Halos and health insurance
Helen Angel is developing a microfinance health insurance scheme in Kerala, India
Helen Angel is a GP who graduated from Queen’s University, Belfast. She has a masters degree in public health in developing countries from the London School of Hygiene and Tropical Medicine, and has spent most of her career working in developing countries. After a career break to raise her family, she has returned to working as a GP before moving to Kerala, India, where she is developing a microfinance based health insurance scheme.
You have worked in many places around the world, including the Solomon Islands, Nepal, Rajasthan, and Israel. Did you foresee such an international career as a medical student?
I decided to study medicine with a view to work in developing countries when I was a teenager, aged about 14. I read about poverty in other countries and felt that there was something not right—that I lived in a wealthy country and had a good education, while people in many other parts of the world didn’t have that opportunity. I wanted to share what I had with those who didn’t have it. I was interested in people and why they do things the way they do so I first looked at psychology, but in those days that field wasn’t well developed so I decided on medicine, which gave me a practical with which skill to help people.
Have you had any experiences that have been particularly eye opening?
I worked in very different environments—for example, I spent five years in the Solomon Islands in the South Pacific where equality was important. In a village there might be about 200 people, but they are all related to one another and own all the land in common, so everything belongs to one community. When they started to have shops, villagers would just come and take things because they didn’t understand it didn’t belong to everybody. Community was important, as was shared decision making. However, in India, hierarchy is important because of the caste and government system. I think this is why there is so much poverty in India, because people are not respected as equal.
I think another thing that was an eye opener for me was that in the Solomon Islands in the 80s, the islanders had no high blood pressure, heart disease, or diabetes no matter what age they were. They ate fresh food from the farms and fish fresh from the sea. This has made me passionate about nutrition and having a healthy diet, and this is why we are trying to introduce good nutrition and healthy diet in India. But it’s much needed all over the world as developing countries are seeing these diseases grow at an exponential rate.
Another eye opening experience was when I was a medical officer in the Solomon islands. I was head of the healthcare system in my area and running several clinics. We had little money to spend on healthcare, so we had to make it efficient. When I came back to the United Kingdom, I was appalled by the waste of money and resources—for example, annual budgeting cycles where at the end of the year you have to use up any money left over to get money for the next year. Also, finance should support healthcare not control it. We could improve our organisation and priorities in the NHS.
Why did you decide to stop working as a GP in Essex and go to India and start your current project?
I loved general practice. Many of my projects have been away from patient care, but I love taking care of people all day. Still, I felt the need to do something on a bigger scale, to change poverty and poor healthcare in other countries. I was asked to help with developing a health insurance scheme, as I had just done a course in microfinance. It has so much potential to make a difference. This microfinance project is under the spiritual leadership of Amma Sri Mata Amritananadamayi Devi, a renowned humanitarian and spiritual leader. I met her 17 years ago when I was very ill, and she helped and inspired me so much in my life.
Can you explain more about the microfinance scheme?
The problem is that in government provided healthcare, doctors are seeing 200 to 300 patients per day—that’s one minute per patient. The government is doing its best, but people go to private care to get better healthcare, which means they can spend a lot of money quickly if it is a serious illness. They need a health insurance scheme, but commercial health insurance is expensive, so we are developing our own insurance scheme.
We have 100 000 women in “Amritasree” self-help microfinance groups. Microfinance schemes offer loans at reasonable rates to poor people, who are responsible as groups for repaying the loans. It has been found that poor people are good at repaying loans. Through the scheme they get training to set up small group businesses. They can take loans to get their business started which helps them earn their own money to repay the loan. This means that women can have some financial independence from their husbands and earn extra income for the family. Women are particularly good at spending the extra income for the health and well-being of their family. They tell me that the Amritasree groups have given them a whole new support system and confidence that they can work together to overcome problems, so it’s made a big difference to their lives.
The government of India has made an agreement with the national banks to give savings and loans to microfinance schemes. However, we are looking running savings and loans internally within the organisation, so that the women keep the interest from the loans, which would then be used to finance a health insurance scheme for the women and their families. The Sri Lankan Women’s Cooperative has developed like this over the past 25 years, starting with eight women. They now have 80 000 women and run their own insurance system. Their representatives are coming to Kerala for a couple of weeks to assist us and train our women.
Does your medical experience help you in coordinating the efforts to set up the insurance scheme?
Yes. You need to have financial people, but you also need an understanding of the medical side of things. The women have to reduce costs when running their own health insurance scheme. They need to use the medical services efficiently—that is, to treat minor issues at home or through government services, but also know the early signs of serious disease so that they can get help quickly and prevent complications. You need experience in healthcare to tell people how to use it most efficiently. Secondly, prevention of illness is important, which I’m particularly interested in. For this, you need to have an overview of health. Working with different organisations I have found that doctors, particularly GPs, have a connection with people and the reality of the situation, which administrators will not have no matter what training they have. They never have that real understanding of what the issues are in healthcare.
The Amritasree programme wants women to be the leaders in developing a health insurance scheme. Why?
It has been found everywhere that if you work through the women the benefits go to the family. That has been experienced all over the world, whether it is to do with educating women or microfinance with women. They also repay the loans better and what money they use, they use for their family, not on alcohol or smoking. It’s time for women to make a difference, in their own homes and in caring for each other, which is what they do so well.
Have you worked as a doctor in India?
I worked for a short time at Amma’s [Amma Sri Mata Amritananadamayi Devi’s] hospital in Kerala, but I can’t speak the local language and there are enough local doctors so it wasn’t worthwhile getting a translator for me. In India there are many doctors and there isn’t a need for outsiders to come in unless you know the language and culture well. However, we can have inputs in different ways, by sharing our methods of doing medicine, and perhaps influencing and sharing our experiences with the health system here.
What do you think about combining a family and a career in medicine?
I find that having children is a full time job, and being a doctor is a full time job, so I stopped working when I had my daughter. I delayed having a family until I was 41 because I thought I couldn’t do both, and I was dedicated to my work. When I had my daughter I stopped work and went back to part time when she was 14. Even then, she noticed that my priorities and my attention had shifted.
What do you think of medical students going on electives in developing countries? Can they make a difference?
I think medical students get their eyes opened being on electives. Whatever country they go to, they are going to learn about different cultures and ways of practising medicine, and understand that the way they’ve learnt to do things is not the only way. They will be able to reflect on what we do well and what we don’t, how we can improve our systems and how we can improve healthcare. Going on elective made a huge difference to me, because I wanted to work overseas, but I had never been in a developing country. I went as medical student to work with one doctor in a 120 bed hospital in a remote area in Malawi, and I learnt so much in a short time. It made me sure that being a doctor was really what I wanted to do. I was a bit bored as a medical student—too much learning—but once I started working it all changed because treating patients is always interesting, challenging, and engages your heart and mind.
Can you make a difference as a medical student?
We did—we were able to run ward rounds, so that the doctor who was there was able to look after another sub-clinic for a day or two while we helped out in the hospital. In many cases you may not be able to make a huge difference, but in some places you will.
Part of the mission of the insurance programme is to “include awareness of the physical, emotional, mental, social, environmental and spiritual health, health promotion, and education.”
Is medical practice too narrow in its scope?
Oh yes. The World Health Organization has said that health isn’t the absence of illness, but total wellbeing. It is our job to treat illness, but we could do a lot more to make people healthy, and a lot of that is emotional, mental, and environmental. Emotional stress and emotional lack of wellbeing affect the physical body tremendously.
Diet is also important. One island in the South Pacific had no diabetes, but then a phosphate source was found and the island turned into a mine. People didn’t have to work any more, and instead of growing vegetables and fishing they imported all their food and even water, and now 60% of them have diabetes. I think as doctors we are in a special position, with people coming to us when they have health problems, and we can have a great role in helping people to be healthier. We also have a role in society, and I think we should take up more of a role to advocate better nutrition, and better emotional and spiritual wellbeing.
- Amrita self help groups www.amritasree.com/
- Barua N. One woman show. Student BMJ 2004;12:1-44.
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2013;21:f5796