The Gudalur Valley is a neglected forested area in the Nilgiri Mountains, 50 kms below Ooty in Tamil Nadu state, India. Although the Nilgiris and its tribes (Adivasis, meaning original inhabitants) are one of the most researched and written about areas in the world, the five tribes of the Gudalur Valley have been consistently exploited and marginalized, becoming progressively worse off as more and more immigrants invaded the hills and deforested this once isolated Valley.
The Adivasis 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 that 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.”
When, in 1986, Stan and Mari, two social activists, along with a group of young tribals set up ACCORD, the adivasis’ plight was pathetic. They were vulnerable and exploited, and working as unskilled seasonal agricultural labourers in lands they once called their own. ACCORD’s objective was to help the adivasis fight for their land rights, stop their exploitation and help them become self-sufficient again. This was done by mobilizing people to form village level organizations, called sangams. In 1988, these sangams federated to form a registered society, the Adivasi Munnetra Sangam (AMS), a peoples’ movement bringing all the five tribes together to fight for their rights. Today the AMS covers over 16000 adivasis in 300 villages.
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, small loans and grants were provided 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; many women died in childbirth; children as well as adults died of preventable diseases like dysentery and tuberculosis. People preferred to stoically await death at home, rather than go to an unfriendly, alien hospital far away.
In 1987, two young doctors, Deva and Roopa, joined ACCORD to fight the health battle. With patience and perspicacity, they trained a cadre of adivasi village women—all selected by the people themselves—as “health workers”. The focus of the work in the villages was the health of the most vulnerable group – namely pregnant women and under five children. 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. An important step had been taken towards the objective of encouraging people to access health services.
After almost three years of gruelling, often frustrating effort, the tide slowly turned. Infant and maternal deaths were no longer accepted as commonplace and inevitable. And patients seeking curative care began pouring in. The problem now was that there seemed nowhere to treat the more serious cases. The government hospital was overcrowded and impersonal, private hospitals prohibitively expensive. Fortunately, in 1990, another doctor couple joined the team. Nandakumar, a surgeon, and his wife Shyla, a gynaecologist had just returned after 10 years in the United States, wanting to start a hospital for the poor in rural India!
So another Society, ASHWINI (Association for Health Welfare in the Nilgiris) was started to cater to the health needs of the community. ASHWINI began by setting up the 20-bedded Gudalur Adivasi Hospital to complement the community health work. Soon afterwards, a process of active decentralization was set up, with the establishment of 8 sub centres (now known as “Area Centre” to divest it of its purely health connotation, since the entire administrative team for the Area functions from here) each covering between 20 and 60 adivasi villages, so as to bring health care to the door step of the villagers.
Today, the area centres are run by trained adivasi nurses called “Health Animators”, who are more skilled in curative care than the health workers were. People come to the sub-centre for all their basic health needs. What the Health Animators could not handle at the area-centre is referred to the Gudalur Adivasi Hospital. A sound recording system with registers for antenatal check-up, child nutrition and immunization, chronic cases like tuberculosis, births and deaths, is maintained by the Health Animators at the sub-centres. The health animators also visit each village on a regular basis. They treat minor illnesses, take health education classes, and continue, in collaboration with the old health workers, to monitor pregnant women, children under five years of age, and persons with chronic diseases like TB, asthma, etc
The change in the health status of the Adivasis, in the years following the establishment of ASHWINI, was remarkable. Maternal mortality came down dramatically, infant deaths plummeted, and deaths from preventable diseases like diarrhoea, anaemia and eclampsia became a rarity. Most importantly, the tribals developed a health seeking behaviour.
The strategy was to increase community participation and to have a wider base of people who would keep the work going. Volunteers from every village came forward to be resource persons in the village and to take responsibility for the health of their village. This is a heart-warming sign of the total involvement by the adivasi community.
ASHWINI’s role has been to train these volunteers in the basics of health care and to build up their leadership skills. Over 200 health volunteers are now being trained.
The process of giving inputs in management and leadership was also started, to run the health programme and the hospital was also started. Training of new health animators to handle all the responsibilities of the work is also an on going process until the work is fully consolidated.
Side by side with organizational sustainability, ASHWINI is also striving for financial sustainability in the next few years. Various steps have been taken in this direction.
Linkages with Community, Leadership and Management
Though ASHWINI was initiated by a group of doctors and social activists, it has over the years been taken over by the adivasi community. Today, there are 14 members in the society, 10 of whom are adivasis. The executive committee is comprised of adivasi leaders.
The mere fact that all the staff is adivasis who are sangam members first and have a strong root in their own villages, ensures that the community’s interests are represented in the organisation at all levels. A large number of health volunteers who have come forward to take responsibility for the health status of their own village is a heart-warming sign of involvement by the adivasi community.
Decision-making is an elaborate process involving a number of people. A ‘Working Committee’ comprising of senior staff look at the day-to-day running of the health programme. Any decisions that need to be made are discussed at the ‘Coordination Team’, which is a group comprising of representative staff from all the sectors. It is then taken to the 8 Areas where the area teams discuss it. The Area Teams consist of staff from all the sectors including education, community organisation, economic and legal sectors. The discussions are taken to the villages by this team and feedback is obtained. This ensures people’s participation in all decision making.
As we move closer to the target of a community owned health care system, we propose to reconstitute the “Management Committee”, a people’s body that will interact with the staff and the board in planning and managing the health programme. This committee will be made up of volunteers representing the different tribes from the different areas
6.0 Existing Project Outline – Main activities
Capacity building of the community through extensive training sessions at various levels is the most important activity of ASHWINI.
• Health Animators and Nurses: This cadre of youngsters representing 4 different tribes, while being groomed to be leaders, are being simultaneously trained as “bare foot doctors” through training in preventive health care, basic curative medicine, ability to detect high risk patients and managerial skills which enable them to plan and evaluate their work. Others of similar background are trained in accounts, laboratory technology, pharmacy and administration. To date, 38 youngsters who have completed training, continue to work with ASHWINI. Another 12 are being trained.
• Health volunteers: Volunteers from the villages who have come forward to take responsibility for the health of their village are given training at various levels:
• During village visits, the health animator or doctor gives them training on the job. This also helps to improve the image of the health volunteer as a resource person in the eyes of the villagers
• Training camps are organised at the area centre and in the hospital on a regular basis when planned teaching is done. Inputs in team building motivational games, analysis of the economic and social situation of the tribal community all form part of the training camps. The health animators who become the trainers in these sessions get inputs in imparting effective training.
• Youth and students camps: Health training is given in youth and student training camps that are organised by ACCORD and VIDYODAYA. The doctors or the health animators participate.
b. Preventive health care
• At the village
This is provided by the village health volunteer or “guide”, who is the first point of contact, or by the health animators or doctors during their village visits. Special attention is given to pregnant women, mothers and under five children. Health education, screening for illnesses like anaemia and tuberculosis, monitoring of growth and planned parenthood activities are some of their main areas of focus.
• At the area centre
There are eight area centres from where all the community activities are coordinated. The Area Centre team includes:
o The animators (involved with community organisation, legal affairs, economic activities, housing etc)
o The education worker
o The administrative person
o 2 health animators
Apart from conducting an outpatient clinic to treat minor illnesses, the Health Animator in the Centre examines and advises ante-natals and patients with chronic diseases like diabetes, hypertension, sickle cell anaemia and tuberculosis. Planned- parenthood activities like IUCD insertion are carried out, and health education sessions for youth groups are conducted at the centre. A number of relevant registers, and an essential drug stock, are also maintained
School health education using a planned syllabus is conducted for school-going children either at the area centre or in the schools. This is combined with library and science experiment activities of Vidyodaya.
• At the Gudalur Adivasi Hospital
A lot of preventive work goes on at the hospital, notably for planned parenthood. All mothers are given advice after delivery and also when they visit the hospital for other reasons. Evening health education sessions, often using television and movies developed by other organisations, are given to the captive audience of over 30 people.
c. Curative health care
• At the village: The village health worker can treat simple diseases like viral fever, minor injuries, anaemia or diarrhoea. When there is an outbreak of any illness needing medical attention, she approaches the Area Centre and the doctor makes a visit to provide curative care.
• At the Area Centre: The health animator conducts regular out patient clinics in seven area centres. All patients with chronic diseases are followed up. About 5000 patients a year are seen in these centres. Patients requiring further attention are referred to the hospital.
• At the Gudalur Adivasi Hospital: The 40 bedded hospital serves as the first referral unit for the community health program. About 10000 tribals are seen as outpatients every year. Apart from this, non-tribal patients are also seen. About 1200 tribals are admitted to the hospital each year. Most illnesses are treated here, including surgeries and deliveries. Only a small minority of the patients are referred to larger centres like the medical college. The hospital is staffed by a full time physician, obstetrician and a surgeon. Specialist doctors visit at regular intervals.