Sustainable Community-Based Health and Development Programs in Rural India

Abstract

In the broader context of Indian state’s commitment to achieve “health for all,” this chapter attempts to study the cross cutting intervention of a non government group to bring about a holistic change in the lives of the communities by uplifting their socioeconomic and health status. The success story of Khoj – a VHAI project operational in the remote rural parts of the country is discussed. The chapter tries to establish the fact that “we cannot achieve Health For All without building on the strengths of the people.” In the Khoj projects there is no concept of recipients as the community is involved in managing the development efforts, as well as figuring out how to obtain the resources needed, (locally if possible). With a vision to create an enabling climate for an overall sociopolitical development of the community in the difficult terrains of the country, Khoj begins with developing an understanding of the social, economic, cultural and political dynamics of the community, and integrates the knowledge gained with action to improve the health and well-being of community members. The chapter is divided into three parts. The first part of this chapter briefly outlines the Health Sector in India – status and trends with a focus on the health inequities in the country. The second part discusses in detail the community-centric sustainable strategy of Khoj in three difficult settings and its impact on the overall well being of the population. The final part contains major findings and concluding remarks.

Appendices

Annex: Success Stories

1.1 Towards a Culture of Preparedness and Sustainability

1.1.1 Aparajita Orissa

The super cyclone struck coastal Orissa in the year 1999 and left the households, communities and the state exposed to the disastrous impact of the calamity. The loss of lives and property could have been reduced substantially if the system of disaster management and preparedness to face natural disaster were in place at both the household and community level. This realization brought out the idea of continuing an innovative long-term development initiative for an integrated development model.

To give this idea substance and meaning, the Khoj project is being implemented in the Kujanga Block of Jagatsinghpur district. The block consists of 27 gram panchayats (local government) and 169 revenue villages. Due to its coastal location, the area is highly disaster prone.

Currently no plans have been made to establish development linkages with the disenfranchised people. Unfortunately, the government and the policy makers have yet to establish a link between disaster preparedness and poverty alleviation. Furthermore, no initiative has so far been taken to integrate relief, disaster mitigation and preparedness into normal development plans. Normal development plans are poorly formulated, too loosely integrated with other programs and haphazardly implemented.

Aparajita’s strategy, right from the onset is to strengthen the capacity of the affected community and minimize their vulnerability. Aparajita’s program focuses on livelihood restoration, healthcare, capacity building of the community, self help, coordination and networking. The provision of livelihood focused inputs had a direct bearing on the earning opportunities of the beneficiaries and accelerated their journey to economic recovery. The healthcare package developed by Aparajita empowered the community in meeting their basic healthcare needs and promoting health status of the community. The coordination and networking have helped Aparajita to avoid duplication, unhealthy competition and conflict, and helped to use its resources, time and energy to reach out to a large number of people with significant inputs.

Aparajita is continuing its efforts to develop, manage and sustain disaster mitigation, preparedness and response planning. However there is a need for implementing more systematic survival strategy and effective coping mechanism to face the future emergencies. It is felt that the Khoj based community initiative will facilitate a long term planning for hazard mitigation, preparedness and capacity building of the community.

Agriculture and animal husbandry are the main occupations of the people. Since the arable land is single cropped, it does not provide sustenance to a family for more than three to four months in a year. Therefore the male population has to migrate to other areas to work as contract labor, road construction workers or to urban areas to undertake sundry activities. Due to the absence of male members in the family, the women have to look after the agricultural activities and animal husbandry. The women also look after the aged and young members of the family, collect wood and drinking water and performing other household chores. This leaves them with little scope for taking care of their own health even during the advance stage of their pregnancy, leading to pregnancy related complications. The reach of health services is inadequate; which compel people to rely on traditional healers, quacks and diviners.

Women and child health is a major focus area of the project. The services are provided through project medical officers, auxiliary nurses, village health workers (VHWs) and trained traditional birth attendants (TBAs). During April 2005–August 2006, 176 antenatal cases were registered and 164 cases were provided complete antenatal care including tetanus immunization. Twenty-one high risk cases were identified and referred to district hospital. Total of 169 births were recorded out of which 162 were conducted by trained personnel, including trained TBAs.

To spread and disseminate the health and development messages to the community, the appropriate mode and suitable media is required. Through the information education and communication (IEC) activities, the project disseminates the development messages to the community. Street theatres and cultural groups are the major media that have been formed and trained to perform on different subjects. In all the five panchayats, these groups have performed on different issues such as mother and child health care, nutrition, sanitation, school health, environment, etc. The health awareness and education program has been attended by more than 15,000 people.

Several initiatives have been started with the SHGs to carry out and expand their livelihood program. One hundred sixty-five SHGs have been formed with a total membership of 2029. A holistic approach has been adopted to set up units of such activities where there is scope for the involvement of more number of women SHGs. Units of stitching and sewing, spices making and bamboo seasoning, and making of products have been supported through this initiative. The women SHGs are also involved in dry fish business, tent house management, agriculture, floriculture, etc.

The Khoj project essentially covers various population groups. There are specially designed program for schools as well as adolescents. The school health programme has different components to serve the health need of the school students of adolescent age group. Health promotion activities, safe drinking water, healthy sanitation conditions are maintained with the available facilities and infrastructure.

To address the specific issues of adolescents, regular monthly meetings amongst them are organized. Their need for education and awareness are very important as they are in the formative stage of their lives. Aparajita addresses these groups by dividing them into two parts, one is the school attending section through its school health program and the second one for the school drop outs. The school dropout adolescents are not only provided education and awareness on health issues; but are also provided with adequate and timely health services, vocational guidance and support to start their own group enterprises for earning livelihood. They have been formed into SHGs. There are 34 such SHGs consisting of 423 members. These groups maintain their group records and have opened banks accounts, so they have savings both in hand and in the bank.

All the initiatives under the Khoj program are regularly reviewed and assessed. Based on the feedback and suggestions of the field and core staff, the plan of action and priority area of intervention is decided.

The village level health workers have emerged as the most active health cadre in the villages of the Khoj operational area. Along with the health team of Aparajita, they are actively taking part in organizing the health activities in their respective areas. With adequate training, now they are well versed with different health issues which are commonly seen in their villages in different seasons. They are also trained to treat common diseases and provide first-aid.

Marginalised and vulnerable groups and individuals have been supported to initiate and sustain their livelihood activities. These marginalized families are identified after intensive interaction with the community, consultation with the panchayats, village leaders and community heads. After a through interaction with the family, their vulnerability is assessed. The support is extended, keeping in view the capacity of the person to take up and manage the activity. Appropriate follow up is done by the volunteers and supervisors.

A rescue equipment demonstration programme has been initiated in five panchayats of the operational areas of the Khoj programme, where five disaster shelters have been identified. These are the focal points of the gram panchayats for the purpose of disaster management and preparedness activities. Regular activities such as mock drills, meetings of disaster management team are organized in these shelters. In the previous year rescue equipments were procured and kept in these shelters.

Hema Manjari Behera, aged 45 years, belonged to a very poor family in the village Ameipala of Kendrapara district. Being part of the fisher folk community, she learnt about group cooperation from the beginning: the men would go fishing while the women would process and dry the fish for selling. When the boats and nets were damaged by the super-cyclone, the male population could not go fishing anymore and thereby women’s work was also interrupted. It became difficult to meet the needs of the families. Hema Manjari and three of her friends went to Paradeep port where bigger boats and trawlers did the fishing, but they were disappointed as the fishermen would only sell in bulk. She realized that they would have to increase their investment capacity. Hema Manjari discussed the matter in a community meeting organised by Aparajita and learnt that women of the village could be formed into self help groups (SHGs) and thus make bigger. She managed to convince all the women and thus four SHGs were formed in the village. They collected money among themselves and went to Paradeep to purchase two truckloads of fish. There was a massive activity of dry fish processing and the women learnt the process of group enterprise. They underwent training for adding value to their products by processing them in a hygienic manner. They also went for an exposure visit to the Integrated Coastal Management Institute at Kakinada. With value-added production, they were able to increase their income and profit. Hema Manjari says “our income was never enough to meet the basic needs of the family. We were not able to think about the education and health of our children. For a set of bangles and few yards of sari, we were dependent on our husbands. But today, we are earning, having our own savings. We care for our children and their future.” Khoj builds on the potential of the community and makes them self sufficient.

Aparajita, Orissa: Impact Assessment

Particulars	Base line year 2004	Year 2000	Year 2006
No. of villages	24	24	24
Health Indicators
(a) Morbidity
Diarrhoea (%)	12.5	14	5.6
ARI (%)	7.8	8.5	5.7
Malaria (%)	6	7	3.9
TB (%)	1.3	1.5	0.1
Aneamia (%)	61	68	38
(b) Mortality
IMR per 1000 live births	62	68	43
Maternal deaths(Total no. of cases)	12	14	4
(c) Maternal and ChildHealth
Complete ANC Coverage (%)	36	21	89
TT immunization	22	18	92
Primary immunization	46	41	86
Births by TBAs	32	25	76
(d) Community Organization (No. of groups)
SHGs	11	None	96
VHCs/VDCs	None	None	24 (VDC) 24 (VHC)
Youth Groups	8	4	21
Any other type of organizations. (Male SHGs)	None	None	19
(e) Income Generation Programme (IGP)
Total No. of programmes	5	5	36
Type of activities	Agriculture Fishery Goatery Poultry Petty trade	Agriculture Fishery Goatery Poultry Petty trade	Agriculture Fishery, Goatery Poultry, Handicraft Activities – Agarbati making, Spices making, Food processing, Floriculture, Vegetable Cultivation, Dairy farm, Petty trade,
(f) Capacity Building
No. of VHWs trained	None	None	52
No. of TBAs trained	21	21	58
No. of persons trained for IGPs	None	None	52
No. of participants inhealth education	No record	No record	12,345

1. ANC antenatal care, ARI acute respiratory infection, IGP income generation programme, IMR infant mortality rate, SHG self help group, TB tuberculosis, TBA traditional birth attendant, TT Tetanus, VDC Village Development Committee, VEC Village Education Committee, VHW village health worker.

Long Term Development Through Community Participation

2.1 Sambhav Social Service Organisation, Shivpuri, Madhya Pradesh

The Khoj project was initiated in 1993 in 20 villages in the Shivpuri block of Shivpuri district in Madhya Pradesh for the benefit of Saharia tribes, which belong to one of the most deprived communities in the state. The block is barely 125 km from the Gwalior city and 300 km from Delhi and yet it had remained resource poor and marginalized for years. Lack of appropriate health services and communication facilities were the major problems. Besides, there were a host of other problems including land alienation, exploitation, illiteracy, and lack of safe drinking water and sanitation. Saharias live under extreme poverty. There is rampant malnutrition especially among women and children, and alcohol was a serious social problem. The resultant effect was a self-perpetuating indebtedness. Khoj project in Shivpuri has been actively involved in the organizing Sahariya tribal communities to assert their rights of equality, health, food and secured livelihood and a respectful place in the society. Since health was a major concern, health services and health education was given top priority. Right from its inception, the project laid emphasis on a participatory approach. Various village based groups, VDCs, youth groups, SHGs, etc., were formed, duly trained and involved in the project. This gave the community a sense of ownership and confidence. While community capacity was thus being built, rapport was established with the district administration. This had a very desirable effect and the community began to demand proper health services from the government. Gradually, the ambit of health services was enlarged to include referrals, pathology tests, immunization, ante and postnatal clinics. A well developed planning and management system, with clearly defined parameters for monitoring, evaluation and a functional management information system⁶ has seen to a very efficient implementation of project.

There has been a tremendous impact of the project on the health and overall development of the people. Improvement in health care has been significant and can be judged by a constantly declining trend in the Infant Mortality Rate (IMR), which from 124 in 1993 has declined to 50 in 2003. Better antenatal and postnatal care coverage (79% as against 16% in 1993), skill enhancement trainings of Dais and better immunization coverage have reduced maternal and infant mortality rates. Now, 100% deliveries are conducted by trained personnel.

There has been an overall reduction in morbidity and mortality due to increased awareness and knowledge about various diseases, their causes, prevention and management, for example, diarrhea related morbidity is well under control and there has been a declining trend in mortality related to the same. No diarrhea deaths were reported during the previous year, against 30 in 1993. Furthermore, increased health awareness has encouraged people to come forward to seek treatment for tuberculosis (TB), which was very difficult for them earlier due to stigma attached.

Local capacity building with a view of long-term sustainability was a very important component. Thus, due emphasis was laid on local capacity building of village health workers (VHWs) and trained birth attendants (TBAs), etc. on regular basis. Village panchayats have been fully involved. Building linkages with the government departments has improved health services, encouraged peoples groups like SHGs, etc. to avail of various income generating schemes of the government. Beginning with nil in 1993 in 2003 there were 64 SHGs, 20 Mahila Mandals and 20 VDCs which helped in raising awareness about existing government schemes and facilities and raised voice for bridging the gaps. This is reflected in various memorandums submitted by people to the government. Promotional programs like education and school health, etc. have resulted in better attendance, increased health and environmental awareness.

Various village development and income generating activities like kitchen gardening; livestock farming, poultry, etc. are being implemented through the above people’s organization. New technologies have been introduced in agriculture. Mahila Mandals have created a conducive atmosphere towards gender equity and overall empowerment of women. They also take care of programmes for adolescent girls. Women actively participate in advocacy campaigns through SHGs and Shabri Mukti Morcha, etc.

After the successful completion of 10 years, to make the programme financially sustainable in future, several funds like a health fund, TB fund, and education fund were set up. There has been an increased collaboration with the government and panchayats for future support to the development programs. There is full community support for TBAs, village meetings and cultural programs, and SHGs have already made rapid advancements towards self support.

One can say with confidence that the project has entered the phase of self-sustenance with due preparation. There is now a strong network of VHWs, Dais, animators and panchayat workers. Health workers are well versed to identify common ailments, their treatment and referrals as well as disease surveillance. It has also a functional training center at Shivpuri. With years of hard work, the project enjoys very good relationship with various government departments.

Sambhav

Particulars	Baseline Year 1993	Year 2000	Year 2003
No. of villages	20	20	20
Health
(a) Morbidity % of total cases
Diarrhea %	10.8	6.5	4.6
ARI %	14.7	4.1	2.3
Malaria %	19.4	9.2	10.4
TB %	2.8	1.2	1.2
(b) Mortality % of total deaths
Deaths due to diarrhea	30	7	Nil
Deaths due to ARI	25	6	8
IMR per 1000 live births	124	64	50
Maternal deaths (Total no. of cases)	15	Nil	Nil
(c) Maternal & Child Health
Complete ANC Coverage %	16	81	79
TT immunization %	20	85	87
Primary immunization coverage %	4.9	68	78
Registration in first trimester	10	60	60
Deliveries/births	35–45% by untrained personnel	100% by trained personnel	100% by trained personnel
Community Organization
SHGs	Nil	14	64
MMs	Nil	20	20
VDCs	Nil	20	20
Capacity building
No. of VHWs trained	Nil	15	15
No. of TBAs trained	Nil	21	21
No. of people trained in health education	Nil	3219	2907
Income Generation Programs
SHG Members	Nil	267	674
Agricultural program	Nil	327	400
Goat Breeding	Nil	10	40
Poultry	Nil	95	100

1. ARI acute respiratory infection, ANC antenatal care, MM Mahila Mandal, IMR infant mortality rate, SHG self help group, TB tuberculosis, TBA traditional birth attendant, TT Tetanus, VDC Village Development Committee, VHW village health worker.