Philip Chacko

Arth's efforts to deliver healthcare in Rajasthan have been a panacea for poor communities battling to cope with disease and debilitation

The topic is child immunisation, the venue is the courtyard of a government school in a hamlet called Gundali near Udaipur in Rajasthan, the audience is a motley group of women from the Bhil tribe, and there are two moderators from Action Research and Training for Health (Arth), a non-government organisation (NGO) working overtime to plug some of the numerous gaps in the muddle that is India's rural health machinery.

We are at the monthly gathering of one of the women's groups that Arth has worked to set up, as part of its 'healthiness through self-help programme', in the rural regions adjoining its base in Udaipur. Arth activist Grirish Paliwall starts the discussion by asking if any of the women with babies have availed of the child-immunisation services being offered at the government health centre. Some of the women nod their heads; others say they haven't. Paliwall holds up his hand, fingers spread. "Five vaccines mean you banish five diseases forever," he says with as much authority as he can muster. Tulsibai Bhil, seemingly about 60 years old, is far from impressed. "I've lived long enough without taking any of these things," she says. The Arth activist knows he has some convincing to do, but the women are willing and trusting listeners and he is a patient and knowledgeable man. For Paliwall and his colleague, Ramesh Gumkar, it's just another day in the office.

At Arth's main health centre in Kuncholi, some 25 km away, Dr Shard Iyengar is dealing with a different kind of problem. Rajasthan is a land of the brave, as even a cursory reading of its rich history will testify, but Roop Singh's courage was incongruous. A local 'medicine woman' had been branding this 40-something's midriff with a red-hot iron rod to get rid of his persistent stomach pains. Called daam in the local Mewari lingo, Singh reckons he has been through the 'treatment' 80-90 times. It worked for a while, he says, the ache inside being subdued by the burning sensation on the outside. But the pain would come back as the seared skin healed. Singh finally had enough and is now at the Arth centre, seeking a less flaming solution to what is, in Sharad's opinion, a gastro-intestinal inflammation.

Tulsibai and Singh are just two of the many thousands of rural poor who have benefited from Arth's efforts in the field of community health. The Kuncholi facility, called the Arth Reproductive and Child-health Centre, is the infrastructure centrepiece of the organisation's operations, which can be broadly classified under the rubric of community health. Within this comes a whole range of initiatives: research, field programmes, publications, advocacy, training and the actual running of two health centres. Established in 1997 by a seven-member team of health professionals, clinicians and managers, Arth's stated mission is to employ operational research and training initiatives in a manner that help rural communities access and use healthcare according to their needs and capacities.

Arth's activities are spread over 27 villages of Udaipur district and 19 villages of Rajsamand district, and its programmes cover close to 50,000 people. Its focus has been reproductive and child heath, which for the most part involves women and infants, but it has been steadily increasing the breadth of its interventions to include men and entire communities. Arth has 40 staffers on its rolls, among them doctors, nurses and midwives, social scientists, supervisors, community organisers and what it calls 'social animators' (activists such as Paliwall and Gumkar).

There are five clear categories that Arth's work can be divided into: operational research that enhances the access and quality of the healthcare available to rural people; utilising its research findings to advocate and influence government health policies and programmes; offering training to health workers and managers; delivering reproductive and child-health services; and supporting endeavours that improve the social, educational and economic status of women. The organisation's reproductive and child-health centres in Kuncholi and Kumbhalgarh provide a variety of services: antenatal and postnatal care; contraception advice and equipment; medical termination of pregnancy; treatment for reproductive tract illnesses, infertility, sexually transmitted diseases and gynaecological disorders; and treatment of infants and children for diarrhoea, malnutrition, etc.

That's the institutional canvas, but it is the difference Arth is making to individual lives that is really striking. Sharad Iyengar, who along with his wife, Kirti, a gynaecologist, is the driving force behind Arth, sees the motivation factor as critical to all that the organisation has achieved. "We felt that if you really want to influence policies and programmes, you need to have credibility," he says, "and that can come only from working in the areas of your advocacy. Otherwise, it can seem negative, particularly if you are an NGO."

The problems confronting the Iyengars and their team are many. "Our efforts are concentrated in an area that is backward, where institutions are weak," says Sharad. "The social and economic differences in Rajasthan are very strong and the tribal and other poor communities we are involved with have to face adversity on a daily basis. They don't have the right land, they don't have the resources, there's violence against women, there's the system of purdah; there are difficulties at every turn. Also, it's a Herculean task getting the right employees. Given that our work is mostly with women, we need women employees - and finding them is never easy."

Research and training are the cornerstones of Arth's work. "One of our objectives is to provide a training platform where people can learn skills, learn a different way of doing things," says Sharad. Kirti emphasises that reproductive rights, maternal mortality and access to safe abortions remain a high priority for the organisation, while elaborating the organisation's attempts to make its two health centres 'best practice' exemplars. "We want to make these a model that can be copied by NGOs, government agencies and others," she says. "We are also trying to see whether self-help groups can play a role in the distribution of certain health products and in maintaining a community health fund so that they can give loans without interest to resolve health-related problems."

Sharad pegs the challenges Arth has to face at a much lower level to the troubles plaguing the poor communities it works with. "They have only so much of space and money to spend on improving their own health; they are far more tied up in the struggle for survival. Secondly, their access to health sources and services is severely limited. There is this vicious cycle of exploitation and unending inequities. The systems don't serve the people. Now we, in our small way, are trying to compensate for this system with our health centres, but they are only drops in the ocean. Where we can really contribute is by coming up with better ways to deliver healthcare to the poor, mobilising communities to make demands on the system, and making the system function better."

Arth, then, is not so much a model heath service as it is a catalyst for the propagation of an archetype that others can implement. It is in recognition of the importance that this holds for changing the way India's health infrastructure functions that the Sir Ratan Tata Trust has been supporting the organisation. In 1999 the Trust granted it Rs 25 lakh for a three-year period and in 2003 it sanctioned Rs 66.5 lakh. "Arth has considerable promise as a professional organisation in the area of health," says Arun Pandhi, a programme officer with the Trust. "In the short span of its work, it has been able to make considerable policy-level contributions."

Sharad's aim for Arth in the years ahead is a simple one: "Our endeavour is to 'de-medicalise' health services, demystify it, make it more accessible and humane for India's poor communities."

Uploaded in March 2005