5) Description of health product/service offering: The Comprehensive Rural Health Project, Jamkhed has been working in partnership with village communities since 1970 to uplift India’s rural poor and marginalized population surviving in appalling conditions. CRHP aims to implement a wide range of interconnected community-based health and development programs that empower women, children and the poor and marginalized through a comprehensive, holistic and value-based approach emphasizing equity and justice. By strengthening families and building healthy communities CRHP has successfully brought about positive transformation and improved quality of life for hundreds of thousands of people living in project villages, primarily in the state of Maharashtra. The focus of CRHP has always been on the priority areas as identified by the people themselves, namely the urgent need for comprehensive health care, water and environmental conservation, and improving animal health. Communities are also linked with available resources of government and NGOs in the region and elsewhere as they might not have known about or been able to access such services. The key change agent became the incredibly successful Village Health Worker (VHW), who is selected by her community and receives training in health, community development, communication, organization, and personal development from CRHP. Her primary role is to freely share the knowledge she obtains with everyone in the community, to organize community groups and to facilitate action, especially among women, the poor and marginalized. At the outset, many of these VHWs were often illiterate women from the untouchable (dalit) caste. Eventually over 300 villages with a combined population of 500,000 were participating with CRHP through the selection, training and support of VHWs and through the formation of community groups. CRHP also operates a 30-bed low-cost secondary care hospital providing quality emergency, medical, surgical, and outpatient care for 1.5 million people in the area.

6) Description of innovation: Founded in 1970, CRHP was the first to introduce the principles of equity, integration, and empowerment in the field of community-based health and development. Equity involves adequate and relevant health resources for all people, especially the poor. Integration refers to the use of a holistic approach utilizing comprehensive interventions including prevention, promotion, cure and rehabilitation. In addition, integration also implies working in diverse fields such as education, agriculture, environment, legal and social/cultural aspects of life in order to achieve a significant and long-lasting impact on health. Such a strategy comes from seeing health and socioeconomic development as being two sides of the same coin. Unlike charity, empowerment involves the process of sharing knowledge and skills with communities to enable them to develop their own resources and human potential thereby placing health in the people’s hands. The concept of empowerment within the project villages of CRHP has translated into training mostly illiterate women, using a value-based approach, in health to effectively deal with health, social, and environmental issues of importance in their villages. CRHP has pioneered and helped to spread throughout the world the concept of health as a human right in a process of overall community development rather than a commodity to be bought. This is achieved through residential training of individuals and organizations from India and abroad at the Jamkhed Institute of Community Health and Population, nation-wide mobile training, and our continuing community-based work with rural communities in Maharashtra including tribal areas. By demystifying medicine, integrating health with other sectors of community development, and combining allopathic with other systems of medicine CRHP has been able to achieve unprecedented improvements in the health and quality of life for the 0.5 million population who worked or is currently working in partnership with us.

7) Operational model: As an organization CRHP aims to uplift the rural poor and marginalized through a comprehensive and multi-sectoral approach to health and development. More than 35 years of grassroots work has shown the value of utilizing empowerment and capacity-building as essential tools of public health. The diversity of our programs and activities are meant to empower the poorest of the poor, especially women and tribals, through socioeconomic development, primary health interventions, and community mobilization. The range of activities spans categories such as agriculture-including a model farm, environment, including watershed development and reforestation, water and sanitation, health, micro-credit, education and training in various capacities. Health activities are arranged according to a three-tier health system. The novel idea of using village health workers as local agents of change and transformation is at the core of the first tier – the village communities. Our mobile health teams consisting of a nurse, social worker, paramedical workers and doctor comprise the second tier. These teams serve as the liaison between village and health centre. Villages are visited periodically, more often in new project areas, to provide support and credibility for the VHWs and offer assistance and facilitation in development activities. The health centre makes up the third tier and consists of a formal training institute, to promote CRHP’s approach as a global model applicable to developing and developed nations among national and international trainees, administrative office and 30-bed low-cost secondary care hospital providing quality emergency, medical, surgical, and outpatient care for the 1.5 million people residing in the surrounding 8 block catchment area. The provision of quality curative services has proven to be invaluable in establishing credibility for community-based primary health programs as well as earning the trust and confidence of the communities with which we work.

8) Human resources: CRHP currently operates on a full-time staff of 60 under the leadership of Drs Raj and Shobha Arole. These are divided between the hospital, farm, training institute, and community-based primary health programs. Recognizing that health is closely inter-related with other socioeconomic issues all 60 can be said to be in some way involved with the health initiative. Experience has also shown that when working with the poor and marginalized those in need of assistance will often turn to the least qualified on the mobile health team as they feel more comfortable rather than approaching a health professional. For this reason and in keeping with the principle of equity all staff, regardless of position and background, receive the same training from CRHP in health and community development. In addition there are hundreds of VHWs and community volunteers working with CRHP on a voluntary partnership basis. The team consists of dedicated individuals possessing varied skills and qualifications including social workers, agricultural experts, and health and other allied professionals. The leadership of CRHP has top qualifications and training from the leading schools in India and the U.S.

9) Key operational partnerships: From its founding CRHP has engaged in key operational partnerships, which made it financially and technically possible to undertake a large number of vital activities such as the drilling of over 250 tubewells to provide the villages with an adequate quantity and quality of drinking water. These partnerships have included Oxfam, United Methodist Church, and Churches Auxiliary for Social Action in the past and currently Lutheran World Relief, Tearfund, American Leprosy Mission, and the Sisters of Notre Dame, Holland. State and central government partnerships have made it possible to spread the community-based approach to health and development throughout India. This is achieved via residential and mobile training of grassroots workers, officials, administrators, and health professionals. Government partnerships have also provided a forum in which to advocate for the rights of the poor and marginalized. This is done through the current participation of Dr. Raj Arole on the National Rural Health Mission, chaired by the Prime Minister, as well as past involvement on various state and national health policy making bodies. The Aroles have been recognized by the Schwab Foundation, part of the World Economic Forum, as social entrepreneurs. Membership in the Schwab Foundation provides access to strategic partnerships with leading business and government organizations that are interesting in social investment. This also provides a valuable platform for exchanging ideas and resources.

10) Financial Sustainability

          • Fees charged to clients?: Yes

          • How do you assure affordability?: CRHP aims to enable communities to achieve sustainable holistic development in which local resources are developed, maximized and used to their fullest potential. Financial reliance upon an outside organization is counterintuitive to achieving this goal. Experience has shown that when communities invest a substantial amount of their own time and resources into health and development activities a much greater sense of ownership and pride develops. The results of this approach have been very positive with communities showing significant interest and commitment to PHC activities long after CRHP reduces its presence. In the hospital, patients are charged fees according to a sliding scale, made possible with input from VHWs who are intimately aware of the socioeconomic status of patients.

          • Earned incomes as a percentage of operating costs: 45%

          • Other funding sources: As an organization devoted to uplifting the rural poor and marginalized it is possible only to become 50% financially self-sustainable without alienating the very same population being targeted. Although financial independence with regard to the majority of our community-based PHC programs is highly desirable the provision of curative services must be subsidized. Access to health services must not be restricted due to an inability to pay. VHWs throughout our project villages provided invaluable information enabling a highly effective sliding scale with regard to patient fees, including surgeries. To operate at an effective level CRHP relies upon a number of private grant-making organizations, including faith groups, as well as charitable donations made by individual sponsors.

          • Strategy for long-term sustainability: CRHP will continue to reach out to national and international donor organizations with similar goals and interests. Being part of the World Economic Forum through the Schwab Foundation will enable us to engage in strategic future partnerships with organizations that are acknowledging the benefits of social entrepreneurship. The tried and tested model of CRHP has proven to be scalable and adaptable to a wide variety of settings, both rural and urban, throughout the world. Such positive experience will give us an advantage when competing for grants and funding in order to continue expansion and training in this field. The majority of our CBPHC programs in established project villages have already proven to be sustainable even with minimal outside support.

11) Current and Future Impact

          • Total number of clients: 2 million

          • Clients in the past year: 100,000

          • Percentage of low-income clients: 80%

          • Impact: The impact of CRHP’s many health and development programs have been far-reaching into nearly every aspect of life – social, economic, physical, and spiritual –as implied by the term “health”. This impact has been described quantitatively through a number of surveys and research conducted over time to identify changes in the health status of project villages. Equally important are the qualitative changes that have taken place with regard to quality of life and expectations for the future. For instance people now willingly accept family planning since they no longer expect their children to die from communicable diseases keeping the average number of births to 2-3. In addition 80% of health problems are effectively taken care of at the villages themselves by well-trained and confident VHWs.

          • Overall "market": Demand and interest in CRHP’s model of community-based PHC is far-reaching and in some ways have outgrown our organizational capacity. This model is being recognized as one of the best methods by which to achieve sustainable health and development in developing and developed countries. Initially spread to over 300 villages in the Jamkhed area we are currently partnered with 100 villages in the Blocks of Jamkhed, Karjat, Ashti, and Bhandardara in which community-based health and development projects and activities are ongoing. Through training activities and partnerships the project has spread to other states of India including UP, Bihar, Arunachal Pradesh and Andrha Pradesh. Officially, various government representatives have come and studied the Jamkhed model to initiate similar CBPHC programmes in Bangladesh, Nepal, Pakistan, Bhutan, Indonesia, etc. Through the United Methodist Church our model has also been successfully promoted and implemented in Brazil, Bolivia, Venezuela, Guatemala, Honduras and Guyana. Eight African countries have likewise benefited from our approach. Rather than initiating numerous branches we joined hands with existing NGOs to promote CBPHC through them.

12) Scaling up strategy

          • Stage of the initiative: Scaling Up stage.

          • Expansion plan: Over the next 3 years CRHP will focus on consolidating our activities with the SERP (Society for Elimination of Rural Poverty) project in the state of Andhra Pradesh through mobile and residential training of staff at all levels of health and development work. At the request of the state government CRHP will expand work in the tribal areas of Maharashtra through training of Ashram boarding school teachers and setting up community-based programs to empower tribals and develop villages. Advocating for health policy reform through the National Rural Health Mission will continue due to Dr. Raj Arole’s sole representation of India’s NGO sector. Locally based expansion will include an increase in the number of project villages and the scope of current programs as well as initiating new ones in response to changing health and socioeconomic conditions in the villages. A greater focus will be placed on the prevention and treatment of chronic diseases that are becoming more common. The hospital will expand in order to upgrade facilities, increase the number of beds and expand services. Expansion of the training institute will also occur to accommodate a growing interest in our programs.

13) Policy change: The mission of CRHP includes working at the grassroots to ensure health for all with equity and justice through holistic development. To this end policy addressing discrimination against the poor and marginalized, especially women, lower caste and tribals, would certainly do much to promote our mission by accelerating social change within India. In addition there must be effective policy at all levels of government to facilitate the empowerment of these groups. Of course effective enforcement and oversight of such policy is critical if any impact is to be made on the current situation.

14) Origin of the initiative: CRHP was founded by Drs Raj and his late wife Mabelle Arole, who committed themselves to serving and uplifting India’s rural poor and marginalized population. The Aroles graduated from CMC Vellore and obtained their residency training in medicine and surgery and masters of public health in the U.S. While in the U.S they planned a project that would effectively meet the immediate and long term needs of the poor and marginalized, especially women, by working in partnership with the village communities. In 1970 Drs Raj and Mabelle Arole returned to India to implement this project. After visiting villages and holding open discussions with people to see where community cooperation and participatory development would be most welcome they decided to work in the areas surrounding Jamkhed in the Ahmednagar district of Maharashtra. Among the many award won by the Aroles was the Magsaysay in 1979.

Contact Information:
Rajanikant [Raj]  Arole
Director
Comprehensive Rural Health Project, Jamkhed
(NGO)
India
Website: http://jamkhed.org