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Community Health Programme

The focus is on providing an integrated range of quality health services to rural communities while simultaneously enabling local ownership through training programmes that help to enhance management capabilities and ensure financial sustainability.The Gujarat Health Systems Development Project (GHSDP), implemented by the Aga Khan Health Service, India (AKHS,I) is improving the health status of rural residents in 54 villages of Junagadh, Patan and Banaskantha districts (Sidhpur region) of Gujarat by increasing access to a quality healthcare system. The focus is on providing an integrated range of quality health services to rural communities while simultaneously enabling local ownership through training programmes that help to enhance management capabilities and ensure financial sustainability. Incidence of disease and infections is reduced as a result of a three-tier system of health centres, diagnostic centres and community volunteers who help ensure that benefits reach out to the wider and dispersed rural community (outreach).

Introduction
A hot, dry climate, scarce rainfall and the high incidence of natural calamities, including earthquakes, cyclones and drought, increase the hardships faced by rural communities in Gujarat. A severe lack of drinking water and depleted or contaminated groundwater sources aggravate the situation. Poor literacy levels among women, low levels of health awareness, particularly on reproductive health, as well as the low incidence of hygiene and poor sanitation are concerns. Socio-cultural norms lead women to deliver children at home, without the aid of qualified and trained medical help. Antenatal and post-natal care is usually lacking and is subject to age-old practices, beliefs and traditions. In poor households, women and children are usually the first to suffer the ill effects of malnutrition or under-nutrition. High child mortality levels on account of diarrhoea, malaria and respiratory tract infections are widespread. Women on the other hand are also vulnerable to reproductive-tract and sexually transmitted infections.

The large volunteer base, primarily women, seeks to ensure service delivery at the household level.The large volunteer base, primarily women, seeks to ensure service delivery at the household level.AKHS(I)’s integrated approach to health care delivery extends the impact beyond curative health care to many of the root causes of ill health, such as building awareness, health promotion and disease prevention, nutrition and personal hygiene. The large volunteer base, primarily women, seeks to ensure service delivery at the household level. Emphasis is on improving the quality of primary healthcare services, enhancing access to secondary care and enabling local, community-based organisations to manage their own health care initiatives.

The Project also effectively highlights how community-based child and reproductive health interventions can achieve a high degree of financial sustainability. Cost recovery of health services, despite increased competition from private practitioners, has remained at an average of
70 percent.

Three-Pronged Approach
Health centres form the nucleus of the health care delivery system, providing outpatient curative services and reaching the wider community (providing outreach services) through a community-based programme that is the cornerstone of the Project. A qualified medical practitioner (part-time or full-time) attends to patients. A qualified lady attendant helps with day-to-day functioning of the clinic and with counselling and clinical services.

Community health volunteers provide preventive and promotive primary health care at the household level and provide outreach services to rural households. Thirdly, diagnostic centres offer radiology, ultrasound, and pathology services in addition to routine laboratory facilities. The diagnostic centres contribute a qualitative aspect to the project by confirming or challenging diagnoses made by the health centres’ doctors or volunteers and by indicating whether referral care is required. The Project also provides for appropriate referral linkages to government and private providers, to beneficiaries outside the traditional coverage area.

Local Ownership, Management and Representation
AKHS,I undertook an extensive community assessment prior to introducing community co-financing. This assessment involved a socioeconomic survey, estimation of household out-of-pocket expenditure, community perceptions and preferences regarding health care financing and current utilisation of services.

The findings were shared with the communities to ensure joint decision-making. Village-level health committees were set up, and consultations held with communities to find out the extent of their health needs. The communities were also involved in deciding the type of community financing to be implemented. For example, it was decided jointly by AKHS,I and the community that user-fees would be the main method of community financing. The communities also determined the fee levels. These aspects of the project have increased their commitment to eventual ownership and management of the health clinics. The health committees also collect community contributions - in the form of user charges and pre-payment contributions. The health committees are allowed to make certain expenditures only. For example, they are not allowed to buy drugs. They are, however, responsible for deciding who should be exempt from paying user-charges, for paying certain bills (including electricity and telephone bills), buying stationery, administering travel allowances for local health volunteers and purchasing emergency medicines.

The strength of the approach lies in the volunteer base. The capacity and commitment of these volunteers is crucial to ensuring long-term sustainability. They often work for up to 12 hours a week, providing doorstep services, keeping track of children’s vaccinations, monitoring the health of pregnant women, meeting with groups of women and children to discuss basic hygiene issues, for example, washing hands with soap after using the toilet. A single trained and supported volunteer can provide services to up to 100 households.

Partnerships with Government and Other Local Groups
The health committees coordinate their efforts with government health workers for immunisation and antenatal care. They work with Aanganwadi (government day-care centre) workers for growth monitoring of children simultaneously maintaining contact with Panchayati Raj institutions (local, grassroots-level government bodies).

Access and Coverage
The Project is currently testing two different models: facilitation in the Junagadh area and replication in Sidhpur. The facilitation approach calls for informing and mobilising communities through Village Health Committees, in order to strengthen links with and improve the effectiveness of the public health delivery system (without establishing additional fixed infrastructure). The facilitation model operates at
two levels.

First, a community organiser informs and mobilises villages and links communities with existing public and private health providers operating in the area. This approach also looks at increasing the effectiveness of auxiliary nurse midwives, anganwadi workers, and traditional birth attendants, all of whom interact with young children and women in the fertile age group. Sidhpur’s replication approach, which is markedly different from Junagadh’s facilitation model, focuses on the construction of new facilities to expand to new areas.

Impact
Though AKHS,I continues to play an important role in project management and implementation, day-to-day control is gradually being handed over to the communities in phases. Though not complete, this level of control has contributed to the Project’s impact in terms of increased health service utilisation, quality of care, and efficiency. No epidemics have been reported in the area. The health centres are well utilised; on average they see up to 20 outpatients a day. The diagnostic centres are also well utilised and have widened their mandate to include adult health problems that are increasingly prevalent such as HIV/AIDS, diabetes, heart disease, oral and dental problems, hypertension
and obesity.

Baseline data has been collected to establish benchmarks. A house-to-house survey was conducted in July-August 2002 and preliminary results show that progress has been made in key areas as compared to National Family Health Survey (1998-1999) data. Particularly significant are achievements in breastfeeding and maternal care. Areas such as family planning however, remain causes for concern.

Cost Recovery
The Project successfully demonstrates a high degree of financial sustainability by cross subsidising one health service with another. For example, services to the under-threes and women of childbearing age, which seldom cover costs, are cross-subsidised.

The diagnostic centres function on a fully commercial basis. High utilisation has helped to cross-subsidise income from the health clinics. Despite a highly competitive commercial environment, cost recovery levels have averaged 70 percent. The aim is to achieve 90 percent recovery of costs and to eventually hand over the operations to the community. Community involvement has also helped to keep costs low. Most of the members of the local institutions serve on a voluntary basis. Local involvement has also led to increased community contributions for health, which has improved financial viability.

Apart from the user-charges, communities have a choice on the pre-payment schemes. Under one scheme, households can contribute toward different packages of health services. One package is for maternal and child healthcare, and includes antenatal, delivery and postnatal care. Another package provides screening services for non-communicable diseases, such as diabetes and hypertension.

In order to improve financial sustainability by increasing cost recovery, an Alternative Health Financing approach was initiated. This included establishing a health fund based on contributions from communities and dairy cooperatives. To join the fund, families pay Rs. 200 (US$ 4) per year. This premium exempts any member of the household from paying registration and consultation fees at the health centres.

It also entitles each family member to have a 20 percent discount on in-patient costs and diagnostic tests, if required. Dairy cooperatives donate a fixed amount of money periodically to cover any financial deficit in a health centre. All households have access to the same benefits available under the health fund.

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