to the high instance of
occurrence of simple diseases and the lack of adequate medical facilities as well as other
infrastructure in the region.

In order to prepare the ground for a future introduction of any insurance scheme,
the delivery of health services in the tribal area around Mungana is imperative.
Introducing rational medical treatment at the village level can reduce the cost of
treatment in most cases and hence can reduce the overall burden due to the disease. This
can also introduce the system of monitoring in order to implement a future insurance plan
etc. Should the plan be successful, it is scalable enough to support more clusters which
may generate a surplus enough to provide better services in Mungana.

Page 49
Annexure: Charts

Figure 1 : Distribution of Income sources

Income Sources

7 83

369 401

Agriculture Labour Artisan Service Other

Figure 2: Age and Sex wise Breakup of the Sample

Age and Sex Wise breakup of sample

0 50 100 150 200 250 300 350 400 450

Female Infants Male Infants Female Child Male Child Female Adolescent
Male Adolescent Female Married Male Married Female Senior Male Senior

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Annexure: Charts

Figure 3: Village Wise access to water sources

Annat
source of drinking water
Boria Handpump
Chun pa Well
Gothda Stream
Hajariguda
Lodia
Naad Pies show counts
Sakarkan d
Ujadkheda
Wagatpura

Figure 4: Distance between Water Source and House

120

100

80

60

40

20 Std. Dev = 1.96


Mean = 3.6

0 N = 404.00
1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5

distance between water source and house


Cases w eighted by WEIGHT

Refer table 4 for the coding

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Annexure: Charts

Figure 5: Distribution of Water Source Distance from House

Over 1 KM

.1%

601-1000 meters

1.7%
401-600 meters
0-25 meters
5.8%
14.6%
201-400 meters
14.7%

26-50 meters
101-200 meters
25.0%
11.8%

76-100 meters 51-75 meters


18.0% 8.3%

Cases weighted by WEIGHT

Figure 6: Distribution of material used to clean hands with (by Household)

ash

2.3%

soil

5.2%

soap

92.5%

Cases weighted by WEIGHT

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Annexure: Charts

Figure 7: Total Pregnancies per woman including miscarriage

Total Pregnancy including miscarriage


20

10
Percent

0
1 2 3 4 5 6 7 8 9 10 11 12

Total Pregnancy including miscarriage

Figure 8: Distribution of Pregnancies per woman

200

100

Std. Dev = 2.32


Mean = 4.4

0 N = 496.83
2.0 4.0 6.0 8.0 10.0 12.0

Total Pregnancy including miscarriage


Cases w eighted by WEIGHT

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Annexure: Charts

Figure 9: Distribution of age at the time of first delivery

400

300

200

100

Std. Dev = 2.68


Mean = 18.6
0 N = 496.71
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0

Age at the time of first delivery


Cases w eighted by WEIGHT

Figure 10: Breakup of Chronic Diseases over the year before survey

T.B., cough

3.1%

Orthopaedic
Other
7.6%
7.1%
Asthma

5.8%

Unclassif ied

76.5%

Cases weighted by WEIGHT

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Annexure: Charts

Figure 11: Breakup of the categorized chronic diseases

T.B., cough
Orthopaedic
13.9%
31.5%

Other
13.9%

Swelling in body

6.5%
Asthma
RTI / STI
24.1%
4.6%
Ear disease

5.6%

Figure 12: Count of cost incurred per chronic disease

T.B., cough Total Cost Incurred

Orthopaedic More than Rs. 25001

Asthma Rs. 10001 to 25000


Paralysis
Rs. 5001 to 10000
Name of the Disease

Ear disease
Rs. 2501 to 5000
Disability
Rs. 1001 to 2500
Mental Illness
Rs. 501 to 1000
RTI/STI
Rs 251 to 500
Sw elling in body
Rs 101 to 250
Stones
Less than Rs. 100
0 10 20 30

Count

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Annexure: Charts

Figure 13: Sex-wise distribution of chronic diseases


Name of the Disease
T.B., cough

Orthopaedic

Cancer
male
Asthma

Paraly sis

Ear disease

Disability
sex of the patient

Mental Illness

RTI/STI
female
Swelling

Stone

Ashtma and TB Cough


0 10 20

Count

Figure 14: Age wise split up of chronic respiratory diseases

T.B., cough
Name of the Disease

age of the patient


Asthma and TB cough
Age 6 - 11

Age 12-19

Age 20 - 30
Asthma
Age 31 - 45

Age 46 - 90
0 2 4 6 8 10 12 14 16

Count

___
Page vii
Annexure: Charts

Figure 15: Age wise split up of Orthopedic problems and Disability

Figure 16: Age wise split up of Cancer, Paralysis and Mental Illness

___
Page viii
Annexure: Charts

Figure 17: Age wise split up of ear disease, RTI/STI, Swelling and Stone

Figure 18: Diseases in the three months preceding the survey

Stomach related
Respiratory disease
Skin disease
Malnutrition Total Cost incurred
Mental illness / epi
Malaria,fever Rs. 5001 to 10000

stomach,respiratory
Rs. 2501 to 5000
stomach,skin
stomach,malnutrition Rs. 1001 to 2500

stomach,malaria Rs. 501 to 1000


The Disease

respiratory,malaria
Rs. 251 to 500
skin,malaria
malnutrition,skin Rs. 101 to 250
stomach,skin,malnutr
Less than 100
0 20 40 60 80 100 120 140

Count

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Page ix
Annexure: Charts

Figure 19: Diseases in the Past three months on which more than Rs 500 was spent

Stomach related

Respiratory disease

Skin disease

Mental illness / epi Total Cost incurred


The Disease

Rs. 501 to 1000


Malaria,f ever
Rs. 1001 to 2500

stomach,malaria Rs. 2501 to 5000

Rs. 5001 to 10000


0 2 4 6 8 10 12

Count

Figure 20: The split-up of diseases in the three months preceding the survey

Other

5.5%
Stomach & Malaria

5.7% Stomach related

27.7%

Malaria,f ever
37.3% Respiratory disease

9.7%

Skin disease
Malnutrition
11.9%
2.2%

Cases weighted by WEIGHT

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Page x
Annexure: Charts

Figure 21: Split up of Non-Malarial diseases

Other

3.0%

Stomach, Skin & Maln

4.5%

Stomach, Respiratory

4.3%
Mental illness / epi
Malnutrition & Skin
4.5%
4.5%
sw elling in body
Stomach & Malnutriti
22.8%
4.5%

Stomach & Skin


Stomach & Respirator
30.1%
21.8%

Cases weighted by WEIGHT

Figure 22: Expenses incurred on various diseases

Stomach related

Respiratory disease

Skin disease

Malnutrition
Total Cost incurred

Malaria,f ever Rs 101 to 250

Stomach & Skin Rs 251 to 500

Rs 501 to 1000
The Disease

Stomach & Malaria

Rs 1001 to 2500
Respiratory & Malari

Rs 2501 to 5000
Skin & Malaria
Rs. 5001 to 10000
0 10 20 30 40

Count

Figure 23: Treatment cost of Malaria from government and private services

___
Page xi
Annexure: Charts

Figure 24: Preferred Means of Planning Family

Means of Planning Family Preferred

Vasectomy

18.1%

Rustic Means

.4%

Mala D

7.6%

Copper T

.9%

Condoms

73.0%

Figure 25: Assistance obtained during pregnancies

___
Page xii
Annexure: Charts

Delivery Assistance

13%
0%

87%

Bai Assisted Trained Bai Assisted Auxillary Nurse Assisted

___
Page xiii
Annexure: Charts_________________________________________________________________

Figure 26: Gantt Chart of the Implementation Plan

_____
Page xiv
Annexure: Tables

Table 1: Split up of income generation activity


Income generation Activity Households
Agricultural Income 99.3%
Labour Income 91.3%
Artisan Activity Income 1.7%
Service Income 2%
Other Income 0.7%

Table 2: Access to BPL and Swasth Card


Access to BPL Card Access to Swath Card Number of People
(Number of Households)
Yes Yes 246
(44)
Yes No 140
(27)
No Yes 23
(4)
No No 1992
(329)
Total 2401
(404)

Table 3: Statistics on Water Source


Descriptive Statistics on Water Source Distance
Std.
N Range Minimum Maximum Mean
Deviation
distance between water
source and house in
meter 404 3000 0 3000 157.82 199.499

Valid N (listwise)
404

Page a
Annexure: Tables

Table 4: Coding of distance of water source


Distance from Water Source in meters Code
0-25 1
26-50 2
51-75 3
76-100 4
101-200 5
201-400 6
401-600 7
601-1000 8
1001-1500 9
1500-3000 10

Table 5: Village wise split up of Chronic diseases


Name of the village
Hajari- Sakar- Ujad- Wagat-
Annat Boria Chunpa Gothda guda Lodia Naad kand kheda pura Total %
T.B.,
cough 1 5 5 1 2 1 15 13.89%
Arthritis 2 2 1 1 5 3 5 9 4 2 34 31.48%
Cancer 1 1 0.93%
Asthma 2 1 6 2 5 4 6 26 24.07%
Paralysis 1 2 3 2.78%
Ear
disease 1 3 1 1 6 5.56%
Disability 1 1 1 3 2.78%
Mental
Illness 1 2 3 2.78%
RTI/STI 1 1 1 2 5 4.63%
Swelling
in body 1 1 2 1 1 1 7 6.48%
Stone 1 1 2 1.85%
Name Ashtma
of the and TB
Disease Cough 3 3 2.78%
Total 6 11 8 4 13 8 19 17 18 4 108

Page b
Annexure: Tables

Table 6: Cost incurred on chronic diseases


Total Cost Incurred
Less Total %
101- 251- 501- 1001- 2501- 5001- 10001- 25001-
than
250 500 1000 2500 5000 10000 25000 30000
100
T.B.,
cough 1 2 2 3 3 1 12 4.53%
Arthritis 2 1 2 3 6 3 1 3 21 7.92%
Asthma 2 1 2 2 1 5 2 1 16 6.04%
Paralysis 1 1 2 0.75%
Ear
Name disease 1 1 1 3 1.13%
of the
Diseas Disability 1 1 1 3 1.13%
e Mental
Illness 1 1 0.38%
RTI/STI 1 1 1 1 4 1.51%
Swelling
in body 1 2 1 4 1.51%
Stones 1 1 2 0.75%
Others 37 28 35 23 27 27 14 5 1 197 74.34%
Total 43 35 42 32 38 43 21 10 1 265
16.23 13.21 15.85 12.08 14.34 16.23 7.92
%
% % % % % % % 3.77% 0.38%

Table 7: Age wise occurrence of chronic diseases


Age of the patient
0 to 6 to 12 to 20 to 31 to 46 to Total %
5 11 19 30 45 90
T.B.,
cough 1 1 6 7 15 3.28%
Arthritis 3 2 10 13 6 34 7.42%
Cancer 1 1 0.22%
Asthma 2 1 2 6 15 26 5.68%
Paralysis 1 2 3 0.66%
Ear
disease 1 3 2 6 1.31%
Name of Disability 1 1 1 3 0.66%
the Mental
Disease Illness 2 1 3 0.66%
RTI/STI
1 3 1 5 1.09%
Swelling
in body 2 2 3 7 1.53%
Stone 1 1 2 0.44%
Others 23 18 18 78 98 115 350 76.42%
Asthma and
TB Cough 1 2 3 0.66%
Total 26 26 23 98 132 153 458
% 5.68% 5.68% 5.02% 21.40% 28.82% 33.41%

Table 8: Split up of first round treatment of Malaria

Page c
Annexure: Tables

Treatment Number of Mean Cost # of Patients Mean Cost of


through patients of treated for treatment
treated for treatment Malaria +
Malaria Only other
Government 34 331 43 337.5
Bhopa 11 118 12 114
Local Medication 14 103 18 104
Private/Quack 41 114 48 110
Total 100 185 120 191

Table 9: Average cost of treatment of diseases that have occurred in 3 months


preceding the survey
Number 
of 
Average  people  Percentage 
Disease  Cost  reported  of Sample 
Code Symptoms / Disease Incurred ill reported
1 Stomach 142.96 189 7.87%
2 Respiratory 168.18 66 2.75%
3 Skin 206.79 92 3.83%
4 Malnutrition 20.00 14 0.58%
Non­Infectious: 
Diabetes, BP, cataract, 
5 cancer 0.00 1 0.04%
6 Animal Bite 0.00 1 0.04%
Mental Illness, 
7 epilepsy 7700.00 1 0.04%
8 Swelling in Body 0.00 5 0.21%
9 Malaria 214.87 254 10.58%
12 Stomach & Respiratory 10.00 6 0.25%
13 Stomach & Skin 85.83 12 0.50%
14 Stomach & Malnutrition 15.00 2 0.08%
19 Stomach & Malaria 127.60 50 2.08%
29 Respiratory & Malaria 70.00 4 0.17%
39 Skin & Malaria 177.50 4 0.17%
43 Malnutrition & Skin 50.00 2 0.08%
49 Malnutrition & Malaria 0.00 1 0.04%
Stomach, Respiratory & 
123 Skin 0.00 1 0.04%
Stomach, Skin & 
134 Malnutrition 100.00 1 0.04%
Total 181.86 706 29.40%

Page d
Annexure: Tables

Table 10: Cost Incurred on common diseases: Split up


The Disease v/s Total Cost incurred Cross tabulation
Total Cost incurred
101 to 251 to 501 to 1001 to 2501 to 5001 to Total
0 to 100
250 500 1000 2500 5000 10000
Count 35 18 8 12 3 3 79
Stomach
related % within The
Disease 44.30% 22.80% 10.10% 15.20% 3.80% 3.80% 100.00%
Count 21 7 2 3 3 36
Respiratory
disease % within The
Disease 58.30% 19.40% 5.60% 8.30% 8.30% 100.00%
Count 15 10 4 2 1 1 33
Skin disease % within The
Disease 45.50% 30.30% 12.10% 6.10% 3.00% 3.00% 100.00%
Count 3 1 4
Malnutrition % within The
Disease 75.00% 25.00% 100.00%
Mental Count 1 1
illness / % within The
epilepsy Disease 100.00% 100.00%
Count 69 29 13 10 6 1 5 133
Malaria,
fever % within The
Disease 51.90% 21.80% 9.80% 7.50% 4.50% 0.80% 3.80% 100.00%
Count 1 1
The Stomach &
Respiratory % within The
Name Disease 100.00% 100.00%
of the
Diseas Count 3 2 5
Stomach &
e Skin % within The
Disease 60.00% 40.00% 100.00%
Count 1 1
Stomach &
Malnutrition % within The
Disease 100.00% 100.00%
Count 12 5 3 2 1 23
Stomach &
Malaria % within The
Disease 52.20% 21.70% 13.00% 8.70% 4.30% 100.00%
Count 1 1 2
Respiratory
& Malaria % within The
Disease 50.00% 50.00% 100.00%
Count 1 1 2
Skin &
Malaria % within The
Disease 50.00% 50.00% 100.00%
Count 1 1
Malnutrition
& Skin % within The
Disease 100.00% 100.00%
Stomach, Count 1 1
Skin & % within The
Malnutrition Disease 100.00% 100.00%
Count 164 71 29 28 15 8 7 322
Total % within The
Disease 50.90% 22.00% 9.00% 8.70% 4.70% 2.50% 2.20% 100.00%

Table 11: Probability of occurrence of diseases

Page e
Annexure: Tables

Percentage Average
Occurrence Expense
in Population (Overall)
T.B., cough 0.62% 1827
Orthopedic 1.42% 2654
Cancer 0.04% No exp
Asthma 1.08% 2323
Paralysis 0.12% 5000
Ear disease 0.25% 633
Disability 0.12% 6675
Mental Illness 0.12% 167
RTI/STI 0.21% 2450

Swelling 0.29% 3214


Stones 0.08% 1100
Others 14.58% 1400
Name of the Disease Asthma and TB Cough 0.12% No exp
Total
27343
% 18.95%

Table 12: VimoSEWA Insurance Schemes


SCHEME 1 SCHEME 2
Famil
Member Husband Child y Member Husband Child Family
Annual 100 70 100 250 225 175 100 480
Fix 2100 1500 5000 4000
Natural
Death 5000 5000 20000 20000
Sickness 2000 2000 2000 6000 6000 2000
Household
Assets 10000 20000
Accidental
death 40000 25000 65000 50000
Accidental
death
(husband) 15000 15000

Page f
Annexure: Tables

Table 13: Costing of First Aid Kit for 139 Households

Rural First Aid Kit for a group of 50 Households(average HH Size of a village)

Symptom / Number Cost of


Medicines Generic Name Disease Dosage Required medicine Cost
Furazolidone + Diarrhea /
Dependal Metronidazole Dysentery 6 36 0.5 18
Paracetamol +
Combiflam Ibuprofen Fever / Bodyache 6 48 1 48
Cyclopam/ Dicyclomine +
Spastin Paracetamol Abdominal Cramps 6 36 1.4 50.4
Acetyl Salicylic Headache /
Disprin Acid bodyache 2 16 0.3 4.8
Promethazine Nausea /
Avomine Theoclate Vomiting 2 12 2 24
Lariago/
Mosquet Chloroquin Malarial Fever 5 40 1.1 44
Diagene Acidity etc. 4 24 1 24
Oral Rehydration Diarrhea /
ORS Solution Dysentery 0.25 2 20 40
Paracetamol /
Chlorphenaramine
M-Cold Hydrochloride Cold / Cough 3 24 1.2 28.8
Nebasulf / Skin
Soframycin Infection/Ulcers 0.1 1 15 15
Cotton Exterior Ulcers 0.1 1 5 5
Gauze Exterior Ulcers 0.5 1 1 1
TOTAL 303

Page g
Annexure: Tables

Table 14: Cash Flow Statement for the Cooperative for 4 years

Cash Flow
Year I Year 2 Year III Year IV
Opening Balance 40,610 61,220 67,568
Cash from operating activity
Net loss/Net Profit 2,420 16,481 18,539 11,576
Depriciation 11,666 7,777 5,185 15,122
14,085 24,259 23,724 26,698
Cash from Investing Activities
Purchase of Fixed Asset
Motorbike (35,000) (35,000)
Cost of Medical Kit (4,000) (6,000)
Cost of ice Kit (500) (700)
Investment in Bank (72,975) (112,475) (3,649) (28,376) (105,000) (146,700)
Cash from Financing Activities
139,000 0 11,000 150,000
Closing Balance 40,610 61,220 67,568 97,565

Table 15: Balance Sheets of the Cooperative for the first four years

Balance Sheet Year I


Liabilities Assets
Capital 69,500 Cash 40,610
Profit (Loss) 2,420 71,920
Medical Kit 4,000
Reserve Fund 69,500 Ice kit 500
Motorbike 35,000
Depreciation 11,666 23,335
Bank 69,500
Intt 3,475 72,975

141,420 141,420

Page h
Annexure: Tables

Balance Sheet Year II


Liabilities Assets
Capital 71,920 Cash 61,220
profit 16,481 88,401
Medical Kit 4,000
Reserve Fund 69,500 Ice kit 500
Motorbike 23,335
Depreciation 7,777 15,557
Bank 72,975
Intt 3,649 76,624

157,901 157,901

Balance Sheet Year III


Liabilities Assets
Capital 88,401 Cash 67,568
profit 18,539
New Member Fee 5,500 112,440 Medical Kit 4,000
Reserve Fund 75,000 Ice kit 500
Motorbike 15,557
Depreciation 5,185 10,372
Bank 100,000
Intt 5,000 105,000

187,440 187,440

Balance Sheet Year IV


Liabilities Assets
Capital 112,440 Cash 97,565
profit 11,576
New Member 150,000 274,015 Medical Kit 10,000
Reserve Fund 75,000 Ice kit 1,200
Motorbike 45,372
Depreciation 15,122 30,250
Bank 200,000
Intt 10,000 210,000

349,015 349,015

Page i
Appendix

APPENDIX 1: Weightage calculation using Census 2001 data:

Number
Village total SC male fem ST male fem of Multiplication
Vill No Name pop male female pop SC SC pop ST ST Cases Factor
5 Annat 780 396 384 2 1 1 761 386 375 5.47% 40 9.90% 0.5529
9 Boria 1040 531 509 28 15 13 1011 515 496 7.27% 23 5.69% 1.2775
4 Chunpa 291 149 142 0 0 0 291 149 142 2.09% 36 8.91% 0.2349
8 Gothda 2601 1265 1336 53 26 27 2372 1142 1230 17.06% 25 6.19% 2.7575
7 Hajariguda 2226 1063 1163 5 4 1 2194 1046 1148 15.78% 47 11.63% 1.3567
10 Lodhia 1474 752 722 0 0 0 1439 734 705 10.35% 62 15.35% 0.6745
2 Naad 3168 1637 1531 87 46 41 2999 1553 1446 21.57% 68 16.83% 1.2817
3 Sakarkand 1921 937 984 113 64 49 1769 852 917 12.73% 57 14.11% 0.9020
1 Ujadkheda 545 286 259 13 8 5 524 272 252 3.77% 34 8.42% 0.4479
6 Wagatpura 560 301 259 14 9 5 541 287 254 3.89% 12 2.97% 1.3102
14606 7317 7289 315 173 142 13901 6936 6965 404

Total ST
Sex Sex
Ratio 996.17 Ratio 1004

From the 2001 census, the figures of the scheduled tribes population of the 10 villages surveyed were obtained. The sampled
population was that of the households of the members of the SHG run by Prayas in the area. The column “Number of Cases”
represents the number of households surveyed within the villages. The column preceding it is the percentage population of the
Scheduled Tribes of the individual villages with respect to the total ST population of all the ten villages.

The percentages represented by the individual villages in the sample taken by Prayas are given in the column after “Number of
Cases”. The sample size surveyed from each village was compared to the actual population of the given villages using the 2001

_________________________________________________________________________________________
Page i
Appendix

Census data. In order to make the sample representative, weights were attached to the data collected in proportion of the discrepancy
between the population representation of each village in the sample and the same in the census data To balance out the percentages,
the multiplication factor or the weights were calculated and weighted in SPSS.

_________________________________________________________________________________________
Page ii
Appendix 2: Treatment Expense Calculations

APPENDIX 2: Treatment Expenses Calculation on Population of 20 villages

Instances after % Mean Probable Probable


Removing population Cost of Instances Cost
Name of the Disease / Symptom Instances Redundancies stricken Treatment in target Incurred
1 Stomach Related 201 261 10.87% 392 1360 533,079.18
2 Respiratory 70 83 3.46% 565 432 244,338.38
3 Skin 86 102 4.25% 639 531 339,598.83
4 Malnutrition 16 20 0.83% 75 104 7,815.49
7 Mental Illness 1 1 0.04% 7700 5 40,119.53
8 Swelling in Body 7 7 0.29% 0 36 0.00
9 Malaria/ Fever 269 320 13.33% 516 1667 860,329.53
Total Probable Cost in Target Population 2,025,280.95

The data in the above table was the result of analysis of the primary data collected in the villages around Mungana. The
diseases had occurred within three months of the survey in the villages. The Instances of diseases were calculated directly from the
household surveys conducted. The second column, “Instances after Removing Redundancies” is a sum of all reported instances of the
symptoms/disease. For example, the instances of Malaria/Fever standalone constituted of 269 cases. However, there were instances of
malaria that occurred along with stomach related problems within the given period. These were 49 cases. These and other such joint
occurrences have been added together to give the result in the second column.

The third column consists of the percentage of population stricken by the disease. This is the percentage of “Instances after
Removing Redundancies” as a part of 2401, the size of the sample surveyed. The mean cost of treatment does not consider the
instances where the patient did not approach the medical services. “Probable Instances in target” is the extrapolation of the percentage
occurrence to a population size of 12510, which is the target size of the proposed alternative. The “Probable Cost Incurred” is the
multiplication of the mean cost of treatment and the probable instances in target.

_________________________________________________________________________________________
Page iii
Appendix 3: Excerpts of Interview of Health personnel

Interview with the P.H.C. Doctor

We have taken interview of Dr. Shashi Kumar Sharma of Mungana P.H.C. and Dr. S. N.
Soni of Parsola which is seven kilometer away from Mungana. The objective of the interview
was to know about the existing infrastructure, services provided by the doctors, subsidies
provided on medicines at the PHC, government schemes on Health, area specific diseases profile
etc. We also enquired about the problems that the doctors are facing in providing services and the
probable solutions of the same.

The P.H.C. at Mungana has two rooms, two beds, basic medical kit and it provides
facility for blood test, urine test, delivery etc. Malaria, tuberculosis and RTI/ STI. etc are treated
free there. Some medicines related to viral fever, cough, diarrhoea are also free depending on the
availability. However, the dispensing of these medicines for free is not in norm at the PHC as has
been learnt from the Focus group discussions. The doctor at the P.H.C. consults only for
outpatient cases like viral fever, diarrhoea, throat infection, T.B., malaria, RTI/STI., nausea
mainly occurred in the villages. There is a doctor, two ANMs and one laboratory assistant
working at the PHC. The ANMs are expected to go to the every village once a week, covering an
average of 2000 people to vaccinate children and consult pregnant women.

The major problem in this area according to the doctor is that the patients in this area
prefer treatment from the traditional faith healers over that of the quacks and as the last resort
before the district level hospitals they come to PHC. The doctor also suggested that there is a
need to awareness creation in the villages to encourage the people to seek rational treatment..

________________________________________________________________
Page iv
Appendix 3: Excerpts of Interview of Health personnel

Interview with the quack (Bangali Doctor)

We have taken interview of the local quack, Varun Majundar practicing in the Mungana
area. They are called bangali doctors because traditionally they come from West Bengal. Usually
the persons are not graduates, tending to be more of pre-university educated people with
experience in some private clinics or medical shops. The charges for treatment of a disease by
the quack is comparably lesser than that charged at the PHC.

The quacks also provide treatment on credit and treatment at doorstep, on demand for a
nominal charge. They usually have a one room clinic in which doubles up as the residence
enabling a round the clock service. Their annual expenditure on the purchase of medicines is
about twelve thousand rupees for a command population of two thousand and earns about four
thousand rupees a month.

________________________________________________________________
Page v
References:

1. World Health Organization (2005) “World Health Report 2005: Make every
Mother and Child Count”, World Health Organization

2. Khanna, Renu, N.R. Mehta and Anil Bhatt (1991) “Volunatry Effort in
Community Health : Review of the community health project of SEWA-Rural”,
Editorial Services Division, Shishu Milap, Baroda

3. Trieschmann, James S., Sandra G. Gustavson and Robert E. Hoyt (2001) “Risk
Management and Insurance”, Eleventh Edition, Southwestern College Publishing,
Cincinnati, Ohio

4. Shalini Sinha (2003) “Strength in Solidarity: Insurance for Women Workers in the
Informal Sector”, Second Edition, Self Employed Women’s Association (SEWA),
Ahmedabad

5. “SEWA Social Security”, Brochure of the Insurance Products, SEWA,Ahmedabad

6. Ron, Aviva, Brian Abel-Smith, Giovanni Tamburi (1990) “Health Insurance in


Developing Countries: The Social Security Approach”, Oxford & IBH Publishing
Co. Pvt. Ltd., New Delhi

7. Wakeham, Patricia F. (1980) “Plan for a Village Health Programme Using Village
Health Workers”, Voluntary Health Association of India, New Delhi

8. Durgaprasad, P. and S. Srinivasan (1993) “Management of Rural Health Care


Delivery Systems: Role and Performance of Grassroot Health
Personnel”,National Institute of Health Development, Hyderabad
9. Pachauri, Saroj (Ed.) (1994) “Reaching India’s Poor: Non-governmental
approaches to community health”, Sage Publications India Pvt Ltd, New Delhi

10. “Making Services Work for the Rural Poor”, World Bank,

11. “Annual Report : 2001-2002”, Prayas, Chittorgarh

12. Malik, Dr. Sanjiv (Ed.) (Volume X, No. 6)“Indian Drug Review”, mediaworld

13. McDaniel Jr., Carl and Roger Gates (1996) “Contemporary Marketing Research”,
West Publishing Company, St. Paul, Minnesota

14. Interview with personnel at Prayas, Dr. Narendra Gupta, Mr. Khemraj Chaudhary,
Ms. Anjali Sharma, Ms. Pallavi Gupta, Mr. Goverdhan Yadav (June-July 2005)

15. Interview with Ms. Uppasna Joshi, SEWA Ahmedabad (20th June, 2005)