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Waves of change in rural health

By Usha Rai

A communications initiative that has spread awareness of healthcare needs and entitlements in hundreds of villages across Gujarat and Rajasthan has had a huge impact

ALERT (Active for Literacy and Environmental Renovation Task)

It was late at night when the mukhiya of Naal village in Gogunda block, Udaipur district, Rajasthan, called the medical emergency helpline 108 for an ambulance to take a pregnant woman to the nearest community health centre for delivery. The ambulance could only reach the next morning at 5 am, he was told curtly.

The reasons for the delay that could have proved costly were discussed at a meeting of the community with elected representatives, health workers and the staff of the local NGO ALERT (Active for Literacy and Environmental Renovation Task) Sansthan that works in 151 villages of Gogunda.

CHETNA (Centre for Health, Education, Training and Nutrition Awareness), based in Ahmedabad, has been working with seven NGO partners like ALERT in Gujarat and Rajasthan on communication strategies to create awareness as well as ensure that the National Rural Health Mission programmes and services reach people in rural areas, however remote. The communication initiative for healthcare using traditional and modern modes of awareness-generation has been working in 10 blocks of five districts of Gujarat from 2008 to 2012 and in Rajasthan from 2009 to 2012. The change in community thinking and its increased access to public health facilities as well as untied funds of the local government is told through heart-warming case studies in a publication called Waves of Change.

So what did the ALERT team do? It helped the mukhiya probe the reasons for the delay in ambulance services to the Bhil-dominated tribal block of Gogunda. The Bhils work on daily wages at nearby construction sites. They regard alcohol as ‘holy spirit’ and many are involved in brewing and consuming illicit liquor.

Discussions with the ambulance driver revealed that the residents of Naal had stoned the ambulance on several occasions earlier so the driver decided not to risk his life at night. Villagers, when questioned by the mukhiya, said the siren had frightened them and they thought it was a police raid on their illicit distilleries.

The NGO then held meetings with the sarpanch, panchayat members, as well as the community, teachers and local health workers to tell them that the ambulance service was an entitlement of the community and would enable them to access their health rights. Villagers realised that their resistance to the ambulance could have negative health consequences for the community. A collective decision was taken for the safe passage of the ambulance and the driver was also informed. The story exemplifies how the ambulance service was effectively resolved by building trust through dialogue.

In Gujarat, the project was implemented in 461 villages in selected blocks of Jamnagar, Kutch, Sabarkantha, Tapi and Vadodara districts and in Rajasthan, it was implemented in 794 villages in selected blocks of Alwar, Banswara, Churu, Karauli and Udaipur districts.

During local fairs and religious festivals like Janmashtami and Navratri, the communities were informed about their health entitlements. Information on health and nutrition services and community entitlements was shared with over 600,000 people in the two states.

Simultaneously, more than 600 service providers and 1,500 ASHAs were trained on their roles and responsibilities for improving services. A needs assessment at the start of the project had shown that only 25% of the people were aware of government health schemes and their entitlements.

At Abdasa, a remote coastal block of Kutch district, where there was low awareness among the fishing and cattle-herding community about child and maternal rights, in addition to using posters, wall writings, street meetings and road shows, the Kutch Mahila Vikas Sangathan, with the support of the health department, produced an audio CD in the local Kutchi language. Cable operators were provided the audio CD for repeated broadcast. It was played to large gatherings in village centres and even in anganwadis. The health entitlements under NRHM were also presented as jingles/advertisements on Akashvani radio.

The CD was used in 100 villages and four primary health centres, reaching out to close to 26,000 people. As a result, the demand for services at primary health centres increased rapidly. Over eight months the use of the ‘108’ ambulance service and the number of institutional deliveries increased. The community was grateful for the information shared in the local language. The audio CD had the desired snowball effect in creating awareness.

In fact, there were several examples of local health issues being resolved through communication initiatives and partnerships with local communities. For example, the anganwadi centre of Sirsili village, Churu block, Rajasthan, and its toilet were in such appalling condition that the daily attendance by children as well as the women who attended the monthly meeting on Maternal and Child Health Nutrition (MCHN) Day dropped drastically. No action was taken despite the community, ASHAs and anganwadi workers repeatedly raising the issue with the ward panch, the sarpanch and members of the Village Health Sanitation and Nutrition Committee (VHSNC). The toilet was repaired only when Saroj, a block link worker with Shikshit Rojgar Kendra Prabandhak Samiti (SRKPS), a partner NGO for the healthcare services initiative, pointed out that there were some untied funds with the panchayat that could be used for repair and maintenance. Within a fortnight of being convinced of the need for repairs and a suggestion from where the funds could be tapped, the sarpanch released the money.

The utilisation of anganwadi services increased by a dramatic 80% and the sarpanch and panchayat members realised the importance of meeting the health needs of the community.

At Mohmadpura, a remote village of Padra block of Vadodara district, it was the sarpanch who played a key role in ensuring that Mamta (Maternal and child health nutrition) Day was celebrated and women and children received the services provided under the National Rural Health Mission. The catalyst was Shroff Foundation Trust, which works with rural communities in the block. During a training programme, the SFT found that Mamta Day was not celebrated every month and promptly organised seven meetings with key functionaries and shared information on health entitlements with the community through popular folk theatre Bhavai. Sarpanch Harman Padhyar stayed in touch with the NGO and ensured Mamta Day celebrations. He also spoke to the anganwadi workers who carried the message of Mamta Day to every home, and frontline village workers counselled mothers about nutrition. Immunisation in the village shot up 100% and mothers and children are healthier and happier.

By the end of the project, in both states there was increased awareness about MCH entitlements and the community began accessing services. More women are having institutional deliveries and are availing of the referral transport; more women and children are attending the anganwadis for immunisation and other facilities as well as the Maternal Child Health Nutrition Day. Regular follow-up by the NGOs and the support of block officials helped fill vacant posts of ASHAs in Tijara block in Alwar district, Abdasa block in Kutch district and Dwarka block in Jamnagar district. Trained VHSNC members have started taking an active role in monitoring and ensuring services and community-based organisations/self-help groups now take up health as an agenda. At the service providers level there is enhanced clarity about roles and responsibilities, based on the rapport built by project partners who are being invited for sector/PHC /block level/district level meetings to share the field realities and gaps in services.

(Usha Rai is a senior development journalist based in Delhi)

Infochange News & Features, April 2013