It is a holistic secondary and tertiary health care (hospital care) coverage for all Tibetans living in exile under the responsibility of the Tibetan Voluntary Health Association (TVHA), registered under the Societies Act 1860. The system is built on the Public Private Partnership model and creates a health fund across the entire Tibetan exile community. It will provide equitable and comprehensive health care coverage on a yearly basis designed to serve the health care needs of the entire exiled Tibetan community by creating a more sustainable financing source. TMS is a non-profit and charitable programme that improves the public health and well-being of the Tibetan community in exile significantly through access to quality secondary and tertiary healthcare in partnership with well-known healthcare providers while reducing financial insecurity and hardship associated with the treatment of catastrophic conditions and hospitalization. TMS will contribute towards a holistic preventive and curative system integrating both ‘SORIG’, the Tibetan traditional herbal medicine, and the allopathic medicine system in order to deliver effective and efficient health care services tailored to the needs of the Tibetan community in-exile.

Why do we need it?•

It will provide financial security to families and individuals when they face serious health problems•    Tibetan Medicare System is a non-profit and charitable programme intended to improve the healthcare services of the Tibetan community in exile.•    It will provide equitable and comprehensive health care coverage to families and individuals who are enrolled in this system•    CTA will not provide any other subsidy for health after this scheme starts

Who are eligible to receive the benefits?

All Tibetan people in exile in India can enrol in the TMS and are eligible to receive the benefits.

How much to pay and what is covered?

In the years 2021-2022, For a family of up to five, there are two categories and one is subsidized and non-subsidized. For subsidized, a household plan implies that all benefits available under TMS can be availed by any member of the household individually or collectively or collectively up to the maximum household cap allotted on a floater basis. The annual contribution for a household plan of a subsidized category is INR 1950 and INR 390 for each additional member on a yearly basis as a contribution. Likewise for the non-subsidized, it is INR 3900 and INR 780. This includes the cost of the medicines prescribed and bought within one month of discharge from the hospital. Individuals who are without a family can opt for individual coverage by paying a contribution of INR 995 for non-subsidized members and for subsidized members it is INR490. For this contribution, an individual would get a cashless benefit of up to INR 120,000 for hospitalization expenses at selected hospitals. This includes the cost of the medicines prescribed and bought within one month of discharge from the hospital.

How to enrol?

You can enrol at the hospital or the health care centre of the Department of Health, CTA, in your settlement. If there is no health care centre, enrollment can be done at the office of the Representative or Welfare Officer. A TMS member has the following responsibilities:•    Attend a meeting or get information on Tibetan Medicare System•    Make a decision on enrollment•    Fill out the enrollment form with the help of an enrollment officer who could be anyone of (Representative, Welfare officer, Doctor, Executive secretary, Health worker, camp leader etc.) •    Submit the form with contribution amount and ID card charge to the enrollment officer•    Verify the accuracy of the information given on your ID card and inform to the enrollment officer if there’s any mistake•    Sign the “Received ID Card” sheet.

How to claim benefits?

In case of sickness, approach the hospital or health care centre of the Department of Health, CTA, or traditional Tibetan medical centre in the settlement. If there are no health centres at the settlement, then go to a designated primary care provider; in case there is a referral, take the referral slip from the first health care centre or hospital and must go only to the referred hospital. The cashless claim payment would be made to the empanelled or network hospitals on a regular basis for all the TMS member patients to whom they have provided the service. But ensure that you carry your TMS ID card for the cashless transaction for the hospitalization. Claim reimbursement will be made only in case of emergencies, where an insured person is not able to reach a designated provider in time and goes to some other provider because of an emergency.  After discharge from the hospital, all the original documents should be submitted to the Representative/Welfare officer/Executive secretary of the settlement for the reimbursement of the claim. Once you are admitted to any of the designated hospitals;•    Show your TMS ID card to prove that you are a member.•    The management in the hospital will match your fingerprint.•    The cashless transaction will start once the identification is matched.•    Please ensure that the treatment you receive and the treatment billed by the hospital match. Inform your primary care provider or settlement officer if you have doubts.•    The balance amount on the card will be shown either on the screen or in written form after each usage.•    During an emergency, enrolled members can be admitted to the nearest non-network hospital to save a life. But one has to inform the concerned enrollment officer within 24 hours of admission to that hospital. Claim will not be entertained in the following cases:1.    Submission of unnecessary or excess bills.2.    Any treatment related to alcohol and substance abuse.3.    Cost related to birth control or pregnancy prevention.4.    Vaccination (Included in primary health care services).5.    Cost of injuries related with fighting.6.    Treatment after attempting suicide. Any other health cost not covered under the TMS.

Introduction

In the wake of the Chinese occupation of Tibet in 1959, His Holiness the Dalai Lama, the Spiritual Leader of Tibet, and about 85000 Tibetan followers, escaped Tibet and sought refuge or political asylum in India. Later, with the strengthening of the Chinese policy in 1987-88, Massive Political Uprisings erupted in Tibet where Tibetan people took to the streets of Lhasa, the Capital City of Tibet, to voice against the hegemonic Chinese Regime, only to be crushed by them mercilessly resulted in mental and physical trauma. Therefore, this program was initiated in response to the immense tyrannical and oppressive policies of Red Communist China, leading to an influx of a large number of Tibetans into India.

Year of Establishment

The Tibetan Torture Survivors’ Program-A special Component under the Department of Health, Central Tibetan Administration-though started in the early 1990s was launched as a full-fledged Program with proper staffing only in October 1996 after the approval of the two major projects: Tibetan Danida Project and Tibetan IPSER/ TPO Project.

Interdisciplinary Approach (Composition and Primary Objectives):

TTSP is headed by a Program Officer who holds the managerial task of administering the proper functioning of the Program and it is a multi-disciplinary forum comprising a team of Tibetan Traditional Doctors, Spiritual Advisor/ Consultant, Allopathic Doctors, Expatriate Psychologists & Doctors and Social Workers to cater to the Psycho-social and Mental Health Care needs of Clients through a collective, integrated system of both the Tibetan Traditional Medicine and Modern Allopathic Medicine, aimed towards this end. The Program undertakes the overall responsibility of looking after the Tibetan victims of torture who have endured severe forms of trauma, and it seeks to reduce physical, psychosocial and psychological sequel resulting from organized violence and politically motivated torture in Tibet.

Main Activities (Treatment)

TTSP provides cost-free medical and psychological assistance to Tibetan victims of torture and other forms of political repression. The mode of treatment is both Tibetan Traditional Medicine and Modern Allopathic medicine, depending upon the choice of the Clients. The cases which cannot be handled by TTSP or in case of any complications are referred to more advanced Indian Hospitals after the recommendation of Consultant Doctors. All medical expenses, including travelling expenses and daily allowances, are borne by this Program.

Rehabilitation:

One of the sole underlying objectives of this Program is to stabilize and rehabilitate these people in a new socio-cultural environment. In the process of rehabilitation, the clients are offered services/assistance such as social support in the form of monthly allowances, stipends, housing allowances and rehabilitation of torture survivors who are too old to work, as well as vocational or skill training to physically able to make them capable of self-supporting and self-reliant after a few years of help from this program.

Training Program

Health personnel are educated and trained regarding Counseling Methods and Psycho- therapy mainly focused on carrying out basic methods of intervention, Identification, Treatment and Management of traumatized people in general.  The first round of training has been successfully accomplished during the last two years and our future endeavour will emphasize Refresher Courses and training of Trainers, forming the core group of trainers to train the Community Health Workers (CHWs) in the Primary Health Hospitals and Centers in various Tibetan Settlements in India and Nepal. The team members also participate in scientific activities such as Seminars, Discussions and Conferences.

Resources Funding

As the work began, the treatment and medical requirements of newly arrived Tibetan Refugees were met by the “Emergency Medical Relief Fund, EMRF” of the Department of Health, Central Tibetan Administration of His Holiness the Dalai Lama. Besides securing sponsorships from some Organizations for individual torture survivors and funds from individual sponsors, the Tibetan Torture Survivors’ Program is able to obtain funds for treatment and livelihood training through two major projects funded by USAID (United States Agency International Development) and Les Amis DU Tibet, LUXEMBOURG. Besides these two projects, we also have some other donors who support torture survivors viz. Stitching Namgyal (Holland) who generously sponsors some of our torture survivors and the Tibetan Snow Lion Friendship Society of Japan have also donated used Clothes, which is a great help to the victims and their families.

Case Referral System:

Due to a lack of financial resources, the services are available to those new arrivals from Tibet who experienced mental and physical torture. However, in the coming years, as we attain maturity or move towards self-sufficiency, we hope to expand our services to all traumatized refugees in general, irrespective of whether he/ she is a political prisoners or not.

Plans:

The TTSP plans to take care of at least 40 torture survivors each year and is working towards gradually integrating this new system into a Community-based Health Care System. Early efforts concentrated mainly on the treatment process, but it has now become increasingly evident that efforts must also focus on raising funds and providing social support. We are also planning for our Indigenous Treatment Method or Spiritual Healing session to have a greater role to play in seeking to address the psychological problems of torture survivors along with religious or spiritual intervention. To this effect, the team has already established contact with one of the senior Buddhist monks to participate in the Group therapy.

Special project desks of the department include the provision of safe drinking water, construction of public and individual toilets, provision of equipment at the health centres, construction of health centres, repair and maintenance of the health centres and provision of ambulances to the hospitals etc. Since the inception of this program, it has benefited over 700 victims. With the immigration program of Tibetan torture victims to Australia currently in 2020 we are supporting eight torture victims.

Drinking Water

Water being the fundamental source of life can also be the key source of various infections. As per WHO guidelines, the department has made it a top priority to provide safe drinking water. The Department continues to build water tanks, drill bore wells, hand pumps and install pipelines to supply water to the public taking the local conditions into account. The department has been supporting the drilling of bore wells to set up underground water supplies in various settlements based on water sources showing every sensitivity toward the water table. The department advocates recharge scheme and roof water harvesting as far as possible and constantly provide training on water management, cleaning system and chlorination of water from time to time to provide safe drinking water.

The Department with the hired expertise from AFPRO, SPACE GEO TECH and other hydrological institutions conduct geophysical and hydrological investigation and survey to sustain any new project. The department also encourages all the settlements to conduct water quality analysis at respective settlements as frequently as possible.

Sanitation

By the WHO definition, “sanitation is safe management of human excreta and includes the provision of latrines and promotion of personal hygiene”. Thus in the light of controlling infectious diseases such as diarrhoea, malaria and so on, the Department of Health funds numerous toilet projects, both public and household, in all Tibetan communities. The desk also supports sanitary infrastructures like the construction of drainage systems, septic tanks and garbage disposals. The main objective of the program is to prevent diseases and support Tibetan people with basic health care needs.

The department of health under the guidelines laid down by Kashag collects some contributions from the beneficiaries to ensure individual ownership as well as the sustainability of the project.

Disable and destitute welfare program

Under the guidelines laid down by the Kashag, Central Poverty Alleviation Committee was formed and conducted an intensive survey among exiled Tibetan population. The reports of the committee were further reviewed by the Review Committee Members of the Tibetan Parliament in Exile. The destitute were categorized among four groups to be taken care of by three concerned departments: home, education and health. So far as of 2021, 268 cases fall under the jurisdiction of the health department.

As per Kashag’s policy and guidelines, the Department of Health provides a monthly stipend and bears all the medical expenses of the poor and needy Tibetan people identified by the committee.

Besides, the department undertook a major survey on physically challenged people in the Tibetan community in exile in 2002. The survey identified 406 people facing severe challenges relating to speech, mental, visual, hearing, physical movement, and epilepsy. To look after the welfare of these people at their own respective settlements, the department has established 11 rehabilitation committees in 11 different settlements. To further elevate the capacity of the concerned staff to deal with such a population, the department provides training to community health workers (CHWs) from different Tibetan Settlements on Disabled Management. The trained CHWs should be included compulsorily in the above-said committees to give guidelines and ideas to the members. The department provides stipends to around 98 differently abled Tibetan people to meet their medical expenses and bears the expenses of aid and appliances devices like wheelchairs, hearing aids, leg braces etc.

The Department of Health has recently introduced Community Based Rehabilitation Program (CBR) in our settlements to give extra care to our disabled people and to make them self-sustainable through rehabilitation.

The Department of Health is currently working towards the integration of traditional Tibetan medicine with the allopathic medical approach in order to provide maximum benefits. It works to increase the frequency of the referral process between the two healthcare systems, the medicines of which run parallel to each other and are used equally by the people.

Mental Program

After a few studies regarding mental health in the early 1990s, the Department of Health felt the need to implement a primary mental health care program to solve the problems of individuals or families in the community. Therefore, the community health workers are provided with basic training on mental health care and the selected mental health field workers are given intensive training on mental health. References are made to local Indian physicians and psychiatrists if further medication is felt necessary. In addition to psychotherapy, the Department conducts training, gives refresher courses and mental health awareness talks in the communities from time to time.

Under this program, Department takes care of the mental and epilepsy patients. The Department reimburses 50% of the mental expenses to all the patients and 100% to those registered under CTA destitute list. The Department also provides more than fifty per cent of reimbursement to those having special recommendations from the respective Representative Office. To date as of 2021, 200 mental health beneficiaries which also include Epilepsy patients from various Tibetan settlements rolled up in the program and continue to benefit from it.

Viral Hepatitis Program

Hepatitis B infection is caused by the hepatitis B virus (HBV), an enveloped DNA virus that infects the liver, causing hepatocellular necrosis and inflammation. Among the communicable diseases, hepatitis B and tuberculosis (TB) are the two diseases that plaque the Tibetan Refugee communities living in India & Nepal. The prevalence of hepatitis B is estimated to be much higher among the Tibetan refugee population living in the Indian subcontinent as compared to the local host population. The findings from a study carried out in the Bylakuppe Tibetan settlement in South India jointly by DoHe-CTA and Johns Hopkins University (JHU) in 2014 suggest that Tibetans living in India has about 9 % prevalence of chronic Hepatitis B infection.

DoHe-CTA has been working in the area of hepatitis B with a focus on prevention; the key intervention strategy being the universal vaccination against hepatitis B virus for under-5 children and the prevention of new infection through three/four dose hepatitis B and they will continue to be the key intervention strategies.

Screening for Hepatitis B infection results in the identification of people with chronic hepatitis B infection who are undiagnosed earlier. With funding support from the US PRM Department of Health, CTA has started Hepatitis B screening, vaccination and Treatment support for Tibetans in India. In 2019, a people of about 11000 has been screened for Hepatitis B and C.

CCOCC Program

Primary health accounts for 70-80% of health problems and the burden of health expenditure on any given society. These issues may be further lowered by initiating targeted preventive healthcare in the community.

A key finding of the Tibetan health system assessment was the underutilization and limited reach of DOH facilities, large due to the lack of an effective community outreach strategy because Tibetans in South Asia are highly mobile and often seek health care outside DOH facilities; DOH has partial information about the health status and health-seeking behaviours of the community it serves.

One of the most effective mechanisms of preventive and primary health service is through effective community outreach programs. Community Outreach is an activity of providing services to any population who might not otherwise have access to those services. The practice of offering support to community members. A key component of outreach is that the groups providing it are not stationary but mobile; in other words, they are meeting those in need of outreach services at the locations where those in need are. In addition to delivering services, outreach has an educational role and raising awareness of existing services. Community outreach provides a basket of health services to the community to ensure health services and information that should reach each and every one. The CCOCC program particularly delivers primary and preventive health services for the community.

Objectives for Community Outreach

• Comprehensive coverage of community – facility visitors & non-visitors
• Complete health information coverage
• Information on community health profile
• Early detection and care – lifestyle and infections
• Proactive behaviour change – Education and knowledge about emerging health issues
• Continued care and follow-up

The nurses and Community health workers who are the backbone of the CCOCC program continue to carry out outreach activities in settlements of India and Nepal. Services offered during outreach visits include household visits, home-based diagnostic services, Carry out Surveys, data collection and provide medication support and referral.

During visits, they follow up on ANC, PNC, Immunization, TB, Hepatitis B and other symptomatic ailments. The nurses also provide doorstep health awareness with education tools like Pico projector, Flipcharts, Tablet etc.