Prasanta, a trained medical doctor, realized that matters of life and death are often in the hands of the communities rather than healthcare professionals. By engaging communities in interactive storytelling and game sessions, Prasanta helps them comprehend and overcome an intricate web of social, cultural, medical and economical causes leading to death and disease among them. This strategy has led to 45 percent reduction of infant mortality in three years. Working in the poorest areas that have almost no access to primary healthcare, Prasanta capitalizes on the most universal resource to improve infant mortality rates, namely the will of the mothers to ensure healthy lives for the children. He is increasing the ability of mothers and communities, as the first care providers, to identify health problems and respond to them effectively.
The New Idea
Prasanta observed that the death of newborn babies had become so common in rural and tribal areas that women ceased to question why their babies were dying. This helped him see that, the first step to realize health for all was to transform the attitude of communities from being fatalistic to becoming critical and proactive.
Working in the poorest areas with almost no access to primary healthcare, Prasanta capitalizes on the most universal resource—the will of the mothers to ensure healthy lives for their children. He is increasing the ability of mothers and communities—as the first care providers, to identify health problems and respond to them effectively. Local facilitators take groups of women through a series of interactive and reflective activities aimed at increasing their health consciousness and critical-thinking abilities. The group meetings are facilitated with an emphasis on collective problem-solving and planning. They are steered to enable women to identify and prioritize maternal and infant health problems and collectively determine and implement strategies to address them.
In the 200 villages across the states of Jharkhand and Orissa where Ekjut has worked, there has been a 45 percent reduction in infant mortality and 20 percent reduction in maternal mortality in three years. After proving his methodology successful, Prasanta started a new intervention to verify whether community mobilization can be effective in addressing malnutrition. Prasanta explores the efficacy of his work with academic rigor to prove that community participation is a cornerstone for designing effective healthcare systems for the most poor. He is identifying collaborators among state governments, funding agencies, and citizen organizations to replicate his methodology for the rural poor.
In India, for every 1,000 live births, 61 babies die in their first year; compared to 25 in China and 28 in Brazil. While many blame this devastating data on insufficient infrastructure, limited access, and social and political disturbance, Prasanta believes that it happens primarily due to the mother’s inability to take care of their infant’s health.
Even today, most of the deliveries in India happen at home. This coupled with the high rates of illiteracy among women, increases their vulnerability to secure the health of their children. For example in the area of Ekjut’s intervention: about three-quarters of women who had had births were illiterate (70 to 78 percent) and the majority of the deliveries occurred at home (83 to 86 percent), generally without a birth attendant (61 to 63 percent). Often the causes of death are easily avoidable. The three most common causes of infant deaths are minor unattended infections, cold, or hunger. Such deaths can be prevented if mothers are equipped with the knowledge and skills to identify and address the symptoms in timely manner.
Based on this common knowledge, The World Health Organization and other development actors have emphasized increasing community participation in health to achieve health for all. However, definitions given to this approach and its implementation vary widely. For example, a government program at the village level, Accredited Health Social Activists (ASHAs), is focused on building capacity of one particular community member to locally address health issues. While it has demonstrated certain success, Prasanta believes that such approaches merely make healthcare services accessible locally rather than increasing the ability of each individual to take care of their own families and communities health.
In addition, there has been little effort to undertake scientific study or measure outcomes of such approaches. Consequently, there are increasing doubts about the efficacy of participatory interventions. The lack of sufficient effort among healthcare actors to build practical and effective models for community engagement left powerful development actors to design top-down interventions that do not engage and leverage behavior patterns of local communities.
At the village level, Ekjut’s intervention consists of a series of meetings guided by trained and paid facilitators. The facilitators do not give health advice—instead, through series of meetings, they help community’s structure a self-exploratory learning process. Their objective is to get communities to reflect on their challenges, overcome their sense of despair and fatalism and invoke critical-thinking to collectively design strategies to address health issues prevalent in their villages.
The facilitators are chosen locally after consultation with elders, opinion makers, and women. They are trained with an emphasis on developing their listening and communication skills—qualities that are critical during initial meetings—focused on speaking with women to identify and prioritize infant and maternal health problems.
Ekjut uses the vast network of Self-Help Groups (SHGs) as an entry point to communities. This is particularly strategic, as rural families often lose their savings due to the health shocks. However, conscious that poor women are often not part of the SHG structure, Ekjut has ensures that the meetings are open to non-members and the rest of community: men, relatives of pregnant women, and frontline government workers. The open structure of the meetings helps to reach out to those most marginalized within the village and enables people to realize their common problems and develop collective commitment to solve them. This approach bears fruit as the data from the areas where intervention was complete shows a 73 percent reduction in infant mortality compared to 36 percent among the general population.
The facilitator begins engaging the women by asking them to recall accidents that have occurred in the village. Drawing from this, the facilitator then depicts different causes of illnesses and strategies to address them. This interaction with the women leads them to weave a narrative, demonstrating a different possibility. Women then vote to identify the problem they feel affects their village most, such as malaria, open defecation, or insufficient access to health services. They then mobilize the village to organize a public action to address the problem.
In the past, such public action has resulted in vaccination camps being organized, open water storages being covered up, and even convincing the Panchayat to build a bridge to the nearest primary healthcare center. More notably, the community discovers its ability to bring about change. Irrespective of the new problems arising they retain their problem-solving ability. Consequently, even years after Ekjut intervention in a village, infant mortality rates do not go up again.
Prasanta is determined to create scientific evidence proving the efficacy of community mobilization for health outcomes. The intervention in the first 200 villages was managed as a medical trial in collaboration with University College of London. Ekjut picked 200 villages as the intervention area and the same number to be the ‘control area,’ where the same data would be collected, but no interventions would be undertaken. Ekjut made sure that the baseline data was consistent in control and intervention areas. Such research methodology gives the most accurate representation of what changes can be accounted to Ekjut’s intervention and what can be attributed to external factors. During the three years of intervention, data was constantly and rigorously collected in both areas. Neonatal mortality rates per 1,000 were 55•6, 37•1, and 36•3 during the first, second, and third years, respectively, in the intervention area, and 53•4, 59•6, and 64•3, in the control area. In 2011 Ekjut was awarded by the prestigious international Trial of the Year Award, which recognizes excellent academic achievements that provide the basis for a substantial, beneficial change in healthcare.
Prior to starting the trial, Prasanta secured funds to ethically expand to control area if the results proved to be positive. The same year the trial was completed, Ekjut began the intervention in the control areas. In areas where the first cycle was completed Ekjut has started new cycle targeting the health of children under the age of five, to address problems like diarrhea, pneumonia, and malnutrition.
Prasanta is pursuing a multipronged scale strategy by identifying appropriate platforms across poor rural areas to integrate with Ekjut’s participatory approach. For example, Ekjut is providing technical assistance to the state governments of Uttar Pradesh and Jharkhand to scale practices for improved maternal, newborn, and child health and nutrition. Ekjut is also implementing a project aims to train government ASHA workers to play the role of facilitators in their communities. In addition, Ekjut is teaching its staff to be professional consultants in participatory methodologies in maternal and childcare. They are already present on several national level committees, such as National Alliance for Maternal Health and Human Rights and the National Asha Mentoring Group.
Prasanta was born and brought up in a small village in Jharkhand. Trained as a medical doctor, he began his career providing healthcare to tribal communities. Later, he got his master’s degree at University College of London, Institute of Child Health, where he focused on researching child mortality in India. One of his greatest learnings was the fact that despite all efforts between the 1980s and 1990s child mortality rates in the country had barely improved.
Prasanta came back to India to join TATA Steel in their CSR wing in Jharkhand. There he organized community-based intervention to combat malnutrition. During this period he was working with the mothers to regularly monitor the growth of the babies and to enable them to prevent malnutrition. The positive results of this work proved to Prasanta that participatory approaches when properly designed can be effective for building healthier communities.
During this time Prasanta visited Jamkhed to meet Raj and Mabelle Arole; an event that inspires his current work. Prasanta says, “They trusted people, they gave information, they respected everyone, they told the truth, and in turn the people of Jamkhed and the villagers nearby were adapting to the complexities of a changing world with exceptional grace and self-respect.” At the same time, he was disappointed that other interventions attempting to replicate their approach were not nearly as successful.
With a desire to understand how the impact could be created in healthcare at significant scale Prasanta joined a large international development agency in Delhi in 1998 as a program director. After a few years Prasanta was disillusioned with the top-down approach of the organization which unintentionally increased inequities by leaving out those most poor. He saw that the approach pioneered by the Arole’s was not considered by the largest actors, in part, because there was not enough research and strategies created for them to embrace it.
Prasanta and his wife, Dr. Nirmala Nair, decided to start their own organization and move back to Jharkhand. While they were still thinking about Ekjut’s strategy, word spread in the villages that two doctors had come to the area. Prasanta and Nirmala found themselves setting up a small clinic in their front yard to be able to attend to all the people, many of whom were mothers with malnourished babies.
It was their house helper Sumitra who first invited them to her village to meet the community, witness the challenges, and explore what could be done. Nirmala and Prasanta started working with the women in village after village, collecting data, and refining how their capacities could be improved. Even after nine years of successful work and not a single staff member at Ekjut, including Sumitra, would say that they teach women: Ekjut collaborates with communities to help them become healthier.