Access to Health Care and Basic Minimum Services in Kerala, India

An overview of the project

A CDS-UdeM Action-Research Initiative

UdeM-CDS /2002

Two Objectives

Intervention: Health Solidarity Scheme

Monitoring: Community Based Monitoring System

UdeM-CDS /2002

Community-based Schemes

Objective: To support Women’s Self Help Groups

and other community organisations in building

and implementing a Community Based Health

Solidarity Scheme (CBMS)

The CBMS aims at improving access to basic

minimum services (e.g. health, education, poverty

alleviation, social protection, etc.) Focus is on reducing exclusion to health care, and raise

access to quality care for the depressed groups.

UdeM-CDS /2002

Health Solidarity Scheme

Three applied research components Community Based Health Insurance (CBHI) that aims

at raising equity in financing of health care and reducing financial barriers encountered by households.

Health promotion/prevention activities (HPPA), among women and among very poor and marginalized populations, such as tribes.

Promotion of community voice (PCV), for advocacy, lobbying, influencing quality control and behaviours of health care providers, etc. (exploration of the means that could be used in order to promote collective empowerment)

UdeM-CDS /2002

Community Based Monitoring System

Objective: To provide the Local Self Government

and communities (Self Help Groups) with a

participative and evidence-based information

system on access to Basic Minimum Services, for

needs-based policy formulation and monitoring.

CBMS is a system in which information is collected,

processed, and used by local actors.

UdeM-CDS /2002

Community Based Monitoring System

CBMS will provide disaggregated information on levels and distributions of health and access to basic services.

CBMS were developed by IDRC and have been implemented in several developing countries.

Thus far, these systems have been used solely for monitoring poverty. However, CBMS may also be useful for monitoring health and access to basic services as well.

UdeM-CDS /2002

Why Kerala?

Although Kerala is known for it’s achievements in health, it

is not a homogeneous state.

There is evidence of inequalities in well-being, health

status, and access to health care and other services.

E.g. the burden of health care is 3 times higher for the poorest (14.4% of their income) than for the wealthiest (4.4% of their income).

A strong decentralisation movement in Kerala provides a

setting where there is strong local government, and a high

level of community participation.

UdeM-CDS /2002

Study site : Kottathara panchayat

Located in the Northern district of Wayanad.

Characteristics

High under/unemployment

Large number of marginalised groups (++ scheduled tribes)

Growing movement of Women Self Help Groups (SHGs) form of micro-credit scheme two networks

NGO supported Kudumbrasree (supported by local government)

UdeM-CDS /2002

Districts of Kerala

UdeM-CDS /2002

Wayanad district

UdeM-CDS /2002

The Needs

Protecting the poor from exclusion and raising access to Basic Minimum Services (BMS)

Evidence of: Exclusion of the poor and marginalized populations

(ST/SC) from many BMS. High inequalities in well-being, health and access,

particularly in access to health care. High economic costs of health care.

Strongly felt need to reduce the burden of health care on the poor.

UdeM-CDS /2002

The needs (Cd)

A strongly felt need for data-based decision-making processes

Absence / Quasi Absence of tools for planning and monitoring policies / interventions implemented by the Panchayats.

“Hand-made” project-linked monitoring systems.

Improve Local Governance and Citizen Participation

Decision-making processes in Panchayats perceived as too impressionistic.

More data-based approaches perceived as essential for LSGIs credibility and good governance.

Support local bodies and make the decentralisation more effective.

UdeM-CDS /2002

Expected Outcomes

General

A community based monitoring system for access to Basic Minimum Services experimented and extendable to the rest of Kerala State and easily adaptable elsewhere.

Carefully validated indicators, tools and methodologies for planning and monitoring access to BMS.

Low-cost and effective methodology for the development and the implementation of Community Based Health Solidarity Systems.

Better capacities in Applied Development Research (academics, NGOs, LSGI).

UdeM-CDS /2002

Expected Outcomes (cd)

Population Enforced citizen partnership and Empowerment of community

groups and organizations (SHGs+++, NGOs, etc.).

Less exclusion from BMS, better access to quality care and lower inequalities in access to BMS.

Local Self Government Institutions Set of relevant information and available longitudinal

measures through Population-based information systems.

Increased knowledge of characteristics of vulnerable populations.

Improved evidence-based planning and abilities.

Available feedback on programs implemented.

UdeM-CDS /2002

Linking the two systems

The CBHSS and CBMS will be designed in an integrated manner, and implemented simultaneously, thus creating two mutually reinforcing systems.

The CBMS will monitor the effects of the CBHSS, the former providing a systematic evaluation of the latter.

Both systems aim to increase opportunities for health and well-being of women and underprivileged groups.

The systems will help to link two of the “actors”, local government and NGOs, with the desire to help create stronger community ties.

UdeM-CDS /2002

The Process

Short term building and implementing the models Development phase (2 years)

consultation, needs assessment, preparatory studies.

Implementation phase (2 years) pilot testing, training, Implementation.

Long term: extension of CBMS and CBHSS.

UdeM-CDS /2002

Development of the CBHSS

It will involve 5 main activities:

(i) exploration;

(ii) consultation;

(ii) needs assessment (health needs, access and utilisation of services);

(iv) preparatory studies (including a population baseline and a panel survey in order to estimate health risks & hazards and gather the necessary information for the development and the assessment of a limited number of scenarios);

(v) assessment of various scenarios of risk coverage and benefits, and of acceptable and feasible prevention /promotion activities.

UdeM-CDS /2002

Development of the CBMS

It will involve five main activities :

(i) exploration (reviewing experiences, and on-site field visits);

(ii) consultation;

(iii) needs assessment (access to basic services and inequalities, local government priorities, management capacities);

(iv) preparatory studies (including a population baseline for poverty, health, and access;

(v) complementary studies, (outcome measures and instrument and procedure testing) .

UdeM-CDS /2002

Where are we?

Preliminary studies

Surveys being implemented Situational analysis Household questionnaire Panel survey

Surveys in preparation Survey of surveys conducted by local government. Survey of « knowledge, awareness, and practices » of tribal

communities.

See note on methodology for further details.

UdeM-CDS /2002

Inputs

Partners Steering committee

Kudumbasree and NGO networks of SHGs, LSGIs, health actors, others.

IDRC : technical and financial assistance. Technical assistance includes capacity building in their respective expertise (in CBMS and CBIS).

Research team: Centre for Development Studies & Université de Montréal

Funding Phase 1: already approved by IDRC, budget = $490, 362

Phase 2: conditional subject to evaluation of phase 1.

UdeM-CDS /2002

Researchers

Principal Investigators

Slim Haddad, Université de Montréal (UdeM)

D. Narayana, Centre for Development Studies (CDS)

Co-researchers

Achin Chakraborty,CDS

Louise Potvin, UdeM

Student researchers

Rolf Heinmuller, Post-doc, UdeM

Katia Mohindra, PhD candidate, UdeM

Shada Raouni, B.Sc, Mcgill University

UdeM-CDS /2002

Timetable

Inception October, 2002

Exploration/reviewing experiences/on site visits October 2002 till March 2003

Finalisation of methods May 2003

Field studies January 2003 till June 2004

Analyses/Consultation/Model building October 2003 till June 2004

Evaluation/final report/dissemination August/September 2004