The Jowar Health Assurance (JHA) program: 1) Provides affordable and accessible primary and secondary healthcare services of high quality to entire villages through direct participation and community engagement. 2) Engages the district's largest not-for-profit hospital, MGIMS, and participating villages in a three-way partnership to deliver universal healthcare coverage to the rural poor. 3) Achieves equity in access to healthcare between the poorest and richest villages through local ownership of the assurance program and voluntary participation of decentralized social units.

1. RURAL HEALTH ASSURANCE SCHEME: A
JOURNEY
Prof Ulhas Jajoo
Head of Internal Medicine Dept
MGIMS, Sevagram, India
&
Dr Sadhana Bose
Consultant in Public Health Medicine
Oxford, UK

2. INTRODUCTION
Presentation focus:
Describe an initiative implemented to Improve
access to affordable rural healthcare, available
to all those in need of care
Examine the role of communities in tackling
socio-economic barriers to equitable access and
in voluntary, health assurance schemes.

3. INTRODUCTION
• Universal Health Cover (UHC): access should be
based on individual need, without forcing the user to
spend money one does not have or preventing
access because of inability to pay
• Jowar Health Assurance Programme (JHA):
- introduced in 1980
- in villages, Wardha district (Maharashtra)

4. UNIVERSAL HEALTH CARE
• Availability - Address financial barriers to access
• Accessibility – pro-poor, universal
• Affordability - Address financial barriers to access
• Sustainable - Limited resource; reduce dependence
• Holistic - social, economic and environmental
• determinants of ill health

5. JOWAR HEALTH ASSURANCE PROGRAMME
(JHA)
• Holistic approach to Universal Health Care
• Reach most-needy at affordable, no additional cost
• Community participation, local partnerships and use
of alternatives to hard cash.
• Initiatives to address wider, socio-economic factors
influencing inequitable access to essential health
services.

6. BACKGROUND
Figure 1. Map of Vidarbha, a region in central
Maharshtra

7. BACKGROUND: VIDARBHA
• Contributes significantly to Maharashtra as India’s
leading cotton producer (2/3rd of the annual output)
• 3.4 million cotton farmers from Vidarbha
• Holds 2/3 rd of Maharashtra’s mineral resources
• Holds 3/4 th of Maharashtra’s forest resources
• Is a net producer of power

8. BACKGROUND: VIDARBHA
• 31.6% of total state land
• 21.3% of state’s total population
• 95% of Vidarbha’s cotton farmers struggle with
crippling debt - Chronic poverty often pushes a
farmer to commit suicide
• Absence of basic necessities – mortgage farmland to
meet family needs is common practice

9. VIDARBHA’S STORY OF INEQUITY
Multifactorial and interlinked
• Environmental (below average regional rainfall)
• Agricultural practices: Rising cultivation costs; Lack of
small irrigation projects; Falling returns from crops
(result of change in farming practices/focus on
maximising output)
• Poor infrastructure: Heavy load-shedding; Ignorance
of role of ancillary occupations to raise income

10. VIDARBHA’S STORY OF INEQUITY
• Chronic poverty: Inability to repay debts following
crop loss; Inability to afford basic medical care for
self and family; Pressure of private moneylenders
and banks; Children inherit family debts and poverty
• Spatial disadvantages arising from harsh climates and
lack of geo-political influence in policy leverage
• Genetically modified BT (Bacillus thuringiensis)
resistant cotton seeds - terminator seeds (2002)

11. INEQUITY IN ACCESS TO BASIC HEALTH
CARE: VIDARBHA FIGHTS BACK
A number of government-aided and voluntary
sector initiatives are in place to address above
mentioned multifactorial causes of health and
socio-economic inequities in Vidarbha’s farming
communities

12. INEQUITY IN ACCESS TO BASIC HEALTH
CARE: VIDARBHA FIGHTS BACK
• Address health inequalities arising from inequitable
access to health care:
1. MGIMS led initiative
2. Initiated in 1980
3. Engaged with resident families using the village
council (Gram sabha)
4. Evolution of the concept of Jowar Health Assurance
programme (JHA).

13. JOWAR HEALTH ASSURANCE (JHA):
VIDARBHA FIGHTS BACK
• An experiential journey
- Started with ill-health
- evolved over time to address issues beyond health
but with impact on health outcomes
• Use ‘Samanvaya’- co-operation across societal strata
– JHA extended scope to include wider socio-economic
factors precipitating suicides

14. JOWAR HEALTH ASSURANCE (JHA):
VIDARBHA FIGHTS BACK
• Embrace whole families (‘Sarvodaya’ - betterment of
the larger society) of villages
• Down to the most needy, most neglected and
excluded (‘Antyodaya’- betterment of the most
downtrodden)
• Path breaking journey of enriching local relationships
and partnership working.

15. JHA: NUTS AND BOLTS
• Every participant village is an active partner in the
assurance scheme
• Annual Harvest - each family in village contributes
Jowar (Sorghum) based on family size/ land holding
• Families contribute based on economic ability but
receive health services based on need
• Collected harvest is sold to generate a base fund

16. JHA: NUTS AND BOLTS
• Base fund is deposited into the JHA account in a local
bank (Sevagram, Wardha)
• At year end, unspent funds are transferred to a
corpus, under the aegis of the MGIMS
• The interest accrued from unspent funds is used to
procure drugs, organize agricultural education and
development activities for participant villages

17. JHA: NUTS AND BOLTS
• Base fund is used to provide health assurance:
1. Strengthen primary care services within the village
2. Subsidise (by 50%) hospital bill for users of planned
medical care provided by MGIMS
• MGIMS provides free in-patient medical care for
unforeseen illnesses
• Co-payment from indoor hospitalisation and the
village annual contribution together account for 10%
of total expenditure to participating villages

18. JOURNEY MILESTONES (1980- 2014)
• Journey started: in 1980 to tackle health
inequalities arising from inequitable access to
healthcare services
• Enroute:
1. Realized need for social transformation
2. Transcended beyond medical care to
comprehensive village development activities
like Dairy farming, Lift irrigation, sanitation, others

19. JOURNEY MILESTONES
• Journey continues:........in 2014
• JHA: foundation for programmes addressing social,
economic, ecological determinants of ill-health
• JHA: adds to evidence on UHC in middle income
countries grappling with socio-economic inequities

21. RESULTS
• Realization that health issues do not become the
vehicle for social transformation
• Realization that acts of common faith are as
important as economic development for an
egalitarian political structure (Figure 2)
• Self-reliance (swavalamban) in felt needs like food,
clothes and finances had the potential to empower
communities by inculcating acts of common faith.

24. CONCLUSIONS
• Micro-financing a health insurance scheme (JHA):
1. Allows entire villages to benefit from universal
health coverage
2. Allows direct access to additional public health
resources from the central and state governments
through MGIMS through a mere 10% equity

25. CONCLUSIONS
• Micro-financing a health insurance scheme (JHA):
3. Design and implementation is an example of
proactive people participation in health care decision
making at local level
4. Key players: respected community leaders,
successful engagement between villages and
healthcare provider, culture of decision making by
consensus

26. SUMMARY: JHA
• Affordable and accessible primary and secondary
care services of high quality to entire villages
• Direct participation by end user i.e.people’s
participation and community engagement
• Buy-in by district’s largest not-for-profit provider
hospital (MGIMS)
• Three way engagement between provider, end user,
participating villages - delivery of UHC to rural poor

27. SUMMARY: JHA
• Equity in access between poorest and rich villages
• Local ownership of the assurance programme and
one’s health i.e. decentralized social unit with
voluntary participation
• Effective healthcare - absence of maternal mortality,
measles, polio, tetanus, whooping cough
• Addressing ill-health with non-health determinants.

28. CONTACT US
Professor Ulhas Jajoo
Department of Medicine
Mahatma Gandhi Institute of Medical Sciences,
Sevagram (Wardha), Maharashtra, India-442102
Website: www.gandhisvision.com
Email: gandhisvision.mgimsalumni@gmail.com,
ulhasjajoo@gmail.com
sadiebose@gmail.com