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Surviving the monsoon

Kalpana Sharma

Lack of access to health care during the monsoon is a serious problem. An NGO, through its work in Maharashtra's Gadchiroli district, has shown a practical way of dealing with it.

MAHARASHTRA, LIKE the rest of India, waits for rains. When the monsoon finally arrives, there is a collective sigh of relief. But there is also apprehension. Especially in the more remote rural areas and in the tribal hamlets.

For, the rains bring with them disease and death because people already cut off from development by the absence of access roads are left stranded during the rains.

During the monsoon there is a spurt in the number of child deaths, especially of infants within the first 28 days of their birth. This period, termed neonatal, is crucial in determining the infant mortality rate (IMR) in India, which stands currently at 68 out of 1,000 live births.

Fortunately, the recently launched National Rural Health Mission has recognised the importance of this by giving special emphasis to newborns and pregnant women.

An integral part of the approach — a shift again to comprehensive health care — is a pattern of decentralised health care and the involvement of local women, Accredited Social Health Activists or ASHAs, as they will be termed.This approach has been tried in the past both by non-governmental organisations and by the government. But it is the work of an NGO in Maharashtra that comes closest to a pattern than can be replicated.

This is the work done by the doctor couple Rani and Abhay Bang and their organisation, Society for Education, Action and Research in Community Health (SEARCH), based in tribal-dominated Gadchiroli district.

Gadchiroli is one of the least developed districts in Maharashtra — it is not connected by rail, it has no industry, educational and health facilities are scarce as are communication links.

Although there is a 100-bed district hospital, a 30-bed rural hospital and one primary health centre for every 20,000 people, lack of access ensures that people cannot reach these facilities most of the time. When the Bangs began working in the district, the IMR was as high as 121 per 1,000 live births.

Crucial factors

Recognising the problems of access, the Bangs trained village women as Village Health Workers (VHWs). Through surveys they also established that it was neonatal mortality that was pushing up the IMR figures. One of the crucial factors causing death, apart from asphyxia during the birthing process and low birth weight, was pneumonia. Studies of the area revealed that 62 per cent of the deaths of children under five were due to pneumonia.

Working in 58 villages through VHWs and focussing on neonates, SEARCH has contributed to the remarkable decline in IMR in Gadchiroli.

It is now under 30 compared to the State average of 48. The Bangs' work was recognised internationally and documented in a special supplement of the March 2005 issue of the prestigious Journal of Perinatology published by Nature. It carries detailed analyses of the field trials of home-based neonatal care pioneered by them.

There are many aspects of the Gadchiroli experiment that are important. But one that has a particular bearing on the rural health mission is the experience of the Bangs in selecting the village health worker. As one of the innovative features of the rural health mission is the appointment of ASHAs to implement the programme, the experience in Gadchiroli should be heeded.

The Bangs concluded that the selection of the right person to this post was "probably the single most important decision for ensuring success at the community level." Twenty years ago, a similar approach had been tried nationwide and had failed.

One of the reasons was that the Community Health Workers were mostly male, were inadequately trained and were inappropriate for the tasks set for them. In Gadchiroli, the Bangs involved the community in selecting the VHWs.

They found this kind of transparent, public and intensive method of selection ensured that the VHWs, all women, performed well and the dropout rate over an eight-year period was only 10 per cent.

SEARCH also stressed the need to train the health workers well once selected. Their experience established that a new literate village woman needed at least 36 days of training spread over a year. By stretching the training in this way, the health worker was able to practice and implement what she had learned. Supervision was built into the programme and every 15 days, the health worker's performance would be assessed.

The VHW's salary was pegged at an amount marginally higher than what she could earn as an agricultural labourer. This ensured that only poorer women applied for the job. And to increase the VHWs' credibility and acceptability in the community, they were trained to deal with routine ailments even in adults and not just in infants.

Treatment demystified

An important contribution of the Gadchiroli experiment is that it has demystified the treatment of neonates. In the medical community, this would be considered a highly specialised task.

But the Bangs were able to train these barely literate village women to deal with the basic causes of neonatal mortality such as birth asphyxia, low birth weight and diagnosing sepsis and treating it with two specific antibiotics. In this way, they were able to provide timely intervention that saved the infant from what would have been certain death in the past.

By picking up and training women from the villages where the problem occurs, the Bangs have shown a practical way to deal with the problem of lack of access to health care.

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