Comprehensive Rural Health Project, Jamkhed, India

Jamkhed International – North America, Carrboro, NC

Sustainability of Wholistic Health Through Empowerment

The Jamkhed Model of Ministry – transforming lives

June 18, 2016 CCIH Annual Conference

Connie Gates, Lavanya Madhusudan, Julia Ann Queale jina@jamkhed.org www.jamkhed.org

Jesus said,

John 10:10

“I came that they may have life, and have it abundantly.”

“Go and do likewise . .“

Our Focus

Health – not just disease and physical Community – not just individuals and

patients

Health

What is health? What does it mean to be healthy? What promotes health? harms health?

WHO definition, root causes (multi-sectoral, multi-disciplines) How to help people be healthier? (individuals, communities)

Health is determined primarily by the quality of social relationships and the fairness (or equity) in the social distribution of material resources.

Health is . . .

Health is . . .

A state of complete physical, mental, social and spiritual well-being, and not merely the absence of disease or infirmity. (WHO)

A dynamic state of well-being of the individual and

society; * physical, mental, spiritual, economic, political and

social well-being; * being in harmony with each other, with the natural

environment, and with God. (UMC)

Health is . . .

“Factors of Health” non-medical interventions have more

impact on health e.g. education of girls lower fertility rate

for long-lasting impact, deal with causes community’s role health professionals’ role for sustainability

Health Problems

What are the main health problems in developing countries?

Children (diarrhea, malnutrition, respiratory) Women (violence, pregnancy-related, TB)

Causes

What are the main causes?

Children (bad water, feeding practices, lack of

knowledge, harmful traditions, etc) Women (harmful traditions, no care, nutrition,

women’s status, etc)

Healthy Communities

What do communities need in order to be healthier?

What has kept them from being healthier?

What are obstacles to becoming healthier?

Basic Premises

Most health problems have simple solutions (prevention, early treatment)

Need a community change agent Community participation/

organizations

What can be done?

In/by the community for: Prevention of health problem and

complications of existing conditions Early diagnosis Simple treatment (e.g. home remedies) Management of health problem

Where in the World is . . .

Jamkhed

Mumbai

INDIA

CRHP Story

Aroles’ commitment to improve the health of communities, strong Christian faith

Mission hospital, medical model not working

No available model, but some examples Developed with the community a model /

approach Now mission is to share model worldwide

Comprehensive Rural Health Project (CRHP), Jamkhed

Vision - People are made in the image of God. They are endowed with talents and abilities, and have the potential for personal growth and development.

Mission - We are called to facilitate and empower communities, especially women and marginalized people, so that their health can be improved in a wholistic and integrated way, available to all with equity and justice.

Goal – To build the capacity of village people to enable them to participate actively and responsibly in primary health care activities to improve the health (physical, emotional, mental, social, spiritual, economic) of the whole community.

Jamkhed Model

Comprehensive Community-based / empowerment Primary Health Care (Alma Ata) Health & Development Value-based, not just technical Process, not project or program Sustainable

Impact on Health Indicators

020406080

100120140160180200

*1971

*1976

1981

*1986

1991

*1996

*1999

*2006

IMR/1000CBR/1000ANC/Del.FamPlanImmun.Malnutr

Infant Mortality

CBR FamilyPlan

Immunization

Malnutr.

ANC/SafeDeliveries

* = year data collected

IMR

Other CRHP Activities: Cumulative (from 1970)

Health Programs: T.B patients treated 7,620 (2000) Leprosy patients treated and rehabilitated 4,611 (2000) Artificial limbs and calipem provided 19,440 (2014) Socio-Economic Development: Plant nurseries (# villages) 45 (2000) Trees planted 5,145,500 (2000) Land leveled (hectares) 9,505 (2000) Irrigated wells dug 492 (2000) Check dams 212 (2000) Tube wells for safe drinking water 185 (2000) Houses built for poor people 270 (2000) Women involved in credit programs 4,978 (2000) Training in productive skills 813 (2000) Veterinary workers trained 93 (2000) Training/Orientation in PHC: National Trainees - grassroots workers 9,442 (2014)

National Trainees - health professionals, social workers, administrators, etc. 25,915 (2014)

International Trainees - from 92 countries 3,057 (2014)

Impact

The impact of the project can be assessed by the statistics, which show the results achieved over a period of time. Beyond these numbers are self-confident men and women, once outside the mainstream of society, taking leadership positions in their villages, affirming that they are created in the image of God.

It is not only the quantitative changes that are important; but even more so the transformation of persons and communities in a qualitative way, which leads to harmony, health and peace - shalom.

Purpose

Building the capacity of communities to do for themselves

Developing potential of everyone Ministry of ‘being’ – sharing God’s love

– especially with poor & marginalized Facilitating the community process

Philosophy

People are the key actors in health. We professionals have to change our attitudes

and need to share our knowledge in a way that poor people can understand and make their own choices according to their needs – not build dependency.

Health professionals need to recognize importance of non-medical activities/programs.

Strategies

* emphasis on the needs of the poorest of the poor

* full community participation and involvement * integration of promotive, preventive, curative

and rehabilitative health services * use of appropriate technology * a multi-sectoral approach to address all

issues affecting health

Based on Christian Values

*technical knowledge & skills are not enough *need to love others, willing to share, care for

others, service – for the staff and for the villagers *being concerned about the social aspects of

problems and root causes, *the justice issues that keep people from

developing their potential as Children of God. *following Jesus’ model of health ministry

Essential Values Example of selfless service Complete love & acceptance for the people Trust Patience & time Equality & equity Team spirit Complete sharing of knowledge Upliftment of the status of women Community participation & empowerment Talking together with all villagers Comprehensive wholistic approach

Principles Equity – poorest of poor, assimilate into community, justice

Integration – wholistic health * multi-disciplines * services (prom, prev, cure, rehab) * other health systems * health programs (MCH, HIV/AIDS, NCDs, etc) * other sectors

Empowerment -- build community capacity

-- community participation, work together -- organize groups around self interest -- assess, analyze, act address their priorities -- leadership, skills, knowledge, attitudes

Video - CRHP

https://www.youtube.com/watch?v=k3cXVNCg04s

(first 7.11 minutes – after adolescent girl testimony, before Helping Hands)

Jamkhed Health System

Village Health Worker * Selected by the community * Accountable to community * Bridge between community and health project. * Trained by CRHP Mobile Health Team (MHT) * Partner with health professionals * Health educator - skills, information, behavior * Shares what she learns with everyone in the community * Health care -- mother & child health, leprosy & TB control, family planning, etc. * Protecting environment * Social & cultural issues * Other development activities * Shows and shares goals and values, and does not merely carry out activities * Change agent, facilitator, organizer, mobilizer, role model, motivator, inspirer

VHW at NCIH Plenary (1988)

This is a beautiful hall and the shining chandeliers are a treat to watch.

One has to travel thousands of miles to come to see their beauty. The doctors are like these chandeliers, beautiful and exquisite,

but expensive and inaccessible. This (oil) lamp is inexpensive and simple.

But unlike the chandeliers, it can transfer its light to another lamp. I am like this lamp, lighting the lamp of better health.

Workers like me can light another and another and thus encircle the whole earth.

This is health for all!

Health for All !

Mahila Vikas Mandal (Women’s Club)

Organized around self-interest (e.g. income generation, religious songs, health & gender discrimination) Functions: * Collect health information and learn relevant skills from VHWs. * Assist VHW in health education, pregnancy care, delivery, family planning, child care. * Improve environment. * Regular treatment and integration of stigmatized conditions. * Collective decision making for better health. * Deal with social evils, gender, caste, alcoholism and dowry. * Promote income generation activities. * Network with others, including government. * Promote caring community and work towards harmony and peace.

Farmers’ Club Organized around self-interests

(e.g. field games, better agriculture & better animal care)

Functions: * Health information (with women) – assessment, analysis action * Health education for attitude & behavior change * Family planning, PALs, snake bite * Social evils – e.g. gender discrimination, caste divisions, alcoholism * Improving child nutrition * Protecting environment, water management and sanitation * Develop land and water resources * Implement Government and other schemes for the poor * Minimize corruption * Check malpractice by witch doctors and local physicians * Collective decision-making for better health

The Process a) identify village(s) that want/invite you b) get to know, build rapport/trust with the villagers c) gather the people (diversity) d) identify socially minded persons e) organize groups (around self-interest) f) identify/address community’s problems by them -

start with their priorities g) select/train/support village health workers (VHWs) h) learn about external resources/programs i) organize seminars for villagers j) follow up, support, encourage

Empowerment

* organize groups, especially women and other weaker sections * provide relevant and useful information and skills both in health and development * awareness of their own deprivation and potential to change * personal development, self-esteem and confidence, spiritual nurturing * promote income generation activities, provide access to credit and training * provide knowledge to deal with social issues * change mindset from personal focus to community benefit * promote value systems, such as justice, equality, courage, love * develop sharing and caring community, promoting reconciliation and peace

Lalanbai

As early VHW Now

Lalanbai Kadam Dalit, Woman VHW, Community Leader

Lalanbai is a woman and a Dalit (outcaste, ‘untouchable’) – which in her culture meant a double victim of human rights violations and indignity. As Dalits, Lalanbai’s family was extremely poor and forced to live on the outskirts of her village, Pimpalgaon. Traditionally Dalits work under inhuman conditions; her parents earned a difficult and meager living providing manual labor to higher caste villagers. As a girl, she was married early and pregnant, bore a son who died within three years, which was enough for her husband to kick her out of the house. Her parents insisted on her marrying again, this time to an old sickly man, who died a couple of years later, after she had given birth to their daughter. After his death, she insisted on remaining a widow, even though that was also culturally unacceptable, especially at such a young age (mid-20s). She was able to find daily wage work, though it was difficult and she was treated poorly, first with a rich family and then with government labor projects. She explains, “As a Dalit woman from Pimpalgaon, I thought of myself as a nobody. I had always been made to feel less than an animal. I had no self-respect because people addressed me with contempt. Everything was darkness.”

Lalanbai Kadam (con’t) Dalit, Woman VHW, Community Leader

In the early 1970s, soon after visiting her village and starting to work with the community members, the Aroles asked the village elders to nominate a woman to be their VHW. Thinking that Lalanbai was expendable because she was a Dalit widow, they chose her to do the work that no one else wanted to do – provide health care to the poorest of the poor in the village. She was surprised to be called by the mayor, who was her former abusive boss, and was reluctant to respond but afraid not to. Through her training, Lalanbai learned to read and write, about health, immediate and root causes of diseases, organizing community groups, personal development; and she was told for the first time in her life that she was a human being worthy of respect and made in God’s image. This was the first time she had experienced love. She fondly remembers that Dr Mabelle Arole was extremely patient, never scolded her, and stressed the importance of being kind to those who had only shown her cruelty. Her confidence grew as she began to realize her potential and the impact she could have on her community.

Lalanbai Kadam (con’t) Dalit, Woman VHW, Community Leader

Working as a volunteer, her main role was to share what she knew with others in her village and to organize community groups to work together and solve problems together. She ran her own businesses so she had independent income and was a role model for other women and helped them. For 35 years, Lalanbai saved the lives of many people, including those who had degraded hers. The impact on her life and her community gives her satisfaction; she says, “No child has died in 5 years.” Lalanbai shares her experiences as one of the first VHWs with new generations. She explains, “You cannot fear anyone in your village, even those from upper castes or those opposed to your efforts. Treat each family individually, recognizing their individual needs.” She also teaches classes for CRHP at the training center, including international health professionals. Throughout the years, Lalanbai became a respected member of her village. She was even encouraged to run for mayor. The incumbent, her former boss, realized she would win; so he pleaded with Dr Mabelle to convince her not to enter. When Lalanbai was told of the mayor’s plea, she laughed and said, “I already rule the hearts of the people of Pimpalgaon. Let him continue to be [the mayor]!” Lalanbai has come a long way from the illiterate, abused servant she once was. One would never know she was a woman with such a difficult past. She has provided a lifetime of leadership and service with her community and saved countless lives yet wants nothing in return. She says, “As I have changed, I have changed the world around me, even this backward village; and that is the best reward for me.”

What happened? Lalanbai

Encounter with Aroles & Christian witness Chosen as village health worker Trained and supported Shares knowledge & skills with others Organized groups of diversity Work and solve problems together Income generation/ economic development Other development, social, cultural issues

Empowerment

Learn from/listen to the community Let community decide what to do Focus on the community’s abilities Community participation / organization / groups Capacity-building of community * Start small, learn to work & solve problems together

* Project’s enabling role - knowledge, skills, attitudes, values * Personal development

3-A cycle (assessment, analysis, action) by community

3-A Cycle

Assessment – problems, resources – set priorities Analysis – causes of all aspects of health Action – local solution

If they need more knowledge, skills or resources, the project helps them.

Methods: surveys - house2house, PRA – by/with all community, focus groups,

discussions With experience, they can do themselves – part of the empowerment process

Ghodegaon Village Sustainable Development through Empowerment

The years preceding CRHP’s work in the Jamkhed area, the residents of Ghodegaon (population approx. 1200) were full of frustration due to extreme drought conditions and lack of government intervention. It was one of the poorest villages in the area. There was no water for drinking, food was scarce, and many young people had to migrate several months a year to work in sugar factories to keep their families from starving. In addition, casteism permeated the village. Dalits (outcaste, ‘untouchable’) had to live outside of the village wall and were exploited, working day and night, only to be paid in leftover food and grain. Ghodegaon was home to 12 illegal breweries and a few gambling dens, and many villagers struggled with alcoholism, gambling, domestic disputes, and worsening health conditions. They relied on devrushis (magicians) for cure and care. Children often died of preventable diseases, and individuals with TB and leprosy were treated as outcasts.

Ghodegaon Village (con’t) Sustainable Development through Empowerment

In 1971 some of the Ghodegaon village people learned of Drs Raj and Mabelle Arole and their work to improve health with village people. Ghodegaon badly needed health services, and so one day a group of both upper caste and lower caste people came to CRHP to meet with Dr Raj Arole and invited him to work in their village. In the beginning, Ghodegaon requested that the Aroles bring in nurses to provide curative health services, but Dr Arole did not agree since he wanted to work with the communities to see what they could do for themselves and develop their potential. After CRHP staff developed a relationship with the village through regular visits, Dr Raj Arole met with members of the men’s group and suggested they select a Village Health Worker (VHW). They chose Yamunabai - she was talkative and outgoing; she liked to mingle with community members when possible; and she was poor so she was able to understand the struggles of the marginalized. She had never gone to school, was illiterate, and spent her days confined to her home.

Ghodegaon Village (con’t) Sustainable Development through Empowerment

Yamunabai received training in primary health practices, personal growth, social and cultural issues, various aspects of development; and she serves as the main organizer of community groups. For 40 years she has served as a Village Health Worker in Ghodegaon. During this period she has conducted over 800 deliveries at home and has not lost a single mother, and she has counselled over 300 women to get tubectomies. Working with the community, 10 individuals with tuberculosis, 16 with leprosy, and 10 suffering from mental illness have been rehabilitated. By mobilizing first around common village-wide priorities of agriculture and health, the whole village came together despite differences in caste and social status. All people worked together to terrace and level the land, plant more than 200,000 trees, and build dams and four irrigation wells. Unified as a group, Ghodegaon was able to demand the Government to give land to the landless and brought enough land under cultivation to produce sufficient food to feed the village. “The whole village worked towards the removal of caste differences, and we have learned to treat women and girls as equals of men. We can proudly say that Health for All has become a reality in Ghodegaon. CRHP has shown us the way, and we have learned to work together for the betterment of our village. Now we do not need to depend on the Aroles or CRHP...” – Shahaji Patil, local farmer, Dalit

Project/Prof. Role

Facilitate the process Train VHWs and other villagers ‘Demystify’ health/medical knowledge Role model, demonstrate Support people & process Identify external resources Medical care (back up)

Go to the people: Live with them. Learn from them. Love them.

Start with what they know. Build with what they have.

But of the best leaders, When the job is done, The task accomplished,

The people will all say, “We have done this ourselves.”

Lao Tse, China, 700 BC

Go to the People

Impact - Diseases

Leprosy accurate knowledge of the disease; example of health workers with patients; early detection by VHW, which also prevents deformities persons affected by leprosy are accepted by and productive members of their communities.

HIV/AIDS accurate knowledge of the disease; preventive practices; caring values in the community low prevalence; persons with AIDS are cared for and die at home, and have a community funeral.

Impact - Social

Caste education about values and the futility of the system all groups work together and help the poorest and low caste.

Status of women discussions with men; personal and socio-economic development of women uplifted and involved as equals in community life.

Harmful traditions (related to health and social conditions) education and discussions about rationale no longer practised.

Impact – Women/Reprod.

Family Planning acceptance of small families, even if no son; variety of methods easily available high rate of use, both temporary and permanent.

Maternal health improved health of women; knowledge of pregnancy; frequent prenatal care by VHWs; identification and referral of high risk pregnancies; women’s knowledge of safe delivery; community transport healthy mothers and babies with home or hospital deliveries.

Impact - Children

Children mothers’ knowledge of and practices related to common diseases (prevention and treatment), nutrition education and demonstration, growth monitoring high immunisation rate; decrease in infant mortality and morbidity, especially diarrhea, malnutrition and respiratory infections.

Adolescent girls education, personal development, group discussions about attitudes, creative activities stay in school; delay marriage; empowered young women.

Video – Systems Thinking

Jamkhed as an Example of Complex Systems Thinking in Health

(CRHP was not involved in this video) https://www.youtube.com/watch?v=wX4p-7p765Y

Sustainability

Knowledge, Skills (building capacity) Attitudes, Values (caring community) Volunteers (building community) motivated Prevention, early detection, treatment, rehab in community; wholistic health Appropriate technology, local resources Multi-sectoral (non-medical interventions) VHWs still involved Spread by villagers to other areas

Jamkhed is . . .

Communities ‘health’ themselves focus on health and on community

- to really improve health in the long term (work together to solve their problems)

Deal with root causes for sustainability (e.g. overcome caste, women’s status, poverty)

Share what they learn with others

We say . . .

Ours is not an innovation in technology but rather an innovation of the people within each community,

to bring about social change and thereby uplift everyone from poverty and disease.

Emphasize belief in a loving God, the spiritual aspects of health and Christian values

in our training and our work.

Transforming lives Kingdom of Heaven on Earth

And Jesus said . .from Isaiah

“The Spirit of the Lord is upon me, because he has anointed me

to bring good news to the poor. He has sent me to proclaim release to the captives and recovery of sight

to the blind, to let the oppressed go free, to proclaim the year of the Lord’s favor.”

“I came that they may have life, and have it abundantly.” (John 10:10)

Jesus’ Ministry of Healing

more than cured disease – physical and mental.

restored people to their families, religious communities, society in general.

reached out to the most marginalized, and those with stigma – esp. women

disobeyed the current religious rules in order to benefit people e.g. by healing on the Sabbath, touching people thought ‘unclean’.

The Kingdom of Heaven on Earth is like Comprehensive Community-Based Primary Health Care

For More Information

If you would like more information about CRHP/Jamkhed, e.g. “The Jamkhed Model of Ministry” (document shown at the session) or anything more specific, please contact

Connie Gates, jina@jamkhed.org (for an e-copy of the Empowerment study report,

contact Lavanya.Madhusudan@gmail.com)