Tuesday, December 2, 2014

Medical Missions in today's time and age ...........


A couple of decades ago , a debate on the essence of medical missions today would not have been necessary. Medical missions meant mission hospitals which were mini townships, often in the middle of the wilderness, sometimes standing with a school and almost always a church. Medical missions has a history in India going back to the Colonial era because it is one of the earliest and most visible manifestation of missions that was visible and still is visible to the common man. It was widely promoted by the then government and can be understood in my view as one of the earliest manifestations of public private partnership. The state often leased out land to the Mission and provided facilities so that drugs and equipment could be brought into the country and in return the missionaries provided medical care with personnel that they brought in. the arrangement worked well at a time when government provided medical care did not extend  beyond  the big cities and hospitals were usually attached to medical colleges or cantonments and in the princely states was dependent on the benevolence of the Nawabs or Rajas in place.  Three developments challenged this cozy arrangement.

The first was the advent of independence and the foundation of the welfare state where the State assumed the responsibility of providing health care (among other facilities) to its citizens as part of the Nehruvian vision. This meant the inauguration of the Primary Health care infrastructure throughout the length and breadth of the country. How effective this vast mechanism was is another question, but for the first time, outside the big towns and cities, a systemic alternative to mission hospitals became available and mission hospitals lost their monopoly. The quality of care at the PHC and associated district hospitals might or might not be great, depending on who manned them but an option to Mission Hospitals had emerged. Also post-independence, the involvement of missions decreased over time as the symbiotic relationship with the Colonial government and a natural chemistry was missing with the new post-independence government.  More on this later

The second big challenge happened in 1983 when Apollo Hospitals opened up in the county and began corporatizing health care with the clear aim of providing clinical services with an eye on the bottom line and increasing shareholder value.  The latter did not necessarily make health care cheaper by default, but it did spark of innovations in health care at the business model level and not just at the clinical level. Till this time, health care in the private sector was at least notionally nonprofit. Health care in the private sector was not usually cheap, but the “profits” were usually ploughed back into the facility, to facilitate research, improve infrastructure and so on. For the first time, a hospital was opening whose sole reason to exist was to earn profits for its owners. Although there were nay sayers, even in the pre-1991 pre liberalization era, the hospital came to be and eventually spawned a whole range of corporate hospitals – big and small.  Now before the advent of the corporate hospitals, there were the mission hospitals and there were a few large nonprofits. Mission Hospitals would treat rich and poor alike and the rich had few options at the time. Along the way, the rich would cross subsidize the poor patients in the Mission hospitals but with the coming of Apollo and others accompanied by aggressive marketing, the rich had more options to choose from.

The third was the entry into India of medical insurance. Although less than 15 percent of India is insured, the entry of health insurance rewrote all or many of the ways in which health care had been practiced hitherto. To rationalize and reduce payments against premiums, treatment protocols began to be rationalized, hospitals began to be graded and tie ups between insurance companies and hospitals began to happen.  As more and more insurance companies set up shop, they brought in practices and norms that one had to adhere to or be outside the mainstream medical system over time.  A limited few medical hospitals adapted and thrived , a lot many simply stayed put and gradually began to get obsolete. It is then that the debate on revisiting medical missions perhaps really started – when mission  hospitals began to be financially less and less viable and the question became very real – how else could medical professionals live out the gospel if the only model in which it had been practiced had become something that could not anymore be practiced ?  

to be continued.........

Saturday, July 10, 2010

Why do men drink so much ?

Recently while on a visit to our program in the slums of Chennai, i noticed that all our programs were structured around women. The program was a very successful one and the team had worked hard with the slum community as well as the local slum clearance board to make thinngs happen and very visibly, the impact was there for all to see. But no men. Of course it was day time and men might be at work; but still I asked. Any programs with men ? No. why ? Some whispers and murmurs, but no answers forthcoming. But curious , i keep probing. In a way, i know what the answer will be, over the years, I have worked with many slum communities and the work is always or almost always with women. So the answer , when it does come, does not surprise me. We do not have any program with the men in the slums because they are either at work or if not , they are drunk.

so why do men drink, I ask ? Well, another round of familiar answers follow. Men go to work and get tired and need a drink for recreation. Oh, they have lots of worries and tensions and alcohol helps them forget their worries and tensions for that period of time when they are drunk. And so they drink. I probe further – what do women do and why don't they drink ? Well, women don't go to work and are not involved in manual labor , so they do not have the compulsions that men have. But they do have their worries and fears don't they ? Oh, yes, I am told- the women have their own fears and worries. So what do they do ? .... well they throw the household utensils around and then go to the neighbour's house to gossip. So in the evening , all the slum women are huddled around gossiping , while the men are slumbering, dead drunk. Neat. Very neat.

For years, i have been observing programs planned with men almost always fail, despite the same dedicated staff, the same meticulous planning and the same effort put in. programs with women succeed; programs with men fail; and usually because nothing consistent can be planned with the menl because of this alcoholism problem among men in the slums. This is case with us in Oasis, it is often the case else where too. Alcohol seems to be the almost universal sopoforic of recreation in the slums and almost the only one it would seem. So can any thing be done for men or are all developmental programs in the slums destined to succeed with women ?

some thing about Oasis's programs among young men gives me a ray of hope. I don't know where we will ever be able to break the scourge of alcohol and its hold among rhe older men, although I should not be pessimistic. But our program with the young men form the slums and others on the verge of dropping out of society which focuses on sports as a tool might be the answer, at least for the younger people. Using football as a glue, Oasis is able to bring together young men who might all have gone their own separate and destructive ways. These young men learn the value and worth of discipline, sportsmanship, fairness and respect for rules and perhaps most importantly make lasting friendships and bondings that may, if they are lucky , last a life time.

The Oasis progam is only a few years old and it could be said that in many ways, it is in its infancy. There is very certainly a long way to ago, and it will be a long time , before we can draw any definitive conclusions. Perhaps , I am being a fool to anticipate so much , expect so much to happen from a program that is so new , so nascent. But even so..I dream that way. I dream that one day it will be possible to walk into a slum and ask the question – not “ why do men drink so much ?” but on the contrary “ why do men play so much ? ”. it will be the day when the brawls caused by drink wll be replaced by the laughter and the banter of sport. That would be change. That would be transformation. That would indeed be life.

Bored meetings or Board Meetings

My organization's Board meeting took place on Saturday. Though the meeting was planned as a whole day event, all business had been conducted by lunch time. There were several eminent people present, all spoke and shared their views articulately and freely. Yet it was still possible to have a vibrant discussion and still all the transactions could be completed earlier than what was anticipated. Every one found time to listen to each other and although by the end of the meeting, a lot of decisions had been, they had been made so collaboratively that it would be very difficult for any one person to have claimed credit for the decision.

The free afternoon time left with lots of time to think of other Board meetings where I have participated, usually as a member, but sometimes as a participant. I remembered meetings of different hues; but the most common memory is that of dull, listless meetings dominated by one person, usually a man, while others sat around with a bored look, wondering what they were really doing there. Some basic, legal requirements were hurriedly gone through monotonously and then the crowd quickly dispersed. They would gather together in a similar fashion in another 6 months or a year for a repetition of this mindless ritual.

Sadly, governance in India is not taken that seriously; at least not in the nonprofit sector where I have spent a lot of my life. It is assumed that because the organizations involved in charity work, are supposedly there with highly altruistic motives, everything is just fine with the way they are run and with the way they are governed. And so Boards and such, by whatever name called, are considered a necessary evil, thrust upon us by the nasty arm of the law. Governance thus is something that is considered an intrusion demanded and required by the law and not something to be pursued for its own intrinsic merit. And so a lot of boards and governing bodies are filled by sycophants and toadies- hangers on with nothing of worth to contribute. The worst case scenario – and yet not uncommon either, are boards staffed by family members and relatives of the founder or the CEO.

This of course is a pity. My own board meeting has impressed upon me the value of having caring, involved people of integrity on the Board. They perform all the necessary statutory duties of course; but go far beyond that limited statutory duty. By virtue of the eminence they have in different fields of occupation, they become helpful sources of information, guidance and most importantly – of advice. They do not intrude in the day to day running of the organization – an activity for which they are too busy any way; but remain available to advise, guide and provide valuable insights – something that only the foolish would overlook.

Although it would see that governance can fall by the way side even in the corporate sector as evidenced by the experience of Satyam, it is an unfortunate fact that in the NGO sector, we do not know enough to educate our board members on what their individual roles and responsibilities are and what they can and cannot do. The sad result is that often NGO boards are either complete rubber stamps nodding assent to everything that the Chief Executive does or at the other extreme, an over bearing, micro managing body, stifling every initiative.

Perhaps , the trick is in having the right composition for your Board. In choosing people, who are eminent in their profession and are also adequately informed about the work of the organization. Individuals, who are committed without being too interfering or intimidating. When a bunch of such people gathers, animated conversation crystallizes into sagely counsel and wise decisions. And Board meetings are no longer bored meetings.

Monday, June 28, 2010

Stop chasing those numbers

A lot of this month seems to have been occupied by numbers – we were writing a proposal for one of donors and if the project were approved, it would mean that we could continue to do the good work that we do. The exercise involved a lot of wrestling with numbers. Numbers to be filled in the budget column ; numbers to be filled in explaining how many people would benefit from the grant and how to make sure that enough number of people had access to the program without us spreading ourselves so thin, that quality itself would be compromised.

Having worked for a funder before, I can understand their compulsions. Funders have to calculate hard data like cost per beneficiary and if that is too high, then the manner in which the program has been designed may not be feasible to run and fund; no matter how good the rationale, the bottom line is always economics – the final question before any funder will sign off – does it make economic sense to fund this program – will enough numbers of people benefit from the grant or a tiny number of them will? If the answer is not satisfactory enough, the application will not be accepted. Working for a donor, I used to examine those numbers and determine whether they were consistent with financial prudence. Today as someone who works for Oasis, an implementing agency, I have to supply those numbers and apply the same parameters.

But just how much should an organization be driven by numbers, is a question I still have not been able to resolve. Numbers are important I know. It costs a lot of effort to raise money and if it is not used in the most efficient and cost effective way, the donor is very likely to feel short changed. Yet as someone dealing with people and their suffering, just to what extent can this be quantified? and even if it can be , to what extent is it fair or right to measure the efficacy and success of our efforts through numbers alone.

At Oasis, a large part of our work is with victims off trafficking. Often they have suffered immensely and in a manner that we can hardly imagine or understand. They have been exploited, abused and brutalized in the most unimaginable ways possible. At Oasis, we try and restore to them some of the lost years of their lives, through a host of interventions. Those interventions are costly. That intervention s is intense. Those interventions take time to work. If at all they work. And sometimes, they don’t because some hurts and experiences human beings cannot deal with, no matter how proficient their methods and how professional their staff. Only God can heal every one, we at Oasis can only try and does our little bit as His agents and instruments.

So is it fair to always ask that question” How many”? How many women did you rescue from the brothels? And how many children? Why so many women? Why so few children? Why did only so many women enrol for your livelihoods program? Why did so few get successfully counselled and come to terms with their past? Why? Why? Why?

As a donor, I used to know how to ask the right questions, and I still do; but today I know how easy it is to ask questions than it is to provide the answers to some unfathomable mysteries. But one thing too I know, that numbers are one piece of the puzzle. Yes money is important, cost benefit ratios are important, effectiveness is important, professionalism is important. All of those things are important. But infinitely more important than all those numbers is the human spirit which we try to heal.

Friday, June 25, 2010

Why Prakash Jha should make another movie

I went to see Rajneeti over the weekend with my daughter. After all the press coverage about how the movie was largely based on the life of Sonia Gandhi and all that, one expected a lot of that, but unless the censors have completely distorted the film by cutting of big chunks of the film, one can hardly see evidence of that. Katrina Kaif for some moments in the film does play a widow and her mannerisms do like one of the Gandhis – could be Sonia or he daughter, the similarity about ends there. The movie is not anything about the Gandhis – Sonia or Priyanka. Rather the movie is about the lumpenization of Indian politics.

We have all grown up with the notion that politics is bad and politicians are the baddies. If one had somehow missed out this bit of a middle class Indian’s education, Prakash Jha can fill the gap. His depiction of Indian politicians – not the underground Maoist types; but the types that fight elections is such that one would come out of the theatre shuddering with horror at our plight as we think about how we are ruled and by whom. And that raises a question.

That politics and politicians are corrupt, inept and amoral has been taught to us from the time we learnt to listen to stories in our mother’s lap. It began with stories of wicked kings and as we grew older, began to be replaced with other people we recognized or knew. Eventually the media created bigger ogres of our ruler and politicians. But coming back to the question that arose after watching the film, I fail to understand one thing – if all our politicians are like the ones portrayed in “Rajneeti”, how are we surviving as a nation?

Rajneeeti’s political figures are barely human. Ranbir Kapoor is supposedly cast in the role analogous to Arjun (the film has shades of the Mahabharata in it), but could well have played the Biblical Satan with ease. Though there is a whole lot of dark side to the so-called democratic Indian political system, but murdering someone from the rival side at the broad daylight in front of masses as shown in the film is like a little too far stretched.

Of course, bad and even villainous politicians live and thrive; we all know that. But what about the good ones, they too exist, don’t they? they may not be saints, and possibly don’t even claim to be one, but they are the ones who ensure that anarchy doesn’t run amuck, and that there is at least some attempt at governance and the rule of law.

Take for example our freedom fighters- people whose birthdays we love to celebrate and whose statues and portraits adorn all public squares and several calendars all over the country. Bhagat Singh, Mahatma Gandhi, Veer Savarkar , Sardar Patel, Nehru... and many , many others. Weren’t they politicians of one hue or another, whose beliefs differed widely, usually vary widely, but because of that they wouldn’t kill each other and cause mayhem. They did give each other that space.

Even today such people exist; politicians who are quietly and silently burning the mid night oil so that they can serve the country as best as they can. They may not make it to the newspaper headlines because they are not looting the exchequer and amassing assets; neither are they plotting intrigue and communal violence in the dead of the night. Such people exist; and it is because of such politicians that the nation still runs and that we are not yet a failed state. Their story too deserves to be told. Prakash Jha ought to write the script of another movie. He has exposed the gory side of Indian politics. Now he ought to project its golden side.

Wednesday, June 23, 2010

Whores and Prostitutes : the baggage that words carry

One of my colleagues was orienting some newly inducted staff about our work among the prostitutes of Mumbai, when an indignant hand shot up to protest. “prostitute” was not a word to be used – especially by our kind of people who were involved in the development sector who ought to know better. After a sheepish apology, the session continued and eventually we proceeded to enumerate the number of "beneficiaries" whom we had rescued from the "flesh trade".

Soon other hands had shot up. The word “ beneficiary” was too patronizing – who did we think we were any way.... and “flesh trade” .... well wasn't the word so coarse and harsh and how could we even think of using such a word, didn't we have any sensitivity at all or what ? I began to have deep sympathies for our communications manager , who presumably has to learn to walk around with a lot of dictionaries and thesauruses to avoid tripping over a charge about the wrong use of words. I was thrilled that I didn't have her role.

Later that day, I was leaving to board a flight. The weather was wet and it had been raining heavily causing traffic jams all the way from my home to the airport. The humidity and the rain had ensured that all all my clothes were soaked to the bone. As the taxi entered the crowded and disorderly airport terminal, i spotted a relatively empty gate meant for “ persons with special needs”. I immediately cataloged all my special needs – I was occasionally breathless, more often than not short tempered and hot headed,m terribly impatient too. Some minor medical ailments were accompaniments too. But the CISF jawan at the gate wouldn't let me in.stripping aside jargon, he told me that the gate was meant for “apang log”, the disabled”. Special needs was an euphemism for disability.

Since then i have been wondering a lot about the words we use. A lot of them have become so much a part of common usage that we use them without thinking and without intending any harm. Yet words carry a lot of weight, can be stigmatizing and devastating for the self esteem. But we seldom know, because we live and breathe in a different world. As a child , I was taught , never , ever to use the word” leper” because it had a certain connotation of exclusion, isolation and neglect. On street corners and traffic signals , I have seen plenty of people who would qualify for the use of the word in its classical sense, but so ingrained is the lesson, that perhaps this is one word that I am most unlikely to use.

Some of course can of course can so completely swing the other way, that they are more concerned about the correctness of their jargon than sensitivity to the person. Indeed it is possible that the people most busy in serving those in need have the least time to update their vocabulary , while those who are right in their nuances of speech are the most indifferent when it comes to doing things that really matter.

So which way does one turn ? While it is perhaps correct to say that one should not be unduly obsessed with words and phrases and that the motive of the heart is far more important than the utterances of the tongue, we should never forget though that words carry a lot of weight and a stray word spoken out of turn and without the slightest ill will intended, can cause paralyzing harm and trauma which we may neither see nor recognize. So let us weigh our words wisely and choose our phrases carefully , in as much as we are able. There is enough hurt in the world, without we needing to add unwittingly, an extra ton.

Monday, June 21, 2010

Volunteers : The silent worker bee

Volunteers are one of the most valuable resources and a voluntary organization can have, especially today when a lot or most voluntary organizations are largely staffed by paid professionals who work for a salary. While the changing nature of the sector and the increasing demands and scrutiny made by government, donors and funders and even the general public may mean that this shift is largely inevitable, volunteers still help to remind us of our roots.
At Oasis, we have been fortunate in being blessed by many volunteers – short term and long term. Some of them have been around for years and while having cost the organization next to nothing, have enriched Oasis in ways that might be difficult to quantify. The other day, we were trying to calculate in monetary terms what the worth of a few specific volunteers with their particular skills and experience might be. I do not know what figure was finally arrived at, but we agreed that if we had to hire all those people and pay them the salaries that they could command, it could hit the organisational balance sheet quite badly.
But money and salaries are one thing. Often volunteers bring with them skills and experiences that are not readily available in the market place. It is not a matter of being able to pay the salaries, often the right people with a suitable combination of commitment and skill are just not around.
When volunteers come from another culture or country, they also enrich local staff in providing them a platform to work in a multi ethnic and multi cultural environment. They usually bring perspectives on a particular situation or a way of doing things that are fresh and new and can help challenge existing notions of how business has always been conducted. More importantly, by their very presence and the dedication they display, they may end up challenging or changing local work culture and practice.
It is worth considering why volunteerism, even for a short spell is not at all entrenched in India. The concept of the ‘gap year’ is not prevalent in India at all unfortunately. It is one straight and long ride from school to college and university and then onto your first job. In most situations, a gap in the resume that does not follow this beaten track would raise eye brows in most interview situation. The concept of taking some time off now and then and follow the call of the heart is not too well understood or accepted in India.
Of course there is also an economic dimension to this that must not be missed. Volunteerism costs. It may not cost the receiving organisation like Oasis directly, but some one obviously is paying the bills that the volunteer worker is incurring in the country- their housing, their grocery bills, utility bills and others. Depending on organisational policy, possibly the office may absorb some bills, but that still leaves a substantial chunk that the volunteer ultimately is responsible for.
We at the receiving end of a volunteer's untainted service are often unaware of what it takes to raise that sort of money that would pay your bills, no matter how frugally you ultimately choose to live. Occasionally mid career professionals have worked long enough and saved enough to manage their own finances, but ever so often we get younger people who are not likely to have reached that stage and need to reach out to friends and family to raise the necessary resources to come.
Volunteers are the silent worker bees that often quietly and unobtrusively keep the bee hive of activity running. More importantly perhaps they keep a much needed notion alive; that in a materialistic society where every one seemingly works for money- not every one really is.
Volunteers represent the incarnational model that often enough it is more blessed to give than to receive and enough people still exist who believe that and live by that.