How do we talk about Universal Health Coverage?

Where health provisioning is concerned, Universal Health Coverage (UHC) has been the defining term for the past few years. WHO has taken it up with enthusiasm and the Indian government likes the word a lot too. In fact, recently Karnataka announced that it had achieved UHC!

I was at a meeting organized by WHO earlier this month, where a film was screened that talked about what UHC 'was' and 'was not'. But there were few specifics and all the visuals focused on antenatal and postnatal care. It is true that we, especially in India, have not yet achieved these basic targets. An example - the Community Health Centre (CHC) in Pisawan, where Sangtin Kisan Mazdoor Sangathan (SKMS) is active, does not have access to running water and its sole hand pump stopped functioning 2 years ago. Recently, a woman in labour left the CHC to find a place to urinate (the toilets there are always locked). She ended up delivering there.

But can UHC remain limited to ante- and post-natal care, deliveries, immunizations and some communicable diseases? When people have to go elsewhere for their other health needs, they will not necessarily return to government services for these. Barely half a kilometre from the Pisawan CHC is a private practitioner that even the poor in these parts rely on. He most likely does not have an MBBS degree (those who do display the information proudly!). A few years ago, he sat in a small shop-front clinic. Now he has an immaculate waiting room, a ward of sorts with a few beds and an examination room. Once as we waited to speak to him, he examined patients with all kinds of symptoms with the attention and 'human touch' that they do not get in the CHC. He wrote up long lists of medicines for most of them. This is the health care most Indians rely on.

To move from what we have to a system that promises true UHC (many health activists instead use the term Universal Access to Health Care), we have to better explain what we envision. I hope to work more on this in the coming months...

    

Back again!

Dear Friends,

It's been four years since I've updated my blog. Four eventful years on the personal front with a birth, a death, moves and multiple changes in plans for the future. I thought of starting a new blog, but since I'm still grappling with fundamentally similar issues and concerns, decided to continue here. So here's to phase 2 of slipping and sliding, hopefully featuring better, more improved posts!

On the professional / social front, I have been working in Bangalore for the past 2 years with multiple organizations with the goal of building a strong network to campaign for health rights. I also continue to work with Sangtin Kisan Mazdoor Sangathan (SKMS) in Sitapur dt., UP from a distance, augmented by occasional visits.

I am restarting my blog on the eve of assembly elections in Karnataka. I was away for most of April, so missed a lot of the campaigning and politicking. Yet, one can't miss it completely, so here are some questions and observations:

• What does one do with one's vote and does it matter? Some communities facing dire situations and fed up with the status quo have decided to boycott the elections. The Aam Aadmi party suggests we vote for 'none of the above'. In a community meeting I attended recently, attendees were advised that they could enter the voting booth and not press any button. But they would still get their finger marked and need not fear any backlash from the goondas etc. A woman stood up and replied that a group from her slum had gone to visit their MLA with some urgent requests – he responded asking why he should help them when no one in their area voted for him. In the marketplace of electoral politics, principled stands have to be chosen by a significant number of people to have any chance of being taken seriously.
• Are the so-called alternative parties and candidates serious enough about winning? Observing some of these candidates, I am reminded of an incident from about 4 years ago. In the last Lok Sabha elections, a coalition of 'progressive' groups decided to field a few candidates across the country. One of those candidates' constituency included parts of Sitapur district. He came to an SKMS meeting to canvass for votes, with an insoucant manner and a bewildering conviction in his 'rightness'. The sangathan saathis listened patiently to his speech and asked him some insightful questions, which he could not answer satisfactorily. For example, for the questions – 'How are you different from any other candidate who comes and promises everything under the sun? How can we be sure that you will remain honest once you come to power?' - he had no answer beyond 'I work for so-and-so, the greatest organization blah-blah-blah and have an amazing man as my guru'! Here, in Bangalore, one candidate from a party claiming to be different visited our area for the first time 2 days ago. Hardly an improvement over the status quo! 
   
• Have advocacy groups, NGOs etc. had any effect during the campaign phase? From what I can see, very little. Many have not worked on a consistent basis and are focusing on awareness sessions, petitions, press meets etc. Others have decided to organize rallies and other shows of strength after the new government takes over – after all, the major parties are very similar. So why not use resources wisely and focus on the party in power?!

Well, seems that the elections are inspiring enough to resume blogging! Wish me luck in the coming days and months as I try to articulate the challenges, insights, frustrations and hope in my current endeavours.

Regards,
Sudha

In search of relevance...

My fellowship with CHC came to a close in March. The rest of the fellows wound up in February, but because of my month in US/Canada, I had requested an extension. My report was due at the end of March and I spent a lot of time on it from December onwards. In retrospect, I'm glad I did and am thankful to CHC. Because of the report and my blogging, I have a much better record of what I did during my first year back in India.

The report can be found here. It's 77 pages long, but I think it is an easy read. I will start blogging again, so there should be more to read out here as well.

From victory to celebration... to reflection

After the achievements of the dharna, plans were made to organize a sammelan, a gathering in Sitapur city. The goals of this sammelan were many: to mobilize other villages in Mishrikh and Pisawa blocks as well as other blocks throughout Sitapur dt., to show the people of Sitapur city, media etc. that the Sangathan did more than organize protests, to discuss the problems of the rural poor etc.

In the meantime, some progress had occured after the dharna vis a vis issual of job cards. Further, work had been started in most of the Sangathan villages. After almost a year of almost no work being provided, ponds were being dug, fields were being leveled and labourers were being employed under NREGA for this work.

For me, most of February was spent planning for the sammelan, from discussions at the village level on the reasons for holding a sangathan to the nitty-gritty of the venue, equipment etc. The expected turnout was 2000-2500, so this was a bigger event than any I had worked on in the past. My role was small – mainly helping out with posters and a small photoexhibit, helping out in meetings etc. Dwiji had a bigger responsibility – he was in the logistics team.

The sammelan was held on the 24^th and 25^th of February. Attendees were expected to arrive by noon, but as usual, it was 2:30 pm before the venue began filling up. The sammelan was inaugurated by the lighting of torches held by 5 women and 5 men of the Sangathan. It was followed by slogans, speeches and songs. Activists and supporters who had arrived from MP, Lucknow, Delhi etc. spoke, congratulating the Sangathan and exhorting the audience to continue the struggle. I found the speeches given by the Sangathan Saathis Bitoli and Prakash as inspiring, if not more. Maybe more because I had seen them practicing and had given feedback. To see all their hard work pay off was immensely satisfying.

After the inaugural, we took a break for three hours to relax and have dinner. Incidentally, meals during the sammelan were being cooked using the rice and wheat flour that had been collected during the dharna. At 9 pm, we re-convened to discuss problems with implementation of NREGA, changes necessary to the Act itself and the problems faced by the poor in general. This session continued till midnight after which entertainment commenced in the form of songs. I guess a gathering this size never sleeps! Some singer performed the traditonal 'alhas' while others sangs songs from movements, ghazals and filmi songs. Some performers bagged a good sum of money through requests!

Over in the food tent, events were progressing less smoothly. About 1500 packets of poori-sabzi were to be distributed in the morning (the turnout was less than expected), but by 4 am only 400 had been made! The team hired for cooking may not have ever cooked for this many people and had clearly not anticipated the effort required. Tea was served early, but by the time there were enough packets to distribute, it was almost 11 am. After distribution, a few people started saying that the sabzi was rotten (it did smell a little off, maybe because it was packed tight and because tomoatoes were used). Anyway, that started a commotion and the next hour was not pleasant!

The sammelan was to end in a rally, but first, word was received that the CDO and PD (Program Director) would show up. They did, and spoke as well. The CDO assured the assembled people that overdue payments for work done would be made before Holi and that work would be started in all villages. He said that the government had enough funds to ensure that every family worked for 100 days in a year. There were just a few problems in the system that needed to be fixed, for which he asked the Sangathan to continue working!

Of course, our friends did not let him get away with that! They thanked him for attending the sammelan but also reminded him of the many things that were still wrong. They took on the issue of overdue wages and he assured the assembled crowd of payment before Holi.

Like with other Sangathan events, the sammelan ended with a rally. The resolution that had been approved in the morning was presented to the DM. With a little bit more of slogan chanting, the sammelan was completed.

The sammelan had its highs and lows, but it was clear that this event marked a new phase in the Sangathan's journey. Sitapur had sat up and taken notice of SKMS. And while all the stated goals of the sammelan were not met, such as mobilizing in other blocks, the seeds have been sown. It was a satisfied lot of people brimming with ideas that returned to their villages on 25^th February.

Two steps forward, half a step... forward?

Immediately following the SKMS dharna, I was down with diarrhoea for 2 days. I had been fine during the summer and monsoon in Sitapur, so to be brought low in the winter was surprising. Thankfully, the dharna was over, so I could concentrate on rehydration and rest.

Things were better on the Sangathan front – account numbers were being collected for payment of the unemployment benefits and work had started in many villages. Of course, there are problems. In Mishrikh and Pisawa, the 3-day camp for job cards started off badly with the Block office asking for just the list of people who needed job cards. No application forms were available and no photographer was present. After a little wrangling, the process improved in Mishrikh over the next 2 days.

On another front, there were rumours that the BDOs who were to receive suspension orders had gone to court. And soon the news came out that they had indeed filed a writ petition in the Lucknow High Court, claiming conflict-of-interest by committee members, labourers incorrectly deemed eligible for benefits etc. The bench mainly ruled on whether the Commissioner at the Ministry of Rural Affairs was the responsible authority with powers to overrule decisions at the district level. They deemed that he was and asked him to review the additional documentation presented by the BDOs within 10 days. They also asked him to ensure that eligible families received the unemployment benefit as they were entitled to. This was a better outcome than many in the Sangathan and among its supporters had expected and the mood was upbeat.

At the village level, there are still problems with work not being made available, applications not being received etc. But some people, at least, have learnt to demand their rights. In one Gram Sabha, a few hundred people went to the Pradhan's house and demanded job cards. He was forced to bring out cards that had been in his keeping since 2006!

Finally, fights in villages continue. In some cases, they seem to be power plays between Sangathan members and those close to the Pradhan or older powerful families. Nerves are also a little frayed and people are reacting to every little thing that seems out of the ordinary. Until the unemployment allowance reaches the accounts of the beneficiaries, this state of affairs will most likely persist.

On another front, planning has started for a sammelan to be held on the 24th and 25th. Farmer-labourers from across Sitapur district and other areas will be invited to share their experiences, learn from SKMS' journey and plan for collective action to ensure a better life. There is talk of about 1500-2000 people attending from Mishrikh and Pisawa and ~500 from other blocks in the district. I think the numbers will be higher. At any rate, Sitapur city will witness a bigger gathering of the rural poor, without any party backing, than it has been accustomed to!