Gates connie-ccih-2016

Comprehensive Rural Health Project, Jamkhed, India
Jamkhed International – North America, Carrboro, NC
Sustainability of Wholistic Health
Through Empowerment
The Jamkhed Model of Ministry – transforming lives
June 18, 2016 CCIH Annual Conference
Connie Gates, Lavanya Madhusudan, Julia Ann Queale
jina@jamkhed.org www.jamkhed.org

Jesus said,
John 10:10
“I came that
they may have life,
and have it abundantly.”
“Go and do likewise . .“

Our Focus
 Health – not just disease and physical
 Community – not just individuals and
patients

Health
 What is health?
 What does it mean to be healthy?
 What promotes health? harms health?
 WHO definition, root causes (multi-sectoral, multi-disciplines)
 How to help people be healthier?
(individuals, communities)
 Health is determined primarily by the quality of social
relationships and the fairness (or equity) in the social
distribution of material resources.
 Health is . . .

Health is . . .
 A state of complete physical, mental, social and
spiritual well-being, and not merely the absence of
disease or infirmity. (WHO)
 A dynamic state of well-being of the individual and
society;
 * physical, mental, spiritual, economic, political and
social well-being;
 * being in harmony with each other, with the natural
environment, and with God. (UMC)

Health is . . .
 “Factors of Health”
 non-medical interventions have more
impact on health
 e.g. education of girls  lower fertility rate
 for long-lasting impact, deal with causes
 community’s role
 health professionals’ role
 for sustainability

Health Problems
What are the main health problems in
developing countries?
 Children
(diarrhea, malnutrition, respiratory)
 Women
(violence, pregnancy-related, TB)

Causes
What are the main causes?
 Children
(bad water, feeding practices, lack of
knowledge, harmful traditions, etc)
 Women
(harmful traditions, no care, nutrition,
women’s status, etc)

Healthy Communities
 What do communities need in order
to be healthier?
 What has kept them from being
healthier?
 What are obstacles to becoming
healthier?

Basic Premises
 Most health problems have simple
solutions (prevention, early treatment)
 Need a community change agent
 Community participation/
organizations

What can be done?
In/by the community for:
 Prevention of health problem and
complications of existing conditions
 Early diagnosis
 Simple treatment (e.g. home remedies)
 Management of health problem

Where in the World is . . .
Jamkhed
Mumbai
INDIA

CRHP Story
 Aroles’ commitment to improve the health
of communities, strong Christian faith
 Mission hospital, medical model not
working
 No available model, but some examples
 Developed with the community a model /
approach
 Now mission is to share model worldwide

Comprehensive Rural Health Project
(CRHP), Jamkhed
 Vision - People are made in the image of God. They are
endowed with talents and abilities, and have the potential
for personal growth and development.
 Mission - We are called to facilitate and empower
communities, especially women and marginalized people,
so that their health can be improved in a wholistic and
integrated way, available to all with equity and justice.
 Goal – To build the capacity of village people to enable them
to participate actively and responsibly in primary health care
activities to improve the health (physical, emotional, mental,
social, spiritual, economic) of the whole community.

Jamkhed Model
 Comprehensive
 Community-based / empowerment
 Primary Health Care (Alma Ata)
 Health & Development
 Value-based, not just technical
 Process, not project or program
 Sustainable

Impact on Health Indicators
0
20
40
60
80
100
120
140
160
180
200
*1971
*1976
1981
*1986
1991
*1996
*1999
*2006
IMR/1000
CBR/1000
ANC/Del.
FamPlan
Immun.
Malnutr
Infant Mortality
CBR
FamilyPlan
Immunization
Malnutr.
ANC/SafeDeliveries
* = year data collected
IMR

Other CRHP Activities:
Cumulative (from 1970)
Health Programs:
T.B patients treated 7,620 (2000)
Leprosy patients treated and rehabilitated 4,611 (2000)
Artificial limbs and calipem provided 19,440 (2014)
Socio-Economic Development:
Plant nurseries (# villages) 45 (2000)
Trees planted 5,145,500 (2000)
Land leveled (hectares) 9,505 (2000)
Irrigated wells dug 492 (2000)
Check dams 212 (2000)
Tube wells for safe drinking water 185 (2000)
Houses built for poor people 270 (2000)
Women involved in credit programs 4,978 (2000)
Training in productive skills 813 (2000)
Veterinary workers trained 93 (2000)
Training/Orientation in PHC:
National Trainees - grassroots workers 9,442 (2014)
National Trainees - health professionals,
social workers, administrators, etc. 25,915 (2014)
International Trainees - from 92 countries 3,057 (2014)

Impact
The impact of the project can be assessed by the
statistics, which show the results achieved over
a period of time. Beyond these numbers are
self-confident men and women, once outside
the mainstream of society, taking leadership
positions in their villages, affirming that they are
created in the image of God.
It is not only the quantitative changes that are
important; but even more so the transformation
of persons and communities in a qualitative
way, which leads to harmony, health and peace
- shalom.

Purpose
 Building the capacity of communities to
do for themselves
 Developing potential of everyone
 Ministry of ‘being’ – sharing God’s love
– especially with poor & marginalized
 Facilitating the community process

Philosophy
 People are the key actors in health.
 We professionals have to change our attitudes
and need to share our knowledge in a way that
poor people can understand and make their
own choices according to their needs – not
build dependency.
 Health professionals need to recognize
importance of non-medical activities/programs.

Strategies
* emphasis on the needs of the poorest of the
poor
* full community participation and involvement
* integration of promotive, preventive, curative
and rehabilitative health services
* use of appropriate technology
* a multi-sectoral approach to address all
issues affecting health

Based on Christian Values
*technical knowledge & skills are not enough
*need to love others, willing to share, care for
others, service –
for the staff and for the villagers
*being concerned about the social aspects of
problems and root causes,
*the justice issues that keep people from
developing their potential as Children of God.
*following Jesus’ model of health ministry

Essential Values
 Example of selfless service
 Complete love & acceptance for the people
 Trust
 Patience & time
 Equality & equity
 Team spirit
 Complete sharing of knowledge
 Upliftment of the status of women
 Community participation & empowerment
 Talking together with all villagers
 Comprehensive wholistic approach

Principles
 Equity – poorest of poor, assimilate into community, justice
 Integration – wholistic health * multi-disciplines
* services (prom, prev, cure, rehab) * other health systems
* health programs (MCH, HIV/AIDS, NCDs, etc) * other sectors
 Empowerment
-- build community capacity
-- community participation, work together
-- organize groups around self interest
-- assess, analyze, act  address their priorities
-- leadership, skills, knowledge, attitudes

Video - CRHP
 https://www.youtube.com/watch?v=k3c
XVNCg04s
 (first 7.11 minutes – after adolescent
girl testimony, before Helping Hands)

Village Health Worker
* Selected by the community
* Accountable to community
* Bridge between community and health project.
* Trained by CRHP Mobile Health Team (MHT)
* Partner with health professionals
* Health educator - skills, information, behavior
* Shares what she learns with everyone in the community
* Health care -- mother & child health, leprosy & TB
control, family planning, etc.
* Protecting environment
* Social & cultural issues
* Other development activities
* Shows and shares goals and values, and does not
merely carry out activities
* Change agent, facilitator, organizer, mobilizer, role model,
motivator, inspirer

VHW at NCIH Plenary (1988)
This is a beautiful hall
and the shining chandeliers are a treat to watch.
One has to travel thousands of miles to come to see their beauty.
The doctors are like these chandeliers, beautiful and exquisite,
but expensive and inaccessible.
This (oil) lamp is inexpensive and simple.
But unlike the chandeliers, it can transfer its light to another lamp.
I am like this lamp, lighting the lamp of better health.
Workers like me can light another and another
and thus encircle the whole earth.
This is health for all!

Mahila Vikas Mandal
(Women’s Club)
Organized around self-interest
(e.g. income generation, religious songs, health & gender discrimination)
Functions:
* Collect health information and learn relevant skills from VHWs.
* Assist VHW in health education, pregnancy care, delivery,
family planning, child care.
* Improve environment.
* Regular treatment and integration of stigmatized conditions.
* Collective decision making for better health.
* Deal with social evils, gender, caste, alcoholism and dowry.
* Promote income generation activities.
* Network with others, including government.
* Promote caring community and work towards harmony and peace.

Farmers’ Club
Organized around self-interests
(e.g. field games, better agriculture & better animal care)
Functions:
* Health information (with women) – assessment, analysis  action
* Health education for attitude & behavior change
* Family planning, PALs, snake bite
* Social evils – e.g. gender discrimination, caste divisions, alcoholism
* Improving child nutrition
* Protecting environment, water management and sanitation
* Develop land and water resources
* Implement Government and other schemes for the poor
* Minimize corruption
* Check malpractice by witch doctors and local physicians
* Collective decision-making for better health

The Process
a) identify village(s) that want/invite you
b) get to know, build rapport/trust with the villagers
c) gather the people (diversity)
d) identify socially minded persons
e) organize groups (around self-interest)
f) identify/address community’s problems by them -
start with their priorities
g) select/train/support village health workers (VHWs)
h) learn about external resources/programs
i) organize seminars for villagers
j) follow up, support, encourage

Empowerment
* organize groups, especially women and other weaker sections
* provide relevant and useful information and skills both in health
and development
* awareness of their own deprivation and potential to change
* personal development, self-esteem and confidence, spiritual nurturing
* promote income generation activities, provide access to credit
and training
* provide knowledge to deal with social issues
* change mindset from personal focus to community benefit
* promote value systems, such as justice, equality, courage, love
* develop sharing and caring community, promoting reconciliation
and peace

Lalanbai Kadam
Dalit, Woman  VHW, Community Leader
Lalanbai is a woman and a Dalit (outcaste, ‘untouchable’) – which in her culture
meant a double victim of human rights violations and indignity. As Dalits,
Lalanbai’s family was extremely poor and forced to live on the outskirts of her
village, Pimpalgaon. Traditionally Dalits work under inhuman conditions; her
parents earned a difficult and meager living providing manual labor to higher
caste villagers. As a girl, she was married early and pregnant, bore a son who
died within three years, which was enough for her husband to kick her out of the
house. Her parents insisted on her marrying again, this time to an old sickly man,
who died a couple of years later, after she had given birth to their daughter. After
his death, she insisted on remaining a widow, even though that was also
culturally unacceptable, especially at such a young age (mid-20s). She was able
to find daily wage work, though it was difficult and she was treated poorly, first
with a rich family and then with government labor projects. She explains, “As a
Dalit woman from Pimpalgaon, I thought of myself as a nobody. I had always
been made to feel less than an animal. I had no self-respect because people
addressed me with contempt. Everything was darkness.”

Lalanbai Kadam (con’t)
In the early 1970s, soon after visiting her village and starting to work with the
community members, the Aroles asked the village elders to nominate a woman to
be their VHW. Thinking that Lalanbai was expendable because she was a Dalit
widow, they chose her to do the work that no one else wanted to do – provide
health care to the poorest of the poor in the village. She was surprised to be
called by the mayor, who was her former abusive boss, and was reluctant to
respond but afraid not to.
Through her training, Lalanbai learned to read and write, about health, immediate
and root causes of diseases, organizing community groups, personal
development; and she was told for the first time in her life that she was a human
being worthy of respect and made in God’s image. This was the first time she had
experienced love. She fondly remembers that Dr Mabelle Arole was extremely
patient, never scolded her, and stressed the importance of being kind to those
who had only shown her cruelty. Her confidence grew as she began to realize her
potential and the impact she could have on her community.

Lalanbai Kadam (con’t)
Working as a volunteer, her main role was to share what she knew with others in her village
and to organize community groups to work together and solve problems together. She ran her
own businesses so she had independent income and was a role model for other women and
helped them. For 35 years, Lalanbai saved the lives of many people, including those who had
degraded hers. The impact on her life and her community gives her satisfaction; she says, “No
child has died in 5 years.”
Lalanbai shares her experiences as one of the first VHWs with new generations. She explains,
“You cannot fear anyone in your village, even those from upper castes or those opposed to
your efforts. Treat each family individually, recognizing their individual needs.” She also
teaches classes for CRHP at the training center, including international health professionals.
Throughout the years, Lalanbai became a respected member of her village. She was even
encouraged to run for mayor. The incumbent, her former boss, realized she would win; so he
pleaded with Dr Mabelle to convince her not to enter. When Lalanbai was told of the mayor’s
plea, she laughed and said, “I already rule the hearts of the people of Pimpalgaon. Let him
continue to be [the mayor]!”
Lalanbai has come a long way from the illiterate, abused servant she once was. One would
never know she was a woman with such a difficult past. She has provided a lifetime of
leadership and service with her community and saved countless lives yet wants nothing in
return. She says, “As I have changed, I have changed the world around me, even this
backward village; and that is the best reward for me.”

What happened? Lalanbai
 Encounter with Aroles & Christian witness
 Chosen as village health worker
 Trained and supported
 Shares knowledge & skills with others
 Organized groups of diversity
 Work and solve problems together
 Income generation/ economic development
 Other development, social, cultural issues

Empowerment
 Learn from/listen to the community
 Let community decide what to do
 Focus on the community’s abilities
 Community participation / organization / groups
 Capacity-building of community
* Start small, learn to work & solve problems together
* Project’s enabling role - knowledge, skills, attitudes, values
* Personal development
 3-A cycle (assessment, analysis, action) by community

3-A Cycle
 Assessment – problems, resources – set priorities
 Analysis – causes of all aspects of health
 Action – local solution
If they need more knowledge, skills or resources, the project helps them.
 Methods: surveys - house2house,
 PRA – by/with all community, focus groups,
discussions
With experience, they can do themselves – part of the
empowerment process

Ghodegaon Village
Sustainable Development through Empowerment
The years preceding CRHP’s work in the Jamkhed area, the residents of
Ghodegaon (population approx. 1200) were full of frustration due to
extreme drought conditions and lack of government intervention. It was
one of the poorest villages in the area. There was no water for drinking,
food was scarce, and many young people had to migrate several months
a year to work in sugar factories to keep their families from starving. In
addition, casteism permeated the village. Dalits (outcaste, ‘untouchable’)
had to live outside of the village wall and were exploited, working day and
night, only to be paid in leftover food and grain. Ghodegaon was home to
12 illegal breweries and a few gambling dens, and many villagers
struggled with alcoholism, gambling, domestic disputes, and worsening
health conditions. They relied on devrushis (magicians) for cure and care.
Children often died of preventable diseases, and individuals with TB and
leprosy were treated as outcasts.

Ghodegaon Village (con’t)
In 1971 some of the Ghodegaon village people learned of Drs Raj and
Mabelle Arole and their work to improve health with village people.
Ghodegaon badly needed health services, and so one day a group of both
upper caste and lower caste people came to CRHP to meet with Dr Raj Arole
and invited him to work in their village. In the beginning, Ghodegaon
requested that the Aroles bring in nurses to provide curative health services,
but Dr Arole did not agree since he wanted to work with the communities to
see what they could do for themselves and develop their potential.
After CRHP staff developed a relationship with the village through regular
visits, Dr Raj Arole met with members of the men’s group and suggested
they select a Village Health Worker (VHW). They chose Yamunabai - she
was talkative and outgoing; she liked to mingle with community members
when possible; and she was poor so she was able to understand the
struggles of the marginalized. She had never gone to school, was illiterate,
and spent her days confined to her home.

Ghodegaon Village (con’t)
Yamunabai received training in primary health practices, personal growth, social and
cultural issues, various aspects of development; and she serves as the main organizer
of community groups. For 40 years she has served as a Village Health Worker in
Ghodegaon. During this period she has conducted over 800 deliveries at home and has
not lost a single mother, and she has counselled over 300 women to get tubectomies.
Working with the community, 10 individuals with tuberculosis, 16 with leprosy, and 10
suffering from mental illness have been rehabilitated.
By mobilizing first around common village-wide priorities of agriculture and health, the
whole village came together despite differences in caste and social status. All people
worked together to terrace and level the land, plant more than 200,000 trees, and build
dams and four irrigation wells. Unified as a group, Ghodegaon was able to demand the
Government to give land to the landless and brought enough land under cultivation to
produce sufficient food to feed the village.
“The whole village worked towards the removal of caste differences, and we have
learned to treat women and girls as equals of men. We can proudly say that Health for
All has become a reality in Ghodegaon. CRHP has shown us the way, and we have
learned to work together for the betterment of our village. Now we do not need to
depend on the Aroles or CRHP...” – Shahaji Patil, local farmer, Dalit

Project/Prof. Role
 Facilitate the process
 Train VHWs and other villagers
 ‘Demystify’ health/medical knowledge
 Role model, demonstrate
 Support people & process
 Identify external resources
 Medical care (back up)

Go to the people:
Live with them.
Learn from them.
Love them.
Start with what they know.
Build with what they have.
But of the best leaders,
When the job is done,
The task accomplished,
The people will all say,
“We have done this ourselves.”
Lao Tse, China, 700 BC
Go to the People

Impact - Diseases
 Leprosy  accurate knowledge of the disease;
example of health workers with patients; early
detection by VHW, which also prevents deformities
 persons affected by leprosy are accepted by and
productive members of their communities.
 HIV/AIDS  accurate knowledge of the disease;
preventive practices; caring values in the
community  low prevalence; persons with AIDS
are cared for and die at home, and have a
community funeral.

Impact - Social
 Caste  education about values and the futility of
the system  all groups work together and help the
poorest and low caste.
 Status of women  discussions with men;
personal and socio-economic development of
women  uplifted and involved as equals in
community life.
 Harmful traditions (related to health and social
conditions)  education and discussions about
rationale  no longer practised.

Impact – Women/Reprod.
 Family Planning  acceptance of small families,
even if no son; variety of methods easily available
 high rate of use, both temporary and permanent.
 Maternal health  improved health of women;
knowledge of pregnancy; frequent prenatal care by
VHWs; identification and referral of high risk
pregnancies; women’s knowledge of safe delivery;
community transport  healthy mothers and babies
with home or hospital deliveries.

Impact - Children
 Children  mothers’ knowledge of and practices
related to common diseases (prevention and
treatment), nutrition education and demonstration,
growth monitoring  high immunisation rate;
decrease in infant mortality and morbidity,
especially diarrhea, malnutrition and respiratory
infections.
 Adolescent girls  education, personal
development, group discussions about attitudes,
creative activities  stay in school; delay marriage;
empowered young women.

Video – Systems Thinking
Jamkhed as an Example of
Complex Systems Thinking in Health
(CRHP was not involved in this video)
https://www.youtube.com/watch?v=wX4p-7p765Y

Sustainability
 Knowledge, Skills (building capacity)
 Attitudes, Values (caring community)
 Volunteers (building community) motivated
 Prevention, early detection, treatment,
rehab in community; wholistic health
 Appropriate technology, local resources
 Multi-sectoral (non-medical interventions)
 VHWs still involved
 Spread by villagers to other areas

Jamkhed is . . .
Communities ‘health’ themselves
focus on health and on community
- to really improve health in the long term
(work together to solve their problems)
Deal with root causes for sustainability
(e.g. overcome caste, women’s status, poverty)
Share what they learn with others

We say . . .
Ours is not an innovation in technology but rather
an innovation of the people within each community,
to bring about social change and thereby
uplift everyone from poverty and disease.
Emphasize belief in a loving God,
the spiritual aspects of health and Christian values
in our training and our work.
Transforming lives Kingdom of Heaven on Earth

And Jesus said . .from Isaiah
“The Spirit of the Lord is upon me,
because he has anointed me
to bring good news to the poor.
He has sent me to proclaim release
to the captives and recovery of sight
to the blind, to let the oppressed go free,
to proclaim the year of the Lord’s favor.”
“I came that they may have life, and have it
abundantly.” (John 10:10)

Jesus’ Ministry of Healing
 more than cured disease – physical and
mental.
 restored people to their families, religious
communities, society in general.
 reached out to the most marginalized, and
those with stigma – esp. women
 disobeyed the current religious rules in order to
benefit people e.g. by healing on the Sabbath,
touching people thought ‘unclean’.

The Kingdom of Heaven on Earth
is like
Comprehensive
Community-Based
Primary Health Care

For More Information
If you would like more information about
CRHP/Jamkhed,
e.g. “The Jamkhed Model of Ministry”
(document shown at the session)
or anything more specific, please contact
Connie Gates, jina@jamkhed.org
(for an e-copy of the Empowerment study report,
contact Lavanya.Madhusudan@gmail.com)

Gates connie-ccih-2016

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