Thursday, February 21, 2008

A diagram of the Shaktishifa model of health services

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Description of Shaktishifa and the Community Health Network

I realized that a lot of people reading this blog (if anyone actually is) have no idea what Shaktishifa is, or why I am here. What follows is a description of the clinic, and the project I am working, the Community Health Network. It's a so-so write-up, but it's all I have for now

Community Health Network

We envision a Hyderabad comprised of healthy families empowered to lead fulfilling
lives. Access to healthcare, education and basic infrastructure, provisions we consider basic human rights, will be guaranteed. The security of such rights will be ensured by educated, engaged and well-resourced communities across the city.

Our mission at its core is to enable the urban poor to achieve greater self determination in promoting their communities’ health and well being. To this end, we will engage community participation to develop truly community-based healthcare.
We will promote community leadership at every level of a comprehensive approach
to healthcare which encompasses preventative, promotive, and curative
aspects. Moreover, we recognize that health is impacted by a constellation of factors, and to this end we will pursue socio-economic development in partnership
with the communities we serve.

Project Description:
The Community Health Network was established in 2007 to extend and complement
the existing activities of the Shaktishifa Health Foundation. Shaktishifa’s services
encompass a three tier system.

At the tertiary level, the foundation utilizes its extensive organizational networks to refer patients onto hospital based care not provided by the organization itself.
At the secondary level, Shaktishifa provides a full-spectrum of primary care services,including diagnostic treatment, lab testing, specialist referrals, etc.
The Community Health Network (CHN) comprises the primary level of services offered
by the foundation. A recent addition to the foundation, funded by a seed grant
from Concern India, the mission of the CHN office is to foster community based
health and development programmes in the localities served by Shaktishifa. Currently,
CHN primarily operates in two bastis, Dewarconda and Shoukatnagar,
comprising a population of 4000 individuals.
Health programmes encompass all levels of healthcare, including curative, preventive
and promotive. Domiciallary services are offered by mobile health teams which
travel directly to the communities we serve, and feature community involvement
through the use of women’s groups and community health workers, CHWs (who
work in partnership with the mobile health teams). Preventive services focus primarily on health education, and again feature significant community involvement
through the role of women’s groups and CHWs. The health education programme
consists of training about nutrition, childhood illness, chronic disease, environmental determinants of health, and various other pertinent topics. Finally, promotive programmes include general development initiatives, including income generation groups, environmental improvement and the like; once again, local involvement
is paramount, in the form of project focused community action groups.
At the core of every CHN program, there is an emphasis on developing self-sustaining
programs. Although we initially provide health services through our staff, we aim
to create self-sufficient health systems in the communities we serve within five
years of initiating activities in a given locality. After this point, we transition to a supportive role, after which we can move on to providing more intensive support
to additional communities, thereby increasing our impact.


I thought I'd add some pictures from my Jamkhed trip. In order from first to last:

Ellora Caves
Gaggle of Indian school girls, Ellora Caves
Buddhist wannabe at the Ellora Caves
Ellora Caves
Village Hospitality
Two very confident men
Cow Mart! Only Rs 20,000. Photo taken at the weekly cattle market
Landscape around Jamkhed
Market Image
A bee eater at dusk
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Small world....

It was bound to happen, but I wasn't expecting it so soon...I ran into a Macalester student last weekend. My alma mater is known for its internationalism, so it was hardly a surprise.

One of the world's top techno/trance DJs showed up in Hyderabad last Saturday. It's his first trip to Asia, and he comes to Hyderabad! I think somebody must have lied to him about Hyderabad's importance. I'm not a huge fan, and I had to leave for the airport at 4:30 on Sunday morning to catch a flight to Bombay but I've seen him with Mac friends in the States and it's probably the only time he'll ever show up here, so I figured I had to go.

It ended up being great fun, quite trashy, but in the best way possible. However, the connections made during the night were what made it truly remarkable. About halfway through the concert, we spotted a group of white people. Like any pair of dodgy Indian guys, we approached them, and introduced ourselves. Within about five minutes, I figured out that one of the girls, Alex, had gone to Macalester and that we shared common friends, that she knew of me, but we'd never met, and she didn't know I was in Hyderabad. Small world....

Towards the end of the concert, both my cousin and I, being friendly drunks, we ended up talking to anybody and everybody we could find, and eventually befriended two Nigerian guys, whom we hung out with till 4 in the morning, after which headed home.

Of course, it's India, and the randomness never ends. At 4:15 AM, about two miles from my house, the car breaks down as I'm driving. Normally it wouldn't be a cause for stress, but I had 15 minutes before I had to leave for my flight, so things got a bit hairy. Fortunately, our driver, Shoukat, was kind enough to pick my cousin and I up on his way to get the rest of my family, and there was a happy ending to the evening.

Sunday, February 10, 2008

Government Partnerships

The past few days have been serendipitous at Shaktishifa. In order to acquaint myself with the broader sweep of activities taking place in Hyderabad, I decided to explore the new website created by the Muncipal Corporation of Hyderabad (MCH). Anyone who lives in or has an interest in Hyderabad should take the time to visit it. The newly authored City Development Plan, an encouraging step in the right direction, is featured on the site. I scanned through several pages and found the contact for the Secretary of Slum Development (what a title...). Dr. Sabera, the director of the Community Health Network (CHN) at Shaktishifa and I thought it would be a good idea to meet her, as we’ve have been considering expanding our services from the slums we currently serve (Shoukatnagar and Dewarconda), to additional areas. Although the latter areas benefit from our services, government clinics exist in the area, so we felt that it was a waste to be running parallel health systems, hence a search for areas unserved by the government. In the course of a twenty minute meeting, the Slum Secretary explained the imminent implementation of the Hyderabad City Development Plan, which calls for the establishment of 150 urban Primary Healthcare Centers (PHCs). Although the MCH is doing its best, they are short on resources for ~20-30 centers. The CDP plan is to be finalized within 15 days; they have been looking for PHCs and we’ve been looking for slums. We walked out of the meeting with a plan for a potential partnership.
The serendipity of the week’s events only got better today. A friend of the family’s, a high-ranking government-type (read: corrupt but helpful), visited the clinic, and decided that he would put in a good word for us if we applied for government funding for our activities. We visited another senior government official today, this time set up through my mom, who didn’t really know about our meeting with the Slum Secretary. This official was receptive to the possibility of funding, but during the course of the conversation, said she needed to discuss the matter with the Secretary of Slum Development to figure out where we might fit in to the CDP. Sabera, a devout Muslim, was convinced it was the hand of God. I didn’t have an opinion, but I’m pleased by the direction things are going.
I’ve been hoping to scale up our programs, to extend them to areas of Hyderabad worst affected by poverty, but funding is an issue. Knock on wood, this week’s developments seem to have killed two birds with one stone. We’ll be able to take on more communities, but with government funding. Moreover, I’m glad to see Shaktishifa emerging from relative wilderness to pursue strategic partnerships, rather than providing services without regard to the broader spectrum of institutions and programs active in Hyderabad.
Quite apart from the clinic, things have been quiet. As pathetic as it sounds, I’ve turned to the internet to find friends in Hyderabad (no, not that kind....). Although some of my friends and family are horrified by it, I’ve found the travel-social networking site, CouchSurfing to be indispensable when in unfamiliar territory. It tends to be used by interesting, altruistic people, so I’ve basically been looking for white people living in Hyderabad on CS (I don’t trust the Indians). There seems to be a community of young professionals working in development in the city, so hopefully I’ll be able to find birds of a feather. It might be puzzling to some why I would seek out friends in Hyderabad when I have so many family members (for those who didn’t know, I’ve easily got a few hundred relatives, and they’re breeding), but walk a mile in my shoes, and you’d be running away from my family in the same footwear. Don’t get me wrong, they’re lovely people (mostly), but I’ve been lectured at least 3 times in the last 10 days about my Shi’ite Islamic morals, or wholesale lack thereof. The local inquisition almost forced me into going to Friday prayers last week, and after a while, I can’t help but seek out less-than-pious company. So to all of my friends and family living in relative religious freedom, if you’re enjoying an alcoholic beverage or something similarly sinful as you read this, be sure to say a prayer for me.

Sunday, February 3, 2008

A bunch of posts follow

FEBRUARY 3rd 2008

I got back from Jamkhed about a week ago, but have just been getting back on my feet since.
As for the rest of the Jamkhed trip:
The Australians took a trip to Aurangabad shortly after my last post, for a break and to see the Ellora caves (essentially a network of Buddhist Temples dating back centuries).
After returning from Aurangabad, we had a whirlwind week. The Australians had the benefit of two excellent instructors, who are both development professionals, and since I was virtually a part of their group by this point, I was welcome to sit in on their lectures. The instruction after the Ellora trip was incredibly relevant to my work in Hyderabad. I learned about Participatory Assessment (a set of methods for generating a qual/quant evaluation of the health of communities). Also included was content on monitoring and evaluation, networking with government agencies/NGOs and similar content. I was thoroughly impressed by the content of the course (I shouldn’t have been surprised, as it is offered by one of Asia Pacific’s premier institutions of public health, the University of Melbourne), although a little puzzled, as most of the participants had no interest in development careers. The coursework culminated with a group project in which each group had to develop a project plan for a different development scenario around the world, incorporating standard assessment, planning, implementation and evaluation techniques used around the world (e.g. Logframe Matrices, popularized by USAID, and now standard operating procedure the world over).
In the midst of the final week, the Aroles threw a massive party for us, and miraculously, had a bottle of tequila that wasn’t Jose Cuervo. Needless to say, we finished the tequila, and I taught the Aussies some Bollywood dance moves, which they made good use of till the wee hours.
The final day of the course was good fun as well, with a performance night which included Australian group doing a Bollywood night.
I returned to Hyderabad the next day with two of the Australians, Kate and Carl, both of whom had become friends.
The Jamkhed experience was fantastic overall. Asia’s most famous community health project, great instruction, and the Australians made for a great experience. On the last note, I had been hoping for a good (looking) group, and I couldn’t have been luckier. It was simple demographics: 20 Australians, 2 men (1 gay), 18 women and me. It was not too unlike the fables of the Hindu god Krishna, in which a young and mischievous incarnation of the god inhabits a village utopia, Brindavan, where he whiles away his days stealing milk and rolling in the hay with Gopis, the pretty female inhabitants of the village. Though I didn’t end up stealing any milk, the remaining parallels were substantial.

After Jamkhed:
Most of my first weekend back went to hosting my Australian visitors, who I toured around the Old City, Golconda and the like. The subsequent week was hectic; during the day, I spent my time getting acquainted with the work that Shaktishifa’s new community health team (of which I am now a part) has been engaged in over the past 7 months. I made several visits to the local slums, co-led a focus group discussion on health with a group of working-class women, and attended a health education on nutrition organized by the project team.....I now have to run to attend a family dinner here in Hyderabad, but will post soon with a more comprehensive update on my activities here.

JANUARY 15 2008

It’s been a little over a week since I’ve gotten here, and I’m still learning about the things they’re doing here. It would probably take another week to describe, so I’ll confine myself to the remarkable aspects.
The Aroles themselves met at the Christian Medical College of Vellore (one of India’s finest medical schools). They were both accustomed to being “toppers” (top students ) in their studies, and each had consistently ranked first in the class at their previous institutions. However, Raj Arole found that at CMC, no matter how hard he tried, he consistently came second in the class, behind the same the person, Mabelle Arole. The two competed throughout school (although Mabelle always came first), until their clinical years, when they discovered during a mutual elective in surgery, that they shared a common interest in community service and the two decided to marry. They practiced surgery for a time in rural Maharashtra, under the instruction of an American surgeon who instilled in them the importance of a comprehensive understanding of health which provided for preventive health care. Subsequently, the pair traveled to John Hopkins School of Public Health (arguably the finest school of public health in the world), where they refined their understanding of population based approaches to healthcare. It was at John Hopkins that they planned the comprehensive care model that they have implemented here at Jamkhed
Upon returning to India, the two searched for an appropriate place to begin their work in rural Maharastra (Raj Arole came from rural Maharashtra). They chose Jamkhed because the local leadership proved very cooperative and welcoming. Additionally, as a market town, Jamkhed served as a natural locus for the surrounding villages, particularly on market days, when farmers would come to sell livestock and produce.
From humble beginnings, the two grew their health system from a simple clinical operation, providing surgeries and other forms of curative care, into a far reaching health system. The telling of the story would comprise a book (in fact, it does, one written by the Aroles), so I’ll stick to salient features. For those readers unfamiliar with rural India, a brief synopsis: generally, rural Indians are intended to obtain curative, or clinical, healthcare at district level hospitals operated by the government. Moreover, preventive care is meant to be provided by village angalwadis, or local village health councils in which government workers operate. In theory, it is a decent system, but in practice, it is pathetic. Clinical care is often dismal, and more importantly, preventive care is non-existent in many places. Thus, health statistics in 1970’s rural Maharashtra were horrifying (e.g. infant mortality of 179/1000, or ~1/5). The dilemma is one faced even in developed countries. Health professionals don’t want to work in rural places; they find it unstimulating and the compensation lacking. In addition, social institutions such as caste and gender inequality were rampant in Jamkhed district, and served to magnify the area’s poverty.
Thus, at the heart of the project, and the model, is the use of illiterate, low-caste and low-status peasant women. The Aroles had an appreciation of the importance of providing preventive health education and primary care, given their background and training. Their early efforts to recruit urban health professionals were largely unsuccessful. However, at the time in public health, there was a growing body of theory that suggested where there existed a shortage of staff, it was appropriate to train local people in basic healthcare delivery. The Aroles did exactly this. By working with local village councils and sarpanchs (elected village leaders, or mayors), they were able to identify candidates for training to become Village Health Workers (VHW).
However, they expanded the role of the village health workers, and community based healthcare far beyond factors directly affecting health. Recognizing that health was determined by a constellation of factors, particularly one’s income and social status, the chose to tackle not only ill health, but social determinants of such as well. Thus, they trained low status women in clinical care and health promotion methods, but also relied on these women as vehicles with which to subvert social institutions such as caste and gender oppression. Parallel to the training of the women, the Aroles pursued general development activities, such as water resourcing. Through such activities, they further subverted social structures, for example, by placing wells in Dalit areas (i.e. low casted) of villages. Income generation projects were also initiated, again with a focus on bolstering the status of low-case villagers.
Moreover, the VHWs themselves were provided income generation training themselves. Recognizing that the village people would not respect these women as health providers unless they achieved equal socioeconomic footing, all received training in various manners of enterprise, from jewelry sales to event catering.
All in all, Jamkhed is an inspiration, and to visit it is to appreciate it. Although the Aroles benefited from excellent training and had exceptional connections in international health, the Comprehensive Rural Health Project is a testament to the agency of individuals to effect transformation.
Finally, a number of my friends are interested in health and development. If anyone should like to find out about visiting Jamkhed for a short trip or an extended training experience, shoot me an email. I know the Aroles personally now, and would be happy to put you in touch.

JANUARY 8 2008

I arrived at Jamkhed two days ago, and it has been quite an experience thus far. Jamkhed is a town of about 20,000 located in drought prone area of Maharashtra, a few hundred kilometers from Bombay.
I’m here with 20 Australians, all of us present to learn about the famed Jamkhed model of comprehensive healthcare. The Aussies have been good fun, very friendly and have taught me a great deal about their country (a list of Aussie vocab I’ve learned so far is below). Curiously, I woke up today to find I was the only one in the group wearing Western clothes, as all the Aussies had embarked on a shopping trip the day before, and had gone thoroughly native since
The Jamkhed project is run by a family, the Aroles. Initially begun 30 years ago by Raj and Mabelle Arole as a small one room clinic, it has since developed into a comprehensive health system serving 250,000 rural Maharashtrans. Leadership of the project is now being transitioned to their children.
Today was an eventful day for the Aroles, and everyone else at Jamkhed. In addition to a team from the London School of Economics, which has been conducting an assessment of the project over the last few months, a team from National Geographic showed up (apparently, Jamkhed is to be featured in an upcoming issue of the magazine), in addition to the health minister from Andhra Pradesh (and her entourage of 40 beaurecrats).
We were able to sit in on a meeting with the Andhra delegation, which was comical (the minister for Women and Children’s Health fell asleep during the meeting). A motley crue was involved: the Aroles, a group of village health workers, the Andhra delegation, the Nat Geo team, a pair of medical anthropologists from New York, the Aussies and myself. The Andhra delegation was being given the opportunity to interact with the health workers (via an interpreter), but was quite clear that the group was more interested in the buffet lunch and the type of transport they would be receiving (“are the cars air conditioned”) for their village visit, than actually learning about the Jamkhed model. Raj Arole suspects that a superior cornered the minister into coming. Regardless, it was both eye-opening for the Aussies and business as usual in India.