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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

By: 
Elijah T. Olivas, Ravi Arole, Connie Gates, and Surekha Sonawane

Program Context: The Comprehensive Rural Health Project (CRHP) is a local non-governmental organization (NGO) serving over 250 villages around Jamkhed in rural Maharashtra, India. Each village has an average population of 1,000. When CRHP was founded in 1970, health indicators in the area were among the worst in India. The infant mortality rate in 1971, for example, was 176 per 1,000 live births in the Jamkhed area compared with a median nationwide estimate of 140 per 1,000 live births1 and an estimated 19.1 per 1,000 live births in the United States.2 The caste system and low status of women were entrenched in the culture, subjecting women to repression within all aspects of politics, economics, and society.3

Jamkhed is located in a largely agricultural area that is susceptible to drought, making poverty common. At the start of the program in 1970, a third of the population was migrating outside of the area in search of food and work. Health care existed only in inaccessible and under-resourced hospitals and primary health centers.3

Using the World Health Organization’s (WHO) Health Systems Building Blocks Framework4, this case study describes CRHP’s approach and outlines how the role of village health workers (VHWs) has changed over time to continuously support health systems changes and meet the health needs of the population.

Program Design: Starting in 1970, CRHP pioneered an innovative, sustainable approach for community-based primary health care and comprehensive development that centered on VHW services. Known as the Jamkhed Model (Figure 1), it contains three interacting components: 1) community-level initiatives, 2) the mobile health team (MHT), and 3) the health center.

Figure 1: The Jamkhed Model

VHW and community-level initiatives: Fellow villagers select women who are mainly from lower castes to be their VHWs (typically one per village), fostering their empowerment. The program’s strong maternal and child health service package makes women best suited to meet the needs in these communities. Each VHW works as a volunteer and CRHP ensures that she has her own business to generate a livelihood (e.g. animal husbandry, bangle sales). VHWs serve in their roles for as long as they desire, with roughly two-thirds working for more than two decades; most attrition is due to death or moving away from a village.

The main role of a village health worker is to share knowledge and skills with her community. VHWs facilitate community-level initiatives in their villages, chosen by the villages according to their priority areas, such as organizing village groups that assist them with activities and addressing environmental programs, socio-economic development, and health care. VHWs’ centrality in these activities permits them to positively affect community buy-in. They also work collaboratively with ASHAs (government-trained and remunerated community health workers), Anganwadi (government pre-school workers), and other local-level health workers to achieve health and development outcomes.

VHWs’ most common roles fall into three main categories: education (e.g. teaching home remedies for common ailments), direct care (with training and assistance from the MHT), and community organizing (with assistance from the MHT toward sustainability).

Figure 2: A VHW checking blood pressure 

Figure 3: A VHW providing health education to a women's group

The MHT’s bridging and supporting roles: The mobile health team, which consists of social workers and trained health staff, bridges communities’ and CRHP’s activities by building and maintaining rapport with communities, providing training and support to VHWs and community groups, assisting with data collection and analysis, and responding to requests for help from villages (e.g. linking to external resources such as government schemes or providing additional training). Once communities are empowered to maintain their own programming, CRHP’s role decreases, requiring less direct engagement from the MHT, although the villages can still request assistance from the MHT at any time.

CRHP as a secondary care and training center: CRHP provides secondary care, referral services, resources and training, administration and management, and a channel through which to organize the network of villages in the Jamkhed area. CRHP is the base of operations for the MHT, providing training and record-keeping. CRHP also trains VHWs to be complementary to Accredited Social Health Activists (ASHAs) and several VHWs also serve as ASHAs.

VHW Program Impact: CRHP’s comprehensive approach to development addresses the determinants of health, leading to sustainable impact across many sectors. Villages that collaborated with CRHP in its first few decades achieved many of the Millennium Development Goals prior even to their adoption in 2000. Since 1970, CRHP has worked with 500,000 people and over 300 VHWs across 300 villages. Table 1 lists advances in major health indicators.

Table 1: Major health indicators among CRHP villages, 1971-2011

Additionally, 87% of children in CRHP project villages were fully immunized in 2004, up from less than 1% in 1970. The proportion of couples using family planning also increased from less than 1% in 1970 to 68% in 2004.5,6 Lastly, an external impact evaluation concluded that, between 1994 and 2007, children in CRHP villages had a 30% lower risk of death after the neonatal period than children in control villages in outlying areas.7

Lessons Learned: The demonstrated improvements to both health indicators and health system elements shows the sustainable, equitable, and resilient effect the Jamkhed Model has had in each community, as well as in its application to state- and national-level systems. CRHP is in a unique position to assist the Jamkhed area in strengthening systems across the six WHO building blocks: leadership and governance, health systems financing, health workforce, access to essential medicines, health information systems, and health service delivery.4

CRHP’s initial activities were conducted in a context almost completely lacking accessible health services. In this context, VHWs were effective in building the health system, given the lack of other health structures. As health systems have improved over time, VHW functions have shifted to strengthening systems. The change in VHWs’ roles over time demonstrates their centricity in long-term, community-level health systems strengthening. Table 2 compares VHW activities in the 1970s (systems building) with current activities (systems strengthening).

Table 2: The VHW’s impact on the Jamkhed area health system

Sustainability and Scale-up: Project villages have demonstrated continued growth and development without reliance on direct assistance from CRHP, some for more than 40 years, through this sustainable empowerment approach. Additionally, more than 3,000 international visitors and 30,000 people from around India have received training in the Jamkhed Model. VHWs assist with trainings, which have resulted in implementation of the components of the Jamkhed Model in both governmental and NGO-driven projects. Still, the most telling indicator of the model’s scale-up is its organic diffusion. VHWs and community members from project villages help initiate development activities with neighbors in nearby non-project villages, who eventually seek assistance from CRHP and begin the official process through the Jamkhed Model. These villages ultimately sustain their activities and begin the cycle anew.

References

  1. UNICEF. Country estimates of under-five, infant, child and neonatal mortality 2018; http://www.childmortality.org/. Accessed April 24, 2019.
  2. MacDorman MF, Rosenberg HM. Trends in infant mortality by cause of death and other characteristics, 1960-88. Vital and health statistics Series 20, Data from the National Vital Statistics System. 1993(20):1-57.
  3. Arole M, Arole R. Jamkhed: A comprehensive rural health project. London: Macmillan Press; 1994.
  4. World Health Organization. Everybody’s business: Strengthening health systems to improve health outcomes. Geneva: World Health Organization; 2007.
  5. The Comprehensive Rural Health Project. Community impact.  http://jamkhed.org/community-impact-page/. Accessed April 24, 2019.
  6. Perry HB, Rassekh BM, Gupta S, Freeman PA. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 7. shared characteristics of projects with evidence of long-term mortality impact. Journal of global health. 2017;7(1):010907.
  7. Mann V, Eble A, Frost C, Premkumar R, Boone P. Retrospective comparative evaluation of the lasting impact of a community-based primary health care programme on under-5 mortality in villages around Jamkhed, India. Bulletin of the World Health Organization. 2010;88(10):727-736.

Author Affiliations

1. Elijah T. Olivas: University of Iowa College of Public Health, Iowa City, IA, USA

2. Ravi Arole and Surekha Sonawane: Comprehensive Rural Health Project, Jamkhed, India

3. Connie Gates - Jamkhed International: North America, Carrboro, NC, USA

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