Education for Health Care
Mrs. Yogini Dolke, SRUJAN, Mangurda

Nirutta Atram, a mother of two resides on one of the Kolam Poad (hamlets) in the Zari-Jamni block of Yavatmal district. Educated up to fourth standard in an ashram school, she was the only literate women from the Kolam community ready to take up the responsibility of being a village health worker from her hamlet. As the VHW, she would have to cater to the health needs of people in her hamlet as well as in two neighboring hamlets.

In the early years, Nirutta was often not informed about baby deliveries nor did anyone come on their own to seek her services. The elderly men and women in her community did not believe that any human efforts could help in saving a new born baby’s life or cure an ailment. Gaining the confidence of her own community members and changing their beliefs and practices has been an uphill task for Nirutta.

Regular visits to the hamlets to distribute medicines to those with various minor ailments, diagnosis and treatment of pneumonia for children under five years of age, regular visits to new-born infants in the neo-natal period has made her one of the most sought after persons now. But regular visits and service provision alone weren’t the key to the changed faith and practices of the community members. The most important part has been the continuous health education on different issues undertaken by Niruttta at the community , family and individual levels.

Nirutta is one of the 32 village health workers volunteering their services under the guidance of the local NGO, Srujan, that has been working in the tribal belt of Yavatmal district since 1998. Srujan’s work is concentrated in the 5 tribal blocks of Yavatmal district particularly amongst the Gond, Kolam, Andh and Pardhan communities that reside in this region. Amongst them Kolam is a member of Particularly Vulnerable Tribal Group (PTG) as categorized by the Planning commission of India in 1961. The PTGs are vulnerable as their population is stagnant or is declining with high infant and maternal mortality rates, and with literacy rates tending towards zero. They are in a pre-agricultural stage of technology, with hunting and food gathering as their primary source of livelihood.

A survey done by Srujan in 1998-2000 on child deaths showed that 96% of the babies were delivered at home in the presence of the traditional birth attendants. The child mortality rate in this area was 110 child deaths per 1000 live births per year. The neo-natal mortality rate was 61. Child survival is one of the most sensitive indicators of human welfare and the effectiveness of public policies. It helps to understand the socio-economic, cultural and political situation, the ineffectiveness of the long list of welfare programmes for the tribal in Yavatmal district. The health care system along with other systems like the education system and other governance systems seemed to have been equally ineffective and inaccessible to the most marginalized section of the society here. Strengthening the local communities to make these systems effective and workable was the best way to make change sustainable.

Community involvement – a key to success
For the Kolam community a new born child’s death was a common phenomenon. So when the Srujan volunteers started sharing the child death survey results with the community members, nothing seemed strange to them. It was only when the linkages of these high mortalities with non-accessible health care services and most of the basic amenities, inadequate nutrition to mothers, the traditional believes and practices regarding child bearing and child rearing were pointed out that people began to look at it as a systemic failure and not just as a divine curse.

However, providing health care is believed to be a doctor’s job. Srujan wanted to introduce the idea that the village need not depend on a professional doctor for basic services and preventive health care, but that women from the village itself could be trained to work as a primary health care provider.
It was essential that the community accept the person and the services she was to provide to the villagers.

At each stage of this experiment the villagers were taken into confidence. Though reluctantly, they gave their consent to the concept of a village woman to be trained as a health worker. A visit of the village heads and community leaders to SEARCH, Gadchiroli also helped in building their confidence. SEARCH has been working on community health care to the tribes of the Gadchiroli district in Maharashtra, since 1985. Since its inception it has been involved training village health workers and traditional birth attendants to manage reproductive and child health related issues. It has also worked on alcoholism and alcohol policy, deforestation, and tribal development in the region.

After two years of initiating the experiment, now these elders and villagers use the data of the six monthly bi-annual child death surveys to question the local authorities and the political leaders about inactions to improve the health situation in their villages and hamlets.

Empowering the women
A strategy for sustainable development is to seek local solutions. Selecting a village woman as health service provider was one step towards the goal of finding local and sustainable solutions.

Married women with basic reading and writing abilities were selected as health workers and continuous training for one year was imparted to them in a step-ladder manner.

The first phase of training was rather difficult as the VHWs were out of touch with books, reading and writing skills. Thus their primary abilities of reading and writing had to be updated and sharpened. The training phase was spread over a year. An assessment of learning was done as part of every training event. After each training the VHWs would go back to their villages, practice the skills taught and come back for the next training with her experiences, problems and triumphs.

As the training and experiment progressed, the VHWs (village health worker) flowered from being ‘common village women’ to confident, committed, more respected and sought after persons in their villages. Most of them are now members of village committees for health, Jalswarajya, the NREGA. The VHW is the new role model for the young girls in the village.

Empowering the Community
Acceptance of the concept that the lives of new-born babies could be saved by trained village health workers has been successfully done. This is all the more important for the Particularly Vulnerable Tribal Groups (PTGs) as their population is already stagnant and declining. Every new-baby’s life saved is like saving a community from extinction.

But saving a new born life is not just a matter of diagnosis and treatment at the village level and referral services offered by the VHW. The community also has to look at its own knowledge, beliefs and practices critically and consider the need for changes in practices and beliefs that are hundreds of year old, if they are not relevant in the current context. An equally critical look is needed at the various developmental schemes available for tribal development, with utilization of those that are relevant and rejection of non-relevant ones.

Another important aspect is the ability to see the interrelation of the high incidence of child deaths with local social and physical conditions - like low literacy, lack of potable drinking water, unhygienic conditions in the village, lack of sanitation facilities, lack of employment opportunities through out the year, the processes of planning, monitoring, management and conservation of the natural resources - being able to see all these aspects as the visible signs of food and nutrition security culminating into the high child morbidity and mortality rates.

One way of increasing community participation in the local development process is regular sharing of information. This often triggers discussions and debates in the village for alternative solutions to the problems. As solutions are locally sought and decisions taken after thorough discussions there is a sense of ownership.

To address the issue of food and nutrition security, the villages have started to consider local nutritious vegetables and fruits, one step processing of non-timber forest produces like honey, and a number of nutritious preparations using the Mahua flower.

Changed Scenario

A survey of the knowledge and practices at the initial period helped in understanding the health education needs of these communities.

Based on the findings, the work patterns of the VHWs were drawn up. The VHW is regularly in touch with the families as she goes from house to house initially to make a list of pregnant women in the community and latter on to update it. She also occasionally conducts group activities for health education such as film or slide shows and discussions. Home visits to meet the mother and her family member - thrice during pregnancy and once on the second day after delivery - have helped in slowly changing the knowledge and practices in new-born health care.

The impact of services provided by the VHW on the health seeking behavior and change in beliefs and practices are:

  • The number of pregnant women to receive all three health education has gone up from 42% in the first year of intervention to 91% after five years.

  • The number of women taking iron folic acid tablets in pregnancy has gone up from 27% to 81%.

  • Presence of VHW during delivery went up from 42% to 68% and examination of babies within first six hours went up from 58% to 87%. The presence of village health worker at the time of delivery assures clean and hygienic practices followed by the traditional birth attendant during the delivery of the baby; it also implies that the family members are seeking the health workers services.

  • A new-born life was never a matter of joy, nor its death a matter of sorrow in the Kolam community. The mother was not supposed to eat a full meal as it was thought that the fetus would gain weight and the mother would face difficulty in delivering the baby. Now, after sustained health education of community members, elderly women in the villages, and family members, all the pregnant women eat full meals whenever they are hungry.

  • Making a pit inside the room where the women delivered her baby was a common practice amongst the Gond community in this region. The placenta and the umbilical cord were buried in this pit. The pit was also used as a bathroom for the new mother as she was not supposed to go outside her house for 40 days after the baby was delivery. Elder family members and the traditional Jat panchayat members were educated about the danger this practice causes to the life of the new-born and the mother. Now the number of families following this practice has gradually gone down to 3% from 67% in 5 years.

  • Due to the raised awareness and information the number of pregnant women getting benefits of the Janani Surksha Yojana, has gone up from a meager 3% to 31%.

  • The percentage of young women’s participation in the village affairs has noticeably gone up in all the villages due to the changed attitude of the village elders.

Lessons learnt
Since independence, India has created a vast public health infrastructure of Sub-centers, Public Health Centers (PHCs) and Community Health Centers (CHCs). There is also a large cadre of health care providers (Auxiliary Nurse Midwives, Male Health workers, Lady Health Visitors and Health Assistant Male).

Yet, this vast infrastructure is able to cater to only 20% of the population. Rural India still suffers from a long-standing healthcare problem. A critical part of enabling health services is education of health service seekers.

Educating people about the importance of a disease-free and healthy life, and making space for people to slowly change their behaviors and practices leads to empowering an individual as well as a community. Knowledgeable service seekers are not helpless at the hands of the service provider; instead they are in a position to demand and ascertain their rights. People in the Zhari-Jamnni block of Yavatmal district hold the Government health care providers accountable and demand that they do they duty towards the tribal population.

For more information contact:
Yogini Dolke
At “Srujan Pod”, Village: Mangurda,
Post Box No-1, Pandharkawada – 445 302
Ph: 9326585234

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