Village Health Workers: Empowering Themselves and Their Community
A child dressed in dirty rags is crying. Her young mother adjusts her pallu over her head, as they tentatively enter the clinic. After waiting for hours among the ill, they are finally seen. The doctor gently pinches the child’s skin and looks into her sunken eyes. She quickly makes the diagnosis – another clear cut case of dehydration due to diarrhea. The doctor then patiently explains the importance of feeding the child an oral rehydration solution. But while she writes out another prescription for antibiotics, the doctor can’t help but feel some frustration. This child will come back again and again with the same illness, because this family simply does not have access to clean drinking water.
Prevention would seem to be the ultimate solution to the scenario. However, the practice of medicine has traditionally followed a strictly biomedical model, focusing on the diagnosis and treatment of disease. Accordingly, medical centers that are viewed as being particularly cutting edge and modern are ones that provide super-specialized, but ultimately fragmented care. While such centers have an important role in researching and treating rare and unusual diseases, what about the types of diseases that are a consequence of a lack of education, systemic inequities based on gender and caste, and poverty? How effective are modern cures if they do not address the social, economic, and developmental issues that are as intrinsic to the pathogenesis of disease as pathogen entry, epithelial attachment, and colonization? Drs. Mabelle and Rajanikant Arole asked these same questions when they founded the Comprehensive Rural Health Project (CRHP) in Jamkhed, India in 1970. They described their first experiences in treating the rural poor:
We were finding that our medicines, however modern, did not provide a permanent cure for common illnesses….We began to see how really shortsighted we had been. We were too busy running an ambulance service at the bottom of a cliff rather than preventing accidents by putting a fence at the top. (1)
In order to truly treat the indigent populations of rural Jamkhed and the surrounding communities, they had to address the root causes of disease: lack of food, unsafe drinking water, and bad sanitation. And in order to reach the neediest, they realized they would have to simultaneously address the social issues of gender and caste.
The CRHP complex
Breaking through deep rooted social constructions is a difficult task, but not insurmountable. The traditional model of medicine is very hierarchical, with nurses and auxiliary and ancillary staff playing strict roles, with doctors at the ‘top’, dictating the management of the case at hand. But in order to make real social change in the communities around Jamkhed, the Aroles decided it would have to come from within. As Dr. Shobha Arole, the Aroles’ daughter and current associate director of CRHP, noted, “Empowerment is the basis of our work.” They facilitated the construction of Farmers’ clubs and Mahila Vikas Mandals (Women’s clubs), which met regularly to discuss the interests and concerns of villagers. The villagers were able to focus on the health of the community only after addressing fundamental issues such as access to food, water, and shelter.
With CRHP, the Aroles introduced innovative ideas for the delivery of care to marginalized populations. But perhaps the most ground-breaking is the concept of the Village Health Worker (VHW). The VHW is a member of the village she served, and is selected by its people. She serves as a conduit of communicating what the community’s specific needs are to CRHP, and as a trusted person who acts on the behalf of CRHP to introduce health interventions such as safe deliveries for pregnant women, nutrition education, and the identification of people suffering from diseases such as tuberculosis and leprosy, to be brought to the hospital for treatment. “The women had first hand experience of surviving in an adverse sociocultural environment. They taught us how village people perceive disease in the context of their poverty and how they respond to various situations.” (1) With their insight, VHWs are able to address superstitions such as villagers treating cobra bites with a trip to the temple and reroute them instead to the hospital; and adapt health care messages using language, imagery and metaphors so they would be relevant to villagers.
Village Health Workers Jijbai and Sonabai
VHWs do their outreach work by spending an hour or two each day visiting different families in their villages. By reaching out to even the poorest families, VHWs would ensure that even the most deprived would have access to preventative services and medical care.
Indeed, many of the VHWs themselves were illiterate before their CRHP training or come from ‘ow caste’ and Dalit (’untouchable’) backgrounds. Salubai, a veteran village health worker, was thirty-five years old when she was chosen by her fellow villagers to be the VWH for her village, Ranjun. Because she is a Dalit, she initially experienced discrimination as she tried to visit the higher caste homes in her village. “When I first started, people would shut the door in my face because I was not educated and of low caste.” But soon, word spread about her effective services. “My first delivery was my cousin’s child. It was a safe, successful delivery and I was very happy with the experience.” Eventually, high caste families started requesting her to deliver their children. Since then, Salubai has conducted over 250 deliveries and boasts a 0% mortality rate for both the newborns and the women she has delivered.
It typically takes about six to eight months for a VHW to establish her credibility within the villages (1). During this time, she attends training sessions at the main CRHP facility and acts as an apprentice to an older, more established VHW. While the VHW acts as a representative of the community, it is also important for the VHW to view herself as a part of the health care team in order to overcome her own disempowerment she’s experienced from being a woman or from a low caste background. The role of the VHW is further reinforced through regular visits from the mobile health team, which typically featured a doctor, nurse, social worker, and other members that conduct medical and social services. “The visible support of deliberately training the VHWs in front of the community legitimised their role in the village. A doctor’s reinforcement of her treatment as the best treatment increased her confidence.” (1)
Because the VHWs were so effective with the knowledge they had gained through their training at CRHP, they gained additional responsibilities such as treating minor illnesses. As reliable providers of medical care, VHWs often found themselves respected members of their communities, despite the structural inequities that many women in rural villages face. Lalanbai, a Dalit from Pimpalgaon, was married at ten years old, illiterate, and received only leftover food tossed to her for dawn to dusk labor (1). “I had thought of myself as nobody. I had always been made to feel less than an animal….I had no self respect because people addressed me with contempt.” (1) After Lalanbai was selected by her village to become a VHW, she flourished in the supportive environment that CRHP training provided her. With her health care training, she was able to effectively intervene in medical issues that were important to the people of her village, particularly safe deliveries and neonatal care. Like any other primary care provider who is intimately involved in the lives around her, she went from being an ‘untouchable’ to an important person in the village. Her fellow villagers, who once ostracized her, then wanted her to become the mayor of the village (1). As Lalanbai describes her own personal revolution, “As I have changed, I have changed the world around me, even this backward village of Pimpalgaon, and that is the best reward for me.” (1)
Empowered by knowledge and self-esteem, village health workers have been able to make a difference not just in their own lives, but in others’ as well. Their role as health care providers allows them intimate access into their neighbors’ lives, providing hope for those who have none. Social issues are often entangled with medical problems, and as members of the same community, VHWs aim to address both. Ratna, a young woman from rural Maharshtra, has a particularly moving story.
She was 16 years old when she married and moved with her husband from rural Maharashtra to a suburb of Mumbai. She felt lucky because was the youngest of four girls and had married someone who did not want a dowry. Within six months she discovered she was pregnant. But not long after that, she found out her husband had AIDS, and that she and her baby had contracted the virus as well. Soon, her neighbors found out. The family was cast out by their community in suburban Mumbai, and they were forced to return to Ratna’s mother-in-law’s house in rural Maharashtra. Life was not much better there either. As Ratna explains, “My mother-in-law would not allow me to cook or touch the drinking water out because they were afraid of catching the illness.” Even when she went to collect water from the public well, other people in the village would wash the area after she used it.
After two months, Ratna’s husband died from AIDS. “My in-laws told me, ‘We have no relations with you,’” and Ratna was forced to take her child and move back in with her mother. There too, her experience was steeped with the stigma of AIDS and ignorance about how it is transmitted. “My mother was afraid that it would spread to the two small boys living in the household. I was not allowed to use the common bathroom or cook in the house.” Determined to earn a living to support her child, she tried to find work as a farm laborer, but there too she experienced discrimination as a result of ignorance, and had difficulty holding a steady job. “Whenever I would find a job, after a few days my co-workers would find out I have AIDS and refuse to work with me. I would be fired the next day.”
At a new job, Ratna was told she couldn’t bring her baby to work. Ostracized by her family and with no money, Ratna was forced to leave the baby alone at home one day. She then came home after work and found her baby dead. Having lost everything with her child dead, her husband dead, and cut off by seemingly everyone around her, she became completely hopeless. She decided that she couldn’t go on living, and took poison in a suicide attempt.
Fortunately, neighbors found her in time, and a CRHP village health worker came to see her. “When she came to see me, I was very weak. She knew what had happened – that I had taken poison to end my life. She was so caring and reassuring; I didn’t want to tell her I had AIDS because I was afraid she would abandon me.” The VHW reassured her that she would continue to support her, and took Ratna to Dr. Arole for treatment. At CRHP she was nursed back to health, but the question still remained regarding her status in society. Physically she had gotten better, but she still suffered from mental and emotional anguish. “They asked me what I did for a living. I told them, ‘I don’t do anything because I can’t get a steady job.’ I was in despair.”
Dr. Arole offered Ratna a job on the CRHP Khadkat farm, the site of CRHP’s Mabelle Memorial Training and Rehabilitation Center. There she learned skills such as operating tractors, and producing jams and jellies. More than that, by including her in social functions and doing things such as simply eating with her, the stigma that surrounded Ratna as a person living with AIDS soon dissipated. Once the other villagers saw Dr. Arole, a highly respected man of the community, including Ratna in social activities, they realized that they had no reason to exclude her from their lives.
Ratna not only survived, but has excelled at her job on the farm. She smiles as she tells us she was promoted to the manager of the farm two years ago, and continues to enjoy that position. She is now an enterprising, vivacious woman who sees hope in her life.
Ratna, giving us a tour of the farm she now works at
Using VHWs to reach out to stigmatized communities has been an effective method to dispel myths and misinformation within villages. By acting as couriers to remote sites, they educate their neighbors and improve access to care. Indeed, a number of health care measures in the villages reached by CRHP have demonstrated staggering results. Indicators such as infant mortality rate have dropped drastically since the inception of CRHP, from 176 deaths per 1000 births down to less than 50 in 1992 (1). Prenatal care and immunizations are now close to approaching universal coverage. In 2005 CRHP reported that in the villages they cover, 99% of children under five were receiving DPT and polio vaccines, while 97% of pregnant women received prenatal care. In contrast, country-wide statistics for India in 2006 indicated only 55.3% of children were immunized, and 50.7% of pregnant women received prenatal care (2).
Monitoring the weight of babies. The babies usually don’t enjoy being weighed, but monitoring their growth is a good way to screen for malnutrition, and an opportunity to give nutritional advice to the mother
Because preventable deaths and communicable diseases have been so well managed in the villages reached by CRHP, their model has received national and international attention. The government of India has recognized the effectiveness of using village health workers to reach out to rural and marginalized communities, and in 2005 started a program called Accredited Social Health Activists (ASHA) based on this concept. The goals of this program echo many of CRHP’s accomplishments, including a reduction in infant and maternal mortality rate, prevention and control of locally endemic communicable diseases, and population stabilization. As a ‘Health Activist’ the ASHA would address the social determinants of health – her primary job would be to dismantle harmful superstitions, encourage parity in the treatment of female and male children, and direct sick individuals to medical care.
Because neonatal/maternal mortality and communicable diseases have been so well addressed, now the VHWs are learning how to screen for diabetes and hypertension. Here Jijbai and Sonabai demonstrate to other VHWs how to check for glucosuria
In theory, it seems simple enough to take one successful program, and apply it to the rest of the country. And while superficially, the CRHP’s village health worker program and the ASHA program appear quite similar; in practice they are quite different. In a conversation with Dr. Arole, he pointed out the social standing of the women selected as the village ASHA is far more important than the degree of her formal education, the latter being a point emphasized with the government program. “It’s important the ASHA be someone that has the time to visit the people in her community. Women who are old enough to have a daughter-in-law helping out at home have time to fulfill the responsibilities of an ASHA. Younger women have more household responsibilities. They also traditionally move to their husband’s village – they would not have the social standing, nor the familiarity that an older, more established woman would have in the community.” Moreover, he also feels the training of ASHA should stress practical information applicable to communities, as opposed to the emphasis on anatomy and physiology in the current curriculum.
A village health worker taking a young pregnant woman’s blood pressure
The ASHA program is not unlike the Voluntary Health Guide program of 1977, an older government scheme that attempted to adapt the CRHP model, and it’s unclear what lessons have been learned from that failed program and what changes have been made. The reality is that a copy-and-paste approach to instituting programs in a country as culturally, religiously, and developmentally diverse as India may produce problems. In the communities served by CRHP, the villagers had organized into pro-active Farmers’ clubs and Women’s clubs, through which they voiced the needs of their community in a collective manner, and then worked together to solve them. In this way, they were empowered to choose the most appropriate person as a village health worker. However, in communities in which the people are not organized or empowered, the selection of the ASHA has become much more political, despite the selection guidelines the government of India has put out. Similarly, the status of women in certain parts of India is much more marginalized than others, and it would not be appropriate to recommend a woman going house to house in these circumstances. “Each community is very different,” says Dr. Arole. “Such a program should first be done on a pilot basis.” Under these conditions, perhaps the selection criteria will be better scrutinized, and the government would be able to play a role in removing political interference.
Today, CRHP cares for over 300 villages, a total population of about 500,000. Some would argue that the key to CRHP’s success is that they worked with the communities around Jamkhed as partners. Traditionally, only highly trained health care professionals have been entrusted to disseminate public health information and provide medical care. Hierarchy prevailed, and medicine was cloaked in a mystique that was only accessible to the wealthy and educated. Now, as medicine is beginning to move towards a patient-centered approach which recognizes the unique needs of each patient, programs instituted with good intentions should also recognize the differences in each community in order to serve them most effectively. Likewise, the paradigm is shifting to accommodate the growing need for primary care in almost every setting. It is increasingly recognized that a ‘teamwork model’ – one that respects the contribution of each member, and acknowledging the communities’ needs as important, rather than experts dictating what’s best – may be a better approach to improve access to care. By working with local people in villages, CRHP was able to identify and address the most pressing needs of the communities they served. Trust is built, aided by village health workers, and only then effective health interventions can be made. Drs. Mabelle and Rajanikant Arole recognized and addressed the link between social issues and health, thus revolutionizing the communities they served. As public health luminaries Daniel Taylor and Carl Taylor succinctly put it in their book, Just and Lasting Change, “[T]he key to building better lives is not technical breakthroughs but changing behavior at the community level.” (3)
Himali Weerahandi is a 4th year medical student at Temple University School of Medicine in Philadelphia, USA
weerahandi@gmail.com
References
(1) Arole, Mabelle. Arole, Rajanikant. Jamkhed: A Comprehensive Rural Health Project. 1994. Comprehensive Rural Health Project.
(2) Arole, Rajanikant. Arole, Shobha. Comprehensive Rural Health Project: Jamkhed India: Annual Report 2007-2008.
(3)Taylor, Daniel. Taylor, Carl. Just and Lasting Change. 2002. The Johns Hopkins University Press.
Please visit www.jamkhed.org for more information.