CHAPTER 6

HEALTH

6.1 Department of Health

6.1.1 Background

6.1.2 Current Activities

6.1.3 Sector Goals

6.1.4 Future Programs and Projects

6.1.4.1 Preventive Health Care Program

6.1.4.2 Curative Health Care Program

6.1.4.3 Strengthening Organizational Capabilities

6.1.4.4 Integration of Tibetan Systemof Medicine

6.1.5 Implementation

6.1.6 Human Resources

6.1.7 Financial Resources

6.1.8 Monitoring and Evaluation

6.1.9 Implications for Free Tibet

6.2 Delek Hospital

6.3 Budget Summary

Appendix of Tables

6.1 DEPARTMENT OF HEALTH

6.1.1 BACKGROUND
Health care is a basic need for the overall welfare and development of a community. Only healthy individuals can participate in productive work or in social affairs. Recognizing the need for good health care for the Tibetan Refugee Community, the Central Tibetan Administration has been taking consistent steps towards creating curative and preventive health care services. The first rehabilitation projects included some Health Care Centers which were funded by various non-governmental organizations. When these organizations handed over the administration of the Health Centers to the respective Settlements, there was a need to establish an apex body within the Central Tibetan Administration to finance and manage the Health Centers as well as to plan a comprehensive health care system for the Tibetan Refugee Community. The Department of Health was thus established in 1981.

Since its inception the Department has been able to establish Primary Health Care (PHC) Centers in almost every Tibetan Refugee Settlement in India and Nepal with a minimum of one Community Health Worker (CHW) to look after the preventive, promotive and curative health care needs of each community.

In addition to the Department's directly managed units, the two important institutions in the Health Sector are Delek Hospital (see 6.2 below), and the Tibetan Medical and Astrological Institute (TMAI) which seeks to preserve, promote and develop the traditional system of Tibetan medicine which dates back to pre-Buddhist times. Traditional Tibetan medical clinics are operating in many of the Settlements with physicians trained at TMAI. TMAI also provides curative services at the hospital and out-patient clinics in Dharamsala and TMAI branches; runs a pharmacy for the production of Tibetan medicines, a medical school for training doctors in traditional Tibetan medicine, and a museum; and undertakes research on Tibetan medicine. TMAI covers most of its expenses through charging fees for its medical services, which in 1992-93 covered 90 percent of its expenditure. Thus TMAI does not receive any funds from the Central Tibetan Administration, although the CTA seconds a few administrative staff to the Institute.

The overall health situation of the Tibetan Refugee Community in India and Nepal is still not satisfactory. This is mainly due to stress and tension of refugee life, economic constraints, poor nutrition, poor hygiene, poor sanitation, illiteracy among the older generations, the language barrier, and an overall low level of health awareness in the Community. The health delivery system has not been developed to a satisfactory level.

Table 1 in the Appendix to this Chapter gives the age-wise distribution of the population derived from data gathered by the IDP survey from 37 Settlements. The profile is based on 55,468 Tibetans in the Settlements, which represents 46 percent of the Refugee Community.

Table 6.1.1.A provides the statistics of crude birth and death rates derived from various sources: the IDP survey covering 34 Settlements in India and Nepal; the Health Data Survey (see 6.1.4.3 below) of the five large Settlements in south India; and an informal survey by the Department of Health of eight Settlements in central and north India.

Note: The infant mortality rate from the IDP survey is based on 21 Settlements only; the infant mortality rate from the health data survey is based on Dhoeguling (Mundgod) Settlement, which is accurate. The rate in the other Settlements in the south appears to suffer from under-reporting, which may also apply to the rate from the IDP survey.

The IDP survey indicated the disease pattern given in Table 6.1.1.B overleaf, which reveals a very high proportion of gastro-enteric and diarrhoea cases, as well as of skin diseases, in both the Settlements and the scattered communities. Such water-borne diseases were reviewed during the Tibetan Health Review Workshop in October 1993, and in order to reduce their incidence by providing the Refugee Community adequate clean drinking water and sanitation facilities, it was decided to give priority to the Drinking Water Program.

Table 6.1.1.C gives the disease incidence revealed by the more detailed survey of the five large Settlements in south India under the Health Data and Evaluation Program (see 6.1.4.3 below). The lower incidence of gastro-enteric and diarrhoea cases reflects the better supply of clean drinking water in these Settlements which are more highly developed than many of the others. At the same time the continuing high incidence of skin diseases suggests that these are related to basic standards of hygiene and can thus best be tackled through health education. During the hot season in particular children often bathe in the streams.

Many of the problems of the elderly are health related. The age-profile indicates that 12.4 percent of the population is over 60. Diseases such as tuberculosis, high blood pressure and asthma are prevalent among the elderly. The Central Tibetan Administration pays special attention to the health problems of the aged.

The number of disabled individuals with different types of disabilities covered by the IDP survey was 1006 (see Table 4 in the Appendix to this Chapter). The major problems faced by the disabled are the lack of income and of adequate care. Medical care and rehabilitation is made more difficult by the distances of many Settlements and scattered communities from major cities where specialized treatment is available. The Department of Health has an Officer in charge of the Rehabilitation Program for the Disabled.

6.1.2 CURRENT ACTIVITIES
The Department of Health of the Central Tibetan Administration caters to the overall health care needs of Tibetans in India and Nepal as well as any non-Tibetans who seek help from the Health Care Centers. The preventive, curative, promotive and rehabilitative services are rendered to all irrespective of caste, creed or color through the PHC Centers in the Tibetan Refugee Settlements. Table 6.1.2 gives the main programs of the Department of Health along with the percentage of the total budget spent on each program in 1992-93.

The infrastructure facilities of the Health Sector include:

Hospitals: Six hospitals with standard hospital equipment.PHC Centers: 60 Centers with elementary health care accessories.Tibetan Clinics: 36 clinics for traditional Tibetan medicine with basic medicines.A hospital or a PHC Center has been opened in all 46 Tibetan Refugee Settlements in India and Nepal, except for two of the very smallest and one where the Settlement manages its own private health clinic. PHC Centers have also been established in 17 refugee communities or institutions outside of the Settlements (7 in Himachal Pradesh, 6 elsewhere in India and 4 in Nepal). In the areas where there is no clinic the Department of Health advances funds to the local Tibetan Welfare Officer, which he can give to poor Tibetan refugees in his area to allow them to use local Indian health facilities. Thus almost all Tibetan refugee communities in India and Nepal are covered by health care provided by the Central Tibetan Administration. So far no health centers have been established in Bhutan (for further details about the health facilities of the health sector see Table 2 in the Appendix to this Chapter).

A team of 224 field staff of the Department of Health carry out the PHC programs, which include training of health staff, providing health education, maintaining Primary Health Care Centers and organizing projects to combat tuberculosis, leprosy and other diseases. Two of the six hospitals have separate dental and optical clinics, three centers have dental clinics, and two centers optical clinics; for other areas periodic eye and dental camps are organized. The units of the Health Sector also collect health related data, treat and rehabilitate leprosy patients, handicapped and disabled Tibetans, and promote the traditional system of Tibetan medicine.

In 1993 the Department of Health organized the first Tibetan Health Review Workshop with 27 participants comprising medical officers, Health Coordinators, nurses, senior CHWs and Tibetan medical doctors, who reviewed all aspects of the health care service provided by the Department of Health for the Tibetan Refugee Community. Some of the conclusions reached at the workshop are reflected in the programs described below. Other workshops in 1993 included one on TB and one Health Service Management course.

The Tibetan Refugee Community is also working to achieve a better health care system by integrating the modern allopathic health care system with the ancient Tibetan system of medicine. The traditional system of Tibetan medicine is a unique, scientific knowledge of healing, which is helping many people around the world and can make a significant contribution to a holistic approach to health care in the future.

6.1.3 SECTOR GOALS

To have all under fives and new comers from Tibet immunized for prevention of diseases.

To provide an adequate supply of safe drinking water and ensure sanitation facilities in the Settlements to reduce the incidence of water-borne diseases.

To continue curative services through the existing Primary Health Care Centers and traditional medical clinics, and to upgrade them.

To reduce the incidence of Tuberculosis in the Tibetan Settlements by 50 percent within the next five years.

To provide the very poor in the Refugee Community with health care by funding their treatment from the emergency fund.To treat and rehabilitate post-traumatic disorders among Tibetan Refugees caused by Chinese torture in Tibet.

To treat and rehabilitate the handicapped, disabled and leprosy patients in the Refugee Community.

To increase the coverage of eye-care and dental services by training eye and dental therapists and technicians and organizing eye and dental camps.

To improve the health data systems for planning, managing and evaluating the health care system.

To increase the knowledge and skills of the community health staff by conducting short courses and workshops.

To preserve and integrate the traditional Tibetan system of medicine by organizing seminars and conferences and providing health education.

To move the programs of the Department in the direction of financial self-reliance in recurring costs.

6.1.4 FUTURE PROGRAMS AND PROJECTS

The Department of Health plans to implement the following four major programs over the next five years listed with their sub-programs or projects.1. Preventive Health Care Program:

- Mother and Child Health- TB Control- Drinking Water and Sanitation- Health Education

2. Curative Health Care Program:

- Primary Health Care Centers and Hospitals- Emergency Medical Relief Expenses- Treatment and Rehabilitation of Torture Victims- Disabled and Handicapped- Eye and Dental Camps

3. Strengthening Organizational Capabilities:

- Health Data and Evaluation- Training and Personnel

4. Integration of Tibetan System of Medicine:

- Seminars and Conferences6.1.4.1 Preventive Health Care Program

Sub-Program 1: Mother and Child Health Program Objective. To increase the coverage of the Program to 95 percent of infants and thus reduce current infant mortality by 75 percent over the next five years by providing appropriate ante-natal care and immunizations for mothers and children.

Rationale. The present infant mortality rate in the five large Tibetan Refugee Settlements in south India is probably around 35 out of 1000 (see Table 6.1.1.A above). Many infant deaths and child diseases are, however, preventable. But most mothers within the Refugee Community not only maintain the household but are also earning members of the family. Thus many go for sweater business in particular, often taking their children with them, and thus the children, as well as pregnant mothers, often do not get vaccinated in time. In some Settlements pregnant mothers do not come for regular check-ups or do not take their children for immunization if the local hospital is not close by, and many times the local PHC Center does not have enough vaccines.

Progress since the first IDP. Through health education many mothers within the Refugee Community are now aware of the need for providing immunizations and proper health care for their children and especially during pregnancy. However, their circumstances, particularly sweater-selling, do not always make it easy for them to act upon such awareness. The Department of Health estimates that 80 to 90 percent of Tibetan refugee children are immunized, compared to only 40 percent three years ago.

Implementation. Children under five will be immunized against the six main child diseases, and pregnant mothers given tetanus toxoid (TT), as well as iron and folic acid tablets. For health education emphasis will be placed on educating pregnant mothers about the importance of having a TT injection and regular check-ups, as well as about appropriate diet, hygiene and exercise. Education will also focus on the importance of providing a proper diet, hygiene and medication for children under five, as these are critical years in a child's development.

Management. In those communities which have a hospital, the hospital is responsible for ante-natal care and immunizations, as well as having a separate delivery room. In those communities with only a PHC Center, the Center does the check-ups, and home delivery is the norm (unless the case has to be referred to hospital); immunization is arranged at the PHC Center or through the local Indian hospital. Since many mothers do not come for check-ups when male Community Health Workers (CHWs) are on duty at the PHC Centers, the female CHWs are taking charge of this Program.

The Department of Health is responsible for the overall management and coordination of the Mother and Child Health Care Program. The Program is managed through the same structure of zones, health coordinators and hospitals or PHC Centers as the PHC Program (see 6.1.4.2 and 6.1.5 below). The responsible staff in the Department review the health data from the PHC Centers and when they make field visits they check the health record books with their immunization schedules of all children under five.

Financial Resources. The total annual cost of running this program is Rs 1,058,000. Mothers covered by the program will contribute the cost of their travel, amounting to Rs 120,000. Thus the funding requested totals Rs 938,000 for one year or Rs 5,181,000 over five years (incorporating 5 percent inflation).

Sub-Program 2: TB Control Program Objective. To reduce the current incidence of TB within the Tibetan Refugee Community by 50 percent by the year 2000.

Rationale. Tuberculosis (TB) has been a major health problem for the Tibetan Refugee Community, with many refugees contracting the disease when they came to India resulting in many deaths. In 1980 a TB Control Program was started from Delek Hospital, and since then TB Control projects have been started in all the major Tibetan Refugee Settlements. Moreover many new born children in the Settlements are now covered by BCG vaccinations. TB control remains an important priority for the Health Sector.

While the prevalence of the disease within the Refugee Community has been reduced, it still remains a major problem. In fact, with the improvement of health care facilities and the health education on TB they provide, the number of reported cases of TB is rising. In 1991 there were 564 reported cases in 20 Settlements giving an incidence of 9.6 per 1000 population; in 1992 there were 740 cases in 25 Settlements, giving an incidence of 11.6. The total number of reported cases of TB in 32 Settlements in September 1993 was 862, distributed as follows: 338 first-line; 436 second-line; and 88 third-line.

Many TB patients, especially those on third line treatment are from poor families, and many of them are also young. Out of the 77 third line TB patients whose treatment is funded by the Department of Health (treatment for the remaining patients is funded by Delek Hospital) 64, or 83 percent, were between the age of 16 to 35. Unfortunately during winter many young people suffering from TB still go sweater-selling in urban centers all over India, and they often suffer relapses due to the tension and stress, forget to take their medicines regularly, or change their regime after consulting private doctors.

Progress since the first IDP. With new funding from the US Congress the Department of Health was able to establish new TB Control projects in two Refugee Settlements in central India, in the three Refugee Settlements in Arunachal Pradesh, and in Kunphenling (Rawangla) Refugee Settlement in Sikkim. This expansion of the Program has led to the identification of more TB patients who are now being given treatment.

Implementation. New born children will be given BCG vaccinations through the existing hospitals and PHC Centers. In addition newly arrived refugees will also be vaccinated; for this purpose the Health Department is reviewing the possibility of deputing two Community Health Workers to the Reception Center in Kathmandu during the months when most new refugees arrive. The aim is to achieve at least 80 percent coverage of these two target groups.

Facilities to undertake basic sputum tests have been given to all PHC Centers and CHWs are given training, including refresher courses. All positive cases of TB will be given treatment, and hospitalized if acute.

In order to address the problem of relapse during sweater-selling the Department of Health is planning to establish a mobile TB clinic on a pilot basis to visit one or two of the urban centers most frequented by Tibetan traders.

The support of the Health Education Program will be a critical input into the TB Control Program, as without greater awareness about how to prevent the spread of the disease and to treat it, the Control Program will not be able to meet its objective of reducing the incidence of TB by 50 percent over the next five years. Nor will it be possible to reduce the substantial budget allocations the Department of Health makes for treatment of TB patients. Thus more training of health staff and more health education for prevention of TB will take place.

Management. The Department of Health has recently established a separate TB Cell within the Department, staffed by a Medical Consultant, a Project Officer and a Project Assistant, which will conduct a base-line survey of TB in the largest Tibetan Refugee Settlement (Dhoeguling, Mundgod in south India) in 1994 to test how accurate and comprehensive the current health data on TB is. The TB Cell will take prime responsibility for managing the TB Control Program.

Financial Resources. The TB Control Program is being funded by the Save the Children Fund (SCF), UK and the US Congress, although these donors do not cover all the costs of the Program. In an attempt to move towards greater self-sufficiency, the health care system is covering only 50 percent of the costs of treatment for first and second-line TB cases in the Settlements in south India. Such treatment is paid from the general hospital budgets, 25 percent of which are raised by charging fees and a further 25 percent from community contributions. This system will be introduced in the Settlements in central India as well in 1994. In other Settlements the patients have to meet between 10 to 50 percent of the cost of treatment, depending on their economic situation. The same applies to all patients with third-line TB; these patients are funded directly from the Department of Health and not through the general hospital or center budgets. For the very poor and destitute the Department of Health bears the full costs of the drugs.

Unfortunately the 1992-93 budget for third line cases ran a deficit of over Rs 1 million, which had to be paid from the Emergency Fund and from bank interest. This was because more patients were identified with the expanding coverage of the Program, the cost of the drugs has risen significantly (by around seven times over the last three years) and, as a result, fewer patients are willing to go to private doctors for treatment. The contribution from the patients' side was in fact poor, because most of the patients were from poor families, and a few families had more than one or two persons suffering from TB. The Department of Health is reviewing the TB Program, including the budget for 1994-95, and will be seeking ways to ensure that those patients who cannot afford to pay 50 percent of the costs of treatment should pay from 10 to 50 percent.

The cost of the survey of the incidence of TB in Dhoeguling will be Rs 85,000. The annual costs of TB treatment are estimated at Rs 9.7 million (which is significantly higher than in the first IDP for the above mentioned reasons). The contribution expected from patients will be Rs 2.4 million (representing 25 percent of the total costs). Over five years the total costs of the Program will be Rs 48.7 million. This figure does not include adjustments for inflation, and thus represents a reduction of the real costs of treatment of at least 10 percent over five years. Even so, the Department of Health will have to continue to utilize around 40 percent of its resources for the TB Control Program. The total support requested from donors for this Program over five years is Rs 36.6 million.

Sub-Program 3: Drinking Water and Sanitation Objective. To provide safe drinking water to residents of those Settlements which currently do not have an adequate and safe source of drinking water.

Rationale. The Drinking Water and Sanitation Program is being given priority because of two factors. Firstly, gastro-enteric, diarrhoea and skin diseases together accounted for a large proportion of the disease incidence in the Settlements and the scattered communities (see Tables 6.1.1.B and C). Secondly, many Settlement communities have on their own initiative selected drinking water and sanitation projects as a priority. This is understandable because on average the Settlement communities are able to get only 63 percent of their drinking water and washing water requirements. As many as 10 out of 28 Settlements for which data is available indicated that they have 50 percent or less drinking water than they require. The balance is drawn from unsafe sources such as running streams, which then leads to stomach disorders. In view of these conditions, the Department of Health will be continuing its Drinking Water and Sanitation Program.

Progress since the first IDP. Significant progress has been made with this Program, especially with funds donated by the US Congress: the first seven out of the ten projects listed in the first IDP have been implemented, and funding has been secured for one of the remaining three. In addition, four additional projects have been implemented or have secured funding.

Implementation. The following projects listed below will be implemented during the second Integrated Development Plan. For this Program the Department of Health works closely with the Department of Home, which has joint responsibility for drinking water and sanitation projects. For example Appropriate Technology for Tibetans (ApTT), UK has been working with the Department of Home to construct pour-flush toilets in the Settlements in south India. Since ApTT and the Department of Home are keen that this appropriate technology should be replicated in other Settlements, they will provide technical assistance for adapting the pour-flush toilet design to suit conditions elsewhere.

Project 1 (1995): Phuntsokling Settlement, Chandragiri, Orissa. This Settlement depends on open wells for drinking water. The water in these wells is contaminated and the project will thus clean the wells (for which the community will contribute unskilled labor) and provide covers. The Department of Health has already advanced funds to clean 15 wells.

Project 2 (1995): Dhondupling Settlement, Clement Town, U.P. The existing tubewell was installed in 1964 when this Settlement was first established, and the tube well is now urgently in need of replacement. The project will sink a new tubewell, and add an overhead tank with piping to individual households. The community will contribute 28 percent of the costs of installing the new tubewell and will pay monthly charges to cover the costs of maintenance.

Project 3 (1995): Tashi Jong Settlement, Paprola, H.P. At present this Settlement in north India has only a few standing taps, which often dry up in the summer, and one seasonal stream, which also dries up in the summer. This project will install two handpumps and one small water tank to provide an adequate water supply of clean drinking water.

Project 4 (1996): Choephelling Settlement, Miao, Arunachal Pradesh. While the pipe connections within this remote Settlement in north-east India have recently been repaired, the water source has now been exhausted, and this project will bring water from a new source 6 km away up the hills.

Project 5 (1996): Mcleod Ganj Area, Dharamsala, H.P. Although there are four public toilets in Mcleod Ganj (Upper Dharamsala) constructed by the Local Government and by the Tibetan Youth Congress (TYC), only two toilets constructed by TYC are useable. With the increase in the population and especially of the many tourists, both Indian and foreign, the need to reconstruct the two remaining toilets is urgent. The total cost for reconstructing the toilets will be Rs 144,500, of which the Local Government will contribute 50 percent, the Tibetan Department of Health 25 percent and the local community 25 percent. The Department of Health is also planning to purchase a truck to carry and dispose of the garbage from the existing garbage bins, as the municipal truck is not sufficient. The cost of a truck is Rs 550,000 of which 50 percent will be raised from the community.

Project 6 (1996): Tibetan Women's Handicraft Center, Rajpur, U.P. Although this Settlement has ten public toilets, there are not enough for the existing population in the Settlement. This project will construct four toilets, as well as four bathrooms.

Project 7 (1997): Tibetan Bonpo Foundation, Dolanji, H.P. This Settlement is divided between two camps which are located over 3 km away from each other. The drinking water problem for one of the camps was solved in 1993 with the construction of a water tank to store water from the small river which runs between the two parts of the Settlement. This project will construct a water tank for the second camp drawing water from the same source.

Project 8 (1997): Bir, H.P. There are two Settlements located at Bir, Bir Tibetan Society and Khampa Industrial Society (Bir Dege). Both Settlements, which are contiguous, do not have a drainage system, and there are no septic tanks for the private toilets which almost half of the households have. As a result the settlement area is often dirty and many settlers use the open fields as their toilet. This project will construct a drainage system, 10 public toilets and 20 septic tanks for both Settlements.

Project 9 (1997): Tashi Jong Settlement, Paprola, H.P. To further improve health and hygiene within this community (see Project 4 above), ten four-cabined public toilets will be constructed.

Project 10 (1998): Dekyiling Settlement, Dehradun, U.P. There are currently 14 public toilets in this Settlement, but no proper drainage. This project will construct a drainage system, as well as six more public toilets.

Project 11 (1998): Dorpatan Settlement, Nepal. This remote Settlement in Baglung District of Nepal has a population of 256. This project will construct seven toilets and one additional one for the monastery.

Project 12 (1998): Nangchen Settlement, Chauntra, H.P. This Settlement at present does not have any toilets, and the settlers have to use the open fields. This project will construct 50 toilets, one for every two households in the Settlement. Because the number of toilets planned is large, the Cooperative will contribute 22 percent of the cost of the project in cash, and the community will contribute free labor.

Project 13 (1999): Dekyi Larsoe Settlement, Bylakuppe, Karnataka: At present the few powered pumps in this Settlement in south India are overused, which causes them to breakdown frequently; they are also very expensive to run. This project will install 64 handpumps, one for each block of eight households in the Settlement. A groundwater survey will be conducted to identify 64 suitable points.

Project 14 (1999): Gangchen Kyishong, Dharamsala, H.P. Gangchen Kyishong is the complex where all the offices and staff quarters of the Central Tibetan Administration are located. This project will construct a water tank and develop the existing drains and wing walls in the complex.

Management. One Deputy Secretary in the Department of Health who has been dealing with water and sanitation projects for the last three years will be responsible for overseeing the Drinking Water and Sanitation Program, including coordination with the Department of Home. She makes field visits to assess the situation in each Settlement and to check on the progress of individual projects. She will also be responsible for providing project reports and accounts to donors. With the improved data being gathered by the Department of Health, it should now also be possible to measure whether the incidence of water-borne diseases declines in these Settlements.

The local Settlement or Welfare Officer, with the help of the PHC Center, is responsible for day-to-day supervision and for submitting reports and accounts to the Department of Health. All payments for the purchase of materials are approved by the local Health Committee. The local communities contribute free labor and/or cash.

Financial Resources. For all drinking water and sanitation projects the Community will contribute either free labor and 10 percent of the cost of the project in cash, or simply 25 percent of the cost of the project. The projects above require a total budget of Rs 7.5 million, of which the Community will contribute Rs 2.1 million or 28 percent.

Sub-Program 4: Health EducationProject 1: General Health Education Objective. To provide health education to all sections of the Tibetan Refugee Community by covering all Settlements and major scattered communities by the year 2000 in order to reduce communicable and water-borne diseases within the Community by 50 percent by the year 2000.

Rationale. Health awareness within the Refugee Community has been very low, including in schools, monasteries and nunneries. However, past experience has shown that health education can be effective in addressing this lack of awareness: with the help of such education over 80 percent of children within the Refugee Community are now immunized compared to only 40 percent three years ago.

Progress since the first IDP. Over the past two years the special Health Education and Media Unit of the Department of Health has conducted health education programs in all the Refugee Settlements, except those in Arunachal Pradesh, Sikkim and Nepal. It produces a bi-annual bulletin in Tibetan and another in English, has published color posters on sanitation, TB and dental care, pamphlets in Tibetan on TB, gastro-enteritis and AIDS, and a booklet on nutrition. With the help of the audio-visual section at TIPA, the Unit is also making a video film on TB. The Department sends some of these educational materials to Tibet, and they can be used in future for health education and training in future Free Tibet.

Implementation. Since the health workers are the main link between the Community and the health care system, the Department will continue to support them in their role as health educators. To this end the Health Education and Media Officer of the Department will a) organize one health education workshop for the health workers each year (some of these workshops will focus on AIDS; see Project 2 below) and b) tour various Tibetan Refugee Settlements every year to conduct health education, together with the local health workers, for the settlers, school children, monks and nuns. When necessary they will invite outside experts in health education to accompany them. Because many in the Community migrate from their Settlements every year, it will only be possible to conduct such health education systematically from February (after the Tibetan New Year) to June. By the year 2000 all the Tibetan Settlements in India and Nepal will have been covered by this Program.

An important part of the Program will be to continue to develop appropriate media through which to provide health education, for example through publications, posters, talks, video shows and so on. The Department will continue to publish its bulletins in Tibetan and English, which include material translated from the World Health Organization and other publications, as well as various pamphlets, books, comics, posters and video cassettes, all in Tibetan.

Project 2: AIDS Awareness
Objective. To increase awareness of AIDS and its prevention within the Refugee Community, especially among those groups most at risk.

Rationale. AIDS is becoming a major problem in the Indian sub-continent. While there is no hard data available, the sharp rise in cases of AIDS in the sub-continent is expected to be reflected within the Tibetan Refugee Community as well, especially because of substantial migration of members of the Community, including many youth, to urban centers throughout India for petty business. A few suspected cases as well as deaths from AIDS were reported at the Tibetan Health Review Workshop in 1993.

Progress since the first IDP. This new project was initiated because of the growing awareness within the Refugee Community of the threat of AIDS. With the help of the International Nursing Services Association, Bangalore AIDS awareness talks were conducted in the eight Tibetan Settlements in south and central India, as well as in Delhi, Dharamsala and neighboring Settlements in Himachal Pradesh. During these trips special time was allocated to cover all the Settlement schools.

Implementation. Experts will be invited to provide health education on AIDS to the public and in schools with the target of covering all Settlements and schools within five years. The Health Education and Media Unit will also update and reprint the pamphlet on AIDS and develop posters on AIDS. The Department of Health is also making efforts to procure free condoms from various agencies for free distribution through the PHC Centers and hospitals. In addition the Department of Health will encourage all the Settlements to disseminate information on AIDS on 1st December (World Aids Day) every year.

Sub-Program Management. The special Health Education and Media Unit with its Project Officer is responsible for the Health Education Program. The Community Health Workers are chiefly responsible for conducting health education within the Settlements and scattered communities.

Financial Resources. The annual costs of running the Health Education Program are Rs 610,000, or Rs 3,370,635 over five years (incorporating 5 percent inflation). To raise some funds to defray about 10 percent of these costs, the Department of Health plans to charge between 50 to 100 percent of the cost price of some of the publications. The Department is thus seeking Rs 3.0 million from donors for this Program.

6.1.4.2 Curative Health Care Program

Sub-Program 1: Primary Health Care Centers and Hospitals Objective. To provide basic medical facilities to all the Tibetan Refugees in India and Nepal by the year 2000; and to provide health care to all people from the host countries who seek treatment from the Tibetan PHC Centers and hospitals.Rationale. Most of the Tibetan Refugee Settlements are situated in remote areas where no medical facilities are available near the Settlement. To ensure that all Tibetan Refugees receive basic health care the Central Tibetan Administration has thus felt it necessary to open a PHC Center in each Tibetan Settlement and major scattered community.

Progress since the first IDP. As planned in the first Integrated Development Plan, three new Health Care Centers were opened in 1993, and the dispensary at Phuntsokling Refugee Settlement in Orissa was upgraded. The Department of Health is giving much importance to essential drug requirements, and has brought out a booklet on essential drugs, based on the guidelines of the World Health Organization, which has been distributed to all the Community Health Workers. In addition a policy has been adopted to charge patients who can afford it 10 percent above the cost of the drugs, so that these funds can be used for the purchase of more essential drugs. Finally, funds have been secured for the construction of a permanent referral hospital in Dekylling Refugee Settlement in Dehradun, which should be completed in 1994, and one resident doctor has already been appointed. This will allow the successful implementation of the on-going TB Control Project in the Doon Valley Settlements. Another hospital for the two Refugee Settlements in Bylakuppe will also be completed in 1994.

Implementation. The development of the Health Care Centers will continue in future by upgrading the existing PHC Centers with more professional staff, trained under the Training Program (see 6.1.4.3 below), better dispensary services, and more equipment to provide better medical care. The hospitals in Dehradun and in Bylakuppe will be completed, as well as the dispensary in the Tibetan refugee camp at Majnu-ka-tila in Delhi. Four ambulances will be purchased for two Refugee Settlements in central India, for the Settlements in Ladakh, and for Jampaling Settlement in Pokhara, Nepal.

Management. Overall management of the Program is undertaken by two Deputy Secretaries in the Department of Health, one for the central and southern zone, and one for the north. They are responsible for raising funds, sending it to the hospitals and centers, monitoring progress through field visits and the review of the health reports from the hospitals and centers, and reporting to donors. The day to day work is managed by the Health Coordinator in the hospitals, or the senior Community Health Worker in the PHC Centers, under the supervision of the Settlement or Welfare Officer.

Financial resources. The capital costs for two hospitals, one dispensary, medical equipment and four ambulances total Rs 4.8 million, of which Rs 3.6 million (75 percent) has already been secured from donors. The annual recurring costs of this Program, chiefly for staff salaries and essential drugs, is Rs 3.1 million. Over five years recurring costs would thus total Rs 16.9 million (incorporating 5 percent inflation).

Although the Department of Health currently has sponsors for all the PHC Centers and hospitals, the Department is trying to move towards self-sufficiency in order to make the health care system more sustainable. In time of course many sponsors will stop funding the clinics. The Department of Health has already asked the PHC Centers and the hospitals to charge patients who are not poor 10 percent above the cost of the drugs. Now, in the Tibetan Refugee Settlements in south India, the Department has asked 25 percent of the Mwsts of running the centers and hospitals to be raised as community contributions, 25 percent as fees, with the remaining 50 percent to be raised by the Department. Gradually the Department will further reduce its contribution. The same policy is being implemented in the large Settlements in central India from the year 1994-95. For budgeting purposes the Department estimates that it will thus be able to raise 25 percent of the costs of this Program over five years from fees and community contributions.It is therefore seeking 75 percent of the total recurring costs over five years (which equals Rs 12.6 million) from donors, as well as the remaining Rs 1.1 million to cover the capital expenditure under this Program.

Because of the needs of poor and destitute patients in particular, many of the Health Centers still rely on drugs gifted by donors. While the Department of Health remains grateful to all those who have donated drugs, it is appealing to them to provide funds rather than drugs so that the Department can purchase locally manufactured drugs, which is more cost effective and efficient.

Sub-Program 2: Emergency Medical Relief Expenses
Objective. To provide funds to poor Tibetan refugees who cannot afford emergency medical treatment they require.

Rationale. There are many poor and destitute Tibetan patients in the Settlements who are very poor and are not able to meet the expenses of their treatment. The Department of Health provides funds to cover all costs of treatment for very poor patients and contributes a percentage of the cost for those who can afford to pay some fees. Of late there have been an increasing number of newly arrived refugees from Tibet requiring health treatment.

Progress since the first IDP. Recently the fund has been used for cases involving a road accident, head injury, stabbing, burns, alcohol detoxification, deworming of school children, lung operation, kidney transplant, ulcer operation, stomach and breast cancer; three heart operations are also pending. In addition the fund provides for nutrition to many pregnant mothers who are newly arrived refugees from Tibet, and has also covered expenses for medical camps, for drinking water and toilets at schools, and for extensions of PHC Centers.

Implementation. When an individual approaches the Department of Health for emergency assistance, the Department requests recommendation letters from the local medical officer on his or her diagnosis of the case, and from the local Settlement or Welfare Officer, as well as the local Tibetan NGOs (Tibetan Freedom Movement, Youth Congress and Women's Association) on whether the applicant is genuinely poor and needs assistance. These NGOs also raise money themselves from their local communities to cover emergency expenses of poor refugees in the Settlements, which the Department of Health encourages. After receiving their recommendation the Department disburses the assistance to cover the emergency medical expenses, either in full or in part. To the extent possible such emergency cases are treated in the Tibetan hospitals, to avoid them being referred to larger hospitals which are often much further away and more expensive.

Management. A Deputy Secretary in the Health Department is in charge of the emergency fund, and is responsible for collecting progress reports on the patients from the health clinics.

Financial Resources. Emergency medical expenses amount to Rs 1 million each year. All donations to the Department of Health which are not earmarked for specific projects are placed in the emergency medical fund. In order to reduce the expenditure of the fund the Department will seek not to cover the full costs of treatment in more cases than at present, requesting the family or local community to contribute the remainder.

Sub-Program 3: Treatment and Rehabilitation of Torture Victims An important reason for many Tibetans to flee their country is that they have suffered from torture under the Chinese authorities in occupied Tibet. While not all the torture victims require treatment, many do suffer from post-traumatic disorders. This Program will identify the nature of torture received by torture victims among the newly arrived refugees from Tibet, and provide medical treatment and rehabilitation to 20 such torture victims each year. The Program was started by the Department of Health in 1993 with a small donation from an individual. A team of doctors and consultants for the Program has been put in place, and ten patients who need immediate treatment have been identified and interviewed. (For further details see Chapter 3A.)

Sub-Program 4: Disabled and Handicapped
Objective. To give treatment for 25 disabled refugees each year, roughly five cases each from among the blind, the deaf and dumb, the crippled, amputees, and the mentally retarded, and to look after an additional 20 leprosy patients.

Rationale. The survey conducted for the second Integrated Development Plan identified 1006 cases of disability within the Tibetan Refugee Community (see Table 4 in the Appendix to this Chapter). Many of these may not have anyone to support them, and in some cases their parents or relatives may find it difficult to care for them, especially during winter when they go for sweater business, which provides essential supplementary income for the household. In other cases the disabled may not seek treatment because they need to earn whatever they can to survive.

Progress since the first IDP. Under this Program treatment has been given to 9 disabled refugees, as well as to 16 leprosy patients who are being rehabilitated at leprosy homes in Palampur in Himachal Pradesh and in Bangalore.

Implementation and Management. One Project Office at the Department of Health is responsible for selecting patients and contacting different hospitals and institutions that can provide appropriate treatment. The Project Officer also monitors the Program by interviewing the disabled and their families during field visits.

Financial Resources. The local Tibetan NGOs often raise money from the local community for these cases, although they approach the Department of Health when they cannot raise sufficient funds. The Department can use some of the funds received from the US Congress for urgent treatment under this Program. Additional funds have to be raised for treatment of other patients. The annual recurring expenses for this Program total Rs 306,000 giving a total of Rs 1,690,843 over five years (incorporating 5 percent inflation).

Sub-Program 5: Eye and Dental Camps
Objective. To provide periodic dental and eye care camps in those Settlements whose Health Centers do not have dental and eye care facilities. Implementation. The Department of Health and Delek Hospital have been organizing such camps. However, due to the lack of trained dentists and opticians within the Refugee Community itself, the Program has had to rely on foreign volunteers for the necessary qualified human resources. To address this problem the Department of Health has been sponsoring ophthalmic and dental training for individuals in the Refugee Community. Two people have recently received training as ophthalmologists to cover the large Settlements in south and central India. Eight dental therapists have been trained, or are under training, as well as two trainees for dentures. In addition one candidate will be going to Australia for one year for training as a dental therapist.

Financial Resources. The annual recurring costs of the eye and dental camps totals Rs 69,000. Over five years it will be Rs 381,000 (incorporating 5 percent inflation).

6.1.4.3 Strengthening Organizational Capabilities

An important objective of the Department of Health is to strengthen the organizational efficiency of the health care system so that the health care programs can have more effective results.

Sub-Program 1: Health Data and Evaluation
Objective. To collect and process reliable data on basic health statistics from a number of widely different Tibetan Refugee Settlements within the next three years.

Rationale. Gathering and processing reliable health data is an integral part of health care activities, which is essential for setting priorities, planning, managing, monitoring and evaluating the provision of health care within the Tibetan Refugee Community.

Progress since the first IDP. The Department of Health launched its Program to collect health data from its Health Centers in 1990. So far the Tibetan Refugee Settlements in south India have been covered by the survey; and preliminary work has been undertaken in a number of Settlements in the Doon Valley in Uttar Pradesh and in Himachal Pradesh.

Implementation. The health survey is collecting reliable data on a restricted number of health variables in the first instance, allowing analysis of such health statistics as disease rates for tuberculosis, diarrhoea, respiratory infections and skin diseases, as well as infant mortality rates and immunization coverage. Since a significant proportion of the Refugee Community comprises monks and nuns (about 14 percent), the survey is covering the monasteries and nunneries in each Settlement as well.

The Program will provide training in 1994 for nine Area Trainers from the large Settlements in south and central India and from the Doon Valley and Ladakh in north India. These Area Trainers will in turn train the Community Health Workers in their respective areas in methods of collecting data, checking its reliability and tabulating it before submitting it for analysis to the Department of Health. The training will be conducted by the Indian Consultant to the Program who has considerable international health care experience.

The Project Officer and Consultant will now visit the Tibetan Refugee Settlements in central India, Ladakh, Himachal Pradesh, Uttar Pradesh, Darjeeling, Gangtok, Arunachal Pradesh and Nepal.

Management. The Department of Health has established a separate unit for collecting and processing health data. The unit is headed by a Project Officer and an assistant, and has been guided by the Consultant. The Consultant provides on-the-job training to the staff involved in this Program. The eight Area Trainers will coordinate and supervise the collection of health data in their respective areas.

Financial Resources. AIDAB has sponsored this Program for three years. The annual recurring costs total Rs 1,638,000. In addition the Program requires Rs 209,000 for equipment, giving a total cost over three years of Rs 5.4 million (incorporating 5 percent inflation). The Department of Health is contributing Rs 100,000 each year towards this Program.

Sub-Program 2: Training and Personnel
Objective. To train and recruit new health personnel and to provide in-service training to existing health personnel both in the field and in the Department.

Rationale. In spite of significant progress made over the last two years there is still a shortage of health personnel in the hospitals and PHC Centers of the Tibetan Refugee Community, and training and recruiting needs to done (for more details see section 6.1.6 on Human Resources below). In addition Community Health Workers receive only three months of basic training before being appointed as CHWs in their respective Settlements. As the chief providers of health care within the settlement communities, they need further training from time to time to upgrade their knowledge and skill, to share their experiences and problems, and thus to increase their motivation. Other health staff, for example laboratory technicians, are also in need of such refresher training.

Progress since the first IDP. Since the first Integrated Development Plan the following health personnel completed their training or are currently undergoing training: 10 doctors; 15 nurses; 24 Community Health Workers; 3 pharmacists; 2 laboratory technicians; 1 X-ray technician and 3 health administrators. In addition one staff member of the Department is undergoing an MA in Public Health. Refresher courses were held every year for all the CHWs in south and north India and in Nepal respectively. Non-medical staff from the Department, as well as from the field, were sent for short courses in Indian institutions, and the Department conducted some of its own courses as well.

Implementation. The Program will train and recruit the following health personnel:

- 5 doctors (MBBS and MD)- 10 nurses (RNRM for 3 years)- 2 X-ray technicians (1 year)- 5 laboratory technicians (1 year)- 15 technicians for basic laboratory work (1 month for CHWs)- 5 pharmacists (3 years)- 3 health administrators (1 year)

The Department of Health is working in close collaboration with the Department of Education and the Tibetan Children's Village to attract school graduates to enter the health profession. For the training listed above the selected candidates will attend appropriate Indian hospitals and health institutions wiMw scholarships secured through the Department of Education. Trainees will be bonded to work for the Department of Health for at least three years. The ten laboratory technicians, however, will be chosen from among existing Community Health Workers and will be given a specially designed training course to upgrade their skills to undertake basic laboratory tests.

The Program will provide refresher training courses of 15 days each for Community Health Workers, covering one zone each year. The training centers are Dharamsala for the north and north-east India, Dhoeguling Tibetan Hospital in Mundgod for south and central India, and Pokhara or Kathmandu for Nepal.

The Program will also provide refresher training courses of ten days for ten laboratory and X-ray technicians every two years to acquaint them with new technologies and methods of investigation. Finally refresher courses of 15 days will be conducted every two years for 20 doctors and nurses.

Management. The Department of Health has appointed a Project Officer to manage the Training Program. Outside health professionals will be hired to conduct the in-service training courses and the course for the ten new laboratory technicians.

Financial Resources. The cost of training the new personnel is Rs 2,056,000 and the CHWs in basic laboratory techniques Rs 120,000. The cost of each refresher course is Rs 145,000 for CHWs, Rs 75,000 for laboratory technicians, and Rs 130,000 for doctors and nurses. Over five years the total cost of the Training Program (incorporating 5 percent inflation) is Rs 3.1 million.

6.1.4.4 Integration of Tibetan System of Medicine
Objective. To promote the integration of the traditional Tibetan system of medicine within the Primary Health Care delivery system by collaborating with the network of Tibetan medicine centers operated by the Tibetan Medical and Astrological Institute.

Rationale. The traditional system of Tibetan medicine is a unique, scientific knowledge of healing, which is helping many people around the world. This system of medicine, integrated with allopathic health care facilities, can make a major contribution to a holistic approach to health care in the future.

Progress since the first IDP. The Department of Health organized a one-day workshop on the integration of the two medical systems in 1993. Both the Tibetan and the allopathic doctors spoke on the issue, and they, as well as the nurses and health workers, were encouraged to refer patients to each other in the interests of providing the best treatment and service to the Refugee Community. The Department of Health also requested the Tibetan medical doctors to make greater efforts in research relating to such diseases as hypertension and asthma, as well as medicines to improve the condition (although not cure) those TB patients who are resistant to TB drugs.

Implementation. The Department of Health plans to conduct one such seminar or workshop for one week each year.

Financial Resources. The costs of organizing one seminar or conference are Rs 120,000. The Department of Health and the Tibetan Medical and Astrological Institute will contribute Rs 20,000 towards these costs. The costs of organizing one such conference every year for five years are Rs 663,000 (incorporating 5 percent inflation), for which Rs 563,000 are being sought from donors.

6.1.5 IMPLEMENTATION

For any health care program or project community participation is extremely important. The Department of Health is not fully satisfied about the efficient and effective functioning of its on-going programs and projects mainly due to the fact that people's participation in community health programs is low. The Department is therefore taking steps to ensure that the implementing authorities at each level make efforts to ensure the community's involvement in health care programs.

Community involvement, community participation, self reliance and self determination are key elements of the Alma Ata Declaration, which envisioned health for all by the year 2000 AD. The health system developed by the Tibetan Refugee Community gives an important role to Community Health Workers and the Health Committee. This Committee is established in each Refugee Settlement and its members comprise the Settlement Officer, the Cooperative Secretary, the senior health staff from the Primary Health Care Center and the Tibetan medical clinic, representatives of the people (such as camp leaders), one representative from each of the Tibetan Youth Congress, the Tibetan Women's Association, local monasteries and local schools. The Settlement Officer is the Chair of this Committee, and he should call a meeting of the Committee at least three times a year to discuss and improve health care in the Settlement. Moreover, during visits of senior staff from the Department of Health the members of the Health Committee are always requested to meet for discussion. In addition, the health care system now demands significant fees and community contributions towards their health care (see 6.1.7 below) which is always discussed with the Health Committee.

There are three implementing agencies for the programs of the Department of Health.

- The Department of Health is responsible for planning health care programs in response to the needs of the Refugee Settlements and other Tibetan communities; for raising and channelizing funds for these programs; and for administering the entire program to the satisfaction of donors.
- The Settlement or Welfare Office takes overall responsibility for implementing the projects and the Office acts as a liaison between the Department and the concerned project area. It also acts as a catalyst in encouraging community involvement in the implementation of the project.
- The Health Care Centers with their staff of Medical Officers, Health Coordinators and Community Health Workers implement the projects on the ground by providing the necessary health care and other facilities.

To assist the Department of Health in its tasks the Tibetan Voluntary Health Association was registered under the Indian Government's Societies Act in 1993. The Association will work within the jurisdiction of the Department of Health. The objective of the Association is to strengthen and promote the health care of the Tibetans as well as people of the host countries who come for treatment to the Tibetan hospitals and PHC Centers.

Coordination of health activities is another area the Department is emphasizing. The Department has therefore divided its geographical program area into two zones, one for south and central India, and one for the north, the north-east and Nepal, with one Deputy Secretary responsible for each zone. There is a Health Coordinator or Administrator, in addition to the Medical Officer, in each of the Settlements in south India (one Coordinator is responsible for both Settlements in Bylakuppe), as well as one for the Doon Valley, one for Ladakh and one in Phendeling (Mainpat) Settlement.

6.1.6 HUMAN RESOURCES The number of staff at the Department of Health and its hospitals and PHC Centers, as well as those at the Tibetan Medical and Astrological Institute and its clinics, are given in Table 3 in the Appendix to this Chapter.

The health care system is acutely in need of skilled health personnel to carry out health care services successfully in the Health Centers. The salaries for field staff have been increased from April 1993. In addition to this the health personnel will also receive yearly and service increments as well as Provident Fund and medical benefits. The Department of Health is also short of staff at the head office, which is aggravated by the shortage of residential quarters. The human resources that the Department needs to recruit over the next five years are given in Table 6.1.6.A.

6.1.7 FINANCIAL RESOURCES For recurring expenses of the primary health care facilities it is a goal of the Health Sector to move towards self-reliance. Incomes in the Refugee Community are low and sometimes the Cooperatives are without funds, so it is very difficult to produce self-reliant Health Care Centers. To start raising some contribution from the people towards their health care the Department started charging 10 percent over the cost price of drugs for all patients who can afford it, and charging for dressing, injections and other services. The Department is now seeking much more substantial contributions of 25 percent as fees and 25 percent as local contributions towards the costs of primary health care. This system was introduced in the five large Settlements in the south in 1993 and will be extended to the three large Settlements in central India in 1994, and will then cover 56 percent of the refugee population in the Settlements. The system will be extended to other areas by the year 2000.

For the programs and projects given above, the Department of Health needs a total of Rs 107.9 million over five years. Major contributions from patients and their communities are expected for the TB Control Program and the Primary Health Care Program, and smaller contributions for the Mother and Child Health Program. The Department is also making small contributions from its own resources towards the Health Data and Evaluation Program and the Integration of the Tibetan System of Medicine Program.

The funds the Department needs to raise from outside sources for its programs over the period from 1995 to 2000 amount to Rs 79.7 million (of which Rs 8.3 million have already been raised). The remaining 20 percent (Rs 19.9 million) will be raised through fees and community contributions.

6.1.8 MONITORING AND EVALUATION The mode of monitoring and evaluating health care programs is through feedback from the Health Care Centers provided through monthly and annual reports as well as during the periodic field trips taken by the Department's staff to the project areas. In addition the Settlement Officers monitor the day to day implementation of projects. After thorough scrutiny of this feedback, the concerned Project Officer or the Assistant Project Officer reports on the outcome of the evaluation. If required further directions are sent to procure updated information.

The Department also organizes review trips to the Health Centers by non-Tibetan physicians, with emphasis on foreign doctors or public health staff who have experience in developing countries, especially in rural areas.

The improved health data on the Tibetan Refugee Community gathered under the Health Data and Evaluation Program will now greatly assist the monitoring and evaluation of many of the Department's programs and projects.

In addition the Department of Health will organize Health Review Workshops for Tibetan health personnel to review all the health care programs every two years. The first such Review Workshop was successfully conducted in 1993.

The Department submits timely progress or completion reports with audited statements of accounts to donors.

6.1.9 IMPLICATIONS FOR FREE TIBET The Department of Health's policy of primary health care integrated with the traditional system of Tibetan medicine is not only proving to be the best system of health care for the needs of the Tibetan refugees, but its operation gives valuable experience for the benefit of running a similar system in Tibet.

It is known that in urban areas in Tibet there are sufficient medical staff and hospitals both in modern allopathic medicine and in traditional medicine, but in the rural areas people have to travel for days to the nearest hospital. As the majority of the population of Tibet are agriculturalists scattered in remote villages or nomads, the primary health care system comprising health clinics and Community Health Workers linked to referral hospitals is practical and workable.

6.2 DELEK HOSPITAL

6.2.1 Background. The Tibetan Delek Hospital, which was built in 1971, first functioned as an out-patient clinic with part-time staff comprising one Administrator, one doctor, two nurses and a pharmacist-cum-peon. At the end of 1978 the Hospital was brought under the control of a newly formed Board of Directors with a new Administrator and registered as a charitable organization.

Today Delek Hospital serves patients in the Dharamsala area, irrespective of caste, creed, religion and nationality. Many of the patients who come are poor and destitute, and the Hospital provides them free food and medical care. Patients who can afford to pay are charged a nominal fee as the Hospital is run on the basis of donations and contributions. Some of the important services provided by the Hospital in 1992-93 are given in Table 5 in the Appendix to this Chapter.

6.2.2 Current Activities. Delek Hospital, as well as its branch in Mcleod Ganj, has facilities for out-patients and in-patients comprising 45 beds, an X-ray and laboratory facilities. The Hospital has also launched Primary Health Care, TB Control and health education programs not just for the Dharamsala area but also for 19 Tibetan Settlements in the State of Himachal Pradesh (H.P.), which staff of the Hospital visit at least three times a year. Since 1981 the Hospital has also been conducting yearly Community Health Worker training courses. The Hospital also has eye and dental clinic services.

6.2.3 Goals - To render medical services to Tibetans and other needy people without distinction of caste, creed, religion and nationality.- To deliver a basic health care service that can serve as a model for Tibetan Settlements.- To promote health education and other health care programs for Tibetans in the State of Himachal Pradesh.- To establish and maintain a training center for Community Health Workers.

6.2.4 Future Programs and Projects The future programs and projects of the Hospital will be coordinated with the goals and the program profile of the Department of Health. Accordingly, the programs and projects proposed for the next five years are:

6.2.4.1 Preventive Health Care Program: Community Health Care Project
: To deliver basic health care (including maternal and child health care, as well as immunization of all under fives) to the Tibetan communities in the project area, namely 19 Tibetan Settlements in the State of Himachal Pradesh (H.P.).

TB Control Project: To bring under control the problem of TB in Tibetan communities in H.P.
6.2.4.2 Curative Health Care Program
Eye Care Project: To provide eye care services to all in need in the project area and at the Hospital.

Dental Care Project: To render dental care services to all in the project area and at the Hospital.

6.2.4.3 Strengthening Organizational Capabilities
CHWs Training Project: To provide basic training for Tibetan Community Health Workers to serve the Tibetan Refugee Community in India and Nepal.

6.2.5 Human Resources. The current staff strength of the Hospital is given in Table 6 in the Appendix to this Chapter. Of these staff only the Administrator is appointed by the Central Tibetan Administration.

6.2.6 Financial Resources. The Hospital renders services to many poor and needy patients irrespective of caste, creed or color. In 1992-93 the total expenditure on programs was Rs 1.5 million, of which a major portion (43 percent) was spent on the TB Control Project. The Hospital's ongoing projects and programs are dependent on outside donations as the Hospital has little income to meet its recurring expenditures. Table 7 in the Appendix to this Chapter gives the expenses incurred by Delek Hospital in 1992-93 for different services.

The Hospital needs more financial resources to be able to run its ongoing programs and projects successfully. The total budget for the projects planned by Delek Hospital over the next five years is Rs 8.3 million (incorporating 5 percent inflation).

6.2.7 Monitoring and Evaluation. Through periodic data prepared by Hospital staff the Administrator reviews the proper implementation of projects and programs. As per the agreement signed between the Hospital and its various donors, it submits periodic reports to donors along with statements of accounts and fund utilization.

The Hospital carries out the TB Control Project in Himachal Pradesh by making periodic medical trips to the Tibetan Settlements in the State. The copies of field reports are sent to the Kashag (Cabinet) Secretariat, the Department of Health and other concerned offices.

6.3 BUDGET SUMMARY

The total budget for the second IDP is Rs 107.9 million. Rs 19.5 million (18 percent) will be raised through fees and community contributions. The remaining Rs 88.0 is being requested from donors. The Save the Children Fund (UK) has already made a commitment of Rs 17.4 million over five years towards the programs of the Health Department. Thus Rs 70.6 million are being sought for the Health Sector under this Plan.

This budget marks a significant increase over the first IDP. This increase is seen primarily in the TB Control Program, where the cost of drugs for third-line patients in particular has increased by around seven times over the last three years and more cases have been identified through the expanding coverage of the Program. Recognizing the need for greater emphasis on prevention and for more careful planning for the health sector, the Department of Health has also significantly increased the budgets for the Health Education and Health Data and Evaluation Programs. In addition, Delek Hospital is allocating more funds to its Community Health and Mother and Child Health Programs. Other programs are largely in line with the first IDP, with a few budgets being reduced slightly with more careful costing. With more hospitals and clinics providing dental and ophthalmic services, it has also been possible to reduce the budget for eye and dental camps.

PROGRAMS	YEAR (all figures in Rs '000s)					TOTAL	Request	Loans
and Projects	1995	1996	1997	1998	1999	(Rs'000)	Donors	Request
AGRICULTURE DEVELOPMENT:	11250	7750	10700	8935	10598	49232	30190	9132
land Development: Norgyeling Tenzingang	700		7400			700 7400	320 4300	0 2000
Irrigation: Jampaling Choepheling Dhargyeling Rabgyeling Lugsung Samling Phuntsokling Phendeling	1050 8300	4500 1600	1100	7685	7685 1590	1050 8300 4500 1600 1100 15369 1590	788 6640 4000 1000 550 7685 795	0 0 0 485 0 4611 477
Mechanizations: Doeguling Phuntsokling Phedeling Dargyeling		1400	2200	1250	1000	1400 2200 1250 1000	700 1106 625 500	420 264 375 300
Other: Tenzingang Orchard Phendelling Dairy Puruwala boundaries	1200	250			323	1200 250 323	1020 0 162	0 200 0
HANDICRAFT DEVELOPMENT:	2605	360	543	576	380	4404	822	1005
Dhargyeling Lama Hatta Dalhousie Lingtsang Herbertpur Manali TRSHH	205 2400	200 160	543	576	380	205 200 160 543 576 380 2400	98 0 0 218 426 80 0	0 200 80 325 100 300 0
INCOME -GENERATION:	1500	802	505	2400	600	5807	670	4005
DickyiLarsoe Mill Delekling Apples Norgyeling Godown Tengang Paper&Cane DickyiLarsoe Block Kamrao Mine Herbertpur Shop Dekyiling Shop	1160 340 205	148 449	205 300	2400	600	1160 488 600 449 205 2400 205 300	0 288 0 382 0 0 0 0	740 190 500 0 135 2100 100 240
REVOLVING LOAN FUND:	170	25170	170	170	25170	50850	0	50000
RLF Capital Staff Training Training of Aplication	70 100	70 100	70 100	70 100	25000 70 100	50000 350 500	0 0 0	50000 0 0
DEPT. OF FINANCE INVESTMENTS:	13000	14000	15000	13000	14000	69000	0	0
TOTAL:	28525	48082	26918	25081	50748	179353	31681	64142

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Last updated: 30-Sept-96