Training the Poor to Help Themselves: A Community Health Approach in India

In the raw poverty of the slums of Kolkata—formerly known as Calcutta—visibly malnourished children with bloated stomachs and patchy hair run barefoot over paths in which human and animal waste mix with mud and garbage. Hundreds of dwellings made of straw, mud, tin, and cardboard are squeezed into areas the size of one small city block. In these cramped dwellings, often only an arm-span in width, entire families live with no running water, no electricity, and no furniture. Few have beds; they sleep on scraps of cloth padding the dirt floor.

The incidence of preventable diseases in the slums is shockingly high. Children routinely die of diseases that could have been prevented by vaccinations, adequate nutrition, and clean drinking water. While there is a desperate need for health care, most slum residents have never seen a doctor. Few health facilities exist in these neighborhoods. And slum residents are generally reluctant to visit clinics outside of their local neighborhood, due to India's rigid caste system—which restricts interaction among different classes—and their inability to pay even modest fees for health services. As a result, many slum residents have literally no access to health services.

Archana Saha lives in one of Kolkata's poorest slums. Like others there, her life has been characterized by deprivation and unmet need. But since she became a community health volunteer for the India Local Initiatives Program (India-LIP), her life and the lives of those around her seem to have more hope.

Archana, LIP volunteer in India, visiting woman in community. Photo by MSH staff.

Every day, Archana goes door-to-door in her community to teach her neighbors about basic health issues. She talks with women about the importance of limiting their family size, tells them about different family planning options, and provides them with contraceptives. She also discusses how to approach their husbands about family planning—often a difficult issue in traditionally patriarchal societies. Archana teaches mothers about childhood nutrition and how to prepare a simple solution to rehydrate their children when they have diarrhea. She informs families about childhood vaccinations—when, why, and how to get them. Finally, Archana brings individuals who need clinical care to a newly established neighborhood health post, where staff provide them with basic services. If individuals need more advanced care, they are referred to a network of doctors who have agreed to treat slum residents at reduced rates. India-LIP provides payment for these services as even these reduced fees are prohibitive for slum residents.

Since 1999, India-LIP has trained almost 2,000 volunteers like Archana in poor and geographically isolated areas of India. With funding from the Bill & Melinda Gates Foundation, the program is being implemented by three local organizations—the Child in Need Institute, in Kolkata; the Himalayan Institute Hospital Trust, in the remote hills of the Himalayas; and the Center for Research in Rural and Industrial Development, in the plains and mountains of the Punjab and Himachal Pradesh. These local organizations work in partnership with US-based Management Sciences for Health (MSH), and the Bangladesh-based organization, Technical Assistance, Inc. (TAI) .

India-LIP is built on a community health model used in Bangladesh. During the ten-year Bangladesh-LIP, nearly 40,000 health volunteers were trained and paid a small stipend to provide family planning services to their communities. The program was credited with helping to drastically reduce the birth rate in targeted areas of Bangladesh.

Three years ago a pilot began in India to test whether the LIP could be adapted to an Indian setting. It has already produced dramatic results. Working in some of the poorest and most remote areas of the country, the program has provided health services to more than 200,000 people. In addition to training approximately 2,000 volunteers, India-LIP has created over 150 new health posts in communities where services were absent or deficient. Over 65,000 children have been fully immunized against deadly childhood diseases. More than 30,000 women have received prenatal care, a critical step in ensuring their babies health. And almost 75,000 women have decided to use family planning methods to plan and space their pregnancies and better ensure the long-term health of their families.

India-LIP's achievement of health objectives in such a short time is striking, and combined with the prior success of the Bangladesh program, suggests that this model could have a powerful impact in other resource-constrained settings around the world.

Through the LIP, many community health volunteers have become empowered in a way that was never possible before. The women volunteers are able to work outside their homes for the first time in their lives, and through their work have gained unprecedented mobility, recognition, and status within their communities. In the words of one volunteer, "Before we became community health volunteers, we were not heard in the community. Now we have a voice."