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

1. Access to Health Care and Basic Minimum Services in Kerala, India A CDS-UdeM Action-Research Initiative An overview of the project

2. Two Objectives • Intervention: Health Solidarity Scheme • Monitoring: Community Based Monitoring System

3. 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.

4. 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)

5. 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.

6. 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.

7. 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.

8. 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)

9. Districts of Kerala

10. Wayanad district

11. 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.

12. 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.

13. 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).

14. 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.

15. 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.

16. 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.

17. 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.

18. 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) .

19. 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.

20. 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.

21. 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

22. 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