On any given day, at any clinic of Swasthya Swaraj (SSS), you would be welcomed by a couple of strong, determined young women clad in pink coats. You will find them near the doctors on Out Patient Department (OPD) days. They will be translating what the patient says in Odia/Kui says to English effortlessly. Or you will find them in the pharmacy, telling the patient ‘Sokhaale gutte, rathirire gutte’ (one in the morning and one at night). Or in Antenatal care (ANC) clinics giving health education to pregnant women with such conviction.
Sometimes also managing the ANC camps alone without a doctor’s presence. And on some days in a village scolding a mother who did not bring her sick child to the clinic. On some other days scolding a ‘buda’ (old man) asking him to stop drinking and to take TB tablets regularly. On few days, you would find them in the home of a pregnant woman delivering a baby. If you go to Silet village, you will meet with a ‘Bahubali’ woman, who would carry a sack of rice on her shoulder like its some cotton bag. And somedays muddling the moped through the hilly roads/rivers. They do it all!
If you are wondering whom I am talking about, they are the nurses at Swasthya Swaraj. But not the one who have studied B.Sc Nursing. They are graduates of Swasthya Swaraj School of Community Health and Practice.
What was the need for a new cadre of health workers?
In the year 2014, when Dr. Aquinas and Sr Angelina Thomas first arrived at Kalahandi and decided to set up their clinics, they were aware of the challenges they were about to face.
When they put out the advertisement for nurses to work in the clinics, they received 100s of them but very few were willing to work in these remote settings. In 2014, there were no roads to the Kerpai clinic or to most of the village’s where SSS works. And ofcourse, mobile network was out of the question. In the more interior villages, to work with the community, Kui (local dialect) was key.
The disease profile and health needs of the tribals were unique. Across India, the problem in remote tribal areas is the same with some variations in magnitude. These are areas where it is extremely difficult to get doctors and retain them. The same is the case with nurses and paramedics. The problems in these tribal areas are far too complex to be only managed by a village health worker/ASHA/ANM, howsoever well-trained she is. To develop a program that addresses this problem, it was clear the model should be developed with a dedicated, competent workforce closer to people and which is responsive to the needs of the community.
In Dr. Aquinas’s words, “A critical look at today’s nursing education points to one thing – nursing education, though it spends many hours of teaching and exposure to community health and public health issues, is focused on producing a workforce for working in hospital-based healthcare facilities. We were clear we needed a workforce to work closely with the community yet be clinically competent like the Bsc Nurses. Solutions for the vexing problems in tribal health issues have to be sought within the tribal community itself. “
“Solutions for the vexing problems in tribal health issues have to be sought within the tribal community itself. “Dr Aquinas, Founder, Swasthya Swaraj Society
The conception story of DCHP
The need for such a workforce led to brainstorming among them, which eventually led to conceptualizing a course that would address this issue. One of SSS’s well-wishers put the team in touch with the Dean of Centurion University, Bhubaneswar. The University was enthusiastic about the idea of a course for middle-level health workers and they were immediately on board.
Dr. Aquinas was clear with how she envisioned the role of these middle-level health workers. The village-level health worker could continue to provide first contact care at the village level, counsel for proper and timely referral, be a link person and also prevent illnesses and organise people to raise demand for health care services. Whereas the middle-level health professionals would be equipped to perform duties more than a village-level health worker, which meant the cadre has to be trained to
- Diagnose common illnesses and handle emergencies such as fractures, acute gastroenteritis, severe pneumonia, seizures, injuries, animal bites, severe malaria, etc.
- Manage these common emergencies and decide about the referral of those that she cannot manage
- Manage a basic laboratory and be competent in performing investigations of common public health problems. Such as tuberculosis, malaria, sepsis, urinary tract infections and diagnosing pregnancy, etc
- Investigate reported outbreaks of illnesses in the area served, and plan its basic management
- Plan community control of common public health problems such as malaria
- Manage chronic illnesses such as hypertension, diabetes, sickle cell anemia, rheumatic heart diseases, and chronic obstructive airway diseases after the therapeutic plan has been made by a physician at the community health center
- Women and child care program needs: running an augmented antenatal care program, conducting home delivery/institutional delivery, managing obstetric emergencies, care of the newborn, running an under 3 year-old child care program.
The next task at hand was to develop a curriculum and design the course to meet these needs. The combination of experience and knowledge – the experience of working for primary health care in tribal areas, knowledge developed on the tribal health challenges and difficulties in the implementation helped shape the Diploma in Community Health Practice. Another apparent decision was the venue of the course. It was clear from the beginning that the students would not be sent to Bhubaneswar or other cities for studying, rather they would be in the villages like a simulation of the work they would take up after their course.
Design of the Diploma course
The Diploma in Community Health Practice (DCHP) is a 2-year full-time course with 6 months compulsory internship in remote tribal villages. The diploma is offered to Adivasi/tribal girls of 18 years and who have successfully completed the 12th examination, preferably from a Science background. Tribal girls from nearby blocks and districts who are willing to live and work in remote and under-served tribal villages are offered the course.
The course is completely free of cost for the students, including their boarding & lodging. The students also receive a small monthly stipend during the course. Swasthya Swaraj has been raising funds for meeting all the expenses. For regular practical learning, Swasthya Swaraj health centers and project villages are being used. But for specific postings, the students have been posted in JSS Bilaspur, Shaheed hospital in Durg, District hospital in Bhawanipatna, and other centres in addition to Govt. PHCs, Sub-Centers, CHC, NRC, Anganwadi, etc.
After completion of the internship and obtaining the Diploma, the candidates will compulsorily work with SSS in the remote tribal areas for a minimum of 2 years. The postings will be done by the organization. After the completion of the two-year service period during which they will be paid full salary, they may or may not continue in the area or may move into a hospital setting. The team also encourages and helps the graduates to pursue higher studies in public health or other professional courses in health. The course is designed in such a way that it prepares the students to serve the disadvantaged with competence as well as encouraging the students to acquire higher professional qualifications in the health sciences or public health background.
The DCHP graduates in action!
Students who graduated from this course are called Community Health Practitioners. CHPs are an integral part of community health programs – providing quality primary healthcare, running health & wellness centers, maternal, and newborn health services, comprehensive obstetric care, immunization services, health education & communication, community mobilization, care of the mentally ill, elderly & disabled in the village, etc. in the hard to reach tribal pockets.
The course prepares a cadre of mid-level health workers who have sound public health knowledge, clinical skills, competencies, and communication skills in preventive, promotive, and curative aspects of health to care for the health needs of the population in hard-to-reach tribal pockets and areas. It also prepares them to interact with the community and facilitate training/ meetings in the community.
The course so far
When the program was flagged off, the major challenge that the team faced was finding girls who have passed Class 12. There were few girls who were already working with the team by assisting in the OPD and other clinics. Some of them decided to join the course. Some of the girls who were interested to join the course had not completed their 12th class. Swasthya Swaraj then helped them in all ways to appear for the exams and pass the boards.
Today, Swasthya Swaraj employs 2 batches of DCHP graduates who have completed their course and also served the bond. While the third batch of students is going to appear for their final semester exams and would be posted in our clinics post that, the fourth batch of students are in their second semester. SSS will be starting the next batch in the next academic year.
Right from finding suitable students, to finding lodging for these many students to funding, the team has struggled to keep the program up and running. The school has seen so many adversities including the COVID-19 pandemic. The students had their share of difficulties in terms of language, subjects, and insecurities.
Despite all this, to see the graduates, I mean the Community Health Workers, work for their community wholeheartedly and seek joy from the work they do, is inspiring.
I hope Swasthya Swaraj reaches the lives of many more young tribal girls and share the joy of working for the people!
Swasthya Swaraj has been doing amazing work in Kalahandi, one of the backward districts of India. Check out their website to know more about their work. If you wish to donate to the organisation, please visit the website.