Abhay Shukla has successfully demonstrated that health care programs can be initiated as a citizen-based, low-cost and locally sustainable activity by drawing upon the resources of existing community-based organizations. By initiating health campaigns on a mass basis in Indian rural and tribal areas, he has laid the foundation for a large-scale democratically directed health movement.
Due to lack of sanitation and clean drinking water and sufficient nutrition, diseases like gastroenteritis, worm infestation, malaria, viral fever, conjunctivitis and scabies are common in rural areas. Malnutrition is a widespread scourge that lays the human body open to a variety of ailments. And yet, it is only when diseases reach epidemic proportions that state capital administrations and health departments mobilize to provide relief, and then only in fringe areas. Little is done to address the basic causes of epidemics.
There is also a modest tradition of community-based health initiatives, sometimes initiated by the government or more often by citizen's groups. Unfortunately, these are rarely sustained by the community and remain dependent on external support. They do not develop the capacity for creating or sustaining their own growth and much of their energy is spent maintaining organizational infrastructure.
The second, more long-term strand to his overall strategy targets national health policy reform through the creating of a national professional "community health" advocacy center that provides support to mass-based organizations and social movements prepared to campaign around health issues.
The approach is presently being piloted through Kashtakari Sanghatna, "Organization of Toilers," an organization that organizes tribal communities in 200 villages of Dabapu Taluka, Maharashtra, mainly around issues of land and forest rights and rural credit. He began by forming health societies (within the overall framework of the Sanghatna) in several villages. In each of the societies, two women were selected and trained as "health workers." Intensive training of the health workers for six to twelve months was provided. During the training period, there are bi-weekly follow-up sessions, where the health workers' progress is monitored, drug stocks replenished and difficult cases explained.
The health societies are responsible from the outset for financing all of the direct costs (medicine, health workers time) of the program. They ask volunteers to contribute Rs.50 ($US1.60) per year per family to buy medicines and support the health workers.
The health societies are also trained in and responsible for documentation, observation and interface between the community and the public health care service. They are prepared to make quick decisions in times of emergency and to lobby for decentralized decisions in resource distribution and preventive strategies. The program equips citizens' organizations to identify possible outbreaks of epidemics, alert the necessary support structure, and apply adequate pressure to ensure that health care delivery occurs in time and in the right amount. People-based initiatives such as the introduction of larvicidal fish in local ponds to prevent the outbreak of malaria are also encouraged.
Because it is self-financing and the "start up" and ongoing support inputs are both modest and scalable, this approach enables wide replication. Already, several mass organizations working in the tribal belt area have expressed interest in adopting the model and the next phase of the project will accommodate this demand.
The second, public education and advocacy strand to Dr. Shukla's strategy is still in the planning stages. Building on the accumulating experience of servicing a fast-spreading community-based and self-sustaining health service system, he plans to bring together sufficient medical and health training professionals in a center that provides support to community-based organizations health education campaigns. Paralleling health service delivery, these campaigns would target state and national health policy on issues like malaria control, pharmaceuticals, resource allocation, and (notoriously inefficient) mechanisms of public health financing. It would also support grassroots health education projects. Dr. Shukla also envisions the center launching a nation-wide feminist health movement.
As a student, his impressive skills in identifying and analyzing problems and working out creative solutions became apparent early on. He studied the working conditions and occupational hazards of textile workers, leading a pioneering effort in the reduction of byssinosis. Later, in collaboration with an Indo-Dutch project to clean the Ganges River, he was able to persuade the management of the tanneries, a major source of river pollution, not merely to clean up their effluents, but to provide health education for their workers as well. As the occupational hazards of tanning are considerable, this entailed real and significant costs for the tannery owners. This was his first taste of social innovation, initiating the path to the work he does today.