The Power of Women’s Social Capital in Madurai

In the 1990s, southern India’s poor were unorganized, with no way to access financial credit except through local moneylenders, at exorbitant interest rates. Even government commercial banks considered them unbankable, doubting their capacity to repay even small loans. Dhan Foundation intervened to rectify the situation, organizing the poor in underdeveloped locations of Tamil Nadu state into “Women’s Self Help Groups (SHGs),” on the basis of mutuality and solidarity-building. Dhan’s sincere and professional efforts helped regulate the savings habits of the poor and raised bankers’ awareness of the power of organized women. At present, approximately 1.4 million poor have organized into 35,000+ Self Help Groups (SHGs), which themselves combine into some 300 registered community-owned institutions called “federations.” Now, nearly all the commercial banks provide financial assistance to the poor in SHGs, the majority of which are women’s groups. In addition to this financial support, the SHGs and federations used social capital to help further our development agenda, including social security, entitlements, livelihood enhancement, health, education, sanitation and more, all for the benefit of the poor.

To address their health care issues, the Women’s SHG federations now run community health, nutrition and sanitation programs, including programs designed to address anemia, child malnutrition, nutritional disorders, HIV/AIDS and malaria, with a focus on prevention and promotion.

Yet there has remained a gap with regard to tertiary care. The government system has not been able to respond on a timely basis, due to inadequate staffing and infrastructure, and the private hospitals are unaffordable for the very poor. Nor have those steering committees charged with overseeing health care provision, including senior government officials, Dhan Foundation and the SHG federations, been able to deliver. This urgent need was therefore identified for affordable, quality services that can stanch the devastating “income leakages” in poor families’ cash flows due to high medical costs. In Theni District, some 75 kilometers from Madurai, the local SHG federation, comprising some 20,000 women, stepped up in March 2007 to meet this need and mobilized the community to work toward opening a primary health center staffed by a qualified physician.

Because Dhan Foundation works closely with the government hospitals to handle referrals for member families, we had developed a strong rapport with many medical officers there, who steered us to physicians drawn to this work by their strong sense of social concern. The Friends of Dhan Foundation in the Netherlands raised funds for the hospital’s infrastructure, equipment and administration, toward which the community itself contributed one million Indian Rupees (INR), or $16,500. Opening with primary care services only, the SUHAM (“Sustainable Healthcare Advancement”) Specialty Hospital has now been expanded to include an inpatient unit with paramedical facilities.

The Theni SUHAM Hospital, the district’s first secondary care community hospital, began serving patients out of a rented building in July 2007, only four months after the women began mobilizing. Now the hospital owns its own building, which serves 20,000 poor federation member households and others in need. This wholly community-owned initiative continues to coordinate closely with the government hospitals, to arrange referrals to tertiary facilities capable of handling complex surgeries and other major procedures.

The grassroots mobilization that made SUHAM Hospital possible is truly an expression of “women power” at work: two Boards of Trustees, drawn from six Theni federations, formed working groups to oversee hospital governance and to guide and monitor the project coordination and implementation teams. They also immediately understood the importance of building ownership among women and their households and quickly took responsibility for this outreach. Within two years, SUHAM Hospital Theni was well known and respected among the district’s poor for its quality and highly affordable care.

The positive experience of SUHAM Hospital – Theni motivated federation members in Madurai’s urban and rural areas in April 2009 to initiate their own effort to build a second community care hospital — is now being replicated, this time, in Madurai City. Approximately 35,000 women, including 12,000 from Madurai City itself, the balance from the peri-urban and nearby rural areas, assumed responsibility for initiating and sustaining the 23-bed hospital, the operative call-to-arms for which was, “By the community, for the community and of the community.” Every Madurai federation member was consulted about this initiative and involved in disseminating it to the public; the community displayed its engagement and ownership of the initiative by contributing INR 2m, or $33,500, toward its construction, and the facility opened in September 2009, only five months after the project got underway. The women involved the community in informing doctors and nurses of the health hazards plaguing their communities and the purpose of the hospital, and socially conscious medical practitioners chose to join the effort. Consultations for all kinds of ailments, as well as simple surgeries, The hospital now pays them through the income generated by the very services those medical professionals provide, offered at sufficiently low cost that poor people can afford them.

By serving the poor almost exclusively, operating in a timely manner and setting benchmarks that have seen cost reductions of 30-35 percent, the SUHAM Hospital has been able to influence the market in Madurai, thereby helping to keep affordable the price of quality care. As in Theni, a governance working group was set up, consisting of members of the Board of Trustees of the local women’s federations, to monitor hospital functions and to guide the staff in managing operations. The governance group also took charge of community mobilization, collecting contributions and promoting the hospital; community-wide monitoring of staff and procedures; and serving as a liaison between the hospital and the community. Under these women’s leadership, since its third year of operations the hospital has managed to sustain itself financially, readily meeting its annual budget of INR 5m ($83,500) from community contributions.

As with any hospital, local government, represented by the Municipal Corporation and its contractors, ensures the facility’s sanitation, hygiene, pollution control and appropriate hazardous waste and garbage disposal, as per state regulations designed to safeguard the environment and the public health.

Over the past six years the Madurai SUHAM Specialty Hospital has grown tremendously. Minimal emergency care is now available, and the facilities have improved, with sophisticated emergency and diagnostic tools now available, including ventilators, scanning, X-ray and cell-counting machines. As in Theni, SUHAM – Madurai is known in the marketplace for its “quality care at an affordable price” and for “benchmarking in pricing,” by setting and maintaining costs of care that can still be managed by some of the region’s poorest residents.

The power of social capital was proved once again in Madurai: when women are effectively organized with the proper knowledge and skills, they can accomplish anything. In this hospital initiative, they have surpassed their own expectations in their ability to achieve “super specialty” care for the poor. The following excerpts from “The Hindu” and “The Times of India” magazines underscore the notable importance of these women’s accomplishment.