The effectiveness of the village health workers (VHW) on the health status of the Adivasi population of the Gudalur valley

Evaluation by Christiane Fischer (1996)

Objective: The evaluation of the village health workers (VHW) on the health status of the Adivasi population of the Gudalur valley, organised inside the NGO ACCORD/AMS is to be evaluated.

Type of the study: An retrospective study with an comparison group

Method: The study consists of a quantitative and a qualitative part. In the quantitative part four health indicators are examined (diarrhoea, nutritional status of children under five, immunization status of children, antenatal coverage. 91 mothers living in villages with a VHW and 87 mothers living in villages without a VHW are given a questionnaire about the health indicators on their children under five. The results are checked by means of the ?²-test, the student t-test and the u-test of Mann, Whitney and Wilcoxon, ? = 0.001
The qualitative part done as a triangulation in form of 29 semistructured single interviews with different people of the team (VHWs, villagers, animators, health animators. hospital staff). The idea is to get an understanding of the different life realities of the questioned people.
By combining the qualitative and the quantitative part the results are supposed to be reliable and valid.

Results: Quantitative part: In all areas which were related to the knowledge of the mothers about prevention and therapy of the examined health indicators, there were significantly better results seen in the group of mothers out of the villages with a VHW. Also this group had significantly better results in the immunization status of the children and the antenatal coverage of the pregnant women. No differences were seen in the incidence of diarrhoea and in the weight/underweight of the children.

Qualitative part: The examined health indicators were seen as fields of change. Other fields of change to be mentioned: the reduction of fear from the outside world, the decreasing of the mother and children mortality and many points from the ACCORD developing programme (land, education of children, increased incomes, tea planting programme). The GAH was seen particularly positive, also the health insurance scheme. The health programme was seen by all groups as an integral part of the work. Critical points to be mentioned: a massive alcohol problem among the men and also the fact that the change is not sufficient yet. The people living in villages without a VHW saw more critical points and less change.
A discrepancy between the villagers and the team was seen when compared to the work of the VHW: the team saw the focus on preventive care, the villagers on curative care.

Conclusions:
The role of the VHW can be understood as a catalyst for changes inside the villages. The positive effect on the health status of the people has to be spread out to all areas of work. It was decided to train all the team and volunteers in health care.

1. Introduction

There are village health workers (VHWs) in many southern countries, which work under low cost medical conditions, one important factor for the work of the health programmes. As members of one certain culture and mostly as members of a village they can take an direct influence on change in health knowledge and health behaviour in a village. At the same time there is the question of financial sustainibility of the VHWs. Here the effectiveness of the VHWs inside the NGO ACCORD (Action for community organisation, rehabilitation and development) / AMS (Adivasi Munnetram Sangham) is evaluated, which is an organisation for the indigenous (Adivasi)-population of the Gudalur valley in the Nilgiris district, South India.

The Nilgiris district is a hilly area where mainly tea is grown. It has 753,000 inhabitants (10); the examined taluk is the Gudalur taluk [administrative area below a district] with about 181,000 inhabitants, out of which about 20,000 are Adivasi. Half of them are organised in ACCORD/AMS. They belong to five different tribes.

ACCORD started in 1986 as a land right movement with the objective to get land for the Adivasi villages. The forest, the traditional common property of the people was destroyed, the traditional subsistence economy as well as other tribal values under threat (decision making processes, equal opportunities for women, tribal languages and tribal culture). ACCORD started a hospital where tribal women were trained as nurses and in administration, schools, a housing programme and a tea planting programme (14). It became clear that for independence, sustainability and self-reliance the institutions of the organisation have to become financially independent. So it was decided to buy an own tea estate as a common property, from which the institutions (hospital, school, housing) etc. can be partly financed. EDCS, the ecumenical development cooperation society, has agreed to grant a loan (15,16). Up to today there have been funds from Action Aid/UK, Cebemo/NL and Deutsche Welthungerhilfe. In ACCORD there are 15 non-tribals (Indians) and about 100 tribals. The decision was made that the non-tribals will withdraw within the next five years.

The health programme consists of the Gudalur Adivasi hospital (GAH) and the village health programme. Since 1992 all sangham members [all people organised in AMS are called sangham members, the sangham meets regularly in the villages to make all important decisions] are health insured with the New India Insurance Company. In 1996 8,754 persons (2,187 families) were insured. The insurance covers all facilities inside the health programme, other hospitals or health care institutions are not covered. The premium is 16 Rs a year per person, from which the sangham members pay a subsidised premium of 10 Rs a year, the rest is paid by ACCORD.

In the hospital (Gudalur Adivasi Hospital) there are four doctors (one surgeon, one gynaecologist, one public health doctor, one generalist). It has 20 beds or mats on the floor (beds are not part of the culture) and an operating theatre. For non-tribals it is open 2 days a week and it is always open for emergency cases. Today, the tribal team handles the administration all on ist own.

In the village health programme there are at the moment 54 village health workers (VHWs) involved, who take care of their own and of some of the surrounding villages. They were trained in the GAH on a 6-week-course and get annual training there. In the areas with a subcenter SC they get additional training units by the health animator (HA). So about half of the sangham villages are visited regularly by a VHW. In six of the eight areas a subcenter (SC) is in existence, with a health animator (HA) working, who does the basic work of a doctor. The HAs were also trained in the GAH. The mobile clinic (MC) used to visit each other week all sangham villages, but now with the subcenters (SC), the MC times have been reduced more and more and the MC runs nowadays only in two areas (4).

The role of the VHW is to bring up the health status of the people, to increase knowledge about health, to create awareness, to reduce people's fears, to provide preventive health education and to provide basic curative health care. The focus of her work is usually to be seen on the preventive side (1,18).

The VHW has the following areas of work:

teaching germ theory
mediation between western medicine and village culture
diagnosis and therapy of simple diseases (diarrhoea, bronchitis, bronchopneumonia
viral infection - the training by the VHW enables them to make different diagnoses and give therapy against these diseases)
diagnosis of symptoms, which refer to severe diseases (TBC, dehydration, dysentery) and referring patients to the SC/GAH
conducting uncomplicated deliveries
diagnosis of pregnancy
delivery complications and referring women to the SC/GAH
cooperation with government services for immunizations
health education of the villagers in preventive care (boiling of drinking water, personal hygiene, household hygiene).

The structure of the health system is equivalent to the government health system (1) (district hospital, community health centre, primary health centre, subcenter and until 1985 VHWs in the villages). The government health system is seen as corrupt and inefficient, and because of that many NGOs see the necessity to build up parallel structures. At the same time there is a big discussion about how particularly a hospital can get self-reliant and financially independent from external funding. In the case of ACCORD a part of the solution is the health insurance, which covers the running costs of the hospital. Another part of the solution is seen in the tea estate which is going to be bought as common property to finance the institutions.

2. Methods

The aim of this study is to evaluate the effectiveness of the work of the VHWs regarding the health status of the people. The study is a retrospective study using a comparison group. The work of the past nine years of the village health programme was evaluated. The study consists of a quantitative and a qualitative part.

In the quantitative part four health indicators are examined:

diarrhoea
nutritional status of children under five
antenatal coverage and deliveries
immunization status of children under five

These four health indicators represent the main working fields of the VHWs (health education, prevention, diagnostic, therapy). The Adivasi organised in ACCORD/AMS (roughly 10,000) live in small villages in the taluk, the 54 VHWs visit about half of the villages regularly.

       A group of 91 mothers living in villages, in which a VHW has been working for a minimum of four years (that is where he has been living or where he has been visiting the village once a week or more) is compared to a group of 87 mothers living in villages where no VHW has been working (i.e. the village has never been visited or less than once a month by a VHW). Only sangham villages (organised in ACCORD) are taken into consideration. In the villages all mothers with children under five were interviewed by means of a questionnaire, and all children under five were weighed and measured with the same weighing machine and tape measure. All other criteria were to be the same: same tribe, same area, same size (number of families and children), same distance and access to the SC, to the GAH and to government and private health services, same socio-economical status of the matched villages. To get a structural identity the matched pairs technique was used, every village with a VHW was matched to a village without a VHW which met the same conditions. The villages with a VHW, where no corresponding village of the same size was found, were matched to two villages.

       Altogether 53 matches were possible. In each group a minimum number from which 17 matches (two from each area and one from the taluk were chosen per random (stratified randomisation). For proving the same socio-economic status the mothers were asked for their school education and for the ownership of land. No significant difference was found.

       The results are statistically analysed with the X² test, the student -t-test and the u-test of Mann, Whitney and Wilcoxon (2,6). The strength of this method lies in its good reliability.

The zero hypothesis is as follows: H0: There is no difference between the groups of mothers of the villages with and without a VHW.

      The alternative hypothesis is as follows: H1: There is a difference between the groups of mothers of the villages with and without a VHW.
       ? = 0.001%

The groups of mothers with and without a VHW are non combined samples, because the villages are matched, the individual mothers, however, are not.

In the qualitative part single semistructured interviews were carried out with six villagers from villages with a VHW, six villagers from villages without a VHW, six animators [political leaders inside the organisation], six VHW, two HA, three persons from the GAH staff (one doctor, one nurse, one administration officer).

They were analysed by means of a memory protocol, written down directly after the interview. Recording the interviews with a tape recorder would have had the disadvantage of a time-consuming transcription of the Tamil interviews. The memory protocol has the advantage of directly filtering the relevant data.

The interviews consist of a semistructured part as guideline interviews, where the main categories are defined in advance, which is open for new aspects, and where the questions are open questions. This interview type promises good comparability and is fast to analyse. The largest part of the interviews consist of key informant interviews: VHW, HA, animator, hospital staff. They all represent a special group inside ACCORD/AMS, so the interviews give a good validity and are independent, they promise a fast way to get information and they represent a certain group inside the system. But they do not represent the weak ones. That means they also have to be included in the interviews, and so a cross-checking has to be done. The semistructured interviews have the disadvantage that they can miss life reality of the people, so it was decided to combine them with an unstructured part in a narrative interview, where relevant issues for the people get clear.

The qualitative part is to be seen as a triangulation: in interviewing different groups about the same issues the idea is to be able to add up the different views, positions and opinions to an overall picture (8).

The qualitative part and the quantitative part have different focuses. In this study the combination of the methods is useful, because they answer different points of the question(7). It has also to be clear that the weaknesses of one method are not completely compensated by the strong sides of the other method.

The qualitative part was done after the quantitative part, because the understanding for the situation was there at a particular moment, something which seemed to be relevant for doing the qualitative interviews. Also for the qualitative interviews a questionnaire was used.

The following categories were chosen for the analysis of the qualitative part:

Assessment and description of the work of the VHW
Role of the VHW in the village
Changes through the work of the VHW and through the health programme
What did not change through the work of the VHW and through the health programme?
Assessment of the health programme (VHW, SC, MC)
Health insurance
The most common diseases
Reasons for being ill
In case of getting ill, where do the people go first?
Changes through the work of the sanghams and ACCORD
What did not change through the work of the sanghams and ACCORD?
Problems of the work and for the villages
Co-operation inside ACCORD and AMS (health programme and the whole organisation)
Differences in the co-operation with the villages with and without a VHW

3. Results

a) Quantitative part

In the quantitative part it came out that in the factors related to the knowledge of the mothers of all four examined health indicators (diarrhoea, nutritional status, antenatal coverage and immunization status), the mothers from the villages with a VHW knew significantly more than the comparison group without a VHW. There were also significant differences in the immunization status of the children and in the frequency of the antenatal coverage. No differences could be found in the incidence of diarrhoea and weight/underweight of children. The interpretation of this was that changes in these points are most difficult, due to multiple factors in their genesis. Statistical testing in itself does not say anything about how the results came about, so it has to be interpreted.

Table 1: Diarrhoea

	VHW+	VHW-	significant (?=0.001)
incidence of episodes within the past two weeks (children under 5 years):	24%	30%	no
treatment (ORT) against diarrhoea:	97%	54%	yes
knowledge in which case a child has to be brought to the SC /GAH (diarrhoea for more than three days, blood and mucous as signs of dysentery, continuos vomiting):	75%	57%	yes
knowledge of prevention of diarrhoea (boiling drinking water):	76%	26%	yes
main information source:	VHW(78%)	neighbours / nobody (59%)

VHW+: group of mothers/children from villages with a VHW (91 mothers, 127 children-0-5years)
VHW-: group of mothers/children from villages without a VHW (87 mothers, 130 children-0-5years)
ORT: oral rehydration therapy

All indicators related to knowledge were significantly better in the group of mothers from the villages with a VHW. Boiling of drinking water for the prevention of diarrhoea is practicable in Tamil Nadu, because the people there traditionally do not drink cold water. Therefore the step from heating to boiling is not too big. Although boiling water is not regarded as the best method, it is accepted and at the moment the only possible way. In the next few years it is planned to drill wells.

The VHW seems to be the main source of information and health education. She is the responsible person for putting knowledge into practice.

In the qualitative part of the study all interviewed groups see in her the catalyst of change of knowledge and practice. Two main questions were discussed with the area teams after the survey: Why is there no significant difference in the incidence of diarrhoea and how can drinking water be made more safe? During the day children drink unboiled water in neighbouring villages and there are no toilets in the villages. Normal water comes out of a waterhole in the village, which is located at the deepest point of the village, so that all the water, also contaminated water from the toilet, is streaming together at this point. This problem occurs in all rural areas of India, where only 0.5% of the population have toilets and only 30% have access to clean drinking water (10). In the literature advice is given to build simple uncemented or cemented toilets (17). However, with uncemented toilets the problem of contamination remains, whereas cemented toilets require water, which has to be carried to keep them clean and smellfree, since dirty toilets will not be used. As a result of this discussion, the architects of the organisation were asked to find a way to solve this problem.

Table 2: Nutritional status

	VHW+	VHW-	significant (?=0.001)
weight/age [For age/weight the classification of the Indian Academy of Paediatrics and for weight/height the Waterlows classification is used. Both classifications are used in the health programme of ACCORD, the weight is registered in the SC, GAH and on health cards of the Voluntary Health Organisation of India, which stay with the mothers (which were only there in about 50% in both groups)] normal weight: severe underweight (grade 2 and 3) (3,11):	59% 11%	45% 19%	no
weight/height normal weight: severe underweight (grade 2 and 3):	30% 26%	23% 36%	no
feeding with ragi (children > 3 months):	35%	7%	yes
number of meals (children > 3 months) no meal: 3 or more meals:	3% 85%	10% 62%	yes
weighed during the last year: never (children >5 months)	70% 17%	43% 42%	yes
health instructions received	68%	37%	no
health instructions followed	49%	15%	yes

VHW+: group of mothers/children from villages with a VHW (91 mothers, 127 children-0-5years, 110 children > 3 months, 105 children > 5 months)

VHW-: group of mothers/children from villages without a VHW (87 mothers, 130 children-0-5years, 115 children > 3 months, 111 children > 5 months)

ORT: oral rehydration therapy

Looking at the number of meals given to the children, the feeding of ragi (a high protein millet, which is one of the traditional crops of the Adivasi) and the frequency of weighing the children, there were significant differences between the two groups. The feeding of ragi is seen as insufficient altogether. All children should get ragi according to the health programme. Ragi is seen as an exellent waining food. For feeding rice to the children the Adivasi have to go to a temple and have to go through a certain ritual, something which requires a lot of money. If there is no money in the family, the children do not often get food apart from mother's milk up to an age of two years in some cases. For feeding ragi this ritual has not to be performed. This is also one explanation for the number of children who did not get any meal during a day. While the mothers bring their children to get weighed, they get information and health education about feeding children. The main information sources were the VHW and other ACCORD health staff (GAH, SC). The children were weighed mainly within the own health institutions; when children were weighed within the government health services, hardly instructions about how to feed the children were given to the mothers. Just giving information does not seem to encourage the mothers to follow the instructions. This only happenes when a VHW permanently stays or comes to a village. Again here the VHW seems to be the key person to get the given instructions put into practice. In the qualitative part, health education particularly about food and feeding the children was seen as one of the main working fields of the VHW. In spite of all factors considered no difference can be seen in the weight/underweight relation of both groups. In order to solve this problem it has to be understood in all its multiple causes, which involve a lot more change than took place up today (1,5). The nutritional situation of children is seen as the most insufficient part of the health programme.

Table 3: Antenatal coverage

	VHW+	VHW-	siGIFicant (?=0.001)
children died:	0%	2%
monthly examination during the last pregnancy: never had an examination:	81% 7%	37% 29%	yes
2 TT immunization received:	85%	56%	yes
iron prophylaxis for min. two months:	89%	59%	yes
hospital home delivery:	35% 65%	17% 83%	no

VHW+: group of mothers/children from villages with a VHW (91 mothers)

VHW-: group of mothers/children from villages without a VHW (87 mothers)

examined: the last pregnancy within the past 5 years

TT-immunization: tetanus immunization

One of the reasons, why the iron prophylaxis is important, is because of the 30% sickel cell anemia in the population, which in the combination with malnutrition leads to severe anemia. The examinations were carried out in the villages by a VHW, followed by the other ACCORD health institutions (MC, SC, GAH), or in the village without a VHW by the MC, SC, and GAH. Government and private health facilities were hardly used from either group (about 10%). Here as well it seems that the permanent stay of the VHW strongly encourages the women to take care of regular preventive care during their pregnancy. The health education and the change in behaviour of the women is seen in the qualitative part as one of the most important tasks of the VHWs, which has reduced a lot of maternal deaths within the last ten years. This reduction of women dying in their pregnancy or during childbirth because of the VHW's work was repeatedly mentioned in the qualitative interviews.

The biggest part of the hospital deliveries was carried out in the GAH. The health programme stipulates that an uncomplicated delivery shall be done at home, hospital deliveries are not encouraged. The number of hospital deliveries is seen as sufficient by the health team. The VHW, who shall conduct uncomplicated deliveries, did this only in 22% of the home deliveries in their villages. One of the reasosns for this is, that a female family member or a traditional midwife conducts the delivery and the VHW is not allowed to do this.

In case of a problem (pedals oedema, twins, prolonged labour, etc.) the mothers of the villages with a VHW always went for professional help (SC, GAH), whereas three mothers from villages without a VHW did not do anything. In the villages with a VHW immediate medical action in case of a problem is taken.

Table 4: Immunization

	VHW+	VHW-	significant (?=0.001)
any immunization received	95%	87%	no
basic immunization	74%	21%	yes
3 DPT and OPV	89%	51%
measles immunization	75%	24%
knowledge of the mothers against which diseases the children got immunized; at least one disease	25%	9%	no

VHW+: group of mothers/children from villages with a VHW (91 mothers, 100 children > 11 months)

VHW-: group of mothers/children from villages without a VHW (87 mothers, 104 children > 11 months)

DPT: diphtery, pertussis tetanus immunization

OPV: oral polio vaccination

All children at the age of one year are basic immunized with: three OPV, three DPT and measles immunization. Normally the immunizations are carried out at an age of 1.5, 2.5 and 3.5 months and measles at an age of nine months. In addition, the children shall be immunized with BCG and with booster one and two OPV and DPT (1.5 and five years). The ACCORD health programme follows the Indian immunization scheme (11).

It is interesting to see that there was no significant difference in the number of children who have received any kind of immunization in their live, so the general awareness about getting children immunized can be assumed both group. But there is a significant difference according to the number of children, who have received the basic immunization (3 OPV, 3 DPT, measles). The same difference can be found in each single immunization. The limiting factor for the basic immunization seems to be the measles vaccination, which is the latest and normally carried out at the age of nine months. Particularly under poor nutritional conditions and with a low immune system of the children measles produce a lot of live-threatening complications like diarrhoea, bronchopneumonia or loss of weight.

When the mothers were asked against which diseases their children were immunized the general knowledge of the mothers was very low. Most mothers (90%) answered that they got the general information to get their children immunized.The VHWs made clear that often they have to remind the mothers of every immunization, because the relationship between the immunization and avoiding severe diseases is difficult to understand.

Most of the children were immunized by the MC (42%), followed by the government health facilities (30%), most information was given by the AHS and the VHWs. With the area teams it was decided after the survey to improve cooperation with government health services within this area. One problem was highlighted, namely that government health services usually use unsterilized injection needles. So it was decided to accompany the childrenand mothers by an animator or VHW to get immunized, and to make sure that only sterilized needles are used.

b) Qualitative part

Particularly the health indicators, which were examined in the quantitative part, were mentioned as fields of changes because of the VHWs' work and the health programme. These answers can be understood in that the VHWs and their work can be seen as one major source of change. In the villages with a VHW people regard her as a main source of information. The new knowledge and health education leads to a reduction of fears of outsiders and hospitals, something which leads to a change of behaviour, like using the health services. This way the death rate is reduced. This shows, too, that she has to be seen as a catalytic converter of change.

Other changes through the work of the VHW, the health programme and the work of ACCORD/AMS, which were mentioned: the reduction of fears of outsiders, the decreasing number of deaths during childbirth and deaths caused by diarrhoea and many points of the programmes of ACCORD (land, education, increased incomes, tea programme). Particularly the reduction of fear was mentioned over and over again and the fear is to be understood as one of the key points, which was holding the Adivasi away from the rest of society. Especially the VHWs help the village people to reduce their fear. They could come to the VHW without fear, and she was a key person to the outside world. An important point for the villagers is that the VHW provides immediate medical help and goes with seriously sick patients to the SC or GAH.

Sunitra, of one of the villages, told us: "Some years ago, we just ran away when outsiders came to the village, we were hiding in the forest. We had a great fear of medicine, hospitals and injections. When we fell sick, we just laid down and waited. Many women died in their pregnancy, many children died from diarrhoea. Since Badmini (the VHW) works for us, we lost our fears. Now we go to the hospital when we are sick. Now we even have our own hospital!"

The GAH got a particularly positive assessment. It is seen as a place where the own tribal languages are spoken, where the nurses are tribals. It is a place of good medical and human care and where the rules are made by themselves. E.g. the wards are mixed, something which is unthinkable in the rest of Indian society. The hospital gives a lot of pride to the people, for them it is a status symbol for social change. The Adivasi, the least people in Indian society, have one of the best hospitals of the region, where non-tribals can come and follow their rules. The GAH is often compared to the government hospitals, which are seen as inefficient and corrupt and where nobody cares about the people. The health insurance, too, was seen as mainly positive. The health insurance is seen as necessary for running the GAH and the health system. Through the health insurance the running costs of the health system are covered. The idea of a health insurance was thought of in many places, in this case it seems to work. In 1996 the Adivasi decided to continue with the health insurance.

The health programme was seen by all groups as an integral and important part of the whole work.

Also the difficult parts of the work were mentioned by all groups with a lot of self-criticism. The main ones are: a massive alcohol problem particularly of the men, something which influences the whole work and many parts of daily life. The alcohol problem was seen as most destructive for the families, the villages and the political work. Particularly the women and children suffer most from it, when all the money is spent on liquor instead of food and education. In the discussion after the survey it became clear that the alcohol problem has to be the next focus of the work.

The changes are not seen as sufficient, but as a start.

The role of the VHW as part of the community is seen by some of themas difficult, because some of the people have more faith in outsiders than in their own people. This describes a problem of many other health programmes, too. The team is of the opinion that a VHW from one's own community is accepted faster, whereas the village people often say that it takes more time to accept one of their own community as VHW, but in the long run faith in the person is more stable (13, 18).

The people in the villages without a VHW mentioned more critical points and saw fewer changes. This means that the VHW is a catalytic converter of change for the villages.

A discrepancy between the village population and the team was seen concerning the focus of the VHWs' work and the role of the MC. The villages people saw the focus of the VHWs' work on curative medicine, whereas the team saw the focus on the preventive medicine. This is a typical discrepancy. Preventive medicine is working on the long term, success is seen only after a long time, while curative medicine shows an immediate success. This argument was most important to train VHWs in curative care as well (12, 18). The villagers wanted the MC to continue or restart. The team had it clear that the SC should take over the role of the MC. While the village people felt more safe with the MC coming every other week, the team saw the advantage of the SC in that a person is available all the time. During the discussion it became clear that the decision to stop the MC was not discussed enough with the sanghams. So it was decided to discuss it again with them.

4. Conclusions

The results were discussed after the survey with all area teams, where the following decisions and conclusions were made:

There is an positive effect on the health status of the people because of the VHWs' work. So the area teams should be trained in health for having that effect also in the villages without a VHW. Two areas decided also to train volunteers in health. The training of two teams started in July 1996.
The alcohol problem has to be one of the next focuses of work.
The role of the MC and SC will be discussed again with the sanghams.
Concerning the immunization there should be a more intensive co-operation with the government health workers.
The hygiene of the drinking water including the questions of toilets has to be improved.

My role as a white West European, as an outsider, was discussed before and after the survey. Two points were seen: on the one hand, there is a little more objectivity, when the survey is done by someone from outside, on the other hand the results can be influenced by an outsider. Although Indians are outsiders for the Adivasi community, the difference was not seen as too big.

      During the qualitative interviews it was clear to the Adivasi that theycould mention critical points even when the person criticised is present. This was announced by the team and observed during the interviews.

      The Adivasi are one of the most marginalised groups in Indian society, who in general have great difficulties to benefit from the government programmes. They belong to the groups who fall through the social net. That is the reason why the Adivasi need special programmes in order to get equal opportunities. One of these programmes is the health programme. As a part of these programmes the effectiveness of the VHWs' work on the health status of the people within the work of ACCORD was evaluated. In the quantitative and in the qualitative part of the study a positive effect of their work was seen. This effect was assessed as positive, too. Many aims which should be reached (not only the aims in the health sector) are not reached yet. But the way of the Adivasi to become equal members of Indian society has been paved.

      The health system of ACCORD and the work of the VHW is running exceptionally well. The final question to be raised is whether this way is a very particular way or whether it could be transferred to other projects. Health and education are never financially sustainable, once they are institutionalised, not even in Germany or in the US. A NGO which has the aim to withdraw after a few years in order to help the people to be really independent is faced with this problem, once they decide to run such institutions. In this case the health insurance solved the problem to cover the running costs and the buying of the tea estate is likely to be the solution to cover also the remaining costs (salaries, repairs, vehicles, extras). This seems to be a very particular solution, which allows exceptionally good medical care, including four doctors for a population of 20 000 people. But on the other hand, this system can be transferred to other projects, once one accepts the analysis behind the project. In order to fight poverty by its roots health and education need to be improved. At the same time these institutions have to get financially sustainable to guarantee people's self-reliance. The way towards self-reliance has to fit into the value-system of the people. In this case the tea-estate was the solution for this problem, because the traditional economy of the Adivasi is based on subsistence and common property. So a tea estate which belongs to the community as a whole and which guaranties the running of the institutions of the community was seen as a possibility to adapt the traditional values to the modern age. In order to transfer this health system to other projects, two points have to be clear: first the health system has to be part of an integral programme against poverty and second, the way of the NGO to withdraw after some time, the way towards self-reliance of the people has to be analysed and a solution be found within the cultural context. The question whether this health programme is particular and the question why it is working can be answered as follows. The health programme in itself is particular for the people of this region, but the thinking and system behind it can be transferred.

5. List of abbreviations

ACCORD: Action for community organisation. rehabilitation and development

AHS: Accord health staff

AMS: Adivasi Munnutra Sangham

DPT diphteris, pertussis, tetanus immunization

OPV: oral polio vaccination

HA: health animator

GAH: Gudalur Adivasi hospital

MC: mobile clinic

NGO: non-governmental organisation

SC: subcenter

VHW: village health worker

6. References

1. Almas A, Alok M, Jill CH, Darshan S, Kali C, Salil B, Sinha NK, Chandra K, Indrani G, Ritu B, Poonam K, Mira S, Amly R, Bermann P, Priti D Kabra SG, Saraf DN , Ravi D Amar J Radhika M, Srivasa R (1992), State of Indias Health, Exellent Printing House, Voluntary Health Assosition of India (Hrsg), New Dehli, 1-175, 229-256

2. Bortz J, (1989), Statistik für Sozialwissenschaftler, 6. ed., New York, Berlin, Heidelberg, 179-186, 830-836

3. Children in the Tropics (1989), Nutritional Status, The Interpreting of Indicators, 1989 Mo. 181/182

4. Devadasan N, (1994), Comparison Of The Effectiveness Of A Health Center And A Village Health Worker, Med. Masterarbeit in Public Health, Antwerpen

5. Ghai OP (1990), Essential Pediatrics, 10. ed., Interprint, New Dehli, 5, 37-52, 114-170, 177-205

6. Harms V (1992), Biomathematik: Statistik und Dokumentation, 6.ed. Harms, Kiel, 154-222, 278-281

7. Kielmann AA, Janovsky K, Annett H (1992), Assessing District Health Needs, Services and Systems, Protocolls for Rapid Data Collection and Analysis, The Macmillan Press LTD, GTZ GmbH (Hrsg) London, Basingstoke, 1-28

8. Maier B, Görgen R, Kielmann AA, Diesfeld HJ, Korte R (1994), Assessment of the District Health System, Using Qualitative Methods, The Macmillan Press LTD, GTZ Gmbh (Hrsg) London, Basingstoke, 1-46, 76-93

9. Murthy N, Deodar NS, Shah MH, Panse GA (1994), Health Monitor Foundation for Research in Health Systems, Ahmedabad, 136-149

10. Murthy N, Sunder Rao PSS, Shah MH, Panse GA (1995), Health Monitor: Foundation for Research in Health Systems, Ahmedabad, 40-75, 104-143

11. Park JE, Park K (1991), Textbook Of Preventive And Social Medicine, 13. ed., Surya Offset, Banarsidas Bhanot (Hrsg), Nagpur, 11-106, 156-157

12. Roy S (1987), Management Training Modules For Health Workers, Ajanta Offset, New Dehli, National Institut of Health and Family Welfare (NIHFW) (Hrsg), New Dehli, 1-45

13. Sathyamala C, Sundharam N, Bhanot N (1986), Taking Sides, The choices before the health workers, Bukprint, New Dehli, ANITRA (Asian Network for Innovative Training Trust) (Hrsg), Madras, 125-304

14. Thekaekara M, (1994), Action For Community Organisation, Rehabilitation And Development, Anubhav, Experiences in Health and Community Development 1994, Voluntary Health Assosiation of India, 2-20

15. Thekaekara S, Thekaekara M, (1993), The Tribal Scenario In India, A Report for the Swiss Development Cooperation Gudalur, New Delhi, 2.2.-2.4., 5.1.-5.3.

16. Thekaekara S, Thekaekara M, (1996), Towards Self Reliance, Gudalur, India

17. Werner D (1994), Where There Is No Doctor, 7. Indian ed., Voluntary Health Association of India, New Dehli, w1-w28, 151-253, 375-456

18. Werner D, Bower B (1983), Helping Health Workers Learn, Voluntary Health Association of India, 1. Indian ed. New Dehli, p. 2.1.-2.18., 3.1.-3.32., 15.1.-15.18., 25.1.-25.44.