Poverty, like disease, comes in several varieties. The lack of supporting institutions like educational and healthcare facilities (and services), lack of infrastructure (such as roads, market places, electricity or telephone, sanitation, potable water) lack of leadership and a dependable food supply are more community related problems. These differ from personal experience of poverty and disease, where personal suffering is highlighted.
Just as a symptom is indicative of underlying systemic imbalance, lack of money is a measure and a symptom of poverty. Treating the symptom or the measuring device will not cure the disease. The causes of the social problem of poverty lie in several factors, especially the big five: disease, ignorance, dishonesty, apathy and dependency. Interestingly, many of us have seen these five to co-exist. Poverty and ignorance contribute to disease, and all others contribute to poverty. Therefore poverty and disease are both somehow linked to more subtle infestations of collective consciousness.
Ignorance may not be a person's fault. It might be caused by isolation so that some people do not know some things simply because they have not heard of those things (information) or have heard distorted versions (mis-information). A lower availability of education and information is the first and perhaps the easiest hurdle to cross. Undoing mis-information is even more difficult. The more the people are aware of commonly known reasons, causative factors and consequences; it is more likely that positive behavior will arise. Liberal exploitation of educational opportunities, sharing of stories & personal experiences between close knit groups, leveraging media & social events regularly and repeatedly over a period of time will slowly drive the point home.
Dishonesty, in turn, is a major social problem. When a person in a position of trust diverts a hundred units of value towards personal use (including accountable public health agencies, doctors and healthcare personnel who take shortcuts), the society at large may lose much more than a hundred units of value that could contribute to development and to the reduction of poverty. That is part of what economists call the "multiplier effect." Dishonesty thrives in an atmosphere of apathy, ignorance and dependency, so here is another example of the inter-linking of factors of poverty and disease. Though we may not alter dishonest behavior of others, but we can choose to be honest and transparent in our dealings and in the way healthcare delivery system is designed. We found that people in villages have somehow been used to cheating and exploitation that they tend to have very poor levels of trust in any new intervention. Therefore, it was advantageous to ride the program on social equity and goodwill of previously active agencies, role models and opinion leaders. Allowing the community to choose the premiums, transparently see the utilization of funds, consistently experience value of insurance in emergency and efficacy of treatments would build their trust in micro-insurance driven healthcare program. Importance of quick wins in early phases cannot be less emphasized. Another important designing factor for us was ensuring accountability. The GPS enabled handheld device with authentication and tracking features bridged the need to a great extent. Just an acknowledgement of the fact by the health worker that each action is being tracked - is a deterrent in itself.
Apathy is both a learnt behavior as well as matter of personal confidence. Shaken confidence in deprived settings makes people apathic. On top of this, health seeking behavior has always been a matter of trust and faith. Therefore it is extremely important for us as healthcare providers to be consistent and positively communicative despite challenges. The caring sentiment toward fellow beings and valuing human life ignites a bond of selfless love which pulls people out of their shells. This has nothing to do with clinical skills, but with the human qualities that we tend to leave behind while maturing as busy professionals.
Dependency on other people to help solve a complex problem is a natural human inclination. In many ways it can become a good contrast to apathy. Charity with a kind heart may help inject sensitivity but unfortunately it does not solve dependency unless the root cause is being addressed. However the same dependant situation can become a doorway to self sufficiency if handled wisely. In dependant situations whether it is poverty or illness, there is a window of motivation - motivation to be healthy or motivation to be wealthy. Channeling this motivation is complex but highly rewarding. We attempted to touch the subject by mixing the two for the family of Village Health Champion. Enabling a low profile local young housewife by education, exposure, training, financial support and public recognition created a role model that other ladies wanted to follow. Involving a self help group (ladies who regularly saved money for health and other emergencies) further consolidated the mutual sharing of independence and responsibility. The local patient is no more a liability on healthcare system- he/she demands and receives the dignity of a consumer because basic healthcare costs are enabled to be within his/her pocket's reach.
These small and seemingly insignificant moves over a period of time may have a more lasting impact than simply becoming another healthcare provider.