Primary health care in rural India

India was always on my bucket list but what drew me here this particular time was the Comprehensive Rural Health Program (CRHP) in Jamkhed, Maharashtra. The University of Melbourne offers a public health subject based at the CRHP campus and I opted to do it as part of my Development Studies program.

The first time I heard about CRHP was in a Global Health subject when talking about the landmark international Alma Ata declaration in 1978, which pledged to achieve ‘health for all’ through primary health care principles. CRHP was recognised as one of the “best practice” examples by the World Health Organisation. A couple of years after first hearing about it I had the chance to go and learn from them with nearly 30 other students from Melbourne Uni.

We all met up in Pune where we were driven to Jamkhed, a rural town nearly 200km away where CRHP started and remains based. The program itself was started by Raj and Mabelle Arole in 1970 and today continues to be directed by their two children, Ravi and Shobah.

The compound includes living quarters for full time staff, admin building, accommodation for visitors, a hospital, a library and training centres and it all sits just on the outskirts of the town.

From the first day we were inundated with new knowledge and information as we began to learn about all of CRHPs programs and the wider concept of Primary Health Care as a way of providing preventative health care on the basis of the principles: equity, empowerment, multisectoral, integration and participation. We were based both in a training room for lectures, presentations and activities with staff and also out in the field where we visited numerous villages and various program sites to see first hand primary health care in practice.

A core component of CRHPs strategy is to have village health workers trained within each village who can carry out basic medical checks and safe birth deliveries. From the beginning the Arole’s realised that much of what people went to the doctors for could be easily delegated to any person if they were well trained in basic health and medical knowledge. So they decided to start training one person from each village and instead of picking any person, they had a selection criteria: a woman, married with kids, illiterate and from the Dalit caste (‘untouchables’ or lowest of the low caste). This way they not only expanded health care into the rural villages but by training these women they were empowering some of the most oppressed and disempowered people of society.

We met many of these female village health workers (VHWs), some who have remained in their role since Raj and Mabelle began, and we visited some of the villages with them to see how they worked. Some of their stories were heartbreaking but all were inspiring. Many had had tough lives of forced marriage at as young as 9 years old, neglect, abuse and abandonment but yet, since becoming VHWs and in gaining people’s trust they had become proud and respected members of their village again. The role is completely voluntary and they are only compensated when they come in for the regular training in Jamkhed but it didn’t deter any of them. In fact, many said that the knowledge and respect they had gained and the ability to have saved countless lives and delivered thousands of safe births was enough payment for them.

The other major part of the Jamkhed model was the mobile health team which was a full time, paid group of around 10 people both doctors and development workers who did outreach to villages, supported the VHWs and acted as a bridge between the VHWs and the hospital.

Not to ignore the men, CRHP also have Farmers Clubs who have been integral in agricultural development and supporting the VHWs. We visited the demonstration farm where organic farming is taught and we also learnt about watershed development which includes various natural techniques to catch and conserve water and reduce erosion for better farming.

Of course in tackling issues such as caste and gender discrimination, CRHP recognised that working with children and teenagers would be important to ultimately change society’s attitudes. They run six month courses for adolescent girls and boys from all the surrounding villages separately every weekend which cover everything from gender equality, all sorts of health and hygiene issues and self defence for the girls.

By the end of our three weeks there, we were exhausted, our brains had absorbed a lot in a short time and the strict schedule had been tiring, but we had also learnt so much, been able to reflect on our own work and potential future and made some great friends and lifelong memories.

Learning from such a respected organisation was a privilege and I definitely learnt more in those three weeks than I have in any subject at uni. Having integrated whole communities into programs with high levels of local participation, the empowerment of thousands of illiterate and outcasted women, the ability to look at health in a holistic way and having dramatic decreases in all adverse health indicators is simply amazing. If any health system could just take one aspect of CRHP the world would be a much better and healthier place!


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