Project Background and Description :
The total health spending in India is one of the lowest in the world, and most of it is private expenditure in the form of out of pocket payments. The majority of this payment is on the purchase of drugs and diagnostics, which are priced exorbitantly when bought individually by patients from chemist shops or pharmacies of private doctors, nursing homes, and hospitals. The same medicines are available in one tenth of the cost if bought in bulk. In spite of the launch of National Rural Health Mission (NRHM) in the year 2005, there seems to be hardly any reduction in the out of pocket expenditure (OoPE) of the people seeking health care. As a result, vast majority of citizens of this country have to spend up to 80% of health care expenditure from out of their pockets. It has been amply established that out of pocket expenditure is the biggest barrier in accessing health care from publicly financed institutions and one of the major cause of continuing indebtedness and loss of assets especially of those more than 50% citizens of this country whose daily income is less than Rs. 45.00. This is largely because receiving care from Government health system still remains very expensive. This is attributed by the health activists to an unaccountable governance in the primary health care in most part of the country and especially Rajasthan.
Keeping the above fact into consideration, Jan Swasthya Abhiyan (JSA) Rajasthan since past few years has been continuously advocating for free treatment to all in the state. JSA Rajasthan had made a very strong pitch for it in recent past through various means such as- dharna outside vidhan sabha, dharnas in districts, submission of memorandums, rallies, many meetings, delegations and a very forceful plea during pre-budget consultation organised by the CM on 24th February. All these efforts did not really go in vain as in a great move towards ensuring health services to all, Rajasthan Chief Minister, Mr. Ashok Gehlot recently announced that the government will provide free medicines at government hospitals to all sections of society. The project is supposed to cover every one below and above the poverty line categories who register for treatment at government hospitals. The programme is to be launched on Gandhi Jayanti (2nd October) this year. JSA believes that this is certainly going to be a path breaking initiative by Rajasthan government and would play a major role in bringing about a positive change in the status of health of the state and ensuring universal health care services. This land mark announcement will certainly increase the access to treatment several folds and 40% patients who used to slide down in poverty after single hospitalization will stop. Free treatment will also eliminate the use of unnecessary and unreasonable medicines which will save the efficacy of medicines for future generations.
However, while this announcement is a very important first step accomplished, its operationalisation is going to be very challenging. Government might have an important role to play in the implementation of the whole project, but there are some major areas where the civil society organizations and the community members will need to intervene and play a crucial part. For instance there will be need to carry out huge awareness campaigns in order to sensitize the masses about the free medicine provision at govt. health facilities and to promote more and more people to access public health services. Since people generally are apprehensive about using medicines which are comparatively less expensive or free (as they tend to doubt the efficacy of these medicines in comparison to those which are more expensive), people will have to be oriented and their mind sets changed for using generic ( less expensive) medicines. This would require mass campaigning especially at the grassroots. Apart from this, even the health workers at village level and the health service providers will also have to be oriented.
Apart from this a strong system of citizen based monitoring of health services will also have to be developed.Unless the health services are monitored in a proper and systematic way, the success of the free medicine provision would remain doubtful. A strong system of monitoring would ensure that periodic data is generated on the status of health services delivery and that the quality of services is upgraded. This is only possible if specific tools of monitoring and data generation are brought into use.
This is where the civil society organizations can play an important role. Given the rich outreach and hold that the civil society organizations have at the grassroots, they can play a significant role in motivating people to access govt. health services and benefit from the free medicine provision. They can also play an important role in monitoring of health services and ensuring community’s participation into it.
This proposal is an attempt to ensure an accountable governance by making people aware of their basic rights and ensuring their participation in the monitoring of the deliverance of health care services.
To orient members of civil society organizations about the basic concept of right to free treatment and its significance in context of right to health and universal access to health care and to subsequently prepare and organize them for setting up systems of citizen based monitoring to ensure that free medicines are available to all as a matter of their right.
We plan to organize orientation workshops with the members of the civil society organizations from across the state. We would hereby like to take advantage of the huge network of civil society organizations which the Actionaid works with in Rajasthan. Once the workshops are completed, the organizations will be organized to develop monitoring systems and to regularly conduct monitoring sessions using appropriate tools and techniques. The data so generated periodically will be assimilated and collated to provide a picture of the state. These data would also be shared through dissemination workshops with different stakeholders and govt. in particular. IEC material will also be developed to spread the information about the free medicines scheme.
Two days state level workshop:
A two day state level orientation workshop will be organised with the members of the civil society organizations (partners of Action Aid and others) from across the state. The two days workshop would largely orient the participants on the basic understanding of various components of health and health rights. Main discussion will be focused on Rajasthan govt.’s announcement on free medicines and its significance. Apart from this, workshop will also tend to develop tools and concepts for the monitoring of free medicine services in public health care facilities. The workshop will be organised in the first month of the programme.
Two days district level workshops:
6 two days district level orientation workshops will be organised in selected 6 districts of the state where Action Aid intensively works in partnership with local organizations. Main issues of discussion would be similar to the state level workshop but with a major focus on orienting the participants on using monitoring tools. District level workshops will be organised in the first quarter of the programme.
The two days workshop would largely orient the participants on the following major issues:
Basic understanding of right to health and health equity
Health care scenario in the country and in Rajasthan
Out of pocket expenditure on treatment and its consequences
Drug market in the country
Regulation of drug prices
Difference between generic and branded medicines
Free medicines announcement by the govt., its significance and how it can increase people’s access to health care services
Best models of free medicines in the country
What are the major challenges in the operationalisation of free medicines in the state
Role of civil society organizations and the community in its operationalisation.
Tools and concepts for the monitoring of free medicine services in public health care facilities
One day district level consultation with stakeholders:
Along with the district level workshops consultations with various stakeholders will be organised. This will be part of the district level workshops and would involve consultations with different stakeholders (PRI,CMHOs, doctors, ANMs, ASHAs, AWWs and other officials from health and other departments) will be organised to make them aware about the free medicines scheme and to sensitize them towards this key issue. It is important to involve different stakeholders with the work because they can also play an important part in the monitoring and follow up of the scheme. The consultations will be organised in the second quarter of the programme.
State level Jan Sunvai and experience sharing:
One state level Jan Sunvai will be organised to share the experience of free medicine services. Members from civil society organizations, implementing agencies and govt. will participate in the jan sunvai. Findings from the monitoring of free medicine services will also be disseminated and discussed during the jan sunvai. It will help to provide a picture of the state and shape the programme for the next phase.
IEC material and relevant publication:
IEC material (posters, broachers, pamphlets etc.) will be developed in local language to spread the information regarding free medicine scheme. These publications will be finalized and printed in the first two months of the programme. It will benefit the partner organizations to circulate the information before the launch date (October 2, 2011) of the free medicine scheme.
Monitoring tool and monitoring visits:
Monitoring tool will be designed and finalized in the state and district level workshops with civil society organizations. Monitoring tool will be made available in printed forms to the partner organizations after the launch of free medicine scheme. The process of monitoring the free medicine scheme will start after the completion of one month of the scheme (tentatively in November 2011). Findings and data from the monitoring of free medicine scheme will be shared in the state level jan sunvai.
Expected Outcomes and Monitoring Indicators :
Participants would develop sound understanding about right to health and the various concepts related to right to free treatment.
They would understand the market dynamics and how it influences pharma industry and drug prices.
They would be well equipped to build up systems of citizen based monitoring of free medicines as well as other health services in their area of work.
A solid system of citizen based monitoring of health services will exist in all the districts of the state.
District level data will be generated based on tools used for monitoring of services in public health facilities.
Assimilation and compilation of district level data to produce state level data.
A continuous process of monitoring of health services will take place along with periodic data generation to keep a track of public health services delivery.
Campaign at village level:
One of the biggest challenges in the implementation of free medicine scheme would be people’s misconception regarding free or low cost (generic medicines) medicines that these medicines are not (or less) effective. To eradicate this thought and to increase access of these medicines in the community, village level campaign would be a best practice. Campaign will create an understanding of the scheme within the community and also focus on the benefits of the same. Campaign will be initiated with the help of ActionAid partners in selected 6 districts in the second quarter of the programme (October to December 2011) with the launch of the scheme.