Monday, 21 March 2011

Health Messenger

An article by Elizabeth Day caught my eye as it describes a practical example of innovation adapted to local culture and conditions, empowering people with lowest status and resources.

Dr Abhay Bang and his wife, Rani, have worked for 26 years training local volunteers in Gadchiroli, a deprived district of Maharashtra, India. The idea was to treat simple health problems at home. The volunteers are called arogyadoots or Health Messengers.

Results are impressive: newborn death rate has fallen from 121 to 30 per 1,000 live births. In 1988 the death rate among children who developed pneumonia was 13%, now it has fallen to 0.8%.

The mission of their charity, Search (Society for Education, Action and Research in Community Health) was to listen to the people and find out what kind of healthcare they wanted.

'"We are very MUCH part of the community," says Dr Bang, ...."I really can't say where the line of separation is between them and me. It is research with the people, not on the people."

Cultural differences derailed efforts by NGOs to impose western models of healthcare on rural India:

'"The villagers said they were scared to go to hospital," he says. "When we asked why, they told us something fascinating. They said: 'Your doctors and nurses drape themselves in white clothes. We wrap dead bodies in white shawls. How can you save lives if you are dressed like a dead person?' They said: 'When they admit a patient, we can only visit between 3pm and 6pm and we don't have wristwatches. We don't have anywhere to stay in town, so we go back to the village. The patient doesn't want to stay on their own."'

Dr Bang ran People's Health Assemblies to consult people on their most pressing issues in healthcare and heard about the high rate of death amongst newborn babies. Local women were then trained in low tech ways of managing neonatal care and went where they were needed using portable health packs. The Health Messengers passed on their knowledge and whole communities became empowered - from consultation, codetermination to control.

He also constructed a hospital that resembled a local village so that patients could stay with their relatives. This shifted a sense of ownership to the local community.

The innovations were driven by local demands (market pull) and the increasing availability of portable tools intended for outreach care (technology push).

Dr Bang was motivated to help by the story of a young woman who arrived too late for doctors to save her baby. She related the practical challenges she faced in coping with isolation, a drunken husband and travelling to the hospital. Rather than feel overwhelmed and give up because of the enormous size of the problem, Dr Bang reflected from a systems thinking perspective:

"But then I looked at the whole situation and asked myself: 'Do I really need to solve all the problems, all the links in the chain of this cause of death?' I started to think: 'Where is the weakest link I can attack?' and that was access to healthcare." He falls silent for a moment. "It was practical compassion, not a flash of genius."

Dr Bang and his wife also campaigned successfully for a ban on alchohol in Gadchiroli district to reduce some of the problems contributing to low income, fractured families and poor health.

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