The ‘Village Health Worker’ initiative was among the first endeavors of HMF that was designed in 1994 to address the deplorable health conditions, aggravated by the massive earthquake of 1993, especially of women, in the Dharashiv (previously Osmanabad) and Solapur districts of Maharashtra. This initiative implemented a sustainable and holistic model that facilitated healthcare delivery to villagers’ doorsteps, especially to the most deprived sections, by training and empowering local women as Village Health Workers – the Bharat Vaidyas.
Evolution
It stemmed from the experiences of Dr. Shashikant Ahankari and Dr. Shubhangi Ahankari, the dedicated founding members of HMF. In 1983, they chose to establish their practice in the Andur village of the Dharashiv district. Their inspiration came from their leadership and involvement in the HALO (Health & Auto Learning Organization) movement, where medical students and doctors endeavoured to improve the health conditions of rural communities in the Marathwada region of Maharashtra. Additionally, they drew inspiration from the work of other notable community health interventionists such as Dr. Baba Amte, Dr Abhay Bang and Dr. Rani Bang.
The experiences they encountered during their practice were unbelievable and overwhelming!
Dr. Shubhangi Ahankari writes: In rural villages, superstition reigned, leading villagers to seek out dubious healers for ailments, and turning to qualified doctors only as a last resort. Leprosy and tuberculosis were widespread within the community.
Large families (on an average a woman had four children) and a heavy reliance on agriculture, sparse rainfall, and recurring droughts, families faced severe economic strain and high levels of deprivation. Poorly maintained roads, limited transport facilities, absence of industries prompted villagers to migrate to urban centres.
Education opportunities were limited, with schools only offering instruction only up to grade 5. Cultural norms often truncated girls’ education, as they were typically married off upon reaching grade 7 and with the onset of menarche. Financial priorities often favoured spending on marriage over investing in daughters’ schooling.
17-year-old young pregnant women, innocent and ignorant about what it entails to be a mother, would come to the clinic, and that too with complications. Undergoing checkups during pregnancy and any sort of prenatal care was alien to them or rather unacceptable. Low haemoglobin levels, poor weight, and hesitancy to take anti-tetanus injections were common. Instances of sterilization surgeries among 20-year-old women were not uncommon, with some even undergoing hysterectomies by the age of 30.
Tragic circumstances, such as widowhood at the tender age of 18, left some women in stagnant life situations.
Empowering village women: Promoting a sustainable door-step holistic healthcare model
Launch of the Village Health Worker Bharat Vaidya initiative.
The situation demanded more than mere medical care facilities; it necessitated a holistic approach that involved a concerted effort towards health awareness and education, and a robust healthcare outreach to the most vulnerable residents in the villages.
In the wake of the devastating 1993 earthquake in the Latur and Dharashiv districts, Dr. Shashikant Ahankari and Dr. Shubhangi Ahankari’s close involvement in relief operations further brought the ground reality to the fore. This experience catalyzed the conception of the ‘village health worker’ model, that aimed at implementing a door-step model, while empowering local women to play a pivotal role in providing healthcare. A Village Health Worker was envisioned as being the first port of call for addressing any health-related needs, particularly for the village women.
Identifying potential, selecting and training of Bharat Vaidyas – the village health workers
The goal of the Village Health Worker (VHW) initiative was to offer primary healthcare services at the village level, aiming to prevent illnesses from escalating into more severe conditions that needed expensive treatment.
HMF constructed the VHW Training Centre at Andur, which provided training and accommodation facilities and served as a project head office until 2007.
Selection:
With a clear understanding to the caste and gender dynamics in the patriarchal rural society, selection of Bharat Vaidyas was done very meticulously using the following criteria:
Gender: women only
Education: 8th grade complete
Age/ fitness:above 18 years
Willingness to undergo 21 days residential mandatory training
In order to bridge caste-based and religion-based biases, priority was given to
– to single women
– women in the scheduled caste category/ Dalit
– women from religious minority (Muslim)
Training:
A number of teaching-learning methods were used to train Village Health Worker, including films, focus group discussions, and lectures by doctors.
The women were taught to identify and refer serious or life-threatening illnesses to the HMF’s Janaki Hospital or any other institution that provides health services.
The women learnt to use a stethoscope, blood pressure monitor and many other tools to detect/understand health status and analyze the pressing health issues in the villages.
The first Village Health Worker was trained in 1997 and the program was expanded significantly since then.
The experience in using Village Health Worker training model enabled Halo Medical Foundation to train nearly 450 women in the states of Gujarat, Madhya Pradesh, Karnataka and other parts of India.
Appointment
Trained Village Health Workers who were evaluated for necessary competencies, were appointed officially by HMF.
Over a period of time, 75 Village Health Workers were appointed in 70 villages
Activities undertaken
Strategy used: Involving the village communities
In the realm of developmental endeavors, it is customary for the Village Governance body (Gram Panchayat) to establish specific committees. Embracing this approach, HMF advocated for the establishment of ‘Bharat Vaidya Sahayya Samiti’ (meaning – Village Health Worker Support Committee),a majority of who were men, in each project village. The aim of this strategy was twofold: to provide support to the Village Health Worker and to empower male community members and decision-makers to take ownership of the health of villagers, particularly that of women.
Acknowledging the critical role of Village Health Workers, such Committees were established in 30 villages. Additionally, twenty-five villages allocated space for ‘Health Centres’, specifically for ante-natal and post-natal checkups for women by the VHWs.
Role of the village health worker:
• Conduct home visits in the village they are based in.
• Participate in HMF’s health education and awareness activities.
• Treat simple illnesses at the village level and refer complicated cases to other local hospitals and government health centers.
• Participate in government education and training programs as well as health and economic schemes in their villages.
• Educate women on preventing domestic violence
• Monitor microfinance activities at the village level.
• Participate in village health activities related to disease prevention and healthy living.
• Participate in a network of village institutions including the local village governance committee (Gram Panchayat)
Challenges
Due to prevalent gender, caste and religious biases, building trust within the community towards Village Health Workers, especially because they were women and many belonged to scheduled castes and religious minorities, proved exceptionally challenging. However, through consistent and diligent efforts, they showcased their competence through small actions, gradually earning the confidence of the villagers. With the support of HMF and village committees, they successfully overcame this hurdle. Notably, their status was elevated as a result of this work, fostering self-confidence among the women village health workers.
Sustainability
The Village Health Worker initiative completed in 2006.
In 2005-06, the government introduced the ‘ASHA’ – Accredited Social Health Activist – programme as part of the National Rural Health Mission (NRHM). Nearly 70 percent of the Bharat Vaidyas were appointed as ASHAs under this Mission.
Also, the training and exposure they received enabled them to develop the necessary skills to contribute effectively to various other projects undertaken by HMF. Consequently, many of them were assimilated into HMF projects and even advanced to supervisory roles. For instance, in 2014, 38 of these Village Health Workers were incorporated into HMF’s violence intervention and research programs.
Funding support
The Bharat Vaidya initiative received financial support from:
Oxfam – 1997-98
Ford Foundation – 2000-03
Tata Trust