The impact of sustainable, community-based health care has been studied and well documented at the Comprehensive Rural Health Project (CRHP) in Jamkhed, India. This program was developed by Dr. Raj and Mabelle Arole out of their Christian faith and concern for the rural poor of India. As shown in the table below, the project has had a significant impact on health indicators.
 
 

Impact on Health Status at Jamkhed, India
Year	1971	1976	1986	1993
Infant Mortality Rate	176	52	49	19
Crude Birth Rate	40	34	28	20
Children Under Five
Immunization: DPT & Polio	0.5%	81%	91%	92%
Maternal Services
Prenatal care Deliveries by trained attendants Couples using family planning	0.5% <0.5% <1.0%	80% 74% 38%	82% 83% 60%	96% 98% 60%
Chronic Diseases
Leprosy Prevalence Tuberculosis Prevalence	-- --	2/1000 15/1000	1/1000 11/1000	0.1/1000 6/1000

The keys to success for these impressive results are the product of an integrated development approach with the health center as a facilitator to empower community organizations and village health workers (VHW).

The Role of the Health Center

The health center itself is a facilitator to bring about these changes. There is a need for facilitators external to the community to bring people together. Staff members from the health center need to act as facilitators with real sensitivity and ability to bring people together. People consider the health center to be their own and also look to it as a place that will give them guidance and support.

There are certain expectations from the people regarding the health center. The community expects prompt, appropriate, good and low-cost effective service. The center also functions as a referral for secondary care. The community supports the center if the facility can meet their needs and respond to emergencies such as dealing with fractures, appendicitis, surgical, medical, obstetrics and pediatric care. At this level they do not look for super specialties and are willing to go to tertiary centers for these problems. People within the community need to have a sense of ownership of the health center.

Further, the communities look at health economics. When patients go to the health center, they like to know the exact cost of care. It is important on the staff’s part to be open and discuss the monetary side of health care. Keeping things sustainable at the health center level involves the staff’s familiarity with health economics and providing low-cost secondary health care that is effective.

Links are also established between the community and the health center, and on returning to the village, the patients are followed up by the village health worker and mobile health team. This linkage among three levels ensures people being aware of the economic background of the people in the communities. It also provides for ongoing support and exchange of information.

An Integrated Development Approach

The role of the health center becomes one of listening to the community, facilitating its development and empowerment, training and sharing information, and support and referral. When the staff first begin to work in a community, they aim to build up relationships and to build and strengthen community organizations. The makeup of a typical village in the Jamkhed area is shown in Box 1.
 

Box 1: A Typical Village in Jamkhed, India A typical village is fragmented, divided by caste, economic, religious, political factions. It is made up of the following groups of people; A few wealthy, high caste people who have easy access to all the necessary services, e.g. school, medical care, government officials, bank and credit facilities, clean water, transportation. They actively prevent percolation of information, knowledge and development to the lower castes.   Poor, marginalized people (the majority) – dependent on the wealthy for their livelihood no decision-making power no access to outside knowledge, government or other development programs little or no access to modern health facilities no access to safe drinking water resorting to local healers (spiritualists, herbalists) and traditional remedies People with leprosy, tuberculosis, HIV/AIDS are ostracized and driven out of the village, living on the outskirts.   Women, who are marginalized and discriminated against both within the household and the community, e.g. maldistribution of available food and no access to money.

Really listening to the community takes much time and a variety of approaches. Games such as volleyball are good ways of bringing people together, relaxing with them, and hearing what they have to say. For example, Box 2 shows a list of community suggestions that typically emerge over a time of listening and discussing.
 

Box 2: Community Suggestions to Improve Health Common minor illnesses should be taken care of by the people themselves, with advice from the VHW, using scientifically sound treatments, including effective traditional remedies.    Increase the knowledge and skills of the VHW and provide her with simple medicines for common diseases.   Use effective measures to prevent diseases.   Certain basic health services are the right of every citizen and should be part of a state health program. This should be provided through public health services in which the community should take more and more responsibility as the process of development progresses. The community also holds the government accountable for providing available programs to all people.    Community organizations should set apart a fund for those few who need to pay for but can’t afford secondary health services.   Community organizations should be partners with health services to ensure that there is equity in health care – that the poor and marginalized have access to care and information and are integrated into the community.

On further discussion, the community decided that with effective community-based primary health care (PHC) the above interventions would reduce the need for a clinic in every village or community. This would include a Village Health Worker selected by and responsible to her village. The community PHC approach would also reduce the number of people that need to be referred and thus reduce the cost of health care.

CRHP has found that effective organizations of women, men and children are vital to successful community health care. Motivated organizations can help cut across caste barriers, religious and other differences; they often include a few socially minded rich people. The community becomes well integrated. When both caring health staff and effective community organizations are present, various changes occur.
 
 

Box 3: Examples of Community Actions 1.  People identified malaria as a leading cause of illness in their village. They understood that malaria was spread through mosquitoes that thrive in stagnant water. As a community they cleaned up the village, made underground drainage pits, and reduced the incidence of malaria. 2.  In one village, Madhu Wadekar was found to have HIV/AIDS. The village people accepted that Madhu had a serious disease and needed support and care. The community organizations took care of him, provided a job for his wife, and ensured that his children were looked after. They supported him well until his death. 3. Sri Mule is a leprosy patient, with ulcers and deformities. He was ostracized and had to live outside the village. Once the community organizations understood about leprosy, they brought him back to his home, ensured that he had proper treatment, and supervised his rehabilitation. Today he is an active member of the men’s group. 4.  Ashok Gavale came from a poor background. He was bitten by a poisonous snake. He could not afford the expensive anti-venom. His community contributed Rs.10,000 towards his care. 5.  Three poor tuberculosis patients were looked after by the community, which met the expenses for medicines, ensured adequate food, and later arranged for credit facilities for them to start income generation activities. 6.  The village people are aware of the preventive programs and ensure that all children are immunized. Growth monitoring of children up to age three is carried out by the organized groups and appropriate action taken if children are found to be malnourished. They make sure the government workers come to give immunizations on schedule.

After three to five years of listening and dialogue, community actions (see box 3) lead to the following common results:
 

• Community organizations include people from all segments of society. 

• A village health worker (VHW) is chosen and supported by the village.

• VHWs and community organizations work in partnership with health service providers (health team) to ensure good services are available. 

• Through proper health information and training from health teams, community organizations can assess their health situation, analyze causes, and develop action plans with the health team. (As they gain more experience and health information with each planning/action cycle, the involvement of the people in determining and becoming responsible for maintaining their health increases.) 

• In analyzing health problems, the people are able to identify the linkages with environment, harmful traditional practices, and discrimination against women that influence health; and they take appropriate action.

• Poverty being an important factor, organized communities are empowered to have income generation programs, access to bank and credit, and access to all development services.

• There is access to information, training and secondary health care.

• Persons ostracized by diseases like HIV/AIDS, leprosy and tuberculosis are well cared for in the community, supported and rehabilitated.

Sustainability

By addressing social issues, people are empowered and have equitable access to all facilities. The close linkages of health with other factors -- such as environment, sanitation, safe water -- need to be recognized. These programs may initially require a large investment, but in the long term they lead to sustainability and effectively improve health.

People need to become aware that good health comes through their own actions, both as individuals and as a community. The more information they receive, the more they can make changes for their own good. Once a certain amount of awareness is reached in the communities regarding health, social and economic issues, sustainability is possible through community participation both at the village and referral center levels.

Sustainability of health care involves working with the communities and the health center in an integrated approach for promotive, preventive, curative and rehabilitative services, and within bounds of the economics of people. Sustainability is not only in financial terms, but more importantly through knowledge, attitudes, practices, values, and the development of caring and sharing communities, where all people are included.
 

Editor's Note" Jamkhed International Foundation is an organizational member of CCIH. This article was published in "Footsteps," Tear Fund, UK, Fall 1998.