India
holds just over 17 percent of the world’s population; that is about
1.2 billion residents dispersed throughout urban and rural areas.
Acknowledged by both domestic and international aid organizations,
programs have been developed to help alleviate some of the health
disparities that are seen throughout this country. India has a very
high infant mortality rate, in 2012; the rate was 44
deaths per 1,000 born.
This is more than nine times that of the infant mortality rate for
the United States, which were 6 per 1,000 births for 2012. Incidence
of tuberculosis is very high in India as well: in 2012, India had 181
incidences
cases of tuberculosis per 1,000 people, compared to just four cases
in the United States. Another alarming fact about tuberculosis in
India is that “In
2009, out of the estimated global annual incidence of 9.4 million TB
cases, 2 million were estimated to have occurred in India, thus
contributing to a fifth of the global burden of TB.”
Malnutrition is a burden suffered by many throughout India; hit the hardest are vulnerable populations, such as children. The last government-run survey on malnutrition (National Family Health Survey) was conducted over six years ago, but more recent, independent-run surveys find the high rate of malnutrition in children not decreasing. The Hungama Survey “showed that among the children under 5 in 100 districts of the country...42 percent are underweight.” India has many challenges in attempting to address health concerns, particularly in rural areas. One of the successful programs combating health disparities in rural communities is the Comprehensive Rural Health Project (CRHP) out of Jamkhed, India.
CRHP
was founded by Drs. Ray and Mabelle Aroles in 1970. Recognizing
Jamkhed, India as poverty-stricken and drought prone, and in much
need of change in ways of healthcare
improvement.
They were dissatisfied not only with the prevalence of poverty in
India, but also the government's lack of support for India’s
desolate and rural communities. Those living in rural areas did not
have access to the health services provided in more urban areas.
These communities lacked education and/or resources required for
adequate hygiene, sanitation practices, or proper nutrition. The
Aroles left well-paying jobs in a city hospital to develop and
implement a program designed to help India’s poor and rural
community. CRHP’s approach is the Aroles solution to fight
oppression and social injustice.
The
CRHP model was developed to help address and deliver treatment and
preventative care to India’s poor and vulnerable populations,
through a community
based approach.
The initial location was a single hospital in Jamkhed, India and soon
the services expanded
to
reach over 300 of the surrounding communities of the central
Maharashtra state. The low-cost hospital has 40 beds and is used for
emergency, outpatient, and surgical services. Beyond the hospital
setting, the CRHP model uses Mobile Health Teams, generally a
physician, nurse, and social worker, who visit rural villages monthly
to provide ongoing support and referrals if needed. The main focus
and promotion for the CRHP model is the Village
Health Worker (VHW).
VHW’s
are women who are elected by their community to travel to receive
training from CRHP Jamkhed in health promotion and primary care
services wherein they return to their communities as an educated and
skilled resource. These are vital positions whose duties encompass a
wide range; from managing sanitation and clean drinking water to
family planning/deliveries and nutrition. Often these women come from
the lowest caste, yet they organize and host discussions to educate
their respective villages regarding services such as primary care,
women’s health, and community development. By serving in poor and
rural areas the VHWs facilitate access to primary and preventative
health services that might otherwise not be available or easily
achieved. By empowering impoverished and often illiterate women while
teaching a much needed skill, CRHP addresses provides opportunities
for women to grow socially and respectively within their communities,
as well as earn a living. The election and support of their
community, allows women to rise in social, economic, and community
value which further strengthens the community as a whole.
The
CRHP model is highly regarded internationally and is a
well-established system of providing health care in the poor, rural
regions of India. It is regarded as a model system amongst projects
aimed at improving health in the most needed areas of our globe, and
many countries have already adopted this model for providing primary
and preventative care to rural areas.
The
CRHP has become very comprehensive and approaches the health of rural
areas holistically by addressing the many aspects of wellbeing and
equity. CRHP is active in communities and participates in many
different
efforts
focused on the improvement of communities. From opening a new
hands-on science center in November this year, to fighting to improve
sanitation with participating in projects like national “Build a
Toilet Day”, CRHP has become an all-encompassing force against
human degradation and health disparities. Services and trainings
offered by CHRP are constantly expanding with new ideas and newly
confronted issues, including sustainable farming and irrigation
system education to adjust to decreased monsoon rains and droughts.
Since
CRHP’s establishment, there have been many research finding
validating its success. Below is a table and graph displaying the
significant effect of CRHP’s involvement in the participating
villages. The success of the program is influenced and driven by many
factors. First, the successful community-based primary health care
approach of CRHP, also known as ”The Jamkhed Model,” empowers the
poor and marginalized groups, including women. This model understands
and addresses root causes of ill-health and helps move forward in
collective action to empower community participation. Second, CHRP
identifies the elements that contribute to long-term community
interest and to sustainability. Community health education covering
holistic and comprehensive preventative care, brought to communities
by VHWs plays a significant role in sustaining the health and
socioeconomic wellbeing of the villages. Increased women empowerment,
autonomy, and self-determination allow women to be “the drivers”
of the health system and add to the overall success and well-being of
a community. Third, Community-based primary health care model applied
in CHRP emphasized three principles: equity, integration, and
empowerment. Without the inclusion of these values, attaining public
health goals, such as the MDGs, will be out of reach.
As
developing countries have a relatively large burden of disease from
both communicable and non-communicable disease, applying
community-based primary healthcare has proven successful in
increasing positive health outcomes in poor and rural areas. The CRHP
model is cost effective, applicable to communities in all developing
countries, and has potential to reduce the global burden of diseases.
Table
1: Health outcomes in CRHP Project Villages over time: 1971-2011
| Year | 1971 | 1976 | 1986 | 1993 | 1996 | 2004 | 2011 | India 2004 |
| IMR (Infant Mortality Rate n/1000 live births | 176 | 52 | 49 | 19 | 26 | 24 | 8 | 62 |
| CBR (Crude Birth Rate) n/1000 | 40 | 34 | 28 | 20 | 20 | 18.6 | 23.1 | 23.9 |
| Antenatal Care | 0.5% | 80% | 82% | 82% | 96% | 99% | 99% | 64% |
| Safe Delivery | <.5% | 74% | 83% | 83% | 98% | 99% | 99.4% | 43% |
| Family Planning Under 5 | <1% | 38% | 60% | 60% | 60% | 68% | * | 41% |
| Immunization (DPT, Polio) | 0.5% | 81% | 91% | 91% | 92% | 99% | * | 70% |
| Malnutrition in children under 5 | 40% | 30% | 30% | 5% | 5% | <5% | * | 47% |
| Leprosy (cases per 1000) | 4 | 2 | 1 | 0.1 | 0.1 | <.1 | * | 0.24 |
| Tuberculosis (cases per 1000) | 18 | 15 | 11 | 6 | 6 | 2 | * |
4.1
|
GLOBAL HEALTH (PHE 444U)
FALL 2013,
Dr. Dawn M. Richardson, DrPH, MPH
Front Row Visionaries
1) Austin Ehli 2) Erin Coppola
3) Heidi Marks 4) Kyle Hubbard
5) Molly Hilken 6) Abdi Hamid
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