Reflections from India: Empowerment through healthcare

I’ve been at the Comprehensive Rural Health Project (CRHP) campus in Jamkhed, India for 6 days now, and my brain is bursting with new information. CRHP has been working with the rural poor since its inception in 1971, over 40 years ago. Its founders, Drs. Raj and Mabelle Arole, developed a model of community-based primary health care that is designed to improve health among the poorest of the poor by addressing the social and economic factors that limit access to health in impoverished and marginalized communities.

More than a broad model of healthcare, the Jamkhed Model is based on the specific voiced needs of the community, and is dependent upon the participation and engagement of the community members to bring health to their own village. Fundamentally, it is a grassroots model that empowers individuals to take health into their own hands, endowing them with the knowledge and training to be self-sustainable rather than relying on the government or well-meaning organizations for support. In so doing, people are empowered individually and collectively to improve health not only directly, but also indirectly by eliminating the injustices of poverty, caste and gender discrimination, stigma, and marginalization that serve as barriers to leading fulfilling, healthy lives. (Read more about India’s caste system, one of the longest suriving systems of social discrimination.) While the Jamkhed Model does include curative medicine for those in need, it predominantly focuses on preventive methods that target the root causes of common diseases rather than simply placing a bandaid on the symptoms when they arise. (The history of the Jamkhed Model is fascinating; check out this book to learn about it from the Aroles themselves.)

The CRHP campus in Jamkhed, India

 

When CRHP began working in Jamkhed in 1971, the primary health problem to be addressed was malnutrition, in addition to diarrhea, cholera, tuberculosis, and leprosy, which resulted in being shunned from the community. Infant mortality rates, often used as the marker of the health of a population, were astronomically high, with 176 of every 1000 newborns not surviving. (To give you some context, during that same time period Singapore had a rate of about 19/1000, Mexico was approximately 69/1000, the Western Sahara was 160/1000, and India as a whole country – not just Jamkhed – was 116/100. If you’re wondering about the U.S., here’s an interesting article.) Since that time, CRHP has worked with over 280 villages, and the statistics, obtained from CRHP annual reports, speak for themselves. In these villages:

• Malnutrition has been virtually eradicated, dropping from 40% in 1971 to less than 5% in 2014
• The infant mortality rate has fallen from 176 to 16 of every 1000 live births (by comparison, the overall rate of infant mortality in India as a country is still high, at 56 of every 1000 live births)
• Safe deliveries, which occurred less than 5% of the time in 1971, are now at 100%
• 99% of children are immunized against preventible diseases like DPT and polio, as compared to 5% in 1971
• Diarrhea is treated easily with home remedies
• Tuberculosis and cholera are no longer present
• Leprosy has decreased in number and is no longer stigmatized, receiving appropriate care while being integrated into the community (which is not the case in many other villages in India)

This success has been achieved through a system in which the villagers themselves are responsible for the wellbeing of their community, and have implemented practices of healthcare, sanitation, agriculture, and income generation that have improved their health and livelihood. With the containment of these primary health concerns, a new era has emerged over the past two decades, with a focus on diabetes, HIV/AIDS, high blood pressure, and mental health.

So how does it work? The Jamkhed model operates from a three-tiered system that involves the village itself, a hospital and training center, and a mobile health team that provides a bridge between the two. A brief overview:

 

The Jamkhed Model, from the CRHP 2013-2014 Annual Report

The village. The most critical component of the Jamkhed model is the Village Health Worker (VHW), who is a local woman selected by her village to receive training from CRHP to deliver health services to the village. Typically illiterate and low caste, she is empowered with knowledge and skills that enable her to be an agent of change who can address the majority of health concerns within her village, and provide health education and prevention services to the individuals and community. She uses tools and methods that are accessible, affordable, and sustainable for the context in which she and her community live, integrating modern techniques with traditional practices that have medical merit. The VHWs are supported in the village by community groups, including the Farmers Clubs and Self-Help/Women’s Groups. Farmers Clubs are comprised of village men from different castes who answer community needs with initiatives such as developing safe water practices, sustainable agriculture, and actively supporting the empowerment of women to shift social attitudes. The Self-Help and Women’s Groups represent grassroots efforts of women to build economic independence, foster self-esteem and self-confidence, and spread knowledge to the community.

The mobile health team. The mobile health team is comprised of doctors, nurses, social workers, paramedical workers, coordinators of men’s and women’s groups, and the director of field operations. These individuals serve as liaisons between the hospital and the village, ensuring that a two-way exchange of information and knowledge about the needs of the community takes place. The MHT makes regular trips to each village, visiting patients who need follow-ups, accompanying patients to and from the hospital if need be, providing specialty clinics (e.g. if a podiatrist is on the team, there will be foot clinics; ophthalmologist, eye clinics), and promoting health education.

The hospital and training center. Once the village, with the assistance of the mobile health team, has become a self-sustaining system supporting its own health and development, the hospital can be a resource used as a secondary healthcare facility. It is equipped with the necessary equipment and medical expertise to complete complex procedures, operations, x-rays, deliveries, intensive care and pharmaceutical distribution. With the majority of preventable illnesses managed by the village itself, the hospital remains cost-effective, with time and resources allocated to those who are in need of these specialized services. Located on the CRHP campus with the hospital is the training center, which regularly holds initial and follow-up routine trainings for VHWs, as well as education and research facilities for national and international healthcare students and professionals.

Importantly, the work of CRHP and the Jamkhed Model is not limited to Jamkhed, India. According to CRHP’s website, their work has been brought to 178 countries around the world. Internationally, they have trained over 2,700 individuals across a number of publich health sectors, including healthcare, government, and NGOs.  Throughout India, their training numbers have reached over 22,000.

There is much more to write about this model, which I hope to do over the coming weeks. What I have learned, above all else, is that this system only works because it is founded in the principles of equity, empowerment, and integration. These principles mean that this model is a partnership between CRHP and the villages – the VHWs are not employees, and CRHP does not decide what is best for the community; the village and the individuals within it are the agents of change. It is built on trust, transparency, and complete access of all individuals to all levels of the three-tiered system. Most importantly, the principles command an understanding that all human beings – especially those who have been oppressed, mistreated, and ignored – are to be treated with care, dignity, and respect.

Note: I hope to update this when I return to provide access to some of the research and articles about CRHP that highlight the impact of the Jamkhed Model both in India and in communities around the world. In the meantime, the CRHP website and blog provide a wealth of resources, as well as the latest news about the activities of the staff, interns, and volunteers.