Increased healthcare expenses and lack of access to hospitals prompted a women’s collective in UP to run a biweekly village clinic on family subscriptions.
Champa’s young daughter was suffering from fever. Care received from the local practitioner did not help. There was no option but to visit the nearest hospital at the block level even if it meant foregoing the day’s work and hence the wage. Champa incurred expenses for travel, consultation and medicines totaling to Rs 450 to seek necessary treatment for her daughter.
This experience made Champa bring up lack of healthcare in her village for discussion in the women’s collective meeting. After prolonged and heated debate on the matter, Leelawati, the leader of the collective admitted, “City people have family doctors. If we fall sick here in villages, what can we do? We should also have a doctor for ourselves.” The women reached a consensus in the same meeting to start a Gaon Dawakhana (village clinic).
With “our health is in our hands” as the motto, the clinic was started in Lalganj block in Pratapgarh district of Uttar Pradesh (UP) in January 2017. Gaon Dawakhana has been designed as a subscription-based model, owned and managed by the community with the help of visiting doctors.
Need for a village clinic
Primary healthcare is the villagers’ first point of contact with the healthcare system. The government has designed a three-tier public health system, the first one being health sub-centers (HSC). These centers, manned by a trained nurse, are meant to cater to a population of 5,000. However, in densely populated geographies such as UP, HSCs often serve 8,000 to 10,000 people.
Consulting a doctor is through a primary health center (PHC) which exists for every 30,000 people. Hence people need to travel to seek a doctor’s consultation. Further, challenges related to infrastructure and competent paramedical personnel at peripheral health facilities still exist. In such a scenario rural people have no choice but to seek care from local practitioners, quacks to be precise, who provide service at the villagers’ doorsteps. What if a qualified physician is made available to serve in their village? Will it sustain? Gaon Dawakhana is an attempt to answer these concerns.
Community-owned self-sustaining clinics
Each household pays Rs 50 per month to avail of healthcare services at the clinic. The beneficiaries’ health cards are updated as soon as the monthly contribution is collected from them. Patients receive free consultation and medicines while visiting the clinic. The subscription amount was fixed at Rs 50, taking the number of family members as five.
Though healthcare services are offered now at the same subscription even if the family size is more, an additional amount of Rs 10 per head may be collected in future. So far, 1,665 families have registered and have paid a total subscription of Rs 1.94 lakh. And on moral grounds, those who are not subscribed are also treated now, but are encouraged to subscribe.
Clinics are held at the Lalganj block on Thursdays and Sundays. Village clinics are held in the panchayat office premises on two days fixed by the women’s collective leaders. Officially a four-hour clinic, the timing is extended if the number of patients is more since patients from neighbouring villages in a 3 km radius also visit the clinic. The clinic in Lalganj attracts patients from ten villages in a 6 km radius.
Presently two homeopathy doctors serve the clinic on a regular basis. Following the demands for an allopathic doctor, a retired Chief Medical Officer (CMO) also offers his service. Expenses towards doctors’ fee and medicine are met from the subscription amount.
In addition to the clinics, quarterly health camps, some focusing on non-communicable diseases, are conducted. This was initiated to help non-subscribers seek consultation and also to encourage more households to subscribe to the dawakhana scheme. Of the 227 patients above 40 years of age screened for risk factors for diabetes and hypertension, 41 suspected cases were found. A trained health worker from the community and on the rolls of Gaon Dawakhana, will actively track these 41 patients.
During health camps, government doctors and paramedical staff, along with the retired CMO offer free services. Medicines available with the public health system are issued free of cost.
During one of the camps, the village chief who found that his BP and sugar level were high, thanked Leelawati for taking the lead for starting Gaon Dawakhana. “I knew my BP was high. But this was the first time my blood sugar level was tested. I need to be regular with medicines now. Also, these camps should happen more often,” he told VillageSquare.in.
Role of the women’s collective
Nari Sangh, the women’s collective was started in 2008 with the objective of empowering rural women, through the joint efforts of Lokpriya Janhit Sewa Sansthan (LJSS), a local community-based organisation (CBO), Tata Trusts and People’s Action for National Integration (PANI). The women learnt to access food security service entitlements such as employment under MGNREGA (Mahatma Gandhi National Rural Employment Guarantee Act), food grains under the Public Distribution System (PDS) and the like.
With a Nari Sangh at every village and leaders identified at each level – from panchayat to state – the collective serves as a pressure group to mobilise and improve grassroots processes. Over a period of time, the women realised that assured food security through enhanced income did not necessarily translate into better health; mainly due to lack of healthcare services. Hence Gaon Dawakhana was a felt need.
“The women informed us that they spent up to 30% of their income on healthcare annually. So we applied our insight and encouraged them to start the clinic through collective contribution,” Shashi Bhooshan of PANI told VillageSquare.in.
Women leaders shared that the villagers’ faith in the Nari Sangh helped them start Gaon Dawakhana. They arranged for homeopathy doctors, considering feasibility and the awareness among villagers about alternative treatments. The very first clinic attracted more than 50 patients.
The Nari Sangh leaders finalised the subscription amount. As a norm, the collected amount is held by the Nari Sangh leaders in a joint account with the CBO representative to ensure transparency. According to Niranjan Tiwari of LJSS, the women follow guidelines set by PANI to ensure transparency in all their work. Women leaders take care of the other aspects such as logistics, allocating funds for consultation fee, etc., pertaining to running the clinic.
Lessons and challenges
“Major learning from Gaon Dawakhana is that women can be mobilised to meet the healthcare needs of the community,” Tiwari told VillageSquare.in. Gaon Dawakhana demystifies the common notion that rural poor are always in need of free services. Poor and vulnerable families are willing to pay for services especially when they perceive value in it.
Still there is a need to work on the mindset of those who are yet to subscribe to Gaon Dawakhana. They need to be made aware that health should be a family priority and that contribution for healthcare is an investment and it is as critical as other expenses.
Despite voluminous efforts, the entire health system is facing multifold challenges to address key attributes of primary health care – availability, accessibility, acceptability, appropriateness and affordability. In densely populated villages, clinic days are crowded and it is a challenge for the doctors to see every patient. Conducting health camps with designated manpower and available budget also pose a challenge. To bring down cost, health camp services can be clubbed with routine village health and nutrition days. Hence, constant engagement with grassroots health system staff – nurse, anganwadi worker and ASHA (Accredited Social Health Activist) workers will be a good option.
Homoeopathy integrated with modern medicine could be a cost effective and feasible alternative to extend primary healthcare services to rural population. According to Bhooshan, Gaon Dawakhana is a true public – private – community participatory model.
The experiment appears promising. Yet it is very much a work in progress and its future course will largely depend on the success of the health camps and sustained interest of community to regularly contribute their subscription amount. Gaon Dawakhana certainly holds the promise of happier Champas who shall be spared from disproportionate expenses to seek basic healthcare services.
Sandeep Chavan is a homeopathic doctor, trained in public health administration from Tata Institute of Social Sciences, Mumbai. Views are personal.