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ASHWINIAssociation for Health Welfare in the NilgirisAn ACCORD initiative towards a community manged health care system and new challenges |
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The Gudalur Valley is a neglected forested area in the Nilgiri mountains, 50 kms below Ooty in Tamil Nadu state. Although the Nilgiris and its tribes are one of the most researched and written about areas in the world, the 5 tribes of the Gudalur Valley have been an exploited and marginalized lot, becoming progressively worse off as more and more immigrants invaded the hills and deforested this once isolated Valley. The aboriginal or adivasi people of the Valley were forest dwellers and hunter gatherers, till some of them became slaves and later bonded labourers. Slavery ended in the 19th century and the abolition of bonded labour was announced in the 1970’s. But the exploitation of these unsophisticated people continued systematically from the early ‘60’s when the government encouraged non tribal people under a ‘Grow More Food Policy’, to clear forests and stake their claims like pioneers of the Wild West. This felling of forests together with a National Forest Policy which pushed adivasis out of their homelands, led to a once self sufficient people becoming impoverished and helplessly inadequate. Bomman, a Bettakurumba elder put it in a nutshell when he said “Our ancestors needed only a knife to survive in the forest. With it, they cut bamboo and grass for their homes and provided food for their families. It was a different world. A self dependent one.” It was during the year 1986t that Stan and Mari, two social activists, along with a group of young tribals set up ACCORD. When ACCORD entered the scenario, the adivasis’ plight was pathetic. They had been reduced to a marginalized, impoverished people. Working as unskilled seasonal agricultural labourers in lands they once called their own. Highly exploited and vulnerable. Their life was a daily struggle centred around earning enough for a frugal meal of “kanji” – rice gruel. ACCORD’s objective was to help adivasis fight for their land rights, stop the exploitation and enable them become self sufficient again. This was done by mobilizing people to form village level organizations, called sangams. In 1988, as the land struggle peaked, these sangams federated to form the ADIVASI MUNNETRA SANGAM (AMS), a peoples’ movement bringing all the five tribes together to fight for their rights. Today the AMS covers close to 200 adivasi villages with nearly 3000 families as members. For convenience, these villages are divided into 8 clusters, caledl ‘Areas’. At each area there is a multi purpose community centre, (called Area Centre) which serves as an office, health centre, meeting place etc. In spite of very early successes, ACCORD was quick to realize that getting land back was not enough. People did not have the means to make the land productive. And so they provided small loans and grants to help the people plant tea on their newly reclaimed lands. Today nearly a 1000 families own small plots ranging from half an acre to two acres. At another level, the health of the people was alarming. Malnutrition was rampant with women and children dying in childbirth and of dysentery. Mari, recollecting those early days, once wrote, “We were appalled by the senseless preventable deaths we saw. Sick people lay on their verandahs and stoically awaited death, preferring to die among their own people than in an unfriendly, alien government hospital. An all-pervasive, fear of the unknown, hostile non adivasi world was the hallmark of all adivasi people in Gudalur.” In 1987, two young doctors, Deva and Roopa, specialists in Community Health from CHAD, Vellore, a centre of excellence, joined ACCORD to fight the Health battle. They trained a cadre of women as health workers. They were all adivasis and were selected by the people themselves. The focus of their work was to reach out to the most vulnerable group – namely antenatals and under five children. The objective was to significantly reduce the incidence of maternal and infant deaths. And to encourage people to access health services. These health workers very quickly became experts in preventive health, treating treatable diseases and identifying and referring serious cases to the doctors. A weekly mobile clinic would visit the villages covered by the health worker to cater to more serious patients and also to upgrade the skills and knowledge of the health worker. It was a long uphill task, dealing with mothers who ran away with their children when they saw the mobile clinic approaching. But the health workers kept at it and after 3 years of gruelling often frustrating effort, slowly the tide turned. Infant and maternal mortality was no longer accepted as commonplace and inevitable. And patients seeking curative care began pouring in. But there was nowhere to treat them. Attempts to work with the local government hospital were anything but successful – often tragically so. There was an adivasi belief “You might walk into the hospital. But you’ll almost certainly be carried out. So its better to die quietly at home.” Government hospital deaths only reinforced this belief. Thus ASHWINI (Association for Health Welfare in the Nilgiris) was started to cater to the health needs of the community. Nandakumar and Shyla donated whatever equipment they had and also a sizable chunk of their savings. With this and little more than a wing and a prayer ASHWINI set up the 25 bed Gudalur Adivasi Hospital as a complement to the community health programme initiated by ACCORD. Operating out of a small rented building, the hospital very quickly established itself as one of the nest in the area. Adivasis, who would never dream of entering a hospital, now began arriving on their own. the
Objective:
The primary objective of ASHWINI has been to establish a health system which is accessible, acceptable, effective and sustainable. It should be owned and managed by the people themselves. A system capable of responding to the growing health needs of the adivasis and their changing social conditions.The focus has always been on good health and preventive care, not just curative medicine. But it was health in the context of a community and all its needs. So there was an overall plan to make this the community’s hospital and health programme. The reason for their poor health was poor nutrition because of poverty. So we were addressing issues of poverty, its causes and how to fight for justice and equity, how to fight for peoples’ rights to livelihood, health, education and housing. Health was situated in the midst of all these issues, not as an isolated entity. The hospital and health programme therefore, had to reflect all this. We were trying to fight the fear of the alien world. So to make the hospital a peoples’ hospital, we took young adivasis with minimal education and trained them from scratch, beginning with basic maths and English lessons. The entire hospital staff with the exception of the doctors and one lab technician, was adivasi. The idea was that the patients who came to the hospital should be welcomed by their own people speaking their own language. They should be entirely comfortable and at home in the hospital. And everyone, non-tribals included, should recognize that this was an adivasi hospital. We were using an institution to make a political statement. Within a year of its inception, our hospital became the best in the district, offering quality health care at the lowest possible prices. The fact that we had an all adivasi staff made it a local talking point. The image of adivasis began to change. And so did the power equations. A couple of years down the line, we realised that there was still a large gap between the village and the hospital. People needed a curative service that they could access more easily than the hospital located in Gudalur town. So we introduced the concept of the sub-centre. There are now 8 sub centres, each covering between 20 and 60 adivasi villages. The sub-centres are run by adivasi nurses trained at the hospital. These nurses, called health animators, are more skilled in curative health than the health worker was. People come to the sub centre for all their basic health needs. What cannot be handled by the health animators is referred to the Hospital. Their work also involves visiting each village on a regular basis and to continue, in collaboration with the health worker, to monitor antenatals, under fives and persons with chronic diseases like TB, asthma, etc. A few years ago, the health workers all decided that the people’s awareness on health had reached a level where the health worker was no longer needed. So the health animators took on some of the roles of the health workers. Today with the AMS now covering nearly 200 villages we feel that the health animators are terribly stretched and cannot really provide quality care especially in terms of preventive health. More frequent and regular monitoring at the village level are still required. And so we have decided to bring back the concept of the village health worker – not as paid staff but as volunteers. We have begun to recruit volunteers – many of them health workers – who will take responsibility to monitor and maintain the health status of the village. By the end of the first year we hope that every village will have a health volunteer or health guide as we call them. In most health programmes, the community health or preventive care component is an add-on, the main activity being curative care delivered through clinics or a hospital. In our case it is the other way around. The hospital in fact grew out of a successful community health programme and till today is seen as an extension of that and not the other way around! Further over the years we have come to realise that the divide between preventive care and curative care is an artificial one. And so our attempt is to provide a seamless health care system that extends from the village all the way to the hospital. So the present health care system provided by ASHWINI works at three levels – the village, the area, and the taluk. The
Village Level
The most striking aspect of our community health programme during the last decade has been the change in the health status of the pregnant women in the tribal villages. Maternal mortality used to be a routine affair in most villages. Today thanks to the antenatal care provided by the health animators maternal deaths are a rarity. The few deaths that do occur are usually from villages which have not joined the AMS.Antenatal care is provided primarily through monthly village visits of the health animator. Every pregnant woman is identified and registered. The health animator then closely monitors the mother to be, ensuring that she has a healthy diet, takes the necessary immunisations and vitamin and mineral supplements. Women are encouraged to deliver at home – but if there is any indication of a complication or a past history of complications, then she is referred to the hospital. One of the offshoots of the antenatal programme is that now all children born are registered with the government. Earlier nearly all adivasi births went unregistered and this would lead to innumerable problems later on in life. Under
- 5 Children Care:
Children who do not develop in spite of all this care are immediately referred to the hospital. As a result, we have been able to detect, quite early, incidents of childhood tuberculosis and other complications. When ACCORD first launched the community health programme, immunisations were unheard of. The entire village would disappear should a medical team approach them. Today we have a near 100% coverage. This is perhaps primarily due to the increased health awareness within in the community but also due to the diligence of the health animators who keep close tabs on every child. Health Education:
We intend to conduct these sessions on a quarterly basis at the area level (with the exception of the rainy season which is from June to September) . This means 3 sessions in each of the 8 areas – so a total of 24 sessions will be held each year. Topics covered will include TB, effects of alcohol and smoking, nutrition, family planning, AIDS etc. Most of these sessions will be handled by the health animators who are already trained for the job. Training
of Village Health Guides:
This strategy is being adopted by all the other institutions working with the AMS. Currently 175 volunteers have been identified of which nearly 90 are specifically health volunteers. Many old health workers have joined this team. We hope by the end of three years we would have covered all the villages of the AMS. We now intend to provide training to these volunteers to enable them to effectively fulfil their role as guardians of health at the village level. The training is planned as follows: 1. One to one contact with the health animators during their village visits 2. Monthly sessions at the area level conducted by the health animators 3. Half yearly sessions conducted by the doctors 4. Annual camps at the taluk level. The topics covered in these sessions will focus on Ante natal care, Under 5 care, Disease Management, especially chronic diseases like TB. THE AREA LEVEL
The
Sub
Centre and the Health Animator:
The
Taluk Level
Non-adivasis are also seen at the hospital – though this is restricted to two days of the week. This is to ensure that the hospital, does not get high jacked by more affluent people. These patients pay both for the medicines and the services. But our charges are significantly lower than any of the other hospitals in the area. This is primarily because we use a rational drug therapy – where unnecessary and expensive combination drugs are not prescribed. Further we tend to use only generic drugs and the bulk of our medicines are purchased from LOCOST, another voluntary organisation that manufactures drugs especially for the voluntary sector. At the hospital we try to maintain an atmosphere that is open and welcoming so our people feel reassured and secure when they have to be admitted. For example we do not have prescribed visiting hours – family are free to come and visit the patient as and when convenient. Each patient is encouraged to have a person staying with them in the hospital. These companions help a lot both with the care of the patient as well at the hospital. Simple food is prepared and patients and their companions can have food at the hospital at nominal cost. Our nurses are all adivasi and so people are able to speak in their own languages. Our hospital has been recognised as one of the best in the area. The government hospital and a number of tea estate hospitals often refer cases to us. On an average we have around 70 admissions in a month of which 90% are adivasi. Each non-tribal OP sees an average of 60 patients. Not many adivasis are seen at the OP since most of them are first seen at the sub centre and are usually referred to the hospital. We now handle a number of complicated deliveries and surgeries. Cases that cannot be handled by us –and these are few and far between – are referred to larger hospitals in nearby cities, with whom we maintain fairly regular contact. Apart from this the Hospital serves as a training centre for the health animators and nurses. The health animators periodically undergo a hospital posting to keep their curative skills honed and up to date. We intend to maintain the high standards of excellence that we have set for ourselves to ensure that one of the most marginalized communities of our society get the best possible health care. MANAGEMENT:
Initially the General Body was made up of doctors and other professionals working with the adivasis, but gradually adivasis, who are members of the AMS, were inducted into the General Body. Today the majority are adivasis. The General Body appoints an Executive Committee and all the present Executive Committee members are adivasis. The General Body through its executive committee oversees the policy and direction of the entire health care system. A Working Committee, consisting of staff members, takes care of the day to day needs of the entire health programme. Representatives of ASHWINI also take part in the fortnightly Coordination Team meeting. In this meeting, representatives from the tribal institutions as well as the adivasi representatives from the 8 Areas participate. The Coordination Team ensures that all the different organisations work in tandem – since we do not see health in isolation but as an integral part of the community’s social, economic, political and cultural fabric. New
Challenges:
Apart from the above, the new challenges now we are facing are the alarming increase in the number mental illness cases reported from these villages. Dr.Seetha, a psychiatrist from St. Johns’ Medical College, Bangalore has been visiting us on volutary basis once in every 2-3 months during the past 3 years. There are 39 psychiatric cases which require medicinal and emotional support were identified and all were undergoing treatment under the guidance of her during this period. A wide range of mental cases from Hypertension to Depression and even different forms of Schizophrenia are reported and undergoing treatment. Most of this cases are identified by the Health Animators during their visit to villages, even though they are not trained to identify or handle such cases. The increasing number of mental illness among adivasis are attributed to the change in their life style forced by the alienation of their forest land and to the market driven economy. While many of adivasis are slowly getting adjusted to the new way of living by becoming wage labourers in the tea plantations and in the farm lands, many are not able to cope with this changes around and are falling prey to different forms of mental illnesses that are manifested in different forms and some ends up with suicide. There were as many as 13 suicides reported during the year 2002. Apart from the stress caused by the changes around the alcohol also do its bit to worsen the situation. We have been knocking at different doors in search of help to come out of this problem all these time . But nothing came fruitful so far and hence we continue our search. Support from any corner to analyse this situation by way of scientific research and suggestions to tackle this issue will highly be appreciated and we hope it would be a meaningful step in our efforts to make the adivasi community healthy in all its sense. Please visit the ASHWINI website: http://www.ashwini.org |
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 Das
Adivasi-Tee-Projekt ist eine AG der Bundes-ESG |
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