Chhattisgarh as a state was born out of Madhya Pradesh on 1 November, 2000. The new state had to deal with demons of high infant mortality rate, malnutrition, chronic communicable diseases (malaria, tuberculosis, and leprosy), poor access to safe drinking water, and sanitary toilets. The geographically dispersed population of the state had very few district hospitals, and primary health centres, and poor connectivity to them. Trained doctors and health workers from cities were unwilling to work in rural areas. All these problems were exacerbated by the low level of health awareness among the people. Media outreach was low, complicated by the diversity of local languages, dialects, and customs. The existing health services were poorly utilised. The gap between people and health services was the primary reason of the poor public health statistics.
Keeping this in mind, a state-wide community health volunteer program was launched by the government in 2002. The health volunteer should hail from the village, to communicate key health messages effectively in the local dialect itself. As they belong to the community, they would be sensitive to local issues. They would fill the gap between the community and the government.
Chhattisgarh has a very interesting, and touching custom of mitanins (read more about it here). The community health workers program was called the Mitanin Program, building on to this custom. The creation of Swasthya Mitanins (health mitanins) meant that village had a friend for health care needs. The use of word ‘mitanin’ created a sense of trust and confidence towards the health workers within the community. It added a sentimental element to the program, something to which the community could connect itself. The strong positive vibes from the name led to welcome anticipation for this programme long before it was actually initiated.
The Mitanin programme thus, acted as a baby of dialogue between the government and civil society, to avoid a major public health crisis in the newly formed state. The broad objectives of the program were to improve health awareness among the people, and provide immediate relief to common health problems. To provide technical support to achieve these goals, the State Health Resource Centre (SHRC), an autonomous institution was set up.
Some of the key features of the program were:
- Women as Community health workers. Women reach out to women more easily than men, culturally. Also, in these rural villages, health of the family was woman’s responsibility. This also added a subtle element of women’s empowerment to the program.
- Well-planned social mobilization. The social mobilisation aimed to create a conducive environment for inter-personal communication with the mitanins. A popular radio programme with mitanin as a protagonist was broadcasted. Women group were encouraged to organise group listening to it and send feedback. The spirit of the programmes was also communicated through songs and skits. Kalajatha or the skit team familiarised the community with the role of mitanin before the selection process began. All this built a sense of faith within the community towards the mitanins.
- Selection at the hamlet level. Hamlet as a unit of the program was an innovation acknowledging that different groups with different power relations among themselves occupy different hamlets, for example, based on caste. Selection at hamlet level ensured that weaker sections of the society also had equal participation in the program. It also reduced the work burden on the mitanins; about 30 to 50 households per mitanin. Moreover, the penetration of health messages would be absolute within the usually geographically dispersed hamlets of the village. Mitanins were selected by the community facilitated by a prerak (motivator) through hamlet level meetings. The prerak ensured that the community understood the programme and made an informed choice.
- Training: a continuous activity for the duration of the programme. The training venue was generally a nearby village market. The on the job training required trainers to visit the villages along with the mitanins and hold local meetings with them. Each block had 15 to 20 mitanin trainers and 3 block coordinators. The trainers were mostly women, accommodating only very few most effective men. Only people living at the block level could join as BCs to ensure that the program was grounded at the grassroots. The women were trained regularly, having refresher courses acting as boosters. Training, material development, implementation, and monitoring was done by SHRC. The training modules were in Hindi. Trainers went through these modules line by line with the mitanins. The content was practical and contextual to their environment. Instead of giving theoretical directional messages, they were encouraged to discuss the problems in presence of all family members, and come up with acceptable and pragmatic suggestions. Specially written songs by Chhattisgarhi folk singers and writers, capturing the thematic messages, were sung in most meetings. They boosted the motivation of everyone in the program and formed a sense of mutual solidarity toward the cause.
- Non provision of honorarium at least in the first year and later limited incentives. This was the most contentious aspect of the program, put in place in order to retain the community based character of the programme. After the first year, a livelihood compensation loss of Rs. 50 was given for each day of training. This ensured that only those sustained by personal motivation participated in the program. The motivation came from the maternal instinct of mothers who wanted to increase their own knowledge, and women using this opportunity to gain social recognition. However, the sole motivating factor that could explain the huge number of women volunteers was the strong sense of community in the rural and tribal villages of the state. The prevailing community spirit that valued caring for one’s own community was embedded in these ladies.
What are the expectations from mitanins? Formal education is not mandatory during mitanin selection, though basic reading and writing proved to be useful in maintenance of Gram Swasthya Register and the Mitanin Diary. Mitanin’s work was designed in a way that it did not affect her livelihood seriously. She was not a government employee. She was a community’s health counsellor, facilitating utilisation of government provided health services and helping in initiation of community self-help measures. The work was more like a volunteering service. The household outreach involved messages on essential care of newborns, nutritional counselling, and management of childhood illness.
At present, Chhattisgarh has about 60,000 mitanins serving in 70,000 hamlets. They are credited for lowering the IMR from 85 in 2002 to 65 in 2005. There was an increase in breastfeeding on first day from 27% in 2002 to 88% in 2006. During the same period, the proportion of underweight children dropped and percentage of full immunisations and women receiving antenatal care rose. The mitanins also played a major role in reduction of malaria, as they acted as drug deposits, and helped in detection. They also contributed significantly to anti-tuberculosis, and anti-leprosy campaigns.
Apart from concrete health indicators, mitanin program gradually enhanced the status of women. As women now had a greater access and control over resources, they also had a role in decision-making. Often, mitanins got elected as panchayat members. The feminisation of local leadership empowered the women to take independent social initiatives within their hamlets or villages.
The mitanin program also demonstrated how state action could lead to individual behavioural change. Generally, large scale community health workers (CHW) program do not work, and small scale CHW programmes are difficult to scale, despite being high on impact. However, the example of mitanin program in Chhattisgarh provided a hope of how a program could be scaled up without compromising on its impact. In May, 2002, pilots of the program were launched, and by June 2004, there was a mitanin in all 54,000 hamlets. The mitanin program later served as a template for National Rural Health Mission’s CHW (ASHA, or Accredited Social Health Activist) programme by the government.
Mitanin is a story of success facing its own challenges now. Keep following this space for next blog on these challenges and my experiences of working with the mitanins.