Lasting change: the Community Based Health Project, Buldhana

Health . . . is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Primary health care . . . constitutes the first element of a continuing health care process.1

At birth, Moses Kharat was given a life sentence of poverty and suffering. Born a lower-caste Dalit in the rural Indian district of Buldhana, he would spend most of his childhood helping his family with hard labour, and was unlikely to ever know an education. Today, he is a medical doctor, and he reminisces about the day missionaries came to his village, providing him and others with the schooling and health care needed to break out of the cycle of poverty. His ambition is to deliver his fellow villagers, as well as some of the 365 million other impoverished people across India, from the same injustice. In 2009 he travelled to the acclaimed Comprehensive Rural Health Project set up by pioneer doctors Raj and Mabelle Arole in Jamkhed, Maharashtra. After learning the principles of community development Moses resolved to apply these principles in his own village.

One of the first tasks Moses faced in Buldhana was to seek out and identify those he aimed to help. In India, members of the vulnerable lower caste are usually isolated from business centres and main roads, hidden away in peripheral villages and makeshift housing. Establishing a health clinic in central Buldhana would attract only a handful of people who travelled there for work, but it would remain unknown to the rest. Indeed, there are many health clinics throughout Buldhana; some are privately owned and charge fees that poor families cannot afford, others are government facilities that are unreliable and often understaffed. How would the villagers know this facility was unlike the others or that its staff, including Moses, could be trusted?

A second challenge was to identify the community’s perceptions of health issues and to negotiate these by applying public health principles. In the satellite village of Mohegaon, many sanitation issues are self-evident, such as a very high level of open-air defecation, and open sewers sharing space with open wells. Despite easy access to public and private toilets, the villagers preferred open-air defecation because they felt it was more sociable and pleasant. An effective intervention would therefore need to address village attitudes towards sanitary practices, instead of installing more unused toilets. This provided an example of how gaining a local perspective is crucial to understanding health issues in the village and devising acceptable interventions.

With such ideas — the need for outreach and access, as well as community participation — in mind, in 2011 Moses officially established the Community Based Health Project (CBHP)2 in Buldhana. It was based on a three-tier health care model. The first tier involves Village Health Workers, women selected from and serving within their own villages who act as a first point of contact to the health system. Travelling door to door, they elicit health concerns, provide basic health care services such as prenatal care, and refer patients needing higher-level care. The second tier involves mobile health clinics, which are monthly clinics in each village run by Moses and a nurse that familiarise families with the CBHP, and reach out to those with difficulties accessing the central clinic because of distance or poor mobility. The third tier is a small hospital in central Buldhana, where Moses and a full-time nurse look after those who require inpatient care. However, this model only dealt with direct health needs; there were still broader economic and political issues afflicting the community, and Moses needed assistance to conduct a health assessment of the area.

In 2009, Moses had befriended a young medical student, James Wei, who was undertaking research at Jamkhed. They shared similar attitudes towards community health care and, taken with Moses’ vision, James assembled a group of medical, commerce and arts students from the University of Melbourne, who travelled to Buldhana in January 2012 to help the CBHP. The students aimed to raise funds for the project, immerse themselves in village life, and conduct a pilot health census through focus group discussions and household cluster surveys. The research aimed to elicit the major health concerns of the communities, and identify the major barriers to health. To make this a lasting, truly community-owned program, there was more emphasis on community concerns than on health issues observed by outsiders.

The students’ research yielded data that would help inform future CBHP initiatives, but often the most telling stories came from unexpected scenarios. A focus group discussion organised with community leaders provided several striking observations. First, most of the community leaders were men, and the women who were present had little to say. Second, when planning the meeting, a complimentary meal was offered as an added incentive for attendance; some men insisted the meeting be held on a particular date when their faith permitted them to eat expensive meats, so these could be purchased for their meal (despite a limited budget). It was puzzling that these community leaders, who had secure government incomes, were so concerned with their complimentary meal when many of their fellow villagers had poor access to water and nutrition.

The research findings were even more sobering. A discussion with several young men and women who had achieved college educations demonstrated that they had little hope of finding employment. The only available employment in the villages was poorly paid manual labour jobs on farms, and government positions requiring exorbitant bribes (the equivalent of thousands of dollars) on application — an unimaginable cost for most families. Many other children had no prospects of receiving a secondary-school education owing to the poverty within their families and the sheer distances and bumpy roads between the villages making journeys to school long and difficult. One girl told us she was forced to marry instead of going to secondary school.

However, armed with their education, these young local people were passionate about improving the situation of their communities. In the focus groups, they stood up and spoke bravely on behalf of their village, articulating the challenges of the current situation and what needed to be done. Some expressed their envy of the comfort and security enjoyed by youth in Western societies, filling their visiting student audience with sympathy as well as guilt. Their optimism and spirit will indeed be a strong driving force for the future work of the CBHP.

These are but some of the stories gleaned from the people of Buldhana. The journey does not end here. With the data gained from the student research, and the diverse perspectives of villagers, CBHP staff and the students from multiple disciplines, strategies to tackle these social problems are coming to fruition. Moses plans to start youth support groups and workshops on sanitation. Meanwhile the students will investigate strategies not limited to health care, including social enterprise, and implementing health-friendly technologies. The program, and our ambition to help the people of Buldhana, grows by the day.

A woman washes her family’s clothes while the children play; clean and safe drinking water is scarce in Buldhana