Comprehensive Rural Health Project, Jamkhed, India

Jamkhed International – North America, Carrboro, NC

Empowerment in Jamkhed (individual & community)

What is it? What are indicators? How to measure.

Lavanya Madhusudan, MSW, MPH (Lavanya.Madhusudan@gmail.com)

June 18, 2016 CCIH Annual Conference

Why Jamkhed?

* Heard about Jamkhed’s success * Wanted to see how it was achieved * Learned that the key is community empowerment - not just providing services and health education * Empowerment was the ultimate goal of CRHP from the beginning – a steadfast commitment by Drs Raj & Mabelle Arole (CRHP founders)

Goals of the Study

* Understand and document the processes and outcomes of empowerment as occurring through CRHP’s model.

* Develop indicators to measure empowerment through quantitative and qualitative tools, for both individuals and villages as a whole.

* Develop a definition of empowerment that reflects empowerment as occurring through CRHP’s model.

What is Empowerment? • Depends on who you ask! • Subjective; shaped by worldview, values and

experiences • Context-specific • Multiple disciplines contribute = many perspectives ▫ Internal vs. external process

• Differing notions of “power” differing notions of “empowerment”

• Is developing a “universal”, functional definition of empowerment even possible or appropriate?

Definition of Empowerment

Dr. Raj Arole:

▫ improving self-esteem and gaining self-confidence

▫ developing critical assessment and analysis skills

▫ identifying with others as a member of a community

▫ participating with others in organizing for community change

▫ realizing environmental and political change

Empowerment & Health

▫ “Empowerment necessarily addresses the social, cultural, political and economic determinants that underpin health, and seeks to build partnerships with other sectors in finding solutions” (WHO, n.d.)

▫ Emphasis on transforming power relations

(Laverack, 2009) ▫ Empowerment improves the outcomes of health

programs (more relevant, meaningful, and sustainable) (Tsey, 2009)

Measuring Empowerment: Considerations

• Unit of measurement? ▫ Individual, family/group, community

• Important domains to measure? • “Universal” indicators vs. context-specific? ▫ Generalizability vs. accuracy and relevance ▫ Who is deciding what empowerment is?

• Use of quantitative vs. qualitative indicators?

Measuring Empowerment: Considerations (cont’d)

Selection of conceptual framework/theory of empowerment?

▫ Individual agency + opportunity structure (Alsop & Heinsohn, 2005)

▫ Conscientization (Freire, 1970) ▫ Developing sense of self + critical comprehension of

environment + cultivation of functional competence to reach goals (Lee, 2001)

Measuring empowerment as a process, outcome, or both? Empowerment as a means to an end, an end in itself or both?

Answers?

The answers lie with the community. They are the experts of their own lived

reality, and know best how to define and measure it.

Strategies from Literature

• START WITH THE COMMUNITY. • IT IS THEIR EMPOWERMENT. ▫ Develop a definition of empowerment ▫ Identify process(es) of empowerment ▫ Identify important domains to measure ▫ Develop process indicators ▫ Develop a tool to track indicators ▫ Set up an ongoing review mechanism

Strategies (cont’d)

Use context-specific indicators ▫ Goal should be to track the progress of own

program, not compare with other programs Important to measure empowerment as a process and an outcome ▫ Empowerment is a moving target (context,

priorities and behaviors which define appropriate indicators change with time) better to measure as a process, but outcomes also needed

Participatory Evaluation

• Evaluation: a process of reflection and assessment

• Goals: ▫ Assess outcomes (of empowerment) ▫ Understand why/how a program works (process of

empowerment) • Participatory: ▫ “shifting power in favor of those who are being

studied” (Springett, 2003) • Evaluation should itself be empowering!

Participatory Evaluation Process at CRHP

Phase 1: Understand CRHP model and how to measure empowerment

Phase 2: Understand villagers’ view of empowerment and most important changes

Phase 3: Develop indicators to measure empowerment

Initial Findings of Empowerment at CRHP

• Values in action = foundation of empowerment ▫ Health knowledge and skills

• Process of empowerment: role models and agents of change: ▫ Primary: Aroles → VHWs → villagers ▫ Secondary: Aroles → Mobile Health Team →

VHWs/villagers

• 2 pathways: ▫ CRHP → health → empowerment ▫ CRHP → empowerment

Areas included in Study:

Domains Outcomes/Impact of specific domain Processes of empowerment in specific domain

CRHP organizational impact VHW role MHT role Villagers’ role: SHG role, ABP/AGP role, FC/MM

Factors outside of domain that facilitated empowerment Current issues / Future goals

Top 5 Domains in Which Empowerment Occurred

Health Gender Equality Economic Status/Empowerment Education Cleanliness

Domain: Health (example)

Domains = areas in which empowerment occurred Outcomes/Impact of empowerment in health Processes and actors that contributed to empowerment

in health CRHP organizational impact VHW role MHT role Villagers’ role: SHG role, ABP/AGP role, FC/MM

Factors outside of health that facilitated empowerment Current issues / Future goals

VHW as primary pathway for facilitation of empowerment

VHW Training for Transformation

Imparting knowledge skills, attitudes, values, behaviors and practices

(e.g. health, environment, social, economics, spiritual principles, relationships among all people based on love & unity)

Integrate values with practical strategies Development of identity and self-worth Confidence building and co-creation of knowledge Developing a culture of caring & sharing Empowering oneself in order to empower others 3 CRHP principles: equity, integration, empowerment

VHW Quotes

“Money is not important in my point of view, but humanity is very important. Because if I don't have money, I can work hard, and somehow I can get it, but humanity should be in every person.” – Rambabai, VHW from Sharadwadi “Because of this work, there is benefit for me also, village people also. Village people benefit because I am doing medical and health things for them, and benefit for me because I get satisfaction from the work. For example if I am serving a patient, I think God is there, and serve the God, because each and everybody has a God. I feel happy in my mind also doing all these things.” – Rekha, VHW from Rajuri

Empowerment - Social Outcomes

Changed Power Relationships, Collective Action, Community Identity, Discussion, Equality, Freedom, Fulfilling Responsibilities, Gender Equality, Good Village Leadership, Helping, Independent, Literacy, Addiction, Child Marriage, Others Listen, Participation, Peace, Respect for and from Others, Self-Decisions, Spirituality, Think of Others, Together, Trust in Others, Understanding

Empowerment - Psychological Outcomes

Confidence, Courage and Strength, Fearlessness, Forgiveness, Happiness, Hard Work, Identity, Respect for Others, Satisfaction, Self-Worth, Solve Own Problems

Empowerment - Physical Outcomes

Access to Healthcare Services, Access to Information, Access to Water, Assets, Basic Amenities, Cleanliness, Community Facilities, Food Sufficiency, Government Linkages, Greening and Beautification, High-Yield Farms, Housing, Improved Health, Jobs and Businesses, Money, Roads, Schooling, Technology, Toilets, Transportation

Lessons Learned

Empowerment starts with individual spreads to community ▫ “empowerment is contagious”

Relationships, trust, love, role modeling, showing, teaching, supporting True community development/health programs should be empowerment programs Everything is related; can’t compartmentalize people’s lives VHWs should be community organizers just as much as they are health workers ▫ Community groups are extremely important

Adolescent programs are essential

Key Aspects of CRHP Approach that Led to Empowerment

Strong foundation in values Driven by community priorities Focus on end goal of empowerment Comprehensive approach Integrated sharing of values and knowledge VHW as a key facilitator of empowerment Belief in human potential

Implications

• Need more focus on values as the foundation for health and social programs.

• Many benefits of community empowerment;

need more focus and investment on community empowerment.

• Need more studies on empowerment in the

context of health programs to identify best practices.

Drs Raj & Mabelle Arole:

“Empowerment is not a one-way process. It is not that we, that one set of people ‘provide’

empowerment for others who receive it. Rather, like water from a well dug in a fortunate

spot, the power flows in many directions and sustains those who may set the process in motion

as well as those disempowered for such a long time. It is a dynamic process which once set in motion

transforms us, persons and communities.”

CRHP Definition of Empowerment

“Sharing knowledge openly with a foundation in human values

through insider relationships built on love and trust improves quality of life

physically, psychologically and socially for individuals and communities as a whole.”

Report of Study

If you are interested in receiving an e-copy of this study, please email the author: Lavanya.Madhusudan@gmail.com