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Transforming India's Rural Healthcare into self sysustaining enterprises. Focus on Millennium Development Goals.

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HEALTHCARE
INTERVENTION
IN THE CIVIL
SOCIETY

sanjayDOCTOR
Project Mentor

mikrofields

A strategic exploration
to face the challenges
of a changing
healthcare paradigm
in India

131, Silver Beach Apts, Suryavanshi Hall
Off Savarkar Marg, MUMBAI 400 02 8
Cell: 989 2000 857. Res:(022)24449311
[email protected]

June 2007
ver 1.0

HEALTHCARE INTERVENTION
IN THE CIVIL SOCIETY
A strategic exploration to face the challenges
of a changing Healthcare paradigm in India
~ TABLE OF CONTENTS ~
Introduction............................................................................................................................................................. 1

PART ONE
1

THE EMERGING PARADIGM OF THE CIVIL SOCIETY.......................................................................... 3
1.1 Evolution of Global Consciousness....................................... 3
1.2 Relective / Living Systems Paradigm..................................... 4
1.3 Peaceful Co-existence................................................................. 6

2

THE CIVIL SOCIETY....................................................................................................................................... 7
2.1 Historical Development............................................................. 7
2.1 Role for Private Actors: Systems Interface.......................... 8

3

THE NASCENT CIVIL SOCIETY IN INDIA ................................................................................................ 9
31 The Voluntary Sector in India................................................. 9
3.2 India Shining............................................................................... 10
3.3 Plural Indian Society................................................................. 11

4

PARADIGM SHIFT FOR VOLUNTARY ACTORS................................................................................... 12
4.1 Organisation renewal............................................................... 12
4.2 The 3 Ps......................................................................................... 12
4.3 The Struggle to Change........................................................... 14

5

THE MILLENNIUM GOALS......................................................................................................................... 16
5.1 Global Development Agenda................................................. 16
5.2 The Health scenario in India................................................. 17

PART TWO
6

NATIONAL RURAL HEALTH MISSION 2005 – 2 012........................................................................... 23
6.1 Program Matrix........................................................................... 23
6.2 Role for Panchayati Raj Intermediaries.............................. 24
6.3 Role for NGOs............................................................................. 24
6.4 Budgetary Support..................................................................... 24
6.5 Thrust Areas................................................................................ 25

7

PUBLIC PRIVATE PARTNERSHIPS......................................................................................................... 26
4.2 Intervention approach for third sector.............................. 26
4.3 Public private partnerships.................................................... 26
4.4 the Contract State...................................................................... 28

8

THE INTERVENTION MATRIX ................................................................................................................. 31
5.1 The vertical span
5.1.1 Macro Dimension: Millenium Goals ....................... 31
5.1.2 Micro Dimension : NRHM Goals............................... 33
5.2 The Program Matrix.................................................................. 40

6

THE AGENTS OF CHANGE......................................................................................................................... 42
6.1 Ground reality............................................................................... 42
6.2 the road ahead............................................................................... 42
6.3 Unlocking the potential in the rural india.......................... 43
6.4 Conclusion...................................................................................... 44

ÌËÌÍW

X
Introduction

This document began as a personal study into the India's
public healthcare. It was to understand and plan micro
interventions into community health. I was relying on my
previous experience of having done a similar study
followed by a decade of work in organic farming. What was
intended to be a short research engagement of a few weeks
turned out to have occupied the entire first quarter of
2007. I have decided to freeze the document at this draft
and circulate it amongst my comrades working in the field.
The document examines the issues at a macro and micro
level. The first part examines the societal issues and the
second part focusses on actual interventions. The reader
can read each part independently or together.
I propose to plan and mentor interventions as outlined
in part two. Also there is an opportunity to create
linkages with organic farming and nutrition. Preventive
healthcare is a sustainable long term solution for coping
with the current healthcare crisis.
The intended impact of the document is to lead social
agents to an internal strategic exploration of how they
wish to intervene into the healthcare sector.
Some copies will also be shared with state agencies to
engage in dialogue.
The document is being distributed in the Acrobat format
as a digital file. Some paper copies have also been
printed as execptions.
Mumbai, June 10, 2007

Sanjay Doctor

I used an orginal copy of MS Windows XP Home and openware software
Openoffice 2.0 (www.Openoffice.org) from Sun to write the document. PDF
was created from OpenOffice's in built writer.

X

Healthcare Interventions in the Civil Society – Sanjay Doctor

|1

PART ONE

N

Healthcare Interventions in the Civil Society – Sanjay Doctor

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CH A PTER 1

THE EMERGING PARADIGM OF THE CIVIL SOCIETY
THE EVOLUTION OF GLOBAL CONSCIOUSNESS
In the post millennium era, the world is moving towards a greater interconnectedness
than ever before. The Butterfly Effect – the flirl of a butterfly in Brazil could cause a
tornado in Texas – has made us all aware that the mankind must think with a groupsoul rather than as self-centred individuals if we must survive and prosper as a species.
At a spiritual level a new evolving consciousness is arising. Father Bede (Swami
Dayananda, Shantivanam Ashram), in his article, 'The New Consciousness' writes:
We are entering a new age. The European civilisation which we have known for the past
2,000 years is giving way to a global civilisation which will no longer be centred in Europe
but will have its focus in Asia, Africa and South America. Christianity will no longer be a
separate religion but will be seen in the context of the religious traditions of humankind as
a whole.
As we enter this new civilisation, the meeting place of the East and West, and of the
nations of the world will be science. The changes in contemporary western science have
provided a new outlook for life for humanity as a whole. The central point is the new
understanding of the universe which is no longer perceived as consisting of solid bodies
moving in space and time, but rather, according to quantum theory, as a field pervaded by
consciousness...
I think that is exactly where we are today; the breakdown of the old civilisation and of
the whole order which we knew, and, within that, the rebirth of meaning, penetrated by a
new consciousness. Science recognises that all order comes out of chaos. When the old
scriptures break down and the traditional form begins to disintegrate, precisely then in
chaos, a new form, a new scripture, a new order of being and consciousness emerges.
The old is always dying and the new is emerging, and that which is new socially and
culturally transforms the old.
...This is really an apocalyptic age.
The old world economics, was based on a two-sector world; there was the Market or
the economy on the one hand, and the State or government on the other. Supported by
the North's colonisation of the South, the world was divided between two dominating
political systems - socialism and capitalism. These replaced the indigenous feudalism
and monarchy polity. Emir Sader, writes in the New Left Review, (Sept-Oct 2002):
From the moment of the Bolshevik revolution - and especially since the Second World War
- the world stage was polarized by the socialist / capitalist opposition, determining
relatively fixed ideological and political reference points. While the Left proclaimed a
struggle between the two systems, the Western superpowers called for a battle of
'democracy' against 'totalitarianism' was the determining contradiction of the epoch.

Healthcare Interventions in the Civil Society – Sanjay Doctor

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REFLECTIVE / LIVING-SYSTEMS
The evolutionary consciousness of our species has led us to a paradigm shift about
our World reality. Science makes great discoveries about our worlds - mapping the
Human Genome in our internal world and going deeper into the Cosmos in our
external world. The Cartesian-Newtonian view, built on a mechanical world view, is no
longer able to explain the mysteries of Life. We are left with many unanswered
questions. There is a great revival to seek out ancient knowledge. Fritjof Capra, in the
'Web of Life' observes:
Since industrial society has been dominated by the Cartesian split between mind and
matter and by the ensuing mechanistic paradigm for the past three hundred years, this new
vision that finally overcomes the Cartesian split will have not only important scientific and
philosophical consequences, but will also have tremendous practical implications. It will
change the way we relate to each other and to our living natural environment, the way we
deal with our health, the way we perceive our business organizations, our educational
systems, and many other social and political institutions
The planet is looked upon as Gaia, mother earth goddess. The Gaia hypothesis is an
ecological theory that proposes that living and non living parts of the earth are viewed
as a complex interacting system that can be thought of as a single organism. Named
after the Greek earth goddess, this theory postulates that all living things have a
regulatory effect on the Earth's environment that promotes life overall. Stephen
Schneider and Penelope Boston in "Scientists on Gaia" (MIT Press) describe:
"James Lovelock and Lynn Margulis coined the phrase the Gaia hypothesis to suggest ...
that life serves as an active control system. In fact, they suggest that life on Earth
provides a cybernetic, homoeostatic feedback system, leading to stabilization of global
temperature, chemical composition, and so forth.
To see the the Earth (and even the cosmos) as interconnected, living systems has led
to the "reflective/ living-systems" paradigm.

Healthcare Interventions in the Civil Society – Sanjay Doctor

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Table 1 : Comparison of the Cartesian and Living Systems Paradigms
(Source: Global Consciousness Change: Indicators of an Emerging Paradigm by Duane Elgin )

The Cartesian View

The Living Systems View

The cosmos is made up of mostly dead matter
and empty space and is not "alive."

Our cosmos is a unique kind of "living
organism" and, as a whole system, is
fundamentally alive.

We are floating through vast reaches of empty
space, and most of life seems to lack any larger
sense of meaning and purpose.

The entire cosmos is a unified system. Each
action is woven into the deep ecology of the
universe. Everything we do matters.

Consciousness-- when viewed from a
reductionist, mechanistic perspective -- is a by
product of biochemistry and is located in the
brain.

Consciousness-when viewed from an integrative,
living systems perspective-is an ordinary
capacity that permeates the universe and
provides a reflective capability appropriate to
each entity within the universe.

The goal in life is material success and social
achievement.

The goal in life is to develop a balanced
relationship between our inner and outer livesto live in a way that is sustainable and
compassionate.

The emphasis is on conspicuous consumption.
The "good life" depends on having enough
money to buy access to pleasures and avoid
discomforts.

The emphasis is on conscious consumption. The
"good life" is an ever-changing balance of inner
and outer, material and spiritual, personal and
social, etc.

Identity is largely defined by material
possessions and social position.

Our sense of self grows through our conscious,
loving, and creative participation in life.

Emphasis is on personal autonomy and mobility.

Emphasis is on personal growth and community.

The individual is defined by his or her body
and is ultimately separate and alone.

The individual is both unique and an
inseparable part of the larger universe. Our
being is not limited to our physical existence.

It is natural that we who are living use lifeless
material resources for our own progress.

It is natural to respect all that exists as integral
to the larger body of life.

Cut throat competition is the norm. You
compete against others to make a killing.

Fair competition is the norm. You cooperate
with others to earn a living.

The mass media are dominated by commercial
interests and are used to promote a highconsumption culture.

The mass media awaken to the challenge of
sustainability and begin to explore more
workable and meaningful approaches to living.

Nations adopt a "lifeboat ethic" in global
relations.

Nations adopt a "spaceship Earth ethic" in
global relations.

The welfare of the whole is left to the workings
of the free market or government
bureaucracies.

Each person takes responsibility for the wellbeing of the world, enabling high levels of
decentralization and freedom at the local level,
and a sustainable harmony at the global level.

Healthcare Interventions in the Civil Society – Sanjay Doctor

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PEACEFUL CO-EXISTENCE
Global security and peace are linked to a productive life for all. The report, Investing
in Development, referring to West-led international developmental goals,
'The Goals not only reflect global justice and human rights, they are also vital to
international and national security and stability'.
And so as consciousness evolves, it begins to conceptualise the human being and
the value of balance and harmony for peace. Professor Panicker, scientist and
Gandhian philosopher explains the logic in his article, Evolution of Humanity :
Aum Shanti: These two words express the aspiration of humanity for evolution towards
harmony and peace. They denote an attitude of life and a way of living. Aum represents
harmony – harmony among creation, sustenance and dissolution; harmony among body,
mind, intellect, harmony among individuals, neighbourhoods and the world. Harmony,
from Greek 'harmos' (= joint), is literally yoga. Yoga is which joins (Sanskrit – yujyate
anena yogah).
Yoga leads to Shanti. Shanti means peace – peace with oneself or inner peace, peace
within community and universal peace. Peace from Latin ' pacisci' (= to agree), is a state of
tranquillity. From harmony to peace is literally an evolution from joint to agreement, from
congruence to unity.
Peace comes to individuals from harmony in living, to communities from living in harmony
with neighbours.
Political thought is headed towards a neoliberal outlook, where the Left has
partnered with the Right wing. Again Edir Salami observes:
With the fall of the USSR and the 'socialist bloc', capitalism was once again sole ruler of the
world scene. The remaining post-capitalist countries reinvented themselves. China opted for
a form of market economy as in all likelihood will Vietnam. Cuba sought to defend the
basic gains of the previous period rather than advance towards socialism. The radical shift
in the balance of forces reverberated through the social and political movements. With
growing unemployment in Europe, unions were thrown onto the defensive, mounting at
best a partial resistance to ‘flexibilization’ while rapidly losing members. In the increasingly
informal and heterogeneous world of labour that was emerging, traditional methods of
organizing had ever less effect. Parties had to confront the universalization of neo-liberal
policies. European social democracy adapted to this at the very moment when, for the first
time, the Centre-Left was in power in nearly every EU state; the Communist parties of the
region shrivelled, or vanished altogether. A similar scenario was enacted in Eastern Europe,
where former Communist parties took up a radicalized neoliberalism or local versions of
the Third Way.
It was in this context that local and sectoral forms of resistance ecological, feminist, ethnic,
human rights, municipal democracy combined to form the movement that, together with
union organizations and anti-WTO groups, would surface so explosively in Seattle in
November 1999. If they represent an advance, in creating new spaces in which opposition
forces can come together, many of them also implicitly renounce any attempt to construct
an alternative society: as if our indefinite confinement within the limits of capitalism and
liberal democracy was accepted as fact.

Healthcare Interventions in the Civil Society – Sanjay Doctor

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CH A PTER 2

THE CIVIL SOCIETY
HISTORIC DEVELOPMENT
The modern idea of the civil society has its roots in the Scottish and Continental
Enlightenment of the late 18th century. Freedom from the State in a domain parallel to
the State; where citizens acted according to their own interests and wishes. It was
transformed to its present form in the 1990s when it was used as a tool for a global
move towards democracy against dictatorial countries. In the West, it was used as tool
for social renewal. In developing countries, as privatisation and other market reforms
took place, the civil society become more mainstream as governments retracted. It
became a key element of the post cold war Zeitgeist. It is seen as a key tool for shaping
peoples' energy and initiative towards peaceful partnerships with the state.

Defining the Civil Society
The Centre for Civil Society, London School of Economics, defines it as as:
Civil society refers to the arena of uncoerced collective action around shared interests,
purposes and values. In theory, its institutional forms are distinct from those of the state,
family and market, though in practice, the boundaries between state, civil society, family
and market are often complex, blurred and negotiated. Civil society commonly embraces a
diversity of spaces, actors and institutional forms, varying in their degree of formality,
autonomy and power.
Gehard Schroeder, Chancellor of Germany (1998 - 2005), in his article, Civil Society:
redefining the Duties of the State and Society, reflects that,
Society senses that a number of traditional certainties of political and social life are no
longer anchored in place.
He makes a strong case for politics to reorient itself to its primary tasks. These go
beyond the traditional tools of intervention – legislation, authority and money. It must
encompass social justice through equal opportunities for all. He sets a new political
agenda for the state:
How do we want to and how should we achieve justice, participation,solidarity and
innovation in the future ? How can we shape an attractive society which is not exclusive
and in which the talents of all can best unfold ? How can we foster initiative, protect the
weak and encourage the strong to make their contribution?

Healthcare Interventions in the Civil Society – Sanjay Doctor

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His concept of a modern civil society is that of a 'civilisation of change' through
political integration and a new civic consciousness – greater individual responsibility
that leads to public good. Civil society is becoming the most important centre of social
participation. It will have to create the sense of identity that ties the individual to
the values and goals of a society as a whole. Within this civil society, citizens regain
an element of subsidiarity and self determination.
The global theatre of a civil societies are populated by organisations such as
registered charities, development non-governmental organisations, community groups,
women's organisations, faith-based organisations, professional associations, trades
unions, self-help groups, social movements, business associations, coalitions and
advocacy groups. Brian O’Connell, Tufts University, brings together the various players
who constitute the civil society in a star formation:
1)
2)
3)
4)
5)

The Individual
The Community
Government
Business
Voluntary Sector

From a liberal right perspective, Sara Evans and Harry Boyte in Free Spaces: The
Sources of Democratic Change in America, locate the primary territory of civil society in:
the public spaces, in which ordinary people become participants in the complex, ambiguous
engaging conversation about democracy: participators in governance rather than
spectators or complainers, victims or accomplices.
They further elaborate:
particular sorts of public places in the community, what we call free spaces, are the
environments in which people are able to learn a new self-respect, a deeper and more
assertive group identity, public skills, and values of cooperation and civic virtue.
Civil society exists at the intersection where the various elements of society come
together to protect and nurture the individual and where the individual operates to
provide those same protections and liberating opportunities for others.

ROLE FOR PRIVATE ACTORS: SYSTEMS INTERFACE
It becomes apparent from the above dissertation that any role envisaged by private
actors in voluntary action must create harmony. This is created by cooperation rather
than opposition to the system – it requires a strong faith. Rather than taking a contra
or confrontational role, the alignment seeks to become an active participant in society.
It also means a coming of age for voluntary action actors. From being missionary
organisations, the move is towards social enterprises working for creating enterprise
value. Whilst passion provides the warmth for the seed to sprout, the actual germ has
to be built around professionalism. Incompetence cannot be condoned for any
participant in the civil society including the state.

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CH A PTER 3

THE NASCENT CIVIL SOCIETY IN INDIA

THE VOLUNTARY SECTOR
Voluntary action actors are often identified as 'NGOs'- non governmental
organisations. The term has been in vogue ever since development work in the post
independence era was driven by foreign aid programs. The PPP (Public-PrivatePartnerships) Sub Group of the Planning Commission summaries the sector as follows:
The voluntary sector in India refers to bodies / institutions set up under the Societies
Registration Act, the Indian Trust Act, the Religious and the Charitable Societies Act, nonprofit making companies under the Companies Act as well as under any other legislation
that may be recognized by the State Government. The voluntary sector also includes
Community Based Organizations (CBO), Self-Help Groups (SHGs), which are generally
informal or unregistered bodies. It does not, however, include all co-operative societies.
The voluntary sector may be broadly classified as traditional, community based and
government sponsored. Traditional sector comprises the various religious and charitable
trusts dedicated to spread education, health care, orphanages and rehabilitation homes etc..
The Community based Organizations (CBOs) comprise societies for relief from natural
disasters, neighbourhood societies, micro-credit societies, women’s associations, wild life
protection committees etc.. Government sponsored voluntary sector comprises agencies
engaged in welfare programmes such as rural development, afforestation programmes,
watershed management, health and education services as well as those engaged in
research and evaluation.
According to one study, the voluntary sector in India can be grouped in five categories
based on their main areas of activity as follows:
(a) Religious ........................................................ 26.50 %
(b) Community Service ...................................... 21.30 %
(c) Education ........................................................ 20.40 %
(d) Cultural ........................................................... 18.04 %
(e) Health................................................................. 6.60 %

Religious and cultural societies put together have a clear edge over other forms of
voluntary sectors in India. Government sponsored voluntary sector in India in the areas of
social sector, such as health and education etc. may, however, soon come to have a larger
share.
In regard to mobilization of resources, moreover, it is stated that half of all 72 sources of
receipts (51%) is self-generated through fees/charges for the services rendered.
This is followed by grants and donations (29%). Amongst the various sources of raising
funds, donations and charity are mostly adhoc and irregular. Private fund raising is,
furthermore, more time consuming. Similarly, while collection of funds from fees and user
charges are market determined, grants-in-aid are rule bound and more dependable

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INDIA SHINING
After 60 years of independence, there is a trickle down effect of the development
work done by the actors and India appears to rated high in the growth rate scorecard.
Key parameters, as stated by the Finance Minister P. Chidambaram in his Feb 2007
budget speech, are as below:
Manufacturing has become the main driver of growth.
Per capita income has increased by 7.4%
Savings rate is 32.4% and investment rate is 33.8%
Foreign exchange reserves $180 billion

Table 2: Key Growth Rate in Gross Domestic Product (GDP) metrics
(Source: RBI report- Macroeconomic and Monetary Developments, Third Quarter Review 2006-07)
(All figures are in percentages)
2001-05

SECTOR
AGRICULTURE SECTOR

Share of real GDP
Manufacturing Sector

Share of real GDP
Services

Share of real GDP
Growth of Real GDP
at Factor Cost

2004-05

2005-06

AVERAGE
2.3

.7

3.9

22.2

20.8

19.9

6.2

7.4

7.6

19.6

19.5

19.3

8.1

10.2

10.3

58.2

59.7

60.7

6.4

7.5

8.4

Healthcare Interventions in the Civil Society – Sanjay Doctor

2006-07
Q1

Q2

3.4

1.7

9.7

10.5

10.5

10.7

8.9

9.2

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THE PLURAL INDIAN SOCIETY
A strong media, dominated by the urban elite press , support the brand of the
'Indian Tiger'. This split in society between the haves and have-nots, the old school
versus the new is exemplified by a poem, published in the Times of India, on 26
January 2007:
There are two Indias in this country.
One India is straining at the leash, eager to spring forth and live up to all the adjectives
that the world has been showering recently upon us.
The other India is the leash.
One India says, give me a chance and I'll prove myself.
The other India says, prove yourself first and maybe then you'll have a chance.
One India lives in the optimism of our hearts.
The other India lurks in the scepticism of our minds.
One India wants. The other India hopes.
One India leads. The other India follows.
But conversions are on the rise.
With each passing day more and more people from the other India have been coming over
to this side.
And quietly, while the world is not looking, a pulsating, dynamic new India is emerging.
An India whose faith in success is far greater than its fear of failure.
An India that no longer boycotts foreign-made goods but buys out the companies that
make them instead.
History, they say; is a bad motorist, It rarely ever signals its intentions when it is taking a
turn.
This is that rarely-ever moment. History is turning a page.
For more than half a century, out nation has sprung, stumbled, run, fallen, rolled over, got
up, dusted herself and cantered, sometimes lurched on.
But today, as we begin our 60th year as a free nation, the ride has brought us to the edge
of time’s great precipice.
And one India - a tiny little voice at the back of the head - is looking down at the bottom of
the ravine and hesitating.
The other India is looking up at the sky and saying, it's time to fly.

The civil society will be dominated by players at two scales. One will be corporate
entities working with the state on mega projects – like the 4 lane highway, airports,
ports and other infrastructure projects. They enter the theatre of developmental work
for the purpose of economic development leading to larger markets in the long run.
Others will continue their work at the micro scale; more ideology based or just plain
legacy. It is these we focus on.

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CH A PTER 4

A PARADIGM SHIFT FOR VOLUNTARY ACTORS
What could be a new role for these players which would benefit society
and at the same time keeps alive the spirit of human society – equal
opportunities, social justice ? Can they be financially viable and find an
ecological niche to sustainably draw resources from the system for their
survival and for executing their programs.

ORGANISATION RENEWAL
Firstly, they must undergo a change management exercise. Change is all around us.
Remaining static, subscribing to dogmas and living in an antiquated business model is
the bane of most of the actors grasping for breath. It implies movement.
Secondly, they must create a revenue generation model. Funding is transformed into
a revenue model. Non-profits must become social enterprises.
These enterprises must tune themselves to global consciousness. They must became
shapers rather than adaptors of globalisation. Programs must originate from the filed
data rather than merely implementing international aid agency agendas. Indigenous
knowledge must be harnessed to find solutions.

The 3 Ps
Being a civil society actor is not them same as being employed in social service or in
a part time 'feel good' hobby. Membership to the club requires competence. At an
organisation level, it means lfrom the Strategy - Structure – Systems model to a
harmonious model built around the 'Purpose – Process – People'. as proposed by
Sumantra Ghoshal. In an article 'A New Manifesto for Management ' (1999), Sumantra
Ghoshal, Christopher A. Bartlett, and Peter Moran explain:

Healthcare Interventions in the Civil Society – Sanjay Doctor

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A different management model is now taking shape, based on a better
understanding of individual and corporate motivation. As companies switch their
focus from value appropriation to value creation, facilitating cooperation among
people takes precedence over enforcing compliance, and initiative is valued more
than obedience. The manager's primary tasks become embedding trust, leading
change, and establishing a sense of purpose within the company that allows strategy
to emerge from within the organization, from the energy and alignment created by
that sense of purpose. The core of the managerial role gives way to the "three Ps":
purpose, process, and people — replacing the tradition al "strategy-structure-systems"
trilogy that worked for companies in the past.
Christopher A. Bartlett is the Daewoo Chair of Business Administration at
Harvard Business School, explains further in Organizational Overhaul,
We’re coming from a corporate model based on 3 S’s: Strategy, Structure, and
Systems. Strategy was set by allocating the scarce resource (capital). Structure was
designed to hold units accountable (divisionalized). Systems provided the means for
the elaborate planning and control process to work. The integrated model created
clear management roles and responsibilities based on delegation and control. Top
management were strategic resource allocators who managed scarce capital
resources, allocated them across competing needs, then measured, evaluated, and
controlled them. Middle management managed the process that supported top
management’s activities. They sent the capital budgets up; they controlled against
the objectives top management sent down. Front line managers were the operating
implementers who lived within the budgets and controls of the top managers.
Today’s critical scarce resource is no longer capital. Quite the opposite, since most
companies today are awash in capital. It is now information, knowledge, and
expertise. In essence, it’s people and the processes that link them to leverage their
know-how. With all of these organizations competing for information, knowledge,
and expertise— essentially, people—today ’s corporate competitive advantage resides
in the people in the company and the organizational capability that’s built around
them. Organizations need to change the way they operate. Some organizational
mind-shifts are crucial.
1. From Strategy to Purpose
In order to create organizational learning, companies have to create a sense of
shared purpose and belonging for all individuals. Companies are no longer simply
economic enterprises. Managers must create and manage companies as social
institutions as well. It’s no small order, but top management must convert the
contractual employee of an economic entity into a committed member of a
purposeful organization: Attracting a scarce resource-smart, capable people-depends
increasingly on creating not just a place where they come to work, but a place where
they can belong, especially in a world where so many social institutions
(communities, neighborhoods, families) are dysfunctional or completely broken
down.
The heart of creating an environment where learning can take place is creating an
internal environment where people can and do relate to each other—formall y and
informally. Social networks are the key link in developing and diffusing expertise
through the organization.

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2. From Structure to Process.
The organization is not just a hierarchy of tasks and responsibilities, but also a portfolio of
flexible roles and relationships. The main task of the organization is to shape behaviors of
people and create an environment that enables them to take initiative, cooperate, and
learn. Formal organization charts are no longer the issue. Now, linking assets and
resources through redefined relationships is key.
3. From Systems to People
Restructure systems to reflect the new source of competitive advantage. The old system
was structured to measure, evaluate, and reward people around financial measures. Not
surprisingly, people were viewed and treated as costs.
Now, with people the source of competitive advantage, Human Resources is the critical
function in today’s organization. HR practices and policies should no longer be abrogated
to some functional unit miles away from the CEO. The chief HR officer, along with the
learning and knowledge management officers, should be literally and figuratively close to
the CEO, with equal (if not greater) standing than the financial officers.
Until organizations can learn to attract, motivate, develop, and retain superior people— and
build a community where these people can leverage their knowledge and expertise—
everything else they do is supplemental. Transforming organizations relies upon
transforming human behavior. Creating an organization based on self-discipline, trust, and
support is about creating this behavioral context. People are the foundation on which all of
this is built. The most sophisticated systems and technical structures will be completely
wasted if there’s leakage of talent, a demotivated workforce, or a culture that doesn’t
support sharing of knowledge.

THE STRUGGLE TO CHANGE
Many of the voluntary organisations find themselves in the bind of being a Missionary
organisation. Henry Mintzberg, Professor of Management Studies at McGill University
in Montreal created this term. These organisations are founded on the ideals and
vision of a strong personality who subscribes to a strong philosophy. This permeates
into all strategies and methods of the organisation. Its a double bind. On one hand it
provides a strong will action allowing for great movement.
.., in a missionary organization the shared values and beliefs among the members hold the
company together. The mission counts above everything, - to preserve it, extend it and
perfect it. The mission attracts people that share the same values, and the shared concern
motivates employees to sustain the company’s strategy, because the individual’s goals are
integrated with the organizational goals. Hence, the common mission increase efficiency,
chances to discover opportunities and the capacity for innovation.
Many NGOs were founded with a legacy of Gandhian Ideology and Vinoba's
Sarvodaya movement. Founded on strong ideologies of swaraj, frugalism and selfless
service, they have now grown into organisations funded by huge grants from the state.
The Council for Advancement of People's Action and Rural Technology (CAPART) has
assisted over 12,000 organisations.

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Caught in the older model of donor – intermediary – recipient , they became
dependent on donors for funds and slowly all indigenous agendas and ideologies were
sacrificed for programs determined by international donors and the state. A new
vocabulary was learnt. As a result capacities were built around competencies required
for this role. Strong documentation, academic approach to development work and
distancing themselves from the beneficiaries through field units. Quality of work is
assumed to be linked to scale. Numbers dominate the reports. As Globalisation comes
to Indian shores, economic liberalisation requires the state moving away from the
donor status. Internal pressures from the staff and project affected people (PAP) has a
stressful bearing on the workings. Operating costs shoot off the ceiling as the staff
demands compensation and benefits equal to the corporate sector. Somewhere the
legacy of the voluntary sector has created a myth that voluntary work is social work
and therefore salaries are to be nominal. But the nature of development work has
changed, the emphasis being on creative problem solving, strategic decisions – all
which rely on the individual professional manager as a working asset. Salaries get
transferred from non-value costs to principal costs.
Once the internal reorganisation takes place, it is necessary to find a vehicle for
work and a section of society to work with. The divide between urban and rural India
has been the driving determinant. Instead we must look right in the midst of our
society's fabric: - in its warp and weft. Because whilst one India moves on, it leaves
another behind. There is an India of those who do not receive the same opportunities
as the elite shining India. They remain defranchised, and resourceless to better their
lives to the same extent as the privileged. Cutting across geographical or social
categories, they exist interpolated in the very fabric of our society. Until now, they
struggled with basic wants of food, clothing and shelter. Now it's their aspiration to
receive the same opportunities in life and to enjoy a quality of life which must be
satisfied. as enshrined in the fundamental rights of the constitution.
Article 21 has been expanded after reading with Arts. 14 and 19. In Francis v/s
Administrator A. (1981 SC 746) the ruling states:
It includes the right to live with human dignity and all that goes with it, namely the bare
necessities of life such as adequate nutrition, clothing and shelter over the head and facilities
for reading writing and expressing one self in diverse forms, freely moving about and mixing
and commingling with fellow human beings (para 7) .
Denial of basic services inspite of a citizen charter, religious discrimination despite a
secular constitution and gender emancipation are issues awaiting direct action.
We will restrict ourselves to healthcare for the purpose of this paper.

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CH A PTER 5

THE MILLENNIUM GOALS
A GLOBAL DEVELOPMENT AGENDA
The well-being of all people especially those billion-plus living in 'extreme poverty'
has become a global concern. In 2000, United Nations initiated the Millennium Goals
Project to remove extreme poverty by 2015. The goals reflect the basic life issues faced
by a defranchised population in the poor and developing countries.
We will have time to reach the Millennium Development Goals - worldwide and in most, or
even all, individual countries - but only if we break with business as usual.
We cannot win overnight. Success will require sustained action across the entire decade
between now and the deadline. It takes time to train the teachers, nurses and engineers; to
build the roads, schools and hospitals; to grow the small and large businesses able to
create the jobs and income needed. So we must start now. And we must more than double
global development assistance over the next few years. Nothing less will help to achieve
the Goals.

Kofi A. Annan : United Nations Secretary-General, 2000
For developing nations around the world , the issues and targets identified are the
new goals for development. Globalisation demands adherence to a global mindset.
Alignment to these goals will allow a partnership with the state and donor agencies.
These goals are no doubt built from quantitative research and the feedback received
from transnational voluntary agencies working across the world. However it may be
observed that the agenda is one seen through the viewpoint of the developed countries
and with built around a socio-religious consensus, especially of the Church.
One of the biggest challenges to be addressed in the under-developed world is that
of the growing population and the strain on the global resources. However the Roman
Catholic church and its auxiliary medical wing do not advocate family planning
through contraception or sterilisation. As a result only passive methods of family
planning are advocated. This reflects in the Millennium Goals which drops this priority
from the list. It also agrees with the fundamental Islamic edicts which prohibit any
form of contraception but circumvents this issue through the advocacy of condoms to
prevent Aids. Nevertheless its a beginning and voluntary actors in India and the state
must adapt these goals to the Indian context.

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5 of the 8 goals specifically address health issues. It draws us to the conclusion that
in the race for global economic development, a large part of the human community
struggles with existence itself. The goals are so basic that for the developed world and
elite class, they are presumed to be available by default. A large part of of the human
race stands a very narrow chance of survival in the coming decades if these issues are
not addresses. Also if this was to be the case, global security and well being would be
severely compromised.
Table 4: Millenium Development Goals

Millennium Development Goals
1

Eradicate extreme poverty and hunger

2

Achieve universal primary education

3

Promote gender equality and empower women

4

Reduce child mortality

5

Improve maternal health

6

Combat HIV / AIDS, malaria and other diseases

7

Ensure environmental sustainablity

8

Develop a global partnership for development

THE HEALTH SCENARIO IN INDIA
The United Nations works through the World Health Organisation (WHO) to drive
health care interventions and reforms around the world. Its statement on the website
(www.who.org) under the heading 'Macroeconomics and Health' presents its policy:
Health is an intrinsic human right as well as a central input to poverty reduction and socio
economic development. Cost-effective interventions for controlling major diseases exist, but
a serious lack of money for health and a range of system constraints hamper global and
national efforts to expand health services to the poor. The high burden of preventable
diseases in poor countries and communities calls for strategic planning of investments
across health and health-related sectors to improve the lives of poor people and
promote development.

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Responding to this urgent need, a macroeconomics and health process helps place health
at the centre of the broader development agenda in countries. It engages Ministries of
Finance, Planning and Health to act in tandem with development agencies, civil
society, philanthropic organizations, academia, and the private sector. Together, they
can take forward a shared agenda for addressing financial and systemic constraints to the
equitable and timely delivery of quality health and social services. This work will contribute
toward achievement of the Millennium Development Goals, global objectives such as "3 by
5", and national health targets.
Countries are driving the macroeconomics and health process, which takes into account
countries' unique health and macroeconomic variables. WHO, working closely with
governments and their partners, advocates for a more prominent role for health within
countries’ macroeconomic agendas. It also offers technical expertise to support country
efforts for developing long-term multi-sectoral investment plans. The work is carried out in
line with three themes:
 Achieving better health for the poor
 Increasing investments in health
 Progressively eliminating non-financial constraint
The WHO works in India through its India Office. Its intervention strategy is
explained by it as:
The Country Cooperation Strategy (CCS) is a medium term, adaptable country specific
strategy that provides the framework of cooperation between WHO and the country. It
articulates a vision and selective priorities for the work of WHO for health development
that are based on systematic assessment of country needs and expectations as well as a
country’s commitment and capacity. The CCS is, in turn, translated into operational plans
that are linked to regular budget and extra budgetary funding.
The CCS is more than a document and it reflects the values, principles and corporate
directions of WHO as one organization and is developed in a spirit of partnership and
mutual respect in the context of the country’s overall efforts for health development. It is a
tool that helps in the process of placing health at the centre of sustainable development,
articulating the linkages between poverty and health, and calling for greater equity in
health.
WHO South East Asia Office

( SEARO) in its document, Status Report on

Macroeconomics and Health: India , 2004 set its agenda for India:
India’s total health expenditure as a percentage of GDP was 4.9% in 2000. Government

spending on health in India is 0.9% of GDP. In 2000, general government expenditures on
health represented 17.8% of total health expenditures and health spending only
represented 5.3% of the general government budget.
India’s health care sector is marked by an extremely high ratio of private spending. Private
health spending represents 82.2% of total health expenditures. The proportion of
public spending is increasing. The ratio of public expenditure on health to total public
expenditure was 1.4% in 1980-81, 1.5% in 1990-91, and 1.8% in 1998-99. The
Commission on Macroeconomics and Health recommends that countries increase health
expenditures by 1% of GNP by 2007.

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Table 5: Social Indicators-Present Status in India
Source: World Development Report 2004 & Tenth Plan Document, Government of India.

KEY PARAMETERS

Measure

Measure % of population below poverty line (1999-2000)

26.1 %

Prevalence of severe malnutrition in children of 1-5 years, (1996-97)

6.2 %

revalence of moderate malnutrition in children of 1-5 years, (1996-97)

44.3 %

Under-5 Child Mortality, per 1000 (2001)

93

Maternal Mortality per 1 lakh live births (1998)

407

Children (6-14 years) not attending school (in millions)

42

Primary pupil-teacher ratio (2000)

40

Male Literacy Rate (2001)

75.9 %

Female Literacy Rate (2001)

54.2 %

Literacy Rate among Scheduled Castes (1991)

29.6 %

population having access to improved water source (2000)

84 %

population having access to improved sanitation facilities (2000)

28 %

India constituted a Task force,

National Commission on Macroeconomics and

Health, led by P. Chidambaram, Union Finance Minister and and Dr. A. Ramadoss,
Union Health Minister. The report published in 2005 became a well planned strategy
document under the stewardship of the technically competent ministers. It sets a
strategy for India's public health system:
India’s health system: The delivery of health care services
The principal challenge for India is the building of a sustainable health system.
Selective, fragmented strategies and lack of resources have made the health system
unaccountable, disconnected to public health goals, inadequately equipped to address
people's growing expectations and inability to provide financial risk protection to the poor.
Access to medical care continues to be problematic due to locational reasons, bad roads,
unreliable functioning of health facilities,transport costs and indirect expenses due to wage
loss, etc. making it easier to seek treatment from local quacks. This explains the gross
underutilization of the existing health infrastructure at the primary level contributing
to avoidable waste.
The reasons for this failure can be attributed to three broad factors: poor governance and
the dysfunctional role of the state; lack of a strategic vision; and weak management. The
structural mismatch in the institutions at the Centre and State levels, with many
departments and agencies duplicating work or working at cross-purposes make
governance in health ineffective. Contributory factors for a dysfunctional health system are
unrealistic and nonevidence- based goal-setting, lack of strategic planning and inadequate
funding.

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The Way Forward
Improving health in India will require building up the health system in the next ten to
twenty years. Five core concerns emerge when facing the challenge of improving health in
India:promoting equity by reducing household expenditure on total health spending and
experimenting with alternate models of health financing;
(1) restructuring the existing primary health care system to make it more
accountable;
(2) reducing disease burden and the level of risk;
(3) establishing institutional frameworks for improved quality of governance of

health;

(4) investing in technology and human resources for a more professional and
skilled workforce and better monitoring.

These concerns need to be addressed by stimulating the process of reform. Reforms should
aim to overhaul the existing system that is dominated by low-quality health care, is costly
and unaffordable for the majority of the people, and where the public sector is underfunded, poorly equipped and constrained by bureaucratic procedures. If India is to stay
committed to achieving the National Health and Population Policies in 2010 and the
Millenium Development Goals in 2015, this Commission recommends that public spending
be increased from the current level of 1.3% to 3% of GDP in the next few years. The
additional resources can form the building blocks for implementing the Commission's
recommendations for a strong and viable health care system in India.
Further it makes an important statement regarding the future role of the state in
public health:

Gradually shift the role of the State from being a provider to
a purchaser of healthcare
A structural outline of the public health care interface is mapped:
Ensure that the three tiers of the primary health system are embedded within the
community........ We recommend a shift in the provision of services from the current
concept of individual vertical programmes to a comprehensive package of services
consisting of three components:
(1) a core package consisting of public goods and costing Rs. 150 per capita, to
be made universally accessible at public cost;
(2) a basic package consisting, in addition to the above, surgery and medical
treatment costing Rs. 310 per capita;
(3) a secondary care package costing Rs. 700 per capita and consisting of
treatment for vascular diseases, cancer and mental illness, and referrals.
The report also outlined the costs involved for their plan and the financial strategy
to meet this requirement:
Government would require a five-fold increase in the budget or Rs 1 lakh crore @ Rs 1160
per capita per year if it is to be the sole provider of the comprehensive package of services
consisting of preventive, promotive and curative services.

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Achieving MDG goals and the Tenth Plan objectives in India, in this scenario, will be
possible only if there is a significant increase in resources, targeting areas and population
groups with low health indicators and focusing on the upgradation of the health system
through a well sequenced process of reform.
Our estimates indicate that public investment for provisioning of public goods and primary
and secondary services alone will require about Rs 74,000 crore or 2.2% of GDP at current
prices.

The breakup of Rs. 74,000 crores is as follows:
Rs 33,000 crore
Rs 9,000 crore
Rs 41,000 crore

capital investment required for building up the battered health infrastructure
premium subsidy for the poor under a mandatory Universal Social Health
Insurance programme covering the entire country over the next 15 years
recurring costs towards, salaries, drugs, training, research.

In a next logical sequence the government decided that instead of a new health
policy, last published in 2002, it would come out with a thrust program, funded in part
with international funding. Also it would dovetail its program with Millennium Goals
so that India stands a chance of showing some achievement in its report.

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PART TWO

N

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CH A PTER 6

NATIONAL RURAL HEALTH MISSION 2005 – 2012
NRHM Mission Matrix
A major thrust is the National Rural Health Mission 2005 –
2012. After the National Health Policy 2002, this is the first
strategic health policy document published by the Government.
Its presents the framework:
Table 6: National Rural Health Mission Matrix
STATE OF
PUBLIC HEALTH
Public health expenditure in India
has declined from 1.3% of GDP in
1990 to 0.9% of GDP in 1999. The
Union Budgetary allocation for health
is 1.3% while the State’sBudgetary
allocation is 5.5%.
Union Government contribution to
public health expenditure is 15%
while States contribution about 85%
Vertical Health and Family Welfare
Programmes have limited
synergisation at operational levels.

GOALS
Reduction in Infant Mortality
Rate (IMR) and Maternal
Mortality Ratio (MMR)
Universal access to public
health services such as
Women’s health, child health,
water, sanitation & hygiene,
immunization, and Nutrition.

Lack of community ownership of
public health programmes impacts
levels of efficiency, accountability and
effectiveness.

Prevention and control of
communicable and noncommunicable diseases,
including locally endemic
disease.

Lack of integration of sanitation,
hygiene, nutrition and drinking water
issues.

Access to integrated
comprehensive primary
healthcare,

There are striking regional
inequalities.

Population stabilization,
gender and demographic
balance.

Population Stabilization is still a
challenge, especially in States with
weak demographic indicators.
Curative services favour the non-poor:
for every Re.1 spent on the poorest
20% population, Rs.3 is spent on the
richest quintile.
Only 10% Indians have some form of
health insurance, mostly inadequate

Revitalize local health
traditions and mainstream
AYUSH.
Promotion of healthy life
styles

Hospitalized Indians spend on an
average 58% of their total annual
expenditure
Over 40% of hospitalized Indians
borrow heavily or sell assets to cover
expenses
Over 25% of hospitalized Indians fall
below poverty line because of
hospital expenses

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ACTION PLAN


Accredited Social Health
Associate (ASHA)


Strengthen Sub-Centres,
Primary Health Care
Centres and Community
Health Centres


Prepare District Health
Plan


Sanitation and Hygiene


Disease Control
Programs


Public Private
Partnerships


Health Financing
Mechanisms


Reorient Medical
Education

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ROLE FOR PANCHAYATI RAJ INTERMEDIARIES
The state envisions the empowerment of local governments to manage the delivery
through panchayati raj mechanisms termed Panchayati Raj Intermediary (PRI) :
1. States to indicate in their MoUs the commitment for devolution of funds,
functionaries and programmes for health, to PRIs.
2. The District Health Mission (DHM) to be led by the Zila Parishad. The DHM will
control, guide and manage all public health institutions in the district, Sub-centres,
Primary Health Centre (PHC) and Community Health Centre (CHC).
3. ASHAs would be selected by and be accountable to the Village Panchayat.
4. The Village Health Committee of the Panchayat would prepare the Village Health
Plan, and promote intersectoral integration
5. Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum.
This Fund will be deposited in a joint Bank Account of the Auxillary Nurse Midwife
(ANM) & Sarpanch and operated by the ANM, in consultation with the Village
Health Committee.
6. PRI involvement in Rogi Kalyan Samitis for good hospital management.
7. Provision of training to members of PRIs.
8. Making available health related databases to all stakeholders, including Panchayats

THE ROLE FOR NGOs
The role envisioned for NGOs is based on patterns of the past. They play a nonstructural role in supportive tasks and sub-contracting of some non-value services.
ROLE OF NGOs IN THE MISSION
1. Included in institutional arrangement at National, State and District levels, including
Standing Mentoring Group for ASHA
2. Member of Task Groups
3. Provision of Training, BCC and Technical Support for ASHAs/DHM
4. Health Resource Organizations
5. Service delivery for identified population groups on select themes
6. For monitoring, evaluation and social audit

BUDETARY SUPPORT
In his budget speech 2007, the Finance Minister has made the following provisions:
Table 7: Key Budgetary Allocations in Union Budget 2007
India's Gross Domestic Product

(Source: Country profile. Economic Intelligence Unit,
The Economist)

Rs. 35,00,000 crore
(US$ 797 billion)

1.0 Plan expenditure

Rs. 205,100 crores

2.0 Total outlay for health and family welfare

Share of expenditure

Rs. 15,291 crores
(increase of 21.9%)

2.1 Outlay for NRHM for 2007-08
[inflation estimate 5.3%]

3.0 In comparison Defence expenditure

Rs.

9,947 crores

(increase is of 21.0%)

Rs. 96,000 crore

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7.6%
4.8%
47%

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THRUST AREAS
And so this is the story of India's healthcare. Poised with an acute understanding of
the environment, the mission is a blueprint without the public finance to put into
action. The plan has 3 main thrust areas:
(1) Building a cadre of voluntary health workers (ASHA)
(2) Upgrading standards of existing health facilities to meet the specifications of
Indian Public Health Standards (IPHS)
(3) Encouraging indigenous and local health traditions (AYUSH) as alternative
alternative medicinal systems to allopathic medicine.
Without an influx of resources from the third sector, the mission is unviable. And
so the interim action calls for a creating / upgrading actors in the civil society to fulfil
the Millennium Goals. The need for voluntary actors to enter and participate with the
state in PPP partnerships is needed more than ever before.
It is not that India does not have the financial resources to meet the expense. The
priorities are different. Defence takes away 47% of the budgetary allocation. A mere
10% diversion of funds to meet the fundamental living standards lacks the political
will. Until corrective action takes place, the People must seeks the solution with their
own resources.

THE HISTORY OF MANKIND is one of continuous development from
the realm of necessity to the realm of freedom. This process is
never ending. In any society in which class exists, class struggle
will never end. In classless society the struggle between the new
and the old and between truth and falsehood will never end. In the
fields of the struggle for production and scientific experiment,
mankind makes constant progress and nature undergoes constant
change; they never remain at the same level. Therefore man has
constantly to sum up experience and go on discovering, inventing,
creating and advancing. Ideas of stagnation, pessimism and
complacency are all wrong. They are wrong because they agree
neither with the historical facts of social development over the
past million years, nor with the historical facts of nature so far
known to us (i.e., nature as revealed in the life of celestial bodies,
the earth, life and other natural phenomena).
Changes in society are due chiefly to the development of the
internal contradiction between the productive forces and the
relations of production, the contradiction between the classes and
the contradiction between the old and the new; it is the
development of these contradictions that pushes society forward
and gives the impetus for the supersession of the new society with
the new.
Chairman Mao Tse-Tung

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CH A PTER 7

PUBLIC PRIVATE PARTNERSHIPS
INTERVENTION APPROACH FOR THIRD SECTOR
A strong case is made out for forging a partnership and working together with the
state to create a sustainable public health system. A study of the government plans and
its public public documents shows that there is an implicit leaning on the private
actors to carry out the unfinished agenda of the government. Inadequate funding, lack
of managerial skills and shortage of qualified medical and paramedical professionals
haunts the system. The framework laid out in the NHRM plan will fail to meet the
goals without private sector intervention. It's theoretical approach will not stand its
test of time in the field. The intentions and goals are in public interest but it is for the
private actors to build a credible public health delivery system.
Private actors must build their capacities to become professional agencies which can
measure their output of service against a measurable, a metric.
A metric would describe (i) the key performance indicators to be quantitatively
measured (ii) the periodicity of taking the measurement and (iii) how the data received
would be interpreted.
Just being a sole provider of civil health services in a remote area or providing freee
services is not enough. They must deliver quality and adhere to the health standards
laid out by the government. In the next 5 years, competencies must be built to tender
for providing public healthcare services and compete with state-owned providers.

PUBLIC PRIVATE PARTNERSHIPS
Wikipedia, the open source knowledge bank provides an introduction:
Public-private partnership (PPP) is a system in which a government service or private
business venture is funded and operated through a partnership of government and one or
more private sector companies. These schemes are sometimes referred to as PPP or P3.
In some types of PPP, the government uses tax revenue to provide capital for investment,
with operations run jointly with the private sector or under contract (see contracting out). In
other types (notably the Private Finance Initiative), capital investment is made by the
private sector on the strength of a contract with government to provide agreed services.
Government contributions to a PPP may also be in kind (notably the transfer of existing
assets).

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Typically, a private sector consortium forms a special company called a "special purpose
vehicle" (SPV) to build and maintain the asset. The consortium is usually made up of a
building contractor, a maintenance company and a bank lender. It is the SPV that signs the
contract with the government and with subcontractors to build the facility and then
maintain it. A typical PPP example would be a hospital building financed and constructed
by a private developer and then leased to the hospital authority. The private developer
then acts as landlord, providing housekeeping and other non medical services while the
hospital itself provides medical services.
The government has successfully tendered partnerships with the private sector
under the agesis of 'Public Private Partnerships' also known as P3 partnerships. The
Planning Commission in its report, 'Public Private Partnership' by the PPP Sub-Group
on Social Sector (Nov 2004) conceptualises P3 as:
2.1 Public-Private-Partnership - The Concept
...The term private in PPP encompasses all non-government agencies such as the corporate
sector, voluntary organizations, self-help groups, partnership firms, individuals and
community based organizations, PPP, moreover, subsumes all the objectives of the service
being provided earlier by the government, and is not intended to compromise on them.
Essentially, the shift in emphasis is from delivering services directly, to service
management and coordination.
It is further explained that the responsibility of delivery remains with the
government. It is an out-sourcing of service deliverables. The potential benefits would
be:
1. Cost-effectiveness- since selection of the developer/ service provider depends on
competition or some bench marking, the project is generally more cost effective than
before.
2. Higher Productivity- by linking payments to performance, productivity gains may be
expected within the programme/project.
3. Accelerated Delivery – s ince the contracts generally have incentive and penalty
clauses vis-a-vis implementation of capital projects/programmes this leads to
accelerated delivery of projects.
4. Clear Customer Focus - the shift in focus from service inputs to outputs create the
scope for innovation in service delivery and enhances customer satisfaction.
5. Enhanced Social Service- social services to the mentally ill, disabled children and
delinquents etc. require a great deal of commitment than sheer professionalism. In
such cases it is Community / Voluntary Organizations (VOs) with dedicated volunteers
who alone can provide the requisite relief.
6. Recovery of User Charges- Innovative decisions can be taken with greater flexibility
on account of decentralization. Wherever possibilities of recovering user charges exist,
these can be imposed in harmony with local conditions.
The model for the partnership, in 3 roles, is explained;
The government may collaborate with the private developer/service provider in any
one of the following ways:
Funding agency: providing grant/capital/asset support to the private sector engaged
in provision of public service, on a contractual/noncontractual basis.
Buyer: buying services on a long term basis.
Coordinator : specifying various sectors/forums in which participation by the private
sector would be welcome.

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Contractual Framework:
The ‘contract’ mirrors the basic objective of the programme /project, the tenure of
agreement, the funding pattern and of sharing of risks and responsibilities. The need to
define the contract very precisely, therefore, becomes paramount under PPP.
Projects/programmes under PPP may, however, broadly be classified under three heads
namely; service contract, operations & maintenance (management) contract and capital
projects, with operations & maintenance contract.

THE CONTRACT STATE
The Contract is the foundation of the partnership. To understand the implict
meaning of the Contract under law,
A contract is a legally binding exchange of promises or agreement between parties that
the law will enforce. In common law jurisdictions there are three key elements to the
creation of a contract. These are offer and acceptance, consideration and an intention
to create legal relations.
The conference document of 'Revisiting the Contract' at the Institute of Development
Studies, University of Sussex (2005), in its commentary states:
All advanced industrial societies are in the process of reforming their employment and
welfare arrangements. This represents an attempt to modernise social, economic and
political institutions established in the post-war period, and before. Modernisation has been
seen associated with the movement towards a more contractual and individualised society.
We are witnessing a paradigm shift in the way in which public services of all kinds –
housing, education, and community care, as well as health– will be delivered. Market
principles of choice are being introduced into the public sector and contract becomes
the vehicle for achieving the goals of increased efficiency, choice, quality, and
accountability. This is seen by some social scientists as a shift towards the 'contract
state', in which the traditional market is replaced by 'quasi-markets'. It has a major
implication for the way in which the third sector will be treated as contractors. In a
Quasi-market purchasers funded by taxation buy services from providers. The
purchasers may buy for themselves or on behalf of the end users. The providers are
either for-profit or non- profits, publicly or privately owned. It is designed to reap the
efficiency gains of free markets without losing the equity benefits of traditional systems
of public administration and financing. A notable example would be the National
Health Service Internal Market in United Kingdom (introduced in 1990): under this
system, the purchase and provision of healthcare in the UK was split up, with
government-funded GP fundholders "purchasing" healthcare from NHS Trusts and
District Health Authorities, who competed against one another for the GPs' custom.
This led to increased efficiency, as hospitals now needed to offer procedures at lower
costs in order to win patients and funding, but without losing the main equity benefits
of the NHS (healthcare remained free at the point of service and financed through
taxation).

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Awarding the contract is suggested in either of the following traditional ways:
1. Competitive Bidding through a well documented and transparent process
2. Competitive Negotiation
3. A pro-active method for voluntary actors
Swiss Challenge Approach
The Swiss Challenge approach refers to suo-motu proposals being received from the
private participant by the government. The private sector thus provides
 all details regarding its technical, financial and managerial capabilities,
 all details regarding technical, financial and commercial viability of the
project/programme
 all details regarding expectation of government support / concessions.
The government may examine the proposal and if the proposal belongs to the declared
policy of priorities, then it may invite competing counter proposals from others (in the spirit
of ‘Swiss Challenge’ approach) giving adequate notice. In the event of a better proposal
being received, the original proponent is given the opportunity to modify the original
proposal. Finally, the better of the two is awarded the project/programme for execution.
In the case of Complex negotiations, a master contractor / Mother NGO may be
appointed who will then award sub-contracts. Payment to the private sector could take
the form of: (a) contractual payments (b) grants-in-aid and (c) right to levy user charges
for the asset created / leased-in. Even the monitoring is outsourced to external
agencies:
Involvement of third party/independent agencies for monitoring appears to be preferable
as they leave the government hassle free over the project and minimize government
control. A certain percentage of the cost of the project needs to be, therefore, earmarked
for contract management. The government and the developer/service provider could
mutually decide the third party. The third party involvement could be further supplemented
with provision for adjudication by the (higher) judiciary.

India has already adopted the PPP model of healthcare as follows:
Ministry of Health & Family Welfare : Department of Family Welfare
The Department has the following schemes, under the Reproduction and Child Health (RCH)
Programme, being implemented fully/partially through public-private partnership, namely;

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PPP

Objective & Function

Service Provider

Sterilisation (for

Improving access to sterilization
services through involvement of
private / NGO health facilities.
Beneficiaries are the acceptors of
family planning services, both
tubectomy and vasectomy.

Private Practitioners/NGOs
having medical facilities.

Involvement of NGOs for
supplementing and complementing
medical services provided by the
Government, especially in unserved
and underserved areas.

NGOs with fixed assets
amounting to Rs.2 lakhs, with
at least 3-5 years experience in
health and family welfare.

Population
Stabilization)

Mother NGO
(MNGO) Scheme

There is a network of 500 field NGOs in 439 districts, overseen by 102
mother NGOs which have been till recently founded directly by the
Department of Family Welfare (Government of India). The scheme has
been revised recently and decentralized to State levels.
To make available Condoms/ Oral
Contraceptive Pill (OCPs) to users at
highly subsidized rates with the aim
of birth spacing / prevention from
AIDS / STD, through Social
Marketing Organizations (SMOs /
NGOs). Beneficiaries are eligible
couples and other users through out
the country.

Social Marketing Organizations
(SMOs / NGOs) network, The
Social Marketing Organizations
(SMOs)/NGOs network. Any
NGO registered under the
Societies Registration Act and
having a minimum of 3 years
experience in the area of
operation and having requisite
infrastructure and staff is
eligible to apply.

Contractual
appointment of
Addl. ANM,
Public Health
Nurse , Lab
Technician.

Improving the condition of suboptimal manpower at district and
sub district levels through trained
staff appointed on contractual basis.
Beneficiaries are pregnant women,
children and others availing
reproductive child healthcare (RCH)
Services.

Auxiliary Nurse Midwife
(ANMs), Public Health Nurses
(PHN) and Lab. Technicians.

Hiring of Safe
Motherhood
Consultant

Improving the condition of suboptimal manpower at district and
sub district level for safe abortion
services and maternal health care
services available in the Primary
Health Centres (PHCs) and
Community Health Centres (CHCs).

Private doctors (Obstetric and
Gynecologists)

Vande Mataram
Scheme

Improved access to ante and post
natal care to pregnant and lactating
women free of cost.

Members and volunteers of
Federation of Gynecological
Society of India (FOGSI).

Social Marketing
of Contraceptives
(viz. Condoms / OCPs)
through social
agencies SMOs /
NGOs

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Client: State Government State
Health and Family Welfare
Society for the Voluntary
Sector (SCOVA).

Beneficiaries are pregnant
women for antenatal care and
post natal care and women
with unwanted pregnancies
desiring termination of
pregnancy.

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CH A PTER 8

THE INTERVENTION MATRIX
Voluntary Actors (VA) may plan their intervention in a matrix : The vertical array
(columns) refers to the span of the choices. The horizontal array (rows) refers to the
scale of operation.

THE VERTICAL SPAN
There are 2 dimensions: (1) The Millennium Goals and and (2) NHRM Goals:

MACRO DIMENSION : THE MILLENIUM GOALS
(adapted to Health Intervention Strategy)

Goal 1: Eradicate Extreme Hunger
and Poverty

Target. Halve, between 1990 and 2015, the
proportion of people who suffer from hunger

Indicators. (1) Prevalence of underweight children under five years of age
(2) Proportion of population below minimum level of dietary energy consumption (FAO)

Goal 2: Achieve Universal Primary
Health Education

Target. By 2015, children will be able to receive
health education in primary schooling.

Indicators. (1) Health Literacy rate of 15-24 year-olds

Goal 3: Promote Gender Equality
and Empower Women

Target. Eliminate gender disparity in health
sector

Indicators. (1) Share of women in wage employment in the health sector

Goal 4: Reduce Child Mortality

Target. Reduce by two-thirds, by 2015, the
under-five mortality rate

Indicators. (1) Under-five mortality rate (2) Infant mortality rate (3) Proportion of 1 year-old children
immunized against measles

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Goal 5: Improve Maternal Health

Target. Reduce by three-quarters, by 2015, the
maternal mortality ratio

Indicators. 1. Maternal mortality ratio (2) Proportion of births attended by skilled health personnel

Goal 6: Combat HIV/AIDS, Malaria
and other diseases

Target. Have halted by 2015 and begun to
reverse the spread of HIV/AIDS
Target. Have halted by 2015 and begun to
reverse the incidence of malaria and other major
diseases

Indicators. 1. HIV prevalence among pregnant women aged 15-24 years 2. Condom use rate contraceptive prevalence rate 3. Condom use at last high-risk sex 4. Percentage of population aged 15-24
years with comprehensive correct knowledge of HIV/AIDS

Goal 7: Ensure Environmental
Sustainability

Target. Integrate the principles of sustainable
development into country policies and programs
and reverse the loss of environmental resources
Target. Halve, by 2015, the proportion of people
without sustainable access to safe drinking water
and basic sanitation
Target. Have achieved by 2020 a significant
improvement in the lives of at least 100 million
slum dwellers

Target 1 Indicators. (1) Proportion of land area covered by forest (2) Ratio of area protected to maintain
biological diversity to surface area (3) Energy use (kg oil equivalent) per $1 GDP (4) Carbon dioxide
emissions per capita and consumption of ozone-depleting CFCs (ODP tons)

(5) Proportion of population

using solid fuels . Target 2 Indicators. (1) Proportion of population with sustainable access to an improved
water source, urban and rural (2) Proportion of population with access to improved sanitation, urban and
rural Target 3 Indicators. (1) Proportion of households with access to secure tenure

Goal 8: Develop a Global
Partnership for Development

Target. Develop further an open, rule-based,
predictable, nondiscriminatory trading and
financial system (includes a commitment to good
governance, development, and poverty reduction
(both nationally and internationally)
Target. In cooperation with developing countries,
develop and implement strategies for decent and
productive work for youth
Target. In cooperation with pharmaceutical
companies, provide access to affordable essential
drugs in developing countries
Target. In cooperation with the private sector,
make available the benefits of new technologies,
especially information and communications
technologies

Indicators. Market access: (1) Proportion of total country exports (by value and excluding arms) to
developed countries admitted free of duty (2) Average tariffs imposed by developed countries on
agricultural products and textiles and clothing from developing countries (3) Agricultural support estimate
fas percentage of GDP (4) Proportion of ODA provided to help build trade capacity
Other Indicators: (1) Unemployment rate of young people aged 15-24 years, each sex and total (2)
Proportion of population with access to affordable essential drugs on a sustainable basis (3) Telephone
lines and cellular subscribers per 100 population (4) Personal computers in use per 100 population and
Internet users per 100 population.

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MICRO DIMENSION : THE NRHM GOALS

Goal 1: Accredited Social Health Associate (ASHA)
First health touchpoint in village. Women Volunteer with basic training
(1 ASHA / 1000 population )
Role: (A) Community mobiliser, awareness and local health planning
(B) Promote good health
(C) Provide minimal package of primary care intervention.
Responsibilities
(1) create awareness and provide information to the community on determinants of
health such as nutrition, basic sanitation & hygienic practices, healthy living and
working conditions, information on existing health services and the need for timely
utilization of health & family welfare services.
(2) counsel women on birth preparedness, importance of safe delivery, breastfeeding
and complementary feeding, immunization, contraception and prevention of
common infections including Reproductive Tract Infection/Sexually Transmitted
Infection (RTIs/STIs) and care of the young child.
(3) mobilize the community and facilitate them in accessing health and health related
services available at the village/sub-center/primary health centres, such as
Immunization, Ante Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS,
sanitation and other services being provided by the government.
(4) work with the Village Health & Sanitation Committee of the Gram Panchayat to
develop a comprehensive village health plan.
(5) arrange escort/accompany pregnant women & children requiring treatment/
admission to the nearest pre- identified health facility i.e. Primary Health Centre/
Community Health Centre/ First Referral Unit (PHC/CHC /FRU).
(6) provide primary medical care for minor ailments such as diarrhoea, fevers, and
first aid for minor injuries. She will be a provider of Directly Observed Treatment
Short-course (DOTS) under Revised National Tuberculosis Control Programme.
(7) depot holder for essential provisions being made available to every habitation like
Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine,
Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug Kit will be
provided to each ASHA.
(8) inform about the births and deaths in the village and any unusual health
problems/disease outbreaks in the community to the Sub-Centres/Primary Health
Centre.
(9) promote construction of household toilets under Total Sanitation Campaign.
Process Indicators: 1) Number of ASHAs selected by due process 2) Number of ASHAs
trained 3) % of ASHAs attending review meetings after one year
Outcome Indicators: (a) % of newborn who were weighed and families counselled (b)
% of children with diarrhoea who received ORS, (c) % of deliveries with skilled
assistance; (d) % of institutional deliveries, (e) % of Janani Suraksha Yojana (JSY) claims
made to ASHA, (f) % completely immunized in 12-23 months age group. (g) % of unmet
need for spacing contraception among BPL (h) % of fever cases who received
chloroquine within first week in an malaria endemic area
Impact indicators : (a) IMR (b) Child malnutrition rates (c) Number of cases of TB /
leprosy cases detected as compared to previous year.

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Goal 2: Strengthen Sub Centre
established for every 3000-5000 population. Managed by Female Auxillary
Nurse Midwife (ANM) and Male Health Worker (MHW). Facility for
Supervised Childbirth. 3 – 5 ASHAs attached to each SHC.
Objective: (1) To provide basic Primary health care to the community. (2) To achieve
and maintain an acceptable standard of quality of care. (3) To make the services more
responsive and sensitive to the needs of the community.
MINIMUM ASSURED SERVICES
A. Maternal and Child Health: (i) Antenatal (ii) Intra-natal (iii) Post natal care
B. Child Health: • Essential Newborn Care • Promote exclusive breast-feeding for 6
months • Full Immunization of all infants and children • Vitamin A prophylaxis to
children • Prevention and control of childhood diseases
C. Family Planning and Contraception: • Education, Motivation and counselling
• Provision of contraceptives and IUD insertions • Follow up Tubectomy/ Vasectomy
D. Medical Termination of Pregnancy (MTP): • Counsel / referral for safe abortion
E. Basket of other services: • Adolescent health care: Education, referral
• Assistance to school health services • Control of local endemic diseases • Disease
surveillance • Water Quality: disinfection, monitoring • Promote use of toilets and
garbage disposal • Field visits • Community needs assessment
F. Curative Services: • Treatment for minor ailments, First Aid • Appropriate and
prompt referral • Organizing Health Day at Anganwadi centres
G. Training, Coordination & Monitoring: • Training of midwife, ASHA and
Volunteers • Monitoring of water quality in the villages • Keeping watch over
unusual health events • Coordinated services for Village Health
H. National Health Programmes: • National AIDS Control • National Vector Borne
Disease Control • National Leprosy Eradication Programme • Integrated Disease
Surveillance Projects • Revised National Tuberculosis Control • National Blindness
Control • Non-communicable Disease + Cancer Control
I. Record of Vital Events: • Report births and deaths to health authority
• Maintenance records concerning mother, child and eligible couples in the area.
Monitoring.
(A) Internal mechanisms: Supportive supervision and Record checking at periodic
intervals by the Male and Female Health supervisors from PHC (at least once a week)
and by MO of the PHC (at least once in a month) as per checklist
(B) External mechanism: Village health and sanitation committee, Evaluation by an
independent external agency, client satisfaction survey etc. by NGOs (15-24 years
experience with comprehensive correct knowledge of HIV/AIDS). Monitoring by PRI
would survey - PRI should also be involved in the monitoring. The following may be
monitored: (1) Access to service (Equity) (2) Location of Sub-centres – ensuring it to be
safe to female staff and centrally located, well in side the inhabited area of the village
(3) Registration and referral procedures; promptness in attending to clients (4)
transportation of emergency maternity cases (5) Management of untied fund for the
improvement of services of the Sub centre (6) Staff behaviour (7) Other facilities:
waiting space, toilets, drinking water in the Sub-centre building. To ensure
accountability, the Citizens’ Charter should be available in all Sub-centres

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Goal 3: Strengthen Primary Health Centre
A first port of call to a qualified doctor of the public sector in rural areas
and typically covers a population of 20,000 in hilly, tribal, or difficult areas
and 30,000 populations in plain areas with 4-6 indoor/observation beds.
Objective: (1) To provide comprehensive primary health care to the community
through the Primary Health Centres. (2) To achieve and maintain an acceptable
standard of quality of care. (3). To make the services more responsive and sensitive to
the needs of the community.
MINIMUM ASSURED SERVICES
A. Medical care: • OPD services: 6 hours, 40 patients / doctor • 24 x 7 emergency
services • Referral services • In-patient services (6 beds)
B. Maternal, Child Health and FP: • Antenatal care • Intra-natal care: 24x7 normal
and assisted • Postnatal Care: home visits, breast-feeding, nutrition hygiene education
and provision of facilities under Janani Suraksha Yojana (JSY) • New Born care:
facilities and care for neonatal resuscitation, hypothermia, jaundice • Care of the
child: emergency care and full Immunization of all infants and children against vaccine
preventable diseases • Family Planning: counselling, contraceptives, IUD insertions,
Tubal ligation and vasectomy
C. Medical Termination of Pregnancies using Manual Vacuum Aspiration (MVA)
D. Management of Reproductive Tract Infections / Sexually Transmitted
Infections
• Prevention and treatment of RTI/ STIs
E. Nutrition Services (coordinated with ICDS): • Diagnosis of and nutrition advice to
malnourished children, pregnant women. • Diagnosis and management of anaemia,
and vitamin A deficiency • Coordinate w/ ICDS.
F. School Health: • Regular check ups, appropriate treatment including deworming,
referral and follow-ups
G. Others: • Adolescent Health Care: Life style education, counselling, appropriate
treatment. • Education about health/Behaviour Change Communication (BCC) •
Referral Services • Training • Rehabilitation: Disability prevention, early detection,
intervention and referral
G. Water and Sanitation : • Promotion of safe drinking water • Disinfection and
testingof water sources • Promotion of sanitation including use of toilets and
appropriate garbage disposal
H. Disease Surveillance and Control: • Prevention and control of locally endemic
diseases like malaria, Kalaazar, Japanese Encephalitis, etc. • Collection and reporting
of vital events • Tuberculosis Control: as DOTS Centres • Integrated Disease
Surveillance Project • National Programme for Control of Blindness
• National Vector Borne Disease Control • National AIDS Control Programme
I. Basic Laboratory Services : • Routine urine, stool and blood tests, Bleeding time,
clotting time • Diagnosis of RTI/ STDs • Sputum testing for tuberculosis, blood smear
examination for malarial parasite, rapid tests for pregnancy / malaria, RPR test for
Syphilis/YAWS surveillance, Rapid diagnostic tests for Typhoid (Typhi Dot) • Rapid
test kit for faecal contamination of water • Estimation of chlorine level of water using
ortho-toludine reagent
J. Monitoring and Supervision: • Monitor and supervise Sub-centre • Monitoring
of all National Health Programmes • Monitor ASHAs
K. Mainstreaming of AYUSH Services
L. Selected Surgical Procedures: • Vasectomy, (laparoscopic) tubectomy MTP
• hydrocelectomy • cataract
Expected Minimum Utilisation: 40 patients per doctor per day 60% utilization of the 6 beds
Monitoring: Internal Mechanism: Record maintenance, checking and supportive supervision
External Mechanism: Monitoring by PRI / Village Health Committee / Rogi Kalyan Samiti
Accountability. (1) To ensure accountability, the Charter of Patients’ Rights should be made
available in each PHC. (2) Every PHC should have a Rogi Kalyan Samiti / Primary Health
Centre’s Management Committee for improvement of service provision of the PHC

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Goal 4: Strengthen Community Health Centre

The CHCs were designed to provide referral health care for cases from the
primary level and for cases in need of specialist care approaching the centre
directly. 4 PHCs are included under each CHC thus catering to approximately
80,000 population in tribal / hilly areas and 1, 20,000 population in plain
areas. CHC is a 30- bedded hospital providing specialist care in medicine,
Obstetrics and Gynaecology, Surgery and Paediatrics.

MINIMUM ASSURED SERVICES
A. Routine and emergency cases in surgery:
• This includes Incision and drainage, and surgery for Hernia, hydrocele, appendicitis,
haemorrhoids, fistula, etc. • Handling of emergencies like intestinal obstruction,
haemorrhage, etc.
B. Routine and emergency cases in medicine
• all emergencies in relation to the National Health Programmes like dengue,
haemorrhagic fever, cerebral malaria, etc. • National Health Programmes integration
C. Maternal
• 24-hour delivery services including normal and assisted deliveries • Essential and
Emergency Obstetric Care including surgical interventions like Caesarean Sections and
other medical interventions • New-born Care • Routine and Emergency Care of sick
children • Other management including nasal packing, tracheostomy, foreign body
removal etc. • Full range of family planning services including Laproscopic Services
• Safe Abortion Services
D. Diagnostic and screening services
• microscopy centre for Tuberculosis • HIV/AIDS Control programme • National Vector –
Borne Disease Control • National Leprosy Eradication
E. Eyecare Services
• National Programme for Control of Blindness • diagnosis and treatment of common eye
diseases, refraction services and surgical services including cataract by IOL implantation
(1 eye surgeon per 5 lakh population) • Integrated Disease Surveillance
F. Others:
• Blood Storage Facility • Essential Laboratory Services • Referral (transport) Services
Expected Minimum Utilisation: 60% utilization of the available indoor/observation
beds (30 beds).
Quality Control:
(1) Internal monitoring: • Social Audit through Rogi Kalyan Samitis/ Panchayati Raj
Institution, etc • Medical audit • Others like technical audit, economic audit, disaster
preparedness audit, etc. • Patient care: criteria for processes like access for patients,
Registration and admission procedures, Examination, Information exchange, Treatment,
Other facilities: waiting, toilets, drinking water, Indoor patients, Linen/ beds, Staying
facilities for relatives, Diet and drinking water, Toilets
(2) External Monitoring: Gradation by PRI(Zilla Parishad)/ Rogi Kalyan Samitis
(3) Monitoring of laboratory: Internal Quality Assessment scheme, External Quality
Assessment scheme

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Goal 5:

District Health Plan

principle instrument for planning, implementation and monitoring. ,
formulated through a participatory and bottom up planning process and
would be an amalgamation of field responses through Village Health
Plans, State and National priorities for Health, Water Supply, Sanitation
and Nutrition.

District becomes core unit of planning, budgeting and implementation.
What a District Plan ought to have
• Background • Planning Process • Priorities • Annual Plan for each of the Health
Institutions • Community Action Plan • Financing of Health Care • Management Structure
• Partnerships for convergent action • Capacity Building Plan • Human Resource Plan •
Procurement and Logistics Plan • Non-governmental Partnerships • Community
Monitoring Framework • Action Plan for Demand generation • Sector specific plan for
maternal health, child health, adolescent health, disease control, disease surveillance,
family welfare etc.
Indicators: Input Indicators and Process Indicators documented in District Health Action
Plan Manual.

Goal 6: Mainstreaming of AYUSH
Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy
• Introduce a qualified AYUSH Medical Practitioner at PHC level • AYUSH Medical kits to
be provided to ASHA • Register and certify indigenous local health traditions • The
additional supply of generic drugs for common ailments at Subcentre/ PHC/CHC levels
under the Mission shall also include AYUSH formulations. • At the CHC level, two rooms
shall be provided for AYUSH practitioner and pharmacist under the Indian Public Health
System (IPHS) model. • Single doctor PHCs shall be upgraded to two doctor PHCs by
mainstreaming AYUSH practitioner at that level.
Indicators.
Field data of number of AYUSH Practitioners deployed and ASHA Kits distributed

Goal 7: Convergence of Sanitation and Hygiene
Components of Total Sanitation Campaign (TSC) include IEC activities, rural
sanitary marts, individual household toilets, women sanitary complex, and
School Sanitation. Presently implemented in 350 districts, and is proposed
to cover all districts in 10th Plan
• The District Health Mission would therefore guide activities of sanitation at district
level, • promote joint IEC for public health, sanitation and hygiene, through Village
Health & Sanitation Committee • promote household toilets and School Sanitation
Programme. • ASHA would be incentivised for promoting household toilets by the
Mission.
Indicators.
Field Data of implementation of TSC in country.

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Goal 8: Strengthen Disease Control Programs
National Disease Control Programmes for Malari a, TB, Kala Azar, Filaria,
Blindness & Iodine Deficiency and Integrated Disease Surveillance
Programme shall be integrated under the Mission, for improved
programme delivery.
Disease surveillance system at village level would be strengthened.
• Supply of generic drugs (both AYUSH & Allopathic ) for common ailments at village,
SC/ PHC/ CHC level.• Provision of a mobile medical unit at District level for improved
outreach services.

Goal 9: Public-Private Partnership
Long term Goal of becoming a purchaser of rather than a provider of
Public Health Services.
• District Institutional Mechanism for Mission must have representation of private
sector • Identify areas of partnership, which are need based, thematic and geographic.
• Public sector to play the lead role in defining the framework and sustaining the
partnership • Management plan for PPPs: at District/State and National levels
Indicators. (1) Ratio of PPP partnerships to state managed programs (2) Total outlay
for outsourced services.

Goal 10: New Health Financing Mechanisms
Shift towards Contract State and Quasi-markets.
Progressively the District Health Missions to move towards paying
hospitals for services by way of reimbursement, on the principle of “money
follows the patient.”
A. Quality of Service Standardisation
• Standardization of services – o utpatient, in-patient, laboratory, surgical interventionsand costs will be done periodically by a committee of experts in each state.
B. Risk Pooling and Health Insurance
• DHM to manage risk-pooling and health security. • Where credible Community Based
Health Insurance Schemes (CBHI)exist/are launched, they will be encouraged as part of
the Mission. • Central subsidies to cover a part of the premiums for the poor, and
monitor the schemes. • The IRDA will be approached to promote such CBHIs, which
will be periodically evaluated for effective delivery.
Indicators. (1) Flow of funds based on actual use of services (2) Number of CBHIs
established

Goal 11: Reorient health / medical education
to support rural health issues
• Medical and para-medical education facilities need to be created in states, based on
need assessment. • Paramedics, technicians and Nurses Cadres • Commission for
Excellence in Health Care (Medical Grants Commission), • National Institution for Public
Health Management
Indicators. (1) Number of new qualified personnel (2) Include Comprehensive
community health syllabus

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Goal 12: Institutional Support
A. PROGRAM MANAGEMENT SUPPORT CENTRE
• basic program management: financial systems, infrastructure maintenance,
procurement & logistics systems, Monitoring & Information System (MIS)
• Manpower Systems: recruitment (induction of MBAs/CAs/MCAs), training & curriculum
development.
• revitalization of existing institutions
• partnerships with NGOs
• Improved Governance: decentralization & empowerment of communities, induction of
IT based systems, social audit, RTI.
B. HEALTH TRUST OF INDIA
• Knowledge institution: repository of innovation, research & documentation, health
information system, planning, monitoring & evaluation etc.
• Public Accountability Systems – e xternal evaluations, community based feedback
mechanisms, participation of PRIs /NGOs etc.
• Developing a Framework for pro-poor Innovations
• Reviewing Health Legislations.
• Experimentation and action research.
• inter & intra Sector Networking with National and International Organizations.
• Think Tank for developing a long-term vision of the Sector & for building planning
capacities of PRIs, Districts etc.

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THE PROGRAM MATRIX
Program

1

Ensure
Primary Health
Care at Family
Household
level

Target 1. Induct and train Voluntary Village Women Health Worker called ASHA ( Accredited
Social Health Associate) as first community health interface animator.
[3,20,000 ASHAs recruited. 2,40,000 have received formal induction (2006)]
Matrix
Selection
Training

MICRO
1.A1
A2

MID-LEVEL

STRUCTURAL

Shortlist candidates

1-B1

Recruitment agency

C1

ASHA Training, Block level
Master Trainers (Train the

B2

Publish localised training
material

C3

State / National level
Training College for ASHA

Competency mapping

trainers)

Program

2

Sub-Centres,
Primary Health
Care Centres
& Community
Health Centres
as per Indian
Public Health
Standards
(IPHS)

Program

3

Plan, forecast
and develop
District level
Public Health
Delivery

Operations

A3

Distribute resource kits

B3

Produce Low Cost Kits

C3

Pharmaceutical Co-ops

Mentoring

A4

Weekly contact sessions

B4

Workshops, Liaison work

C4

Survey, assessment

Logistics

A5

Ambulance, Patient care

B5

Sarai in district town

C5

Travel Subsidy, advocacy

Benefits

A6

Monthly Stipends

B6

Employ private ASHA
cadre

C6

CSR funding, P3
partnerships

Target 1. Strengthen Sub-Centres, Primary Health Care Centres and Community Health Centres
Matrix
Infrastructure

MICRO

MID-LEVEL

STRUCTURAL

2A1

Basic repairs, sanitary

2B1

Build / upgrade facility to
IPHS specifications

3C1

Monitor and develop IPHS

2A2

On the Job Training

2B2

Workshops, Courses

2C2

Medical student volunteer
/ internship

Operations

2A3

On-line support

2B3

Manage facility under P3

2C3

Start social enterprises

Equipment

2A4

Donate critical list

2B4

Activity based donations

2C4

Source used equipment

Supplies

2A5

Provide in kind

2B5

District level distribution

2C5

Manufacture supplies

Staffing

2A6

Financial Support

2B6

Private field cadre

2C6

Training

Grants for Doctors

Target 1. Prepare District Health Plan
Matrix
Data

MICRO
3A1

MID-LEVEL

STRUCTURAL

Village situational survey

3B1

IT support

3C1

Analysis

3A2

Village assessment

3B2

Collation of Data Tables

3C2

District level data maps

Planning

3A3

Participatory with PRIs

3B3

Facilitate District wide

3C3

Training of Facilitators

Consensus

3A3

Village feedback and vote

2B4

District stakeholders

3C4

State level audit

Research Methodology

roundtable

Program

4

Preventive
community
health
measures to
combat
disease

Preparation

3A4

Design and DTP

2B5

IT Support, Printing, Web

3C5

Mass media support, funds

Awareness

2A5

Multi media at village level

2B6

Mass Media District wide

3C6

Government liaison, audit

Target 1. Sanitation and Hygiene
Matrix
Infrastructure
Awareness

MICRO
4A1

4A2

MID-LEVEL

Toilets and Water Supply

4B1

Village level awareness

4B2

Healthcare Interventions in the Civil Society – Sanjay Doctor

STRUCTURAL

Drinking water and
greywater sumps

4C1

Watersheds, Sewage
Treatment Plants

Multi-media

4C2

CSR Funding

| 40

Program

5

Theme based
control
intervention

Program

6

Revitalise
Local Health
Traditions

Program

7

Societal
Interventions

Target 1. Disease Control Programs
Matrix

MICRO

MID-LEVEL

STRUCTURAL

Awareness

5A1

Village level campaign

5B1

District level campaign

5C1

Training

5A2

ASHA training, workshops

5B2

Delivery Agency

5C2

State Mission Liaison

Operations

5A3

ASHA Mobilisation

5B3

Task Force

5C3

Audit and Monitoring

Monitoring

5A4

Village Reports

5B4

Periodic Reports

5C4

Advocacy

P3 partnerships

Target 1. Mainstreaming of Ayurvedic, Unani and Siddha Medicine (AYUSH)
Matrix

MICRO

Awareness

6A1

Training

MID-LEVEL

Document Local Health
traditions/ pharmacology

6B1

6A1

ASHA / ANW training,
workshops

Operations

6A1

Staffing

6A1

STRUCTURAL

Database, resources list of
district / bioregion

6C1

Advocacy and Lobbying for
local health traditions

6B2

Staff training material

6C2

Training College for
AYUSH paramedics

Village Health camps

6B3

Prepare AYUSH Kits

6C3

AYUSH pharmacy Co-op

AYUSH Paramedics

6B4

Private AYUSH Cadre

6C4

Reorient Medical education

Target 1. Linked actions for community level impact
Matrix

MICRO

HIV

7A1

Nutrition

7A2

P3

7A3

Gender

7A4

Contraceptives / safe sex
Kitchen gardens

7B1

Develop PRI

7B1

SHG to be active

7B1

7B1

STRUCTURAL

Hospice and clinics

7C1

Mass media support

Organic farming

7C2

R&D for traditional foods

Training for PRI

7C3

P3 and CSR advocacy

SHG enterprises for health

7C4

Leadership Training

District insurance plans

7C5

TPA for health insurance

intermediaries

Equality
Insurance

MID-LEVEL
7B1

7A5

Sell Rural Mediclaim

Healthcare Interventions in the Civil Society – Sanjay Doctor

| 41

CH A PTER 9

THE AGENTS OF CHANGE
GROUND REALITY
From the data presented so far, the following conclusions may be reached about the
NRHM :
(1)

The funds required for a comprehensive public health program are not
available through public funding.

(2)

Qualified medical staff including doctors not willing to work at PHC level

(3)

Statistical base for providing health services is not realistic and the ratio of
capacity to population ratio is too high leading to a collapse of public health
services.

(4)

PRIs and panchayats are severely affected by politics and will lead to
diversion of funds.

(5)

Lack of political pressure from the masses leads to complacency amongst
planners and bureaucracy.

(6)

The role envisaged for private agencies is not participatory and there are no
plans to build competencies in third sector.

THE ROAD AHEAD
The Third Sector must urgently heed the task of creating a new agenda for
intervention in the public health system. At a broader level it is an issue of equity and
social justice. How can we overlook the denial of fundamental human rights to a

large portion of our urban and rural population ?
The apathy of the government is symptomatic of a governance paradigm followed in
this country since its inception and even before. The rural masses have a less than
disproportionate allocation of state resources whether through policy or neglect.
Indian companies follow international best practices and are selected for Business
Process Outsourcing (BPO). However our bureaucracy is left in a time warp of the
British raj where governance meant administration and tax collection. Democracy and
public participation has never seen the light of the day. We are a defranchised
populace who expected to either behave as obedient subjects or become extremist
revolutionaries (read terrorists) to claim our basic rights.

Healthcare Interventions in the Civil Society – Sanjay Doctor

| 42

Prime Minister Manmohan Singh implores the beuracracy to undergo a change
management exercise. On his speech given to IAS officers , Times of India reports:
PM: Act as agents of change
Unfolding the agenda for reforming the babudom, Prime Minister Manmohan Singh on
Saturday said that in the era dominated by phenomenal economic growth citizens should
be central to all government activities. Singh said the years of economic reforms and strong
growth impulses of the economy had changed the old notion of governance and
bureaucracy.
"The government is no longer seen merely as a law enforcer or a controller of basic
services and public goods; people expect the government to facilitate development," he
said. Dropping clear hints that the babus would have to take a backseat in the new scheme
of things, he said, "Civil servants have to shift from being controllers to facilitators and
from being providers to enablers." Counselling them to reinvent themselves and adjust to
the changed scenario, Singh said, "They need to master new technologies and new styles of
functioning."
Calling for an innovative approach to address the challenge of making the bureaucracy
more efficient and result-oriented, the PM proposed introducing 'agents of change' who
could work as catalysts for speeding up reforms in governance. He defined the 'agents' as
"public-oriented personnel of outstanding calibre and would be strategically located to
engineer reform. Advocating changes in the government machinery and work-style and
orientation of the officials, he called upon the civil servants to play an 'enlightened role' in
bringing about this kind of transformation. (21.4.07)
It is time for voluntary actors take on an aggressive stand and assert their rightful place
in this theatre.

UNLOCKING THE POTENTIAL IN THE RURAL INDIA
A people led public health initiative is possible by unlocking the potential of its various
actors.


Self Help Groups (SHG): Today there are more than SHG groups in India with
an estimated of Rs.

crores in savings. SHG invest this money in lending funds

to their members on an auction basis and have become thrift societies. The
time has come for these funds to be used in productive investment cycles. For
many of the village level activities Social enterprises can be formed which will
not only serve the health requirements but also earn a modest profit for its
members. For example, the village can invest in an ambulance which would
charge an affordable fee for its services.


Educated unemployed Youth: The youth is an untapped force awaiting to be
mobilised into productive work. If only given an opportiunity they can realise
many of the ideas into action. Working at a village level,

they have the

idealism and drive lacking in the state run sector.

Healthcare Interventions in the Civil Society – Sanjay Doctor

| 43



Women power: Vinobaji had termed this latent power as Stree shakti. The
rural women can come together as a collective and overcome their individual
shortcoming. Stil driven by strong maternal family drives, this stree shakti can
vercome all social economic and social barriers by their collective.



Appropriate technology: the great contribution of science and technology is
that its is downsized to a scale which allows for the tools of production to be in
the ownership of the worker. Never was this posssible except Man was an
artisan and a self sustained farmer. The industrial age defranchised . Micro and
cottage enterprises can compete at a an international market and produce the
the product and quality that once required an entire factory to produce.

CONCLUSION
The challenges ahead may be listed as:


A change management exercise from NGOs to
social enterprises



Partnerships with the state and corporate sector



Tapping into peoples' power



Self Reliance

Healthcare Interventions in the Civil Society – Sanjay Doctor

| 44

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