42024 REACHING THE POOR 2007 WITH HEALTH SERVICES India Community-Based Women'sTrade Union Brings Health Care to the Poor The Self-Employed Women's Association (SEWA), a trade care, it has many unqualified practitioners who likely provide union, was founded in 1972 in Ahmedabad, Gujarat State, too many inappropriate treatments. Patients pay out of India, to empower poor women who earn a living outside the pocket for much of their care, both public and private. formal sector through their own labor or small business. In Gujarat, relative to all-India, the private for-profit These women don't earn a regular salary and have no welfare health care sector is thriving. The problems with publicly and benefits like those employed in the organized sector. privately provided care are the same in Gujarat as elsewhere SEWA had two main goals; (a) to help these women in India. Most people, in both urban and rural Gujarat, use achieve full employment which would offer security for the private sector for outpatient and inpatient services. work, income, food and social protection, and (b) to make According to the 1995­96 National Sample Survey Organi- them individually and collectively self-reliant, economically zation (NSSO) survey, nearly 82 percent of outpatient treat- independent and capable to make their own decisions. In ments among rural residents were obtained from private addition to banking and credit services (SEWA Bank), and providers, as were 76 percent in urban areas. The private sec- insurance (Vimco SEWA), SEWA became actively involved in tor accounted for 71 percent of hospitalizations in urban public health services in the early 1970s, to provide its mem- Gujarat and 67.4 percent in rural Gujarat. Among the areas bers and non-members with some form of preventive and pri- included in this study, the public health care system is strong mary health care. It aimed to serve the very poor, particularly only in Ahmedabad City, where four large government hos- those living in areas not otherwise served by government or pitals provide outpatient and inpatient care. non-government organizations (NGOs). SEWA had to over- Distance and lack of financial resources are major barriers come many challenges to provide the needed health service to to health care seekers among the poor in Gujarat. Health care those very poor. (particularly curative, expensive, inpatient care) is widely available in urban centers. But for village dwellers far from an urban center, the closest source of health care may be hours Health Care in Gujarat away. Twelve percent of rural women have to travel at least 5 In India, as elsewhere, the poor die earlier, are more prone to km to reach the nearest health facility. Based on the 1995­96 illness, and have less access to health care than the better off. NSSO Survey, the wealthiest quintile of rural Gujaratis (meas- Reaching this poor, largely illiterate, and geographically dis- ured by yearly household expenditure) was 4.6 times as likely persed population, especially residents of remote rural areas, to have been hospitalized over a one year period than the poses many challenges. Foremost among them are identifying poorest quintile. In urban areas, the ratio was 2.9. and overcoming difficulties the poor face in obtaining health care. SEWA Health Services India's public sector is vast but underfunded and not nearly large enough to meet current health needs. The private sector SEWA first became actively involved in the public health field is growing quickly, but it is unregulated. Lacking standards of in the early 1970s through health education and provision of www.worldbank.org/wbi/healthandaids maternity benefits. In the early 1980s, SEWA negotiated with The Reproductive Health Mobile Camps the Indian government to help distribute maternity care to In response to demand from people in remote and under- poor women. A focus of SEWA Health has always been to serviced areas, SEWA Health began organizing reproductive build capacity among local women, especially traditional health (RH) mobile camps for women in 1999. RH mobile midwives (dais), so that they become barefoot doctors in camps are carried out mainly in the slum areas of Ahmed- their communities. Today, SEWA's health-related activities abad City and in the villages of three districts and are funded are many and diverse. They include: primary health care largely by the United Nations Population Fund (UNFPA) and delivered through 60 stationary health centers and mobile the Government of India. More than 35 camps are carried health camps; health education and training; capacity build- out per month, and the mean attendance per camp is 30 ing among local SEWA leaders and dais; provision of high- women, for a total of more than 12,500 patients per annum. quality low-cost drugs through drug shops; occupational and Health care at the camps is provided by empanelled physi- mental health activities; and production and marketing of cians and 50 barefoot doctors and managers. The camps are traditional medicines. Reaching the Poor deals with the three repeated in each area, on average, once per year. activities summarized in table 1. Table 1.TheThree SEWA Health Services Covered by Reaching the Poor Reproductive health Tuberculosis detection Variable mobile camps and treatment Women's education sessions Start-up date 1999 1999 1999 Target population Women, reproductive age Men and women, all ages Women, reproductive age Geographic coverage Mainly Ahmedabad, Kheda, North and East Zones of Mainly Ahmedabad, Kheda, and Patan Districts Ahmedabad City and Patan Districts (but also (population 375,000) the other districts where SEWA Union has members) Services Education and training; examination Diagnosis; treatment; medicines Education: SEWA orientation; and diagnostic tests (cervical first aid; general disease examinations and Pap smears; and HIV/AIDS; immunization treatment, referral; follow-up and child care; airborne and waterborne diseases and tuberculosis; sexual and reproductive health Annual utilization rate 12,500 women 575 patients under treatment 6,000 women at the DOTS center; 23 served by barefoot DOTS workers Cost to user Rs 5 consultation fee; medicines Services free; indirect costs only Rs 5 SEWA Union sold at wholesale price (about membership fee one-third market price) External donor UNFPA and Indian government WHO, Indian government, Indian government, UNFPA and Ahmedabad Municipal and Ford Foundation Corporation Human resources 6 part-time physicians 5 stationary centers (each with 35 grassroots workers and 50 barefoot doctors and managers 2 to 3 staff) and 11 grassroots full-time staff DOTS providers DOTS Directly observed treatment, short course; UNFPA United Nations Population Fund. Source: Table 9.1, Gwatkin, Wagstaff, and Yazbeck (2005). Activities at the RH mobile camps include health educa- tions of Gujarat, using recent, representative surveys. It was tion and training, examination and diagnostic tests (includ- found that the RH mobile camps are very effective at reach- ing cervical examination and Pap smears), treatment, referral ing poor women in Ahmedabad City. A comparison based on and follow-up. Camps are usually held during the afternoon, a composite SES index showed urban camp users to be sig- and their duration is three to four hours. Those attending the nificantly poorer than the population of Ahmedabad. Camp camps are asked to pay a 5 Rupees (US$0.11) contribution, users (and their families) were, for example, significantly less and one-third of the total cost of medicines provided likely to possess a motorcycle or scooter (12 percent vs. 43 (although even these fees may be waived for those who are percent), were more likely to rely on public (vs. private or very poor.) shared) toilets (22 percent vs. 9 percent), and were less likely Increasingly in rural areas, SEWA Health is conducting to use natural gas as a source of cooking fuel (35 percent vs. these camps in collaboration with the Government of 66 percent). Figure 1(a) illustrates the distribution of urban Gujarat, with camps held right at government primary health camp users by deciles of the SES index score­the leftward centers (PHCs), which are usually located in or near small skew of this graph indicates that camp users were more likely villages. These camps differ from the standard "area" camps to be from poorer segments of the general population. The (described above) insofar as medicines are given for free, the percentage of camp users falling below the 30th decile of the range of medicines available are restricted to those on the SES score--which roughly approximates the poverty line in government's formulary, and health care is provided by pub- India--was 52 percent (Figure 1). lic doctors and nurses. Free transportation is provided by In rural areas, the camps were less effective in reaching SEWA to women living in neighboring villages. poor women. Rural women did not differ significantly from the general, rural population in terms of their SES index score. Figure 1(b) indicates that the majority of rural camp Reaching the Poor users are from less poor deciles of the population. Only 5.7 376 urban and 158 rural women were surveyed to assess the percent of users fell below the 30th percentile­suggesting that socio-economic status (SES) of the women using the RH SEWA Health's rural RH mobile camps do not effectively tar- mobile camps, as they attended randomly selected camps. get the very poorest. They were compared to the general urban and rural popula- Figure 1. Frequency distribution of SEWA reproductive health mobile camp users, urban and rural, by deciles of the SES index score 35 35 30 30 25 25 e e ag 20 ag 20 entc entc 15 15 erp erp 10 10 5 5 0 0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1(a) Urban (N=376) 1(b) Rural (N=158) Source: M. Kent Ranson, Palak Joshi, Mittal Shah, and Yasmin Shaikh: "India: Assessing the Reach of Three SEWA Health Services among the Poor," in Reaching the Poor, Gwatkin, Wagstaff, andYazbeck Editors, World Bank, Washington, 2005 What Worked and Why · Weaker "links" between members and local Vimo SEWA representatives in rural areas (i.e. the contact between For the most part, the urban services seemed to be effectively members and the organization is less frequent, and less targeting the poor. Reasons for this success are likely to intensive, in rural areas); include: · Weaker capacities among Vimo SEWA grassroots workers · SEWA personnel treat people with respect and warmth in rural areas. and give them detailed information; SEWA Health has taken steps to improve the accessibility · Services (especially RH mobile camps and women's educa- of the rural RH mobile camps. SEWA Health waives the reg- tion sessions) are offered "right at people's doorsteps", i.e. istration fee and the medicines fee for those who appear to be SEWA Health takes the services to the poor, rather than particularly poor­typically a few women presenting to each trying to bring the poor to the services; camp. Perhaps these exemptions could be granted more lib- · The services are delivered by women and by (or at least in erally, and in a manner more objective, for example, by pro- part by) the poor themselves; viding exemption to all those who possess a below poverty line (BPL) card. · The services are generally combined with efforts to edu- It must also be remembered that failure of a service to cate and mobilize the community; for example, preceding reach the poorest of the rural poor does not necessarily mean the RH mobile camps, SEWA Health workers go door-to- that the service has failed in "reaching the poor." Even those door, educating people about the service, and educating households that fall in the higher deciles of the SES index in people on how to use it; rural areas should be considered "less poor" rather than · Services are free or low cost and medicines are much "wealthy." Compared to their urban counterparts, these cheaper at SEWA facilities than in private shops; rural households have less in the way of cash reserves, mate- rial wealth, and thus economic security. · SEWA is an entity that people know and trust. In conclusion, the findings of this study suggest that deliv- ery of services through a broad-based, development-oriented In-depth interviews with SEWA Health grassroots work- union can facilitate equitable delivery of health care services. ers suggest that there are two main barriers that prevent poor Government and donors can help to ensure that established rural women from using the RH mobile camps. First, for NGOs, with an interest in providing health services, have the some, the 5 rupee registration fee prevents some from attend- capacity and the resources to do so. ing the camps. Second, the camps may be difficult for women to attend, as they often coincide with hours of work. This brief is intended to summarize good practices in Health, Nutrition, There are likely to be other, broader reasons underlying and Population. It was adapted from M. Kent Ranson, Palak Joshi, the difficulties in delivering services to the rural poor. Studies Mittal Shah, and Yasmin Shaikh, "India: Assessing the Reach of Three in other SEWA departments have documented similar dis- SEWA Health Services among the Poor," chapter 9 in Reaching the crepancies in the equity of utilization of rural versus urban Poor with Health, Nutrition, and Population Services: What Works, What Doesn't, and Why," Davidson R. Gwatkin, Adam Wagstaff, and services. For example, the poorest rural members of SEWA's Abdo S. Yazbeck, eds. (Washington, DC: World Bank, 2005). The views insurance scheme (Vimo SEWA) have lower rates of claims expressed in this note do not necessarily reflect those of the World than the less poor. Reasons for this differential include: Bank. · Problems of geographic access, both to inpatient facilities and to Vimo SEWA's grassroots workers; www.worldbank.org/wbi/healthandaids