In rural and tribal areas, the well-being of pregnant and lactating women and new-born often faces numerous challenges due to limited access to healthcare, inadequate knowledge and cultural barriers. Recognizing the importance of promoting maternal and child health, various initiatives have been undertaken by the government to create awareness and empower these vulnerable groups.
As an AIF BIF fellow, I have been placed at Seba Jagat Kalahandi and have been working on the project of public health. Seba Jagat is implementing the project called Management of Primary Health Centre under a public-private initiative supported by the National Rural Health Mission of Odisha. This blog explores the experience of creating awareness among pregnant and lactating women in some of the rural and tribal areas of Kalahandi. I used to go with the Swasthya Sampark Sanyojak (Community Health Coordinator) of the Health and Wellness Centre to attend the Immunization, Village Health, and Nutrition Day to co-facilitate awareness sessions on health and follow-up of Gaon Kalyan Samiti meetings.
Chewing books and research papers in academics and hanging out in conferences and workshops, I was trying to understand the approaches, methodologies, and strategies to reach the last person in the respective entity. I believe this helped a lot to engage with the grassroot workers of public health in Kalahandi. Working on public health projects for the last 8 months, I suppose it is quite challenging to handle this public health system. India has a diverse and vast landscape and various cultures and communities. Looking at the geography, cultures, languages, and socio-economic contexts, Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwife (ANM), and Anganwadi Workers are the crucial people who bring government health services to the doorstep of communities. Together, they form the backbone of the public health system, especially in rural and tribal areas.
For the effective implementation of the program, it is important that we familiarize ourselves with the community and the geography of the village. Most of the villages I have been visiting have a larger tribal population, and they speak languages like Odia, Kui, etc. Initially, it was difficult to interact with them. I started understanding Odia over time, and the health coordinator of the PHC helped a lot with communication. Meeting with the stakeholders of the project, reading government guidelines, and observing the situations used for better understanding. I have been mostly attending 3 programs in different villages: immunization, village health and nutrition day, and the Gaon Kalyan Samiti meeting. We will see what these initiatives are.
Immunization: The immunization initiative in Odisha focuses on providing widespread vaccination coverage to protect individuals from various preventable diseases. The program is implemented by the government and involves a systematic and organized approach to immunization. It offers a range of vaccines to target different age groups, including infants, children, adolescents, pregnant women, and adults. The initiative ensures the availability of vaccines at healthcare facilities across the state and promotes awareness and education about the importance of immunization through various channels. It also emphasizes reaching remote and marginalized communities through mobile vaccination units and outreach programs to ensure equitable access to immunization services. The goal of the immunization initiative is to reduce the burden of vaccine-preventable diseases and improve overall public health in Odisha.
Village Health and Nutrition Day: VHND stands for Village Health and Nutrition Day, also called ‘Mamta Divas’, which is an initiative implemented in Odisha, India. The VHND program aims to provide essential healthcare and nutrition services to rural communities. It is a monthly event organized at the village level where ASHA, ANM, and AWW, along with healthcare workers and community health volunteers, gather to deliver a range of services. These services include immunizations, antenatal check-ups, postnatal care, family planning counselling, growth monitoring of children, referral of cases for diagnosis and treatment, sanitation, communicable diseases, gender-based issues, promotion of health and nutrition, and distribution of essential supplements like iron and folic acid. Creating awareness among pregnant and lactating women, families, and communities also includes door-to-door visits. The VHND initiative plays a crucial role in promoting maternal and child health, preventing and treating diseases, and creating awareness about nutrition and hygiene practices in rural areas. Through these regular healthcare sessions, the program aims to improve the mortality and morbidity rates and the overall health and well-being of the rural population in Odisha.
Gaon Kalyan Samiti: Gaon Kalyan Samiti is a Communication Campaign: Awareness to Empowerment with the aim of Sustha Gaon, Sustha Panchayat, and Sustha Orissa. The Village Health and Sanitation Committee (VHSC), also known as Gaon Kalyan Samiti (GKS) in the state of Odisha, is a revenue-generating village-level institution constituted by the community as a simple and effective management structure for improving the health and sanitation standards of the villages as a part of the National Rural Health Mission initiative. Gaon Kalyan Samiti plays an important role in identifying local health issues and taking suitable measures to solve them. It also acts as a facilitating body for the implementation of various village-level welfare and developmental programs being implemented by the government.
Important roles and responsibilities of GKS include organizing camps for mobile health units, providing assistance during flood situations, managing epidemic situations, reviewing births and deaths, informing authorities about health emergencies, and organizing Village Health and Nutrition Day, or Mamata Diwas. The National Rural Health Mission provides Rs. 10,000 as an untied fund to each GKS for undertaking different activities. This fund is directly deposited in the bank passbook of the GKS, and the passbook is opened and operated jointly by the president and convener of the committee. Besides, GKS also mobilizes resources from other sources required for activity implementation. Various programs implemented by GKS are
- Village Health Day (Gaon Swasthya Diwas) (last Thursday of every month, in your village)
- Village Health Plan
- Health Bulletin Board (Swasthya Kantha)
- Health Message (Swasthya Barta)
The socio-economic and cultural locations of the village and communities shape access to public health services. An ANM, while responding, said, “For immunization, some pregnant and lactating women living in the outskirts and dense forests have to walk more than a kilometer, passing by forests and bunds. One might enjoy the privilege of exploring the one kilometer by walking, but for someone in Kalahandi, it can cut off access to health services, affecting the lives of mother and child.” For example, Barabandha Health and Wellness Centre covers 32 villages in 2 gram panchayats. Only 4 immunization points and 8 VHNSD points are available for 32 villages, and they are overseen by 1 Community Health Officer, 1 ASHA, 1 Swasthya Sampark coordinator, and 1 Male Health Worker.
ASHA, ANM, and AWW play a vital role in improving access to the Indian public health service system. But they also stand at a vulnerable position where they face different challenges. These ASHAs and ANMs cover the villages in the dense forest, sometimes accompanied by someone and sometimes alone. An ASHA, while responding, said, “I face various challenges working in the field. First of all, after multiple meetings and messages, people won’t listen to you; they will just believe in traditional healing and care. It may create complexities during pregnancy, delivery, or after delivery. The communities have limited awareness about health issues, and there are cultural beliefs and practices that hinder proper healthcare-seeking behaviors. I also have to respect their culture and beliefs while working here; otherwise, I will not be able to work, and the government will ask me why there is malnutrition and anemia, why the mortality and morbidity rate is increasing in your area, and why there is a low number of institutional deliveries.”
In an immunization session, there were eight pregnant women who came for a regular check-up and were collecting iron-folic tablets. Interestingly, after attending regular check-ups and awareness sessions, taking mid-day meals, and taking iron-folic tablets, all of them were anemic. When asked about their food practices and timetable, a woman said, “I drink only tea in the early morning because I have to go to the forest to collect Mahua flowers, Sal leaves and I take lunch in the afternoon.” She was 6 months pregnant. Each of them must go to the forest every day to obtain forest products for livelihood. Another major thing was that 5 out of 8 women hadn’t done an ultrasound, and all of them were 5-8 months pregnant. Poor access to health services and a lack of awareness could affect them so much that they even don’t go for an ultrasound in 9 months, which can cause complexities before, during or after delivery, and result in disabled babies.
When I asked about that, they were just smiling or nodding that they would go soon. Also, they consult with the elder women in the family, traditional healers (Baidya), and traditional birth attendants (Daai) in the village. In a country like India, I observed that we have always been more dependent on households and family care, especially care provided by women, and glorified it too. While this is changing, it is still preferred in many ways over professional caregiving or institutional care. Values are one part of the picture.
Over the period of time, I attended several awareness meetings and sessions. As an outsider, it was important to build trust and ensure that the message reached the target audience effectively. Communicating health messages in the local language and considering cultural norms and practices enhanced understanding and acceptance among the community. Topics we cover include nutrition, hygiene, prenatal care, breastfeeding, immunization, common health issues during pregnancy, regular health check-ups, consumption of iron-folic tablets, and hygiene management.
Talking with a Panchayati Raj Institutions (PRI) member, she said, “Conducting regular health programs like VHND, immunization, and GKS meetings for pregnant and lactating women, their families, and community members helps to reduce mortality and morbidity rates. We also try to strengthen the GKS and utilize all the GKS funds for the people who are vulnerable.”
Training and capacity building of ASHAs, AWWs, ANMs, and traditional birth attendants to provide basic healthcare services and accurate information to pregnant and lactating women empowers the community and ensures sustainability. As there are many geographical areas and communities the government can’t reach, the public-private partnership and collaboration with non-governmental organizations (NGOs) and government agencies to leverage their resources, expertise, and networks can strengthen the impact of awareness programs and improve access to healthcare services, especially where the region is socio-economically and politically vulnerable.
The staff of the Health and Wellness Centre utilizes traditional communication channels such as weekly haats (markets), folk songs, outreach programs, and street plays to effectively disseminate health messages. At weekly haat (market day), they put up a stall where they treat people and create awareness around malaria, TB, STDs, and healthy lifestyle practices. These types of channels help make people aware of how to access public health services.
In our sessions, we use a small projector to show small videos and documentaries about antenatal and postnatal care, family planning, menstrual health and hygiene, counselling, and other important aspects of health. The government has produced ample amounts of knowledge material on health in the local language, which helps a lot to spread the correct message. Incorporating these channels into awareness campaigns helps maximize reach. Mobile technology, videos, and audio-visual aids help convey health messages in local languages in an engaging and accessible manner. These tools can be particularly helpful in areas with low literacy rates.
Creating awareness requires a multi-faceted, holistic approach that considers the specific needs and challenges of the target population especially in rural and tribal areas. This is a vital step towards improving maternal and child health. Community engagement also provides valuable insights into the cultural nuances and specific needs of the population, facilitating tailored approaches. Using local language, traditional stories, lived experiences, and culturally relevant examples in health education sessions helps them resonate with the target audience. This approach fosters a sense of inclusivity and promotes the adoption of healthy practices within the community. These initiatives bring healthcare services directly to the doorsteps of rural and tribal communities, eliminating the barriers of distance and transportation. Such initiatives are particularly crucial for reaching remote areas where access to healthcare is limited. Through community engagement, culturally appropriate communication, health education, outreach programs, training, and collaboration, we can help reduce the child mortality and maternal mortality rates.
