Crumbling walls, cramped and crowded spaces, dirty floors, scurrying rodents, the long wait, and neglect - are these the first things that come to your mind when you think of a government health care facility? You would be surprised to know that there is a stellar exception to this disappointing picture, right here in our small state of Kerala in India. A grand reception, beautiful wall art, and a children’s play area- this is how the Punalur Taluk Hospital greets its visitors. If you are sceptical of the outer polish, then the quality of service offered and the inspiring work environment here are sure to convince you otherwise. All it took was one person’s unique vision and his unflinching commitment to it. Dr. Shahirshah is the man behind the scene. His relentless work and farsightedness have transformed the unassuming taluk hospital into a beacon of humanitarian healthcare.

As the People’s Plan Campaign basks in the pink of its Silver Jubilee, Dr. Biju Terrence and Dr.Biju S.K., have a passionate conversation with Dr.Shah on how he developed a sustainable democratic public healthcare by integrating local people into its planning.

Excerpts from the interview:

The Punalur Taluk Hospital was a Dharma Ashupathri at the time of the Rajas of Travancore and what began as a Community Health Centre was later upgraded to a Taluk Hospital. Dr. Shaw joined the hospital only in 2010. Ever since, the centre has been consistently developed as a people’s model of public healthcare- a Humanitarian Health Centre. Principles do matter and they must be the driving force behind any initiative be it revolutionary or otherwise. However, princi-

ples alone cannot achieve practical goals. Many public servants enter into service with high revolutionary ideals but once faced with the bitter realities at work, they withdraw themselves in disillusionment [1]. I was very fortunate to not meet with this very same fate. Thanks to the People’s Plan Campaign (PPC¹) of 1996 under the Government. Under this initiative, I got ample opportunities to learn how to effectively integrate people into public planning and institutional operation.

In 1995, I was an early career doctor at Primary Health Centre (PHC), under a Grama Panchayat (GP). The PPC, put into place just a year into my service, helped preserve my student idealism all through my career. Being a PHC, had short-term goals to achieve under this campaign. Not all of them succeeded but they were not total failures either. For example, ‘The Swasthya Gramam (Peaceful Rural Area) Programme’ launched here flagged in many ways a prototype to the concept of an ‘Asha Worker²’. Remember, ‘Asha Workers’ arrived only in 2008, almost a decade later. Every Kudumbasree unit under the Panchayat had a post of ‘Aarogya Dayaka/Healthcare Provider’. A GP can easily have 100-150 such units. The idea was to promote these 150 women as active contributors to the healthcare system. They were entasked with regular, rigorous sanitizing and quality checks on each house in the Panchayat for a nominal remuneration of Rs.2 per house. The funds were drawn from the Panchayat and even after 15 years, their remuneration is still the same. This and many other small interventions made here were the invaluable groundwork for me. I realized that it was indeed possible to achieve all the ideals that my profession honours.

Back when I joined the taluk hospital in Punalur, it was a very backward locality. There was a serious lack of funds, facilities, infrastructure, and educated individuals in the community. One can always wait for the grants and orders from the Government but when the question is of health, time ticks like a bomb waiting to explode. I knew I had to make immediate and effective interventions. We announced a one-day volunteer work program at the hospital for the locals. The work included cleaning, waste management, plumbing, painting, and many more. To be frank, I was trying my luck. But to my surprise, people turned up in huge numbers. Local clubs and political outfits took up the work enthusiastically and finished them promptly. It was a huge eye-opener for me though the WHO promotes community participation [4]. So, such work needed hardly any motivation to go.

Community participation is a fundamental element of an equitable and rights-based approach to health that is proven effective in optimizing health interventions for positive public health impact [5], I decided to push further. There was an acute staff shortage at that time and again I did not want to put patients on the waiting list of Governments to get their rights. So, the idea was to encourage volunteer medical staff service - nursing assistants, lab assistants, trainees for various scanning procedures, etc.- from locals. On completion of their service, certificates were issued and while hiring contract staff, these volunteers were strictly preferred over others. With this in place, we were able to limit the political influence in appointments and there was a palpable reduction in the rush of applicants from outside for such vacancies. So, community participation encourages self-reliant systems and has the power to save lives, especially if it concerns health.

Decentralization of decision-making to promote community participation gained wider traction during the 1990s, with the creation of committees composed of local people to make decisions about financial allocations to health, education, and community development [6]. One of the main objectives of the PPC, the outcome of decentralisation, as I see it, is to reduce dependency on the Government or the State. But you are right, one cannot completely absolve of this dependence. So, when I received the award in 2005, the minister asked me what gift I would like on the occasion, I immediately asked for a new building for the Punalur Taluk Hospital. A proposal was drafted for an eco-friendly hospital that had a holistic approach to health.

The architecture of such a hospital had to be conducive to natural medication but at the same time be cost-effective. In due consultation with experts, an initial sketch was also drawn. It took 13 years of struggling forthe dream to come true. The ten-storied building that we have now was made possible by the support of the Government’s fund in 2018.

So, one has to inevitably rely on the State for big-budget projects but bureaucracy is an unreliable system that most often than not underdelivers. It also entails a long wait and sometimes all it takes is one administrative officer down the ranks to put an end to the hopes and dreams of millions. We have to find ways to tackle these hurdles. One always can, if one has the will.

The purpose of a charity box like this is not to raise crores to fund expensive surgeries or to treat terminal illnesses. If a patient reports a serious lack of finance for any of these in our hospital, we facilitate State health insurance, health schemes, grants and even run small campaigns to secure sponsors for them. But there are certain other essentials that need a cash bank ready to supply money whenever required. For instance, emergency transportation- an ambulance to begin with. This could involve transferring a critical patient to the Medical College, an emergency admission into the hospital for those lacking a private transport of their own, medicine for the underprivileged, and so on.

Humanity is a marvel and I truly believe in the human conscience despite witnessing the opposite many times. Whenever I feel like I would be the last man standing in this fight, I see more people joining the effort. At Punalur, I have seen this materialize time and again. So, it was a big lesson - never underestimate the power of the people [8].

The lack of effective connection and communication exacerbated women’s experiences of alienation, loneliness and isolation were universal in women’s account [9], There are manifold interventions happening in the medical field to empower women. Birth, be it vaginal or C-section is the most sensitive and I would say, even a traumatic event for the woman. Most women in India are from middle-income families and they can only avail the facilities of government healthcare. Most women are left to be alone during a time when they need and deserve the utmost care and love of their partner. The presence of their partner can make a huge impact in managing labour pain and anxiety to a certain level. But, just like how each child is unique, so is the mother's labour. Contemporary medicine has found safe ways to ease labour pain but only a few hospitals, hardly any government ones, offer this service.

Note, that this happens in a country where the overwhelming majority of Gynaecologists and Obstetricians are women. I can only blame the regressive mindset of both medical practitioners and people alike. It seems that, here, women more than men, subscribe to the notion of glorifying the trauma of labour. This certainly is a phenomenal setback.

At Punalur, we offer a non-invasive and safe analgesic to ease labour pain. A therapeutic gas Entonox is carefully administered through an active monitoring strategy. Because it demands the doctor's active involvement. Now, people recognize me when I go to various places and they deeply express their gratitude for assisting them through their delivery.

Right now, there is no doubt that the hospital is at its sustainable best. We take pride in not outsourcing any tests under the prescription. Fully functional labs and sufficient paramedics to support the staff that created a very healthy balance. We achieved this without the support of the government. I must also mention here that we were able to pay an electricity bill of Rupees 5o lakhs on our own. This is not taken from charity or sponsorship. It is purely from the hospital’s income. The rates are subsidized [10] for patients in general, while for the BPL category, they are free of cost. The margin for profit is found in the number of cases being attended to, the number of tests performed, etc. And we are making a profit by observing John Rawl’s Law of Distributive Justice [11].

Two incidents come to my mind. We charge a nominal amount for the tests when compared to the private labs. Needless to say, how it also saves the patient’s valuable time. Once, a lady came to me complaining that a doctor in the hospital had prescribed a test to be taken from a particular lab outside. She could not afford it and hence she approached me. I asked the alleged doctor about it and at first, he denied it. But when I sent him the photo of his prescription to the lady on WhatsApp, he was dumbfounded. Later, he came and apologized. Our hospital is in a rural area, Jamalizadeh and colleagues in their study [12] concluded that the geographical area of the hospital, as a sub-dimension of Access to care, had the highest priority, which confirms the results of the current study. Moreover, the results of Hamidi and colleagues' study [13] showed that the service tangibility and physical appearance had the lowest impact on the service quality, but the care that we are given is important.

Another incident in connection with entrance fee collection. Though it began as a manual collection, later it was mechanized. But I observed that after reaching a peak collection, the revenue from the entrance fee began dropping drastically. I began monitoring the staff closely and found out that they did not register every entrance ticket that they sold through the device and this revenue went into their pockets. Technology can reduce corruption [14], hence I called the company that sold this device and told them my problem. They duly made some changes to the device. The staff who were behind this act came to know of this and the matter resolved itself quickly after.

So, in both instances, no one was penalized. Once these people realized that everyone is aware of their deceit, they ceased to continue it. This is how I dealt with the resistance and it worked!

There are loose talks, I don’t want to list them all here. But I will tell you what needs to change fundamentally so that all these other drawbacks can be automatically fixed to a great extent. An attitudinal shift is what needs to happen for true change to begin. Public servants in our country think of themselves as mere employees who draw an annual salary from the State. They look at the State as a paternal figure which has to always provide for them, no matter what. This impedes the pinch of responsibility that public servants must share with the State to resolve crises democratically. So, I would say, public servants, must develop a sense of ownership in operating public institutions along with the State. Such a sense of ownership will drive them to take ground-breaking initiatives to ensure the smooth functioning of their institutions. It is teamwork - you, the State, and the people. When you do your part well, the State will pitch in eventually. And even if the State doesn't, the people will. Because they trust your service and want it to continue benefiting future generations. They will respond with power and magnanimity as I told you before. Because, when you integrate people into planning, you awaken the sleeping giant in a democracy.

These days, health organizations face many challenges that can be classified into four major areas: increases in the cost of health services, rapidly growing technology dependence, pressure on health organizations to decrease costs and improve quality to cope with the international organizations that establish standards and give licenses [15, 16] and finally satisfying patients’ needs, a major demand requiring hospitals to maintain high-quality services [17]. The Punalur experiment overcome the challenges by adopting modern technology, reducing the cost of services through a voluntaristic work strategy, improving and innovative service delivery, thus attaining customer satisfaction. This country is on a hunt round the clock, looking for opportunities to sell to the public sector. It is often framed as a financial liability or a non-performing asset that needs to be amputated for the larger good. The thorough administrative failure and the sheer lack of political will are glaringly obvious in this. Amidst such a deplorable state of affairs, the government taluk hospital at Punalur shines an illustrious beam of hope for democracy and humanity. For the public, a casual visit to this hospital is enough to see a fully functional, democratic model of offering services to the people. For the derelict bureaucrats and policymakers, it may even open an eye or two!

In the general framework, the ruminations of Dr. Shahirshah on his efforts to set a hospital to heights of excellence, flare up questions as to how to maintain a decentralization of decision-making when the construction of the Taluk Hospital was performed with economic support from the government and the state, and when the same hospital is a public institution. The crux of matters lies in the fact that Kerala has been following a big bang approach in decentralisation by devolving functions, functionaries, and funds. Thus, the institutions and their functionaries at the cutting-edge level are transferred to the Panchayat Raj Institutions (PRIs) and naturally it opens up the space for decentralised decision-making. However, it remains a hindrance that there are only a few of the functionaries who respect and accord decentralised governance and initiate projects through a decentralised system. Generally, in a Panchayat Raj System, the stakeholders take an upper hand in the decision-making of an institution, and thus though the funding is from the government, the requirements’ finalisation is done with different stakeholder meetings and expert opinions.