Gaurav Madan: Citizen’s Health Initiative, Uttarakhand
SEPT 15, 2008 – MAR 15, 2009
CITIZENS’ HEALTH INITIATIVE
SIMAYAL VILLAGE, UTTARAKHAND
Gaurav Madan, August 2008 Fellow
Central Himalayan Rural Action Group (CHIRAG)
Background and Project Vision
CHIRAG has been active in the hills of rural Kumaon for over two decades and works in over a hundred villages on a wide array of issues ranging from agriculture to health and from education to livelihoods. Specifically within the sphere of health, CHIRAG works through both curative and preventive measures.
My project has been to work with Gram Panchayats in neighboring villages to create health committees within the Panchayat structure, work with these committees to understand their roles and responsibilities, come up with yearlong health action plans to address major health issues, and work to implement these plans. A large focus of organizing with Gram Panchayats on health issues has been within the framework of the National Rural Health Mission.
My role largely with CHIRAG has been helping to create health committees in ten to fifteen villages and working with them to move forward. Outside of health, I have also contributed to other initiatives including working with the adolescent girls’ program and the CHIRAG school. My vision for my project is to have health committees that are sustainable on their own, aware of their rights, and confident in their own ability to positively impact the health of their communities.
When I arrived at my project site and was first given the task of creating health committees, and helping these committees to create actionable health plans, I certainly acknowledged that it was going to be a steep learning curve. In fact, I had my doubts about the whole project. Not only was this my first time working on preventive health issues, and my first time working in rural India, this was the most remote place I had ever been to. The geography of the place in itself, at the foothills of the Himalayas, was a challenge I did not really understand until I began to traverse the area. My understanding grew a lot as I learned about how the National Rural Health Mission was working, what major health issues existed, the state of maternal and child health, the role of ASHAs, ANMs, and Anganwadi workers, and what had been done in the past regarding working with Panchayats on health-related topics.
My initial goal when arriving at CHIRAG was to firstly understand what the major health issues were. I spent a lot of time just talking to people in villages, shadowing extension workers, and reading up as much as I could on CHIRAG’s past work in health and the framework of the National Rural Health Mission. After gaining some understanding of this, my goals included beginning the process of helping to form health committees in around ten villages, provide trainings and workshops for these committees, working with the health committees to draw out action plans, and begin to help implement these plans. Through this process I saw that a certain amount of coordination should be established between the health committees, the NGO, and local government, primarily at the block level (through the Primary Health Centre) and district level. Another goal then was to help initiate communication and collaboration on health issues between Panchayats and block and district level government. Through of all this a more obvious task was to simply raise the awareness of people about health and preventive measures that people could take to stay healthy. Lastly, a goal of mine has been to generate a greater level of enthusiasm and excitement in tackling public health amongst the people I have been working with, both in the villages and in the NGO.
Project Implementation Progress and Future Plans
The first couple months at CHIRAG were largely focused on learning about the area, the work CHIRAG has been doing, and the health situation. I spent a lot of time in the surrounding villages talking to people, attending meetings, and trying to get a grasp on what are the most salient issues and what peoples’ attitudes towards health and health-related issues are. I ended up helping conduct surveys on the current health status, on the health infrastructure in the area (hospitals, clinics, etc) and specifically on certain illnesses. After this I began to help with the creation of health committees. This basically involved accompanying CHIRAG field staff into villages and trying to organize committees through Gram Pradhans and Panchayats. After a couple months, nine health committees were formed in the area I was working in. My main focus in this process was in two specific villages – Kilore and Bhiyalgaon. After this I helped come up with a module for workshops about the roles and responsibilities of health committees. I helped implement these workshops in several villages over the next two months. I also helped with this process in other geographical areas CHIRAG works in outside of the area I had been based in. After providing trainings and workshops for newly formed health committees I began to help in the process of working with these committees to write out yearlong action plans. These action plans included identifying main health problems (eg. Waterborne illnesses, anemia, leucorrhea, lack of health supplies, etc), coming up with a plan of action of what health committees can do to address these problems, and what coordination is needed between the committees and either the government or NGO. In some cases I helped do this along with other field staff, and in other cases on my own. The action plans that have been written out still need further work, I feel. In some cases they are not detailed enough, in others they do not address the main health needs. Regardless the action plans that have been drafted have been sent to the block and district levels. Some implementation of these plans has begun including de-worming camps in both Kilore and Bhiyalgaon and committee and village members cleaning water tanks and sources.
Another significant accomplishment worth mentioning from the last six months has been the restoration of Iron Folic Acid (IFA) tablets to the block. For the majority of the past two years IFA tablets have been largely unavailable in the entire block. After getting many Gram Pradhans to write letters to the PHC about this issue I personally went to meet the Medical Officer there with a copy of these letters in hand. These letters were also sent to the Chief Medical Officer of Nainital District. After a few months word has reached that there has been a full restoration of the supply of IFA tablets to the block.
Where I would like to see this project go forward is firstly, to make sure the yearlong health action plans that have been written are actually being implemented. This means following up with the health committees and coordinating with local government to make sure there is a convergence on what has already been planned. Another point I would like to see taken up by health committees is demanding for better health facilities and services from local government clinics and hospitals. Under the NRHM a focus is put on improving all government sub-centres, PHCs, and hospitals. Health committees can play a key role in helping to facilitate this process by nudging the government on to fulfill their plans. This in turn will help improve levels of health in the area by creating better curative health facilities in closer vicinity.
Detailed Goal-setting & Implementation Planning
Goal: Follow-up on health plans
To do this it will be important to go over what plans have been made along with health committee members and NGO staff. In doing this it will be clear what major health issues need to be addressed, what has already been planned to address these issues, where NGO help is needed, and what possibly more needs to be done.
Goal: Implementation of health plans
Upon going over the yearlong health action plans it will be important to help organize what has already been stipulated. This will mean coordination through village health committee meetings, NGO staff meetings, and meeting with local government at the block level. This may also include providing necessary support in facilities and equipment for things such as anemia testing. Further implementation will depend on the specific plans made by health committees and other issues that arise over time.
Goal: Demanding improved health facilities
The first step in achieving this goal is having health committee and committee members become aware of what should be available at local government hospitals and clinics. Upon getting and understanding this information visits could be organized to local centers. These visits could provide an opportunity for members of the community to see what facilities are and are not available. After doing this pressure through letter-campaigns and meetings could be put on local government to improve the status of local health facilities.
Goal: Further building capacity of health committees, ASHAs, ANMs
To further extend and build the capacity of health committees to oversee and manage public health issues in their communities it will be important to have these committees continuously stay active on health issues, be engaged on these issues, and feel like they are making an impact. Furthermore, additional workshops and trainings should be held to provide information and support in this process. Specifically regarding ASHAs, CHIRAG is to become the District ASHA Resource Center for four blocks in Nainital District and this will provide an opportunity to reach out to more ASHAs and provide training and support.
Outside of the more broad themes of learning about myself, development, rural India, and development in rural India there are more nuanced learnings I have taken away from the past six months. To start with, my understanding of life in this corner of the world has dramatically increased. Furthermore, I have learned a fair amount about preventive health, healthcare, government-adopted programs to address health issues, and what can be done by people on the ground. For example, how waterborne illnesses spread and can be prevented, what precautions can be taken for safe deliveries, and how to measure a community’s health levels through monitoring systems. I have also learned a lot about the challenges related to these issues.
Through working with Panchayats, I have learned a lot about this form of local village governance. I have seen how Panchayats operate, legally what power is invested in them, and the potential for Panchayats to take a strong role in addressing social and development issues.
Lastly, as CHIRAG operates in so many fields of development I have been able to learn a little bit about issues like agriculture, animal husbandry, rural education systems, SHGs, forestry, and natural resource management. CHIRAG takes on an “integrated approach” where many issues are tackled at the same time in any given village. This has exposed me to many different people, issues, and theories behind “development.”
My experience in working in rural Kumaon has been one of the most challenging things I have had to do in my entire life. Actually living and working in such a rural area, with limited support, has pushed me pretty far out of any sort of comfort zone I have known. Through this, I reckon, there are many ways I have developed and grown over the past six months. I am not sure if I am even able to recognize most of these, but some things have become clearer to me, about me. I have become better at adapting and dealing with change. I have certainly become more confident in my ability to go into new and unknown situations and be able to perform – whether that means address a group of people, run a workshop, or call together a meeting. My ability to deal with adversity in a way that does not prevent me from getting things done, even while I may struggle personally, is also something that I see I have developed. There have many times when I felt low, due to internal or external factors yet have continuously pushed on with my work, and the reasons why I came to India to begin with. I have been forced to really know myself in ways that have not always been pleasant. I have seen what comes easy to me, and the things I struggle with. And while it is still hard for me to be alone, I have also gotten better at that.
Possibly one of the most important aspects of my personal growth this year has been a re-energizing commitment to social change and social justice. Whereas throughout my youth I was active on a lot of social and political issues, in more recent years this activism had tapered off. Coming to India as an Indicorps fellow has helped to re-spark this dedication, as well as help frame my work within the larger principles of justice, progress, and solidarity.