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.
The New Idea
Abhay Shukla, a medical doctor, seeks to generate rural-based and easily sustainable health care programs in relatively short periods of time within the context of an existing people's organization. The rationale for this is both organizational economies of scale (there is no need to recreate infrastructure or to re-establish trust and credibility) and the fact that health problems do not exist in isolation and are best handled as part of the overall development effort. Dr. Shukla's work in facilitating the formation and sustainability of the construction worker cooperatives at the Indian Institute of Science at Kanpur gave him insight into the dynamics, possibilities, and limitations of developing mass-based organizations. He realized that too much effort had been spent in getting people together to initiate a health program. He identified existing mass organizations as a potential human resource, trained and skilled, and ready to assist with health care management. His program brings together medical and training professionals to provide health-related support for mass movements and to help engender a number of health programs in existing mass organizations. With this professional support structure in place, these organizations then identify significant public health opportunities that they can manage directly. Their well-tuned advocacy skills, in particular, are directed at the public health systems accountable to suggest better allocations of resources and to demand more effective service delivery.
Primary health care for populations living in remote rural and tribal areas is wholly inadequate. A severe lack of facilities is compounded by several other biases inherent in the urban-based system. Health services are often located in the urban areas and most people in the villages are not aware of them. Only twenty percent of hospital beds are in rural areas, where 76 percent of Indians live. The thousands of rural Primary Health Care Centers in every district of the country are so under-staffed and poorly equipped that they only handle nine out of every hundred patients treated. Those few who are treated find themselves in an autocratic environment in which an inappropriate emphasis on technical innovation is favored over a preventive approach that would have to be rooted in familiarity with local conditions. In sum, the existing system encourages dependency and does not create local capacity to sustain and strengthen health care. 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.
Dr. Shukla has a two-part strategy. The first part is, in essence, to integrate health into the work of existing, effective mass-based organizations. There are two basic elements to implementing this strategy: (1) creating an appropriate professional health advisory support for the mass-based organization and (2) working with the organization to determine the ways that it can best contribute to the health care system in its geographic area of concern.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.
Born in India in 1962, Abhay Shukla spent most of his childhood in the US. He returned to India to start pre-university education, where he excelled. He was top ranked at the All India level school and intermediate exams, and a recipient of the National Science Talent scholarship. Following his father's career choice, he enrolled in an engineering degree program. Just before he began college, however, his father introduced him to a husband-wife doctor team who were working with the poor in Calcutta. About the same time, Dr. Shukla read "The Scalpel, the Sword," the story of a doctor who gave up his career to build the first blood banking system in Republican Spain. These coinciding experiences inspired him to study medicine at the prestigious All India Institute of Medical Sciences.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.