Systems Thinking for Capacity in Health
We believe that systems thinking and complexity science can be transformational in global health by increasing local capacity and shared learning, and minimizing unintended consequences.
CRHP Jamkhed and Systems Thinking
Equity and “Health for All” at Jamkhed, India’s Comprehensive Rural Health Project
by Bryce Johnson
Introduction
More than thirty years ago, at what is now Almaty, Kazakhstan, the world came together for better health. Dignitaries, diplomats and academics from around the world took a hard look at the global disease burden, and spent six days deliberating how to tackle it. In time, they would draft and unanimously endorse The Declaration of Alma-Ata, which designates Primary Health Care (PHC) the best path to WHO’s mantra, ‘Health for All’. The principles outlined in the declaration, however, were nothing new or groundbreaking. The authors based much of what they wrote on the experiences of several, small Community-Based Health Programs (CBHP) scattered throughout Asia and Latin America whose success with marginalized populations was such that it could not be ignored(1).
Of these model programs, only one still exists. It is the Comprehensive Rural Health Project (CRHP), headquartered in Jamkhed, India. Speaking of the project, one scholar noted: “The health improvements which have occurred since 1970 in the Jamkhed Project population are among the best ever documented for a community health project”(2). In fact, the Jamkhed region has some of the best health indicators in all of India(3).
So what is the key to the project’s success? According to Dr. Raj Arole, the founder and former director of the project, CRHP’s approach to PHC, “is a radical approach that goes beyond medicine. Its central theme is equity that aims to achieve ‘Health for All’.”
I met Dr. Arole at the beginning of my stay at CRHP for its one-month course for medical and public health students. In subsequent weeks, it became apparent that equity in health is the prevailing, unifying motive in everything CRHP does. I will review how this was evident to me during the one-month course as well as briefly how CRHP’s success with ‘Health for All’ in India can be achieved elsewhere.
Background on CRHP
CRHP was established over forty years ago by Drs. Raj and Mabelle Arole, who were both born, raised, and medically trained in India. After a few years of medical practice, they became unsettled with the way poverty and disease dominated rural Indian communities and how little the government was doing for these underserved populations. The Aroles recognized that they had a lot to learn about rural health if they were to help such communities, so they applied to John Hopkins University, Baltimore USA, to pursue advanced degrees in public health. During their stay in Baltimore, they rubbed shoulders with international health pioneers like Carl and Henry Taylor, Henry Perry and others who helped them craft a community-based development model that would be both sustainable and equitable, and that would address the real needs of the poor Indian villages in which they would work. Upon completing their degrees, the Aroles flew home, learned of the great need in Jamkhed, and settled into what was to become their life’s work.
Ina few short years, CRHP began to have tremendous success. Infant mortality and crude death rates plummeted. Farmers were successfully growing crops and more people had access to clean water and basic medical care. Villagers were gradually getting healthier, wealthier, and happier, while the centuries-old traditions of caste and gender discrimination were all but disappearing. And most impressive: the people were doing it all on their own. With CRHP’s strict emphasis on community, or stakeholder participation and mobilization (which created a shared vision amoung members of the community), the villagers were running emergent self-help groups, “Farmer’s Club” meetings, women’s discussion groups and, door-to-door health services. CRHP simply provided training, encouragement and a small hospital for emergency care and surgery.
Equity at CRHP
Global health professionals consider equity a high priority in their work. They see all human beings as entitled to certain basic rights, one of which is health. WHO’s constitution affirms its position: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”(4). However, although equity is highly valued and widely discussed by governments, NGOs, and virtually all health- service providers, the socioeconomic diversity of populations and the limited resources of these organizations often make equity, in practice, difficult to adopt. Over the years, this has certainly been the case at Jamkhed.
When the Aroles started CRHP, people in the rural villages could not get the same health services people in cities could. Villagers knew little about basic sanitation and nutrition, and most were extremely poor. Although working in urban hospitals would have been more lucrative and laudable than working in poor rural communities, the Aroles left their jobs in hospitals for what they perceived as more pressing work. They called their project the Comprehensive Rural Health Project, and in so doing, set out to turn equity as an evasive ideal into a practical reality.
Today, the development model they built exudes equity. During one of our weekly village visits, a staff member showed us a giant stone well CRHP built when it began its work in the village. She explained that when CRHP built a well in any village, it was purposefully placed in one of the poorer parts, where the lower caste villagers lived. That way, they could easily reach the well, without higher-caste villagers taking ownership of it and restricting lower castes from using it. While this generally displeased wealthy villagers, it ensured that all villagers would have free access to the local water supply. The Aroles’ attention to potentially inequitable circumstances caused by careless well placement and ability to adapt to local context, is but one example of the way equity fits into the CRHP model.
Achieving equity often means being resourceful or implementing high-leverage activities. Programs and initiatives whose budgets exceed those of local economies are rarely sustainable. With this in mind, the doctors at the CRHP hospital have identified local herbs and plants that can be used as remedies for common ailments. Sometimes, as in the cases of scabies and diarrhea, herbal remedies are as effective as available prescription drugs, and everyone can get them for free.
Being resourceful also means tapping into abundant human resources and promoting the emergence of transformational leadership. Soon after CRHP started its work, Dr. Raj, was offered a position as chairman of the local school board. His first determination was to go door-to-door in the villages urging parents to send their children—both sons and daughters—to school. He convinced them that their daughters had the capacity to learn and be productive, just like their sons. As a result, thousands of girls have received education alongside their brothers. On a visit to the school, I sat in a classroom where a young woman was teaching calculus to 18-year old boys. She spoke with confidence and clarity, and the boys respected and learned from her. In a traditionally patriarchal society, where men have a voice and women sit in silence, this was a reversal of roles—and an inspiring moment. Indian women can now contribute meaningfully in their homes and communities. Research suggests that women who have some kind of education make healthier decisions for their families (5). The Aroles’ knew that equity in health wouldn’t necessarily begin in a hospital, and their vision has benefited thousands of women, as well as the people that depend on them.
The entire Jamkhed model is centered on equity—toward helping people be physically, emotionally, spiritually, and economically healthy, no matter whom they are or where they live. But what is most impressive is that CRHP doesn’t achieve equity by simply giving people what they lack. Instead, they increased the capacities of villagers by teaching them what they need to know to help themselves. In dry regions, for example, where farmers struggle with inconsistent rain, CRHP teaches them to create water tables that will conserve the little rain water they do get. I visited one of these man-made water tables. It is a flourishing green oasis in the middle of an arid desert. The topsoil is black and moist, unlike the hard, orange-brown dirt that covers the majority of India. The people also know how to maintain the land, and they are able to farm and make money for their communities, despite their parched locale. While it would be reasonable to accept the reality that some villages do not have the good fortune of having plenty of water for farming (and that they must cope with some less profitable source of income), CRHP has worked to level the playing field for these disadvantaged regions.
Although the CRHP’s decision to work in Jamkhed put health services in closer proximity to many rural villages, basic primary-care services were still inaccessible to many project villages; the provision of “Village Health Workers” (VHWs) aimed to combat this. VHWs are primarily responsible for monitoring the overall health and well-being of households; providing door-to-door health remedies and home birthing assistance; and sharing their knowledge of (allopathic and natural) basic medicine and nutrition. They make health services equitable by adapting and taking them literally to people’s front doors.
But VHWs do more for equity than make health services more accessible. They work in adaptable ways, confronting whatever barriers keep people from “the highest available standard of health”—which, according to the WHO, means addressing a wide range of socioeconomic and environmental influences. For non-local NGOs or health planners, doing this would be a nearly insurmountable task. Getting villagers to talk openly about sensitive or stigmatized subjects like leprosy, HIV/AIDS, caste hierarchies, gender roles, perceptions about medicine, risky sexual behaviors and so on—all of which strongly impact a person or community’s overall health—would be impossible for outsiders. However, VHWs use the relationships they have with their fellow villagers, (a high-leverage activity) what they know about villagers’ lives and personalities, and what they know about the culture of the people to address these issues. With VHWs, equity is truly in reach because they are trained to see poor health as a complex, social problem instead of merely an access problem. With the insight of the VHWs into their own communities, they have the ability to tackle the problem of poor health sensitively and effectively.
In a recent speech, Margaret Chan applauded health professionals around the world for their work toward ‘Health for All’. However, she gave the firm reminder that we are nowhere near reaching that lofty goal. If health care is to be equitable worldwide someday, contributors to the cause of global health will need to, like the Aroles have, let their efforts be guided by equitable thinking and equitable action. CRHP’s model is one way of doing that, and more must be found.
1. Werner DS, David. Questioning the Solution: The Politics of Primary Health Care and Child Survival. Palo Alto: HealthWrights; 1997.
2. Perry H, Robison N, Chavez D, Taja O, Carolina H, Shanklin D, et al. Attaining health for all through community partnerships: principles of the census-based, impact-oriented (CBIO) approach to primary health care developed in Bolivia, South America. Soc Sci Med. [doi: DOI: 10.1016/S0277-9536(98)00406-7]. 1999;48(8):1053-67.
3. Rohde J, Wyon John. Community-Based Health Care: Lessons from Bangladesh to Boston. Boston: Harvard School of Public Health; 2002.
4. Organization WH. Constitution of the World Health Organization. 2006.
5. Desai S, Alva S. Maternal Education and Child Health: Is There a Strong Causal Relationship? Demography. 1998;35(1):71-81.
Systems Thinking for Capacity in Health 