Interview with Dr. Rajaratnam Abel, a Public Health Consultant

RUHSA was started in January 1977 and I joined the organization in November 1978 and worked till my retirement in September 2005. The experiences shared here relate to this period.

The following are some of the changes that were made possible having a positive impact on the lives of over 120,000 people of KV Kuppam Block of Vellore District in Tamilnadu, India as well as people beyond.

• Empowered the poor to transform from their attitude of fatalism enabling them to face economic uncertainties such as drought and other catastrophic situations in the family with confidence.
• The most significant impact was to develop people to be self assured in making decisions to carry on with their own sustainable development even after organizational support was withdrawn from providing the services.
• Students from India and abroad came to RUHSA to participate in the training programmes ranging from short course workshops to completing MPhil and PhD academic work.
• The department was recognized by the Thiruvalluvar University as a research centre for registering doctoral students to carry out PhD level research.
• Systematically carried out simple studies on the effectiveness of growth monitoring eventually leading to PhD level research by a visiting student concluding that good growth monitoring of regular weight checking alone of children in the absence of other health inputs was not effective.
• Carried out a research on stunting among children in Tamilnadu which finally resulted in a complete modification of the nutrition programme in Tamilnadu after professional advocacy through the Tamilnadu State Planning Commission.
• Developed a cascading model of behaviour change communication which brought about behaviour change in the community. This model was applied in the of control kala azar disease in four districts of Jharkhand and malaria in select populations numbering over 100000 in Orissa resulting in both decreased disease and deaths due to malaria.

RUHSA was Christian Medical College, Vellore’s response to meeting the health needs of the rural poor in K V Kuppam Block of Vellore District, Tamilnadu India.

Several factors contributed to its success:

• The Program was founded on very specific philosophies with detailed planning using clearly defined time bound and measurable objectives.
• RUHSA was probably one of the first Non Government Organizations providing integrated health and economic and social development with a positive bias for the poor.
• All selected health problems were handled in a comprehensive manner rather than implementing few selected interventions targeted at any specific population group.
• Community education for changing health and health seeking behaviour as well as to utilize available services was carried out using curriculum design as educational technology.
• The Program was implemented as a community based organization with services being provided based on needs expressed by the community
• The Program blended professional expertise of a team of professional managers backed by periodic need based capacity development of staff.
• RUHSA believed in working in partnership with the government resulting in the government involving RUHSA in various state functions and tasks.
• RUHSA promoted community participation in decision making for their own development then moving on to promoting community ownership.
• The focus of RUHSA was on increased productivity rather than just on distribution of available resources which was provided when indicated.
• The ultimate success of RUHSA was in empowering women through Self Help Groups to overcome poverty and increase their social standing in society along with the support of men members of the community.

The Program performed periodic evaluations and carried out mid course corrections backed by systematic documentation.

Yes the department is still operational.

The major changes witnessed in the areas of health and developments are listed below:

• Control of communicable diseases among children in KV Kuppam was the earliest impact with decreasing deaths due to measles and tuberculosis, deformity due to poliomyelitis, and severe illness associated with whooping cough, diarrhoea and pneumonia.
• Significant decrease in malnutrition was witnessed in all age groups with decreased stunting and wasting among young children.
• Significant demographic changes were observed with decreased deaths including female infanticide and with increased adoption of family planning it resulted in decreased births.
• Increased income and decrease in poverty in the community through effective cattle cross breeding by artificially inseminating local low milk yielding cows with imported bull semen from USA resulting in off spring with increased milk yield.
• Facilitated downstream use of increased milk production by converting into the solid form ‘Khova’ or ‘peda’ giving longer shelf life for marketing with simultaneous increase in livelihood opportunities.
• At the height of RUHSA’s direct inputs there was over 20,000 broiler chickens in the community. When the community took over in partnership with the corporate sector this increased to over 600000 birds.
• Organized communities especially over 6000 women into over 300 Self Help Groups with savings of over Rs.30 million or 3 crores, along with a number of self employed microenterprises as well as additionally being involved in social issues.
• Over 20,000 youth were trained in vocational skills enabling them to start sustainable livelihood opportunities or engage in gainful employment.

There has been a change in the programme currently. The focus today is on health more than development and within health the focus is on chronic diseases along with care of the elderly.  After completing a decade of development and as people became confident in managing their own development activities the need for professionals in these areas steeply declined such that after 25 years the staff strength had reduced from 220 to 120 with continued support to essential programmes being maintained.

There were three major sources of funding with different sources contributing the major amount at various stages of its life.

• Christian Medical College (CMC) the parent institution. RUHSA was started as one of four major outreach activities of CMC. The financial needs of RUHSA were underwritten by CMC and over time has been the single largest contributor to the core budget of RUHSA.
• Private grants from overseas and India formed the second major component. In the early stages of RUHSA grants formed the major source of income as they were freely available and the concept of RUHSA was innovative. However most of the funding agencies expected financial sustainability and in later years it was restricted to specific activities. Only grants contributed to the capital and infrastructure development of RUHSA.

Government grants formed the least of the three components earmarked only for specific government programmes.

This question has been raised up among our own team members as we began to see the work successfully expanding based on the needs expressed from the local community and from outside as well. The range of professionals who were involved, the magnitude of skills available and the spectrum of programmes clearly indicated that RUHSA in its entirety could not be replicated elsewhere.

Only specific programmes either individually or collectively could be implemented according to the needs of the specific area. However this type of replication actually took place through different students applying what they learnt in different parts of the country.

There was at least one expert who raised and answered this question himself. He indicated that each district requires at least one similar set up to take care of the training, research, documentation and development coordination needs of the government. The frequency with which various government departments used the training infrastructure of RUHSA as well as the training staff indicated that there was an unmet need for such a set up at a district level as envisioned by this outside expert.

RUHSA’s experiences are replicable even today for the health of the poor.

The gaps in health care delivery are relatively well known. Unfortunately not enough attempts have been made to change these, and even where sincere efforts have been made there has not been the desired impact always.

Public health institutions need to be strengthened, both infrastructural as well as in human resources including providing wages comparable to other sectors. Health needs to be declared as a right and the government made responsible for providing this care especially the poor and marginalized.

An effective balance needs to be struck between the four main sources of health financing namely;

• Government funded health care,
• Private health care involved with out of pocket expenses,
• Health insurance promoted as a service to prevent financial shocks arising from catastrophic illnesses rather than as a business and
• Charitable health institutions providing free or subsidized care.

With doctors preferring more towards working in urban and periurban related centres, the possibility of training and equipping nurse practitioners to provide effective primary care at least in rural areas should be promoted.

Medical malpractice involving collusion between physicians and laboratories carrying out clinical investigations on one side and pharmacies or medical shops on the other hand coupled with irrational prescriptions of drugs needs to be curtailed.

Drug pricing in India is becoming costlier not because of increased research and development costs but because of higher profits by companies. Regulatory mechanisms are needed to balance fair profits and essential drugs.

Health management is a discipline that needs to be developed with a variety of specific skills needed to ensure that health care is provided in a equitable manner so that the poor are not denied the care they need.

The unmet health needs of India’s poor are increasing without adequate financial investments and programmes by the public sector to ameliorate their suffering while many from outside India come for medical treatment.

Except for effectively handling childhood immunization preventable diseases, the DOTS programme in tuberculosis and the care and support in HIV/AIDS, government interventions have not resulted in effective impact.

The country has been so engrossed in tackling communicable diseases among children, tuberculosis and HIV/AIDS which were the leading causes of childhood mortality in the past that it has been tardy in responding with suitable programmes to meet the increased burden of emerging chronic disease like diabetes, heart diseases and cancers.

Although the government has created a good infrastructure for effective health care delivery throughout the country, it has almost abdicated all its responsibilities to the private for profit health industry, which could lead to a similar situation prevailing in the USA currently lead by health insurance.

The unholy nexus between physicians on the one side and the laboratories carrying out investigations and the pharmaceutical industry in the research of new drugs on the other side could have serious impact on patients both financially and medically.

Malaria which is a disease which could be effectively treated or prevented has not been adequately handled in certain pockets like Orissa, North East India and some other states.

Anaemia which is a silent disease has been refractory to all the interventions initiated towards its control affecting a large proportion of people..