Jainetri Merchant.
Spring 2018. I was one of hundreds of students sitting in a toasty-warm lecture hall, attending the final semester of an epidemiology class. We were studying a chapter on maternal disease and death. I sat in the glow of a colorful power point slide, which had graphs illustrating the variance in maternal mortality ratio globally. I typed away on my laptop, hanging on to every word the professor uttered. Do you know what a university classroom sounds like? It is the clatter of hundreds of fingers typing simultaneously on tiny plastic keys, synchronized with the hum of the projector. In midst of that constant clatter, I leaned back in my seat, thinking I understood the weight of that statistic through the pixels of my screen.
In the two months of my Antara Foundation fellowship in Madhya Pradesh’s Betul district, I find myself in a classroom of a different kind. Be it in the labor room of a Community Health Centre or even the lawn of an Anganwadi Centre, I have had the opportunity to understand maternal, child health and nutrition challenges from the community health workers themselves – the Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi Worker (AWW) who are the foundation of our health system. Together, they deliver critical health services at the village level and their understanding of the community’s needs is unparalleled. Serving as the link between the health system and the community, data from these women flow upwards to the block, district, and state levels. On a national scale, numbers reported by them present a holistic picture of health across India’s villages, also informing policy for frontline health delivery.
From my field experiences thus far, I wish to share two instances that have given me a deeper understanding of how we engage with and co-create solutions with community health workers.
Know the community health workers
On an initial field visit, I met an ASHA named Bindu (name changed) at a sub-health centre in Dhaba, a remote and rural village in Betul. Bindu sat cross-legged on a bright green chatai (mat) in her purple saari, the standard uniform of ASHA workers in Madhya Pradesh. She had an air of confidence and ardor that I simply could not overlook. My colleague Pushpinder and I asked her where one of the village’s pregnant women lived. Without stuttering for even a moment, Bindu responded “kirana dukaan ke samne, Manu ke ghar ke piche. Do bhai saath rehte hain aur yeh chhote bhai ki patni hai. Yeh uss mahila ka panchva mahina hai.” (“In front of the grocery store, behind Manu’s home, two brothers live together, and she is the younger brother’s wife. The woman is five months’ pregnant.”) She had a map of her village and her community in her mind.
Had it not been for the ANM, I would never have guessed that Bindu could not read and write fluently. Where contextual knowledge requires technical ability, Bindu was at an impasse. However, with the help of other ASHAs and the ANM, she manages to maintain her paperwork. I learnt there isn’t a singular kind of frontline health worker. They vary on the spectrum of aptitude, motivation and ability to work with others. Despite lacking an essential tool in her technical quiver, Bindu struck me as a highly motivated woman, aiming to do her best. As she puts it, “padhne likhne mein dikkat hoti hai madam, lekin kaam mein mann laga ke karti hoon.” (“I find it difficult to read and write madam, but I do my work sincerely.”).
Meeting her was a reminder that though public health professionals communicate in the language of data, the stories behind the numbers and the women who report them lend a richness to our understanding of health. They paint a picture which numbers simply cannot.
Photo: Facilitating a village mapping exercise with the AWW and ASHA in Khedla village
Understanding the dynamics of health delivery in tribal communities
Community health workers in Betul also reflect the various cultural dynamics of the Korku and Gond tribes in the district. These tribal communities reside in pockets, often scattered across rural terrain, making it challenging for health services to reach them. In a field visit with my colleague Atul, I went to a village in Bhimpur block where the predominant Korku tribal community reside. The Korku people are reluctant towards seeking essential health services such as immunization due to their distrust in the medical system and other cultural beliefs. The ASHA and AWW we met recalled how the region did not have an ANM till two years ago and the lack of support health workers faced from the community. As they unburdened their troubles to our keen ears, I noted the traditional tribal tattoos on the hands of the ASHA. I realized that the two women were daughters of the tribal village themselves, sandwiched between the system they work for and their tradition. A close understanding of such complexities, and the predicament of community health workers in tribal villages made me realize different obstacles in the provision and uptake of health services.
Our team’s interactions with health officials in Betul revealed an interesting dynamic that tribal societies, at the cusp of tradition and modernization, share with the health system. A health official narrated the case of a pregnant tribal woman, whose hemoglobin count was 3.6 g/dL. She had severe anemia, a risk factor prevalent in Indian women, which if left undiagnosed and untreated, can prove fatal. The block official immediately sent an ambulance to bring her to the district hospital for a blood transfusion. Much to his disappointment, the woman chose not to stay and complete her treatment. She had to get back to work on her farm.
The incident, probably one of many, begs the question – what does it take to motivate communities to prioritize their health? Outreach initiatives, behavior change programs, counselling sessions, field visits, subsidized care. I do not know if there is a single answer, but one thing is for certain – the next time I see a member of a tribal community at a health facility, I will certainly appreciate the efforts and countless hours of counselling by our dedicated community health workers that brought her there.
In understanding health through the prism of supply and demand of health services, I find myself also thinking about the meaning of impact in public health. Is impact seeing a statistic decrease over time, is it seeing a community health worker take ownership of her village, or is it deep-rooted behavioral change among the community? When I hear of impact, usually reflected as a change in numbers over time, I think of Bindu and many other health workers I met. Seeing three women putting aside their differences to take charge of their village is impact of a different sort. It is a lasting social change.
As I continue my grassroots journey, I find myself especially grateful for those moments when I have accompanied an ASHA to her home, where we often break into laughter over a crispy hot plate of barbati ke vade (long bean cutlets) and chai. My lecture hall was definitely never this inviting.
ABOUT THE AUTHOR
Spring 2018. I was one of hundreds of students sitting in a toasty-warm lecture hall, attending the final semester of an epidemiology class. We were studying a chapter on maternal disease and death. I sat in the glow of a colorful power point slide, which had graphs illustrating the variance in maternal mortality ratio globally. I typed away on my laptop, hanging on to every word the professor uttered. Do you know what a university classroom sounds like? It is the clatter of hundreds of fingers typing simultaneously on tiny plastic keys, synchronized with the hum of the projector. In midst of that constant clatter, I leaned back in my seat, thinking I understood the weight of that statistic through the pixels of my screen.
In the two months of my Antara Foundation fellowship in Madhya Pradesh’s Betul district, I find myself in a classroom of a different kind. Be it in the labor room of a Community Health Centre or even the lawn of an Anganwadi Centre, I have had the opportunity to understand maternal, child health and nutrition challenges from the community health workers themselves – the Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi Worker (AWW) who are the foundation of our health system. Together, they deliver critical health services at the village level and their understanding of the community’s needs is unparalleled. Serving as the link between the health system and the community, data from these women flow upwards to the block, district, and state levels. On a national scale, numbers reported by them present a holistic picture of health across India’s villages, also informing policy for frontline health delivery.
Photo: An unusual learning site, Anganwadi Centre in Thapoda village, Bhainsdehi block, Betul.
From my field experiences thus far, I wish to share two instances that have given me a deeper understanding of how we engage with and co-create solutions with community health workers.
Know the community health workers
On an initial field visit, I met an ASHA named Bindu (name changed) at a sub-health centre in Dhaba, a remote and rural village in Betul. Bindu sat cross-legged on a bright green chatai (mat) in her purple saari, the standard uniform of ASHA workers in Madhya Pradesh. She had an air of confidence and ardor that I simply could not overlook. My colleague Pushpinder and I asked her where one of the village’s pregnant women lived. Without stuttering for even a moment, Bindu responded “kirana dukaan ke samne, Manu ke ghar ke piche. Do bhai saath rehte hain aur yeh chhote bhai ki patni hai. Yeh uss mahila ka panchva mahina hai.” (“In front of the grocery store, behind Manu’s home, two brothers live together, and she is the younger brother’s wife. The woman is five months’ pregnant.”) She had a map of her village and her community in her mind.
Had it not been for the ANM, I would never have guessed that Bindu could not read and write fluently. Where contextual knowledge requires technical ability, Bindu was at an impasse. However, with the help of other ASHAs and the ANM, she manages to maintain her paperwork. I learnt there isn’t a singular kind of frontline health worker. They vary on the spectrum of aptitude, motivation and ability to work with others. Despite lacking an essential tool in her technical quiver, Bindu struck me as a highly motivated woman, aiming to do her best. As she puts it, “padhne likhne mein dikkat hoti hai madam, lekin kaam mein mann laga ke karti hoon.” (“I find it difficult to read and write madam, but I do my work sincerely.”).
Meeting her was a reminder that though public health professionals communicate in the language of data, the stories behind the numbers and the women who report them lend a richness to our understanding of health. They paint a picture which numbers simply cannot.
Photo: Facilitating a village mapping exercise with the AWW and ASHA in Khedla village
Understanding the dynamics of health delivery in tribal communities
Community health workers in Betul also reflect the various cultural dynamics of the Korku and Gond tribes in the district. These tribal communities reside in pockets, often scattered across rural terrain, making it challenging for health services to reach them. In a field visit with my colleague Atul, I went to a village in Bhimpur block where the predominant Korku tribal community reside. The Korku people are reluctant towards seeking essential health services such as immunization due to their distrust in the medical system and other cultural beliefs. The ASHA and AWW we met recalled how the region did not have an ANM till two years ago and the lack of support health workers faced from the community. As they unburdened their troubles to our keen ears, I noted the traditional tribal tattoos on the hands of the ASHA. I realized that the two women were daughters of the tribal village themselves, sandwiched between the system they work for and their tradition. A close understanding of such complexities, and the predicament of community health workers in tribal villages made me realize different obstacles in the provision and uptake of health services.
Our team’s interactions with health officials in Betul revealed an interesting dynamic that tribal societies, at the cusp of tradition and modernization, share with the health system. A health official narrated the case of a pregnant tribal woman, whose hemoglobin count was 3.6 g/dL. She had severe anemia, a risk factor prevalent in Indian women, which if left undiagnosed and untreated, can prove fatal. The block official immediately sent an ambulance to bring her to the district hospital for a blood transfusion. Much to his disappointment, the woman chose not to stay and complete her treatment. She had to get back to work on her farm.
The incident, probably one of many, begs the question – what does it take to motivate communities to prioritize their health? Outreach initiatives, behavior change programs, counselling sessions, field visits, subsidized care. I do not know if there is a single answer, but one thing is for certain – the next time I see a member of a tribal community at a health facility, I will certainly appreciate the efforts and countless hours of counselling by our dedicated community health workers that brought her there.
In understanding health through the prism of supply and demand of health services, I find myself also thinking about the meaning of impact in public health. Is impact seeing a statistic decrease over time, is it seeing a community health worker take ownership of her village, or is it deep-rooted behavioral change among the community? When I hear of impact, usually reflected as a change in numbers over time, I think of Bindu and many other health workers I met. Seeing three women putting aside their differences to take charge of their village is impact of a different sort. It is a lasting social change.
As I continue my grassroots journey, I find myself especially grateful for those moments when I have accompanied an ASHA to her home, where we often break into laughter over a crispy hot plate of barbati ke vade (long bean cutlets) and chai. My lecture hall was definitely never this inviting.
ABOUT THE AUTHOR
Jainetri Merchant is a Fellow with the Antara Foundation.
She completed her B.Sc. in Human Biology from the University of Toronto. Prior to joining the Antara Foundation, Jainetri was a fellow at SEARCH (a non-profit in Gadchiroli, Maharashtra) and an intern at the WHO/PAHO (Pan American Health Organization) in Guyana.
Disclaimer: The article has been written in personal capacity, and the views and opinions expressed are those of the author
Comments
Post a Comment