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Introduction

The Community Health & Development Programme in EHA continues to grow rapidly both in terms of the volume of work as reflected by the increase in the number of projects, but also in the profile and nature of work. Currently EHA has 42 projects in 21 locations. 30 of these projects are managed by EHA Hospital Units while the remaining 12 are stand-alone projects.  These projects are located in 35 blocks or slums, 26 districts and 12 states of North and North-east India covering a population of 3.3 million.  15 projects work with tribal/Adivasi communities, 10 are largely focused on schedule caste/dalit communities while the remaining 17 projects work with heterogeneous communities.

Highlights & Trends

• We celebrated 10 years of the Anugrah Project in Herbertpur. The Anugrah Centre celebrations included a special function where the children delighted the audience with their talent.  The project also held a number of events to celebrate God’s goodness and the wonderful progress that they have witnessed.
• The first batch of 10 fellows successfully completed the Community Health and Transformation (CHAT) fellowship programme and will graduate this July.
• This year one of the major focus areas has been working on Food Security and Nutrition.  Mr. Abraham Dennyson joined as Programme Manager of this programme in June 2012. The Spandana Project in Seoni District, the Madhepura CHDP, along with others have been working on various aspects of food security and nutrition. This year Nav Jiwan hospital also started work on Climate Adaptation and is working on addressing the growing issue of food security among the tribal population of Palamau District.
• The UP Urban Health project was launched in 2012 and works among urban slum communities in Agra and Aligarh. In a reasonably short period they have been able to mobilize these urban poor communities to work together towards obtaining their health & other entitlements.  EHA now has 7 urban projects.
• EHA role of working with churches and faith-based agencies to facilitate integral mission has been expanding with the starting of the Uday Basti projects, which works with churches in Mussoorie.  The SHALOM project in Delhi, AWDR Project in Udulgiri and the Injot Project in Jharkhand have all been working with churches.
• Community based mental health got a boost with the launch of the SHIFA Mental Health Project in Saharanpur District in UP. This is a project of the Herbertpur Christian Hospital
• EHA’s work in Community Based Rehabilitation has been steadily expanding with the starting of another two projects this year.  The LCH Samvedna project began working on disability in 60 villages of Tehri District.  Nav Jiwan Hospital has started a CBR project in 3 districts of Palamau.   With these EHA now has 7 CBR projects. Besides this the inclusion of disabled people in all EHA projects and programme activities (mainstreaming of disability) is slowly happening.
• EHA-UNDP Strengthening Rashtriya Swasthya Bhima Yojana (RSBY) Project Phase 2 finished successfully in February 2013. This phase culminated with Learning’s Workshop on Community Monitoring for RSBY, which was held, in Jagdalpur, Bastar District in Chhatisgarh in April 2013. The project learning’s were reviewed and the workshop came up with certain recommendation that will be forwarded to the Ministry of Labour & Employment (MoLE). It is hoped that Community Monitoring will be incorporated as a feature of RSBY.
• EHA’s first community college was started as an initiative of the Herbertpur Christian Hospital and ran two courses with 40 students. This included students with disability. In the coming years we hope to multiply these community colleges in other units.
• The Poor Area Civil Society (PACS) project is implemented by EHA in four locations from 2012.  It works on strengthening civil society and mobilizing communities to demand their health and nutrition entitlements.  It is being implemented in Bastar, Champa-Janjgir, Seoni and Panna Districts of Chhatisgarh and MP.

COMMUNITY TRANSFORMATION

Health

Health promotion and community education focused on influencing change in health seeking behaviors continues to be an important component of CH projects. Traditionally the focus has been on educating people on primary prevention, however with the dual burden of disease and the increasing recognition of the huge problem of non-communicable disease, increasingly the focus on education is also shifting to lifestyle and health promotion. The projects in Champa, Jagdeeshpur and SHARE (in Bijnor) focused on RCH related behaviors and report that they have jointly covered 2876 households. In these communities they found that 68%, 73% and 70% of the households adopting positive health seeking behaviors. This has led to the increasing utilisation of Government primary healthcare services like antenatal care for pregnant women, immunization of children and institutional delivery of pregnant women. The impact on reduction in disease burden needs to be measured. Many of the projects are involved in the prevention and control of malaria and tuberculosis. Some of them are linked to the Axshaya Project, which is the GFATM project on strengthening the RNTCP. Following the end of the CHASINI project, HIV/AIDs prevention has been mainstreamed to most of the community programmes.  The Spandana project has been implementing an HIV-AIDs control project that works with the general population but also with truckers.  The project is in partnership with District Health Department and runs an ICTC centre for counseling and testing people for HIV/AIDS.

Mobilizing communities in taking up health initiatives and strengthening village level healthcare planning has been another trust of our projects. The LCH CHDP project worked with the Village Health & Sanitation Committees (VHSC) in Tehri-Garwal by building their capacity through training and education on their health entitlements. 170 villages have submitted village health plans to the district health department. VHSCs in Chhatisgarh, Uttarakhand and UP were mobilized to monitor the enrollment of villagers to the RSBY Programme (National Health Insurance Scheme). This has increased the overall rate of people with RSBY Cards (Increased enrolment by 50% in target villages but by 10-15% in the district) and also the utilisation in accessing healthcare.  Over a lakh people have utilized various primary healthcare workers for basic healthcare needs like immunization, antenatal care, TB sputum screening etc.  While we do not have solid data of utilisation it would be accurate to say that the projects have increased the access and utilisation of primary care services and strengthened the referral of patients for secondary care.

Some of the projects still do direct medical outreach or conducted village level clinics (6 projects – Raxaul, Herbertpur, Tezpur, Chhatarpur, Fatehpur and Jagdeeshpur), however nearly all the projects today partner with ASHA’s, Auxilliary Nurse Midwives (ANM) and the ICDS workers. Training and building the capacity of these primary health workers has become an important component of the CHD’s work. This has strengthened the functioning of the Government District health system and the result has been an improvement of the quality of healthcare services and increased utilisation.
The CBR projects work through the village level CBR workers and teams. Our projects are now registered under the PWD act and also with the National Trust of India.  These projects have increased the access of care for people with disability (PWD).  The Primary Mental Health programme is also focused on increasing the access of people to Mental Healthcare.

Economic and Livelihood

Agriculture remains the backbone of the economy in rural India.  Some of the EHA projects now support small and marginal farmers by helping them develop seed banks, obtain seeds and fertilizer through various Government schemes and provide training through the Krishi Vigyan Kendra’s and other exposure visits, helping them to adopt new practices and adapt to the erratic rainfall patterns and other challenges. The projects in Seoni, Madhepura, Champa and Chhatarpur together work with 107 farmers groups with a combined membership 873 farmers. Madhepura undertook to train the farmers in SRI technique (system of rice intensification) successfully. This method works well with less water and better yield. The groups now approach the Government Agriculture department for support. These interventions are critical in sustaining agriculture and the livelihood of small/marginal farmers and agricultural labourers.

Many of the EHA projects work on improving the income levels and provide social security to poor households through self-help groups (SHG). Nearly all these groups are engaged in savings and micro-enterprise. Together EHA projects run around 400 groups, which jointly have access to over 50 lakhs rupees worth of credit.

Many of the SHG groups are actively working on accessing social security including old age or widow pensions, food subsidies through the public distribution system and access to work through the National Rural Employment Guarantee Scheme (NREGS). Unfortunately we find that NREGS hardly ensure livelihood for many marginal farmers who depend on wages from labour to meet their needs. Also our analyses of data from the projects show that people from SC/ST community have less access to these schemes. In addition this year projects in Champa and Chhatarpur were able to facilitate the formation of 4 federations. These federations are created on different issues – some on banking and interloaning, healthcare and advocacy, healthcare financing etc.

Learning & Education

This component has four types of intervention – strengthening the primary education systems with a focus on reducing the gender gap in education, non-formal education, adult literacy and vocational training/ en-skilling of the youth.  EHA projects run 187 Adolescent groups with over 2200 members who are taken through a life skills curriculum developed by EHA called “Badte Kadam” (Progressive steps). Some of the girls who were earlier not enrolled in school are provided literacy classes and subsequently enrolled in to schools. Many of these young people go on to take up vocational training. This is also offered to school dropouts. The children at risk programme identify families that are vulnerable and link them to vocational training courses (Injot project).  Adult Literacy programmes continue in EHA and in 2013 we had 118 literacy groups (all women) with 2162 completing the course.

The development of a community college in Herbertpur is a more organized and standardized method of providing both life skills and vocational training. This is one initiative that has tremendous potential to develop and grow. We hope to see EHA run many more community colleges in the future.

Natural Resource Management

Since for most of rural India agriculture remains the economic driver agricultural land and water become crucial natural resources. Small landholdings make agricultural unsustainable and the unequal distribution of land becomes a key determinant of the socio-economic status.  The Spandana project, Champa and this year the Nav Jiwan Hospital in Satbarwa are involved in watershed management. Through this they were able to reclaim unused barren land.  This is one of the climate adaption interventions and aims at better management of water. They also promote the cultivation of millets and other drought resistant crops. In project areas where there is still significant forest coverage and where adivasi communities have traditionally depended on forest produce; projects are trying to restore livlihoods. One example is the efforts to restore lac cultivation in Jharkhand.

Programmes

Advocacy & Research: The advocacy programme works on enabling households to obtain their entitlements under various Government schemes.  This year five advocacy manuals for Chhatisgarh, Bihar (both in English & Hindi) and for Haryana (only English) were completed. Advocacy manuals are now available for 8 states of North India. In addition two specialised manuals for Disability and Indian Citizen’s Rights were developed. These manuals are being used extensively, even beyond EHA projects as evident from the fact, that last year there were more than 30,000 downloads. Mark Delaney who manages this programme conducted 13 workshops in which he trained 312 EHA and other NGO participants. In the coming year these trainings will be adapted for community based groups.

Mainstreaming Disability: The programme completed the sensitization and training of EHA staff largely from the community projects. Much of Jubin Verghese work involved visiting project teams and reviewing the programmes to see if people with disability were being included and to conduct unit level trainings. 5 units – Mussoorie, Baster, Jagdeeshpur, Raxaul and Satbarwa were visited. The 3rd Annual CBR Workshop for EHA units was held in Tezpur and involved 69 participants from 6 CBR projects. Besides this EHA’s experience in “inclusion of people with disability in development” is increasingingly being recognized and Jubin has contributed to various conferences, workshops and   organizations even in the Netherlands and Australia.

Mental Health: There are three major interventions – The Delhi Mental Helpline; Community based mental health and Integrating Mental Health in EHA hospitals. The Mental Helpline continues to provide telephonic counseling to many. Community based mental health is being piloted through the SHIFA mental Health project which was started in Saharanpur District in Uttar Pradesh.  In the coming year SHARE project in Bijnor will also start work on Mental Health.  Dr. Alex Duncan trained the staff at three hospitals – Herbertpur, Chhatarpur and Raxaul in Primary Mental Health. Herbertpur already provides psychiatric care but we hope that the other two hospitals will be able to integrate mental health in to their existing clinical services.  Jessica Parmar, Kaaren Mathias and Raja have been spearheading these efforts.

Climate change & Disaster Risk reduction:  Much of the work so far has been about sensitizing the CHD staff on issues related to climate change and to do needs assessment and mapping exercises in partnership with the community. So far training programmes on participatory methods in doing a needs assessment have been conducted for the project staff from Herbertpur, Landour Community Hospital, Chhatarpur, Lalitpur, Spanadan (lakhnadon), Duncan and Satbarwa. While a couple of project proposals were developed and submitted for multi-location projects on climate adaptation none of the projects have been accepted so far. The Spandana project and the Nav Jiwan projects are currently working on climate adaptation strategies. Thomas John and Jeph Mathias have been leading this initiative.

Children at risk: This project is currently focused on the issue of child trafficking and child abuse in the community.  Three community based projects – Injot Project (Khunti District), Raxaul CHETNA project and AWDR Project of the Tezpur Baptist Hospital in Udulgiri is currently focused on the reduction of trafficking. All three projects work on sensitizing the community regarding the problem, prevention of trafficking and early rescue involving CBO’s and other community institutions. All the projects have been able to rescue a few children. The Child Protection Policy Handbook has been developed and the training of all EHA staff from the hospital and community projects will be implemented over the coming year.

Food Security & Nutrition: The programme began this year with Mr. Dennyson joining as the Programme Manager. The programme focused on networking towards advocacy on issues related to food or nutritional security, supporting/handholding the projects that are already engaged with some aspect of food security or nutrition, training and capacity building of staff and CHD teams. Initially the Programme manager developed a couple of position papers that clarify and articulate EHA stand on issue related to the programme.

Health Financing: The main thrust of this programme has been the EHA-UNDP project to strengthen RSBY. This project completed its second phase. Besides these two other community health insurance projects were implemented in Robertsganj and Chhatarpur. The Chhattarpur Community Health Equity Funds (CHEF) is a pilot attempt to develop an insurance progamme that covers primary healthcare and outpatient hospital care and works on a mutual healthcare model.

Training & Capacity Building: This component of our work is crucial to the overall development and strengthening of community programmes in EHA. Kaaren Mathias and Feba Jacob have done a great job of coordinating all the training efforts over the year. Four different inter-locking approaches to develop capacity, competency and skill across the CHDP are listed below.

1. Training programme for all EHA CHDP staff – a series of 3-4 day trainings that are offered to specific staff groups/ locations that respond directly to training needs identified by project and programme staff. 13 training workshops were held which trained over 150 people.
2. The Fellowship in Community Health and Transformation – a 2-year training programme for senior CH staff that seeks to give a comprehensive, mentored capacity building using a competency based curriculum, assessments and block trainings.
3. Safar magazine – a themed quarterly publication promoting best practice/ resource sharing and education
4. Resource development and sharing.

ACKNOWLEDGEMENT

I would like to thank all our partners who have supported our work during this year.  Tear Fund UK, Tear Fund Australia, Tear Fund Netherlands, De Verre Nasten (DVN), Baptist World Aid Australia, CBM – SARO, SIM, Geneva Global, UNDP (India), DFID- PACS, New Zealand High Commission (Delhi), EMMS (UK), EHA Canada and EHA USA.

My gratitude extends to the CHD Central Team of Deputy Directors, Programme Managers, Administrative Executive, Finance Team and all the Project teams whose hard work and efforts are reflected in this report.