A Community-led Approach to Promote Rural Health Care

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A Community-led Approach to Promote Rural Health Care

India
Project Summary
Elevator Pitch

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Gram Vikas is a development organization working with tribal and other poor and marginalized rural communities in Orissa, the poorest state of India, since 1979. A study we conducted revealed that 80% of common diseases, particularly among infants and children, were traceable to contaminated drinking water and bad hygiene practices. Waterborne diseases are a major cause of death among children under 5 and loss of productivity among rural communities and hence constitute one of the root causes of poverty. MANTRA is a rural health initiative in nearly 300 villages across Orissa, which facilitates poor communities to come together to establish, operate and manage their own water supply and sanitation systems. The facilities are created with their own efforts and resources, with some assistance from external agencies. Community managed water supply and sanitation is the entry-point and core-rallying element for all families in a village to come together, cutting through social barriers. MANTRA directly targets waterborne diseases such as diarrhoea, worms, gynaecological problems, skin diseases and other infections due to contaminated drinking water and lack of sanitation. MANTRA informs and mobilizes communities to construct toilets and bathing rooms for every household in the village. Once completed, the community builds an overhead water tank with the assistance of Gram Vikas. Every household gains piped water directly to its toilet, bathroom and kitchen. Soak pits, dug adjacent to toilets hygienically absorb waste. The hardware is complemented by an ongoing awareness and education campaign that promotes the importance of toilets, hygiene and overall cleanliness of the village environment. A village committee is set up to manage the system and enforce a system of fines for unclean toilets or open defecation near the village. We have seen an 85% reduction in the incidence of water-borne diseases in villages where MANTRA has been implemented.

About You
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Your idea
Focus of activity

Disease Prevention and Health Promotion

Start Year

1992

Positioning in the mosaic of solutions
Main barrier addressed

Limited reach of healthcare infrastructure

Main principle addressed

Design inclusive systems

We believe a further principle should be 'access to safe water and sanitation facilities'. Sanitation can to a great extent ensure the quality of water and safe water can reduce rural morbidity by at least 80%.

Innovation
Description of health product/service offering:

Gram Vikas is a development organization working with tribal and other poor and marginalized rural communities in Orissa, the poorest state of India, since 1979. A study we conducted revealed that 80% of common diseases, particularly among infants and children, were traceable to contaminated drinking water and bad hygiene practices. Waterborne diseases are a major cause of death among children under 5 and loss of productivity among rural communities and hence constitute one of the root causes of poverty. MANTRA is a rural health initiative in nearly 300 villages across Orissa, which facilitates poor communities to come together to establish, operate and manage their own water supply and sanitation systems. The facilities are created with their own efforts and resources, with some assistance from external agencies. Community managed water supply and sanitation is the entry-point and core-rallying element for all families in a village to come together, cutting through social barriers. MANTRA directly targets waterborne diseases such as diarrhoea, worms, gynaecological problems, skin diseases and other infections due to contaminated drinking water and lack of sanitation. MANTRA informs and mobilizes communities to construct toilets and bathing rooms for every household in the village. Once completed, the community builds an overhead water tank with the assistance of Gram Vikas. Every household gains piped water directly to its toilet, bathroom and kitchen. Soak pits, dug adjacent to toilets hygienically absorb waste. The hardware is complemented by an ongoing awareness and education campaign that promotes the importance of toilets, hygiene and overall cleanliness of the village environment. A village committee is set up to manage the system and enforce a system of fines for unclean toilets or open defecation near the village. We have seen an 85% reduction in the incidence of water-borne diseases in villages where MANTRA has been implemented.

Description of innovation:

MANTRA differs from past approaches by breaking with the formula that equates poor people with low quality services and products that assault their dignity. Every family obtains a fully enclosed toilet, bathing room and piped water. The quality, convenience and privacy of the design has led to widespread behaviour change, inducing communities with no history of fixed point defecation to adopt new habits. The provision of quality hardware to the poor is facilitated by an innovative set of integrated social, financial, and institutional processes that support inclusion, social equity, gender equity, sustainability and cost-sharing. 100% social inclusion: the program calls for 100% participation of all households without exception. All members of the community benefit equally and there are no losers, only winners. The community comes together across barriers of caste, class and gender for communal decision- making. Financial commitment: a corpus fund is collected at the outset with an average contribution of around $22 per family, with the better-off paying more and the poorer less, enabling every family to obtain the same infrastructure. The interest supports the social cost of future extension of the system to new households, ensuring all households are covered at all times. Building capacities: capacities of men and women in technical and organizational aspects are built over time to enable handing over to communities and Gram Vikas's withdrawal. The MANTRA approach sets a new pattern for water and sanitation coverage by prioritising sanitation in addition to safe drinking water, and establishing that to reach the poorest, water and sanitation systems must be inclusive and designed to meet a number of quality, economic, cultural and social factors, otherwise they will fail to bring about genuine behaviour change and improved health. Safe disposal of human waste, hygiene and access to safe water can eliminate 80% of morbidity in rural India.

Operational model:

MANTRA is an integrated habitat development program with water and sanitation as the key entry-point activity. Gram Vikas undertakes activities in education,infrastructure, people's institutions, livelihoods, food security, and further health initiatives on a context- specific basis on the strength of the improved well-being and greater cohesion of the community fostered by the water and sanitation initiative. Gram Vikas believes that poor rural communities are entitled to the same level of infrastructure and services that urban populations take for granted. Basic infrastructure needs investment the social costs of which society at large must meet. To meet the social costs, Gram Vikas provides approximately $67 per household for the toilets and bathrooms in the form of external materials including ceramic pan, footpads, doors, cement and steel for roof casting. To meet this subsidy, we mobilize funds from government and external donors. For the cost of the water supply system, funds are mobilized from government programs for the provision of water supply to rural communities. We also believe that the poor can and will pay for beneficial services. The communities themselves bear more than 50% of the capital costs of sanitation, 25% of the costs of water supply and full operation and maintenance (O&M) costs, far higher proportions than what are borne by wealthier urban populations. In each village, people, primarily landless, are trained in masonry, enabling them to contribute skilled labour. The masons lead the construction of the toilets and bathrooms. The community ends up contributing a large proportion of the costs through their labour and collection of locally available materials for construction. Context-specific resources such as community horticulture patches, fish rearing in community ponds and social forestry, are developed from the outset to contribute to a separate O&M fund.

Human resources:

Gram Vikas currently works in 21 districts of Orissa with over 400 employees of diverse backgrounds. The organization coordinates the initiative from its head office in Mohuda village, Orissa led by the management team, which is comprised of individuals most of whom have decades of experience working in the field in rural Orissa. The management team is supported by Accounting, Auditing, PMED (Planning, Monitoring, Evaluation, Documentation), Purchasing, Resource Mobilization, and Information Technology departments. In each district of Orissa where Gram Vikas works, a semi- autonomous project office operates with its own staff including village supervisors, a PMED assistant, accountant, and a project coordinator who is responsible for coordinating the team and reporting monthly to Gram Vikas management. Gram Vikas is a field-focused organization. More than 85% of staff is based in the field and support staff and management also spend a large proportion of their time in the field as appropriate.

Key operational partnerships:

The most important partnership is with the communities who drive the program and bear a large proportion of the work and costs. Gram Vikas makes efforts to synergise with government initiatives where they exist, instead of creating parallel streams. and through its intervention demonstrate more effective utilisation of public funds. The bulk of the financing for water supply comes from government programs. Communities are capacitated through their registered committees to seek funds from government for further development activities. We have formed long and fruitful affiliations with national and international funding agencies. These partnerships are primarily financial but with some human resources support from the agencies. We are open to all partnerships that are beneficial to the rural poor, for instance with academic institutions for research activities, and other organizations for knowledge and technology sharing. Gram Vikas networks with several small and medium size NGOs to undertake similar activities in areas where they operate. Through workshops and joint implementations, Gram Vikas capacitates these organizations to implement its tested model. This increases the overall capacity of the NGO sector to implement community managed water and sanitation systems and extends coverage to new areas. The joint implementations in the new areas serve to raise awareness and demand for sanitation facilities, catalysing water and sanitation coverage in these new areas.

Impact
Financial Sustainability:

<ul><li class="entry-label">Fees charged to clients?: <span class="entry-text">No</span></li><li class="entry-label">How do you assure affordability?: <span class="entry-text">People's labour and the collection of local material meet most construction costs (50% of sanitation and 25% of water supply). A corpus fund is collected of around $22/family where the better-off pay more. Interest from the fund is used to cover the social costs of extending the system to new households, ensuring coverage of all families at all times. Gram Vikas doesn't charge fees but the village committee collects a monthly fee from every household to meet all recurring costs. Community resources such as horticulture patches, forests, and ponds are developed to contribute towards operating costs such as electricity for pumping water. Also 0.25% to 0.5% of the harvest goes to operating costs so payment is proportional to landholding, meaning the landless, typically the poorest, don't pay </span></li><li class="entry-label">Earned incomes as a percentage of operating costs: <span class="entry-text">0%</span></li><li class="entry-label">Other funding sources: <span class="entry-text">Gram Vikas does not earn income or profit from its initiative. MANTRA is financed in large part through the people's own contributions in the form of labour, locally available materials, local resources as well as cash contributions. Secondly, government programs are accessed as another key source of funding, particularly for financing piped water supply. Domestic and international donors form a third funding source. Any financing gaps are met from Gram Vikas's own resources. Given Gram Vikas's proven track record of mobilizing resources from all these sectors, and specifically its ability to form and cultivate long-term partnerships with donor agencies, the initiative is financially sustainable at an institutional level.</span></li><li class="entry-label">Strategy for long-term sustainability: <span class="entry-text">The strategy to ensure long-term financial sustainability at the village level has been described above. At an institutional level, the strategy is two-fold. First, we continue to lobby government state and national levels to devolve power and funding for water and sanitation to local levels of government, in accordance with national and state guidelines, including sufficient funds to meet the social costs of infrastructure. Our aim is that by 2010, all funding for hardware will be resourced from government, reducing our reliance on external funds. Second, Gram Vikas is continuing and expanding efforts to forge new relationships and realize new avenues for accessing national and international donor funds to meet its personnel and overhead costs.</span></li></ul>

Current and Future Impact:

<ul><li class="entry-label">Total number of clients: <span class="entry-text">122,148</span></li><li class="entry-label">Clients in the past year: <span class="entry-text">30,849</span></li><li class="entry-label">Percentage of low-income clients: <span class="entry-text">90%</span></li><li class="entry-label">Impact: <span class="entry-text">Through awareness promotion, quality infrastructure, and social pressure systems such as toilet inspections and fines for unclean toilets and open defecation, MANTRA has inculcated sanitary practices in communities where the idea of toilets and keeping the place of defecation clean were unheard of. MANTRA also supports cleaner villages, solid waste management, 100% school enrollment and 100% immunization coverage of children under 5. Traditionally, women and girl children traveled long distances for water to meet household needs. Clean piped water has eliminated this drudgery. Sanitation units in every household now allow women dignity while performing basic functions. MANTRA enables people, particularly women, to live with greater well-being and dignity.</span></li><li class="entry-label">Overall "market": <span class="entry-text">For India to meet its MDG target of 53% sanitation coverage, WaterAid estimates there is a finance gap of $11.6 billion. In Orissa, according to the 2001 census, only 7.7% of rural households had access to some type of latrine. This translates to approximately 5.8 million households without access to improved sanitation. Across India, where only 15% of rural households have access to improved sanitation, the potential market for toilets and bathing rooms is likely above 100 million households. While most rural households are officially 'covered' under water supply, government estimates count only installations of hardware and do not account for functionality, actual use, seasonal variations and distance from household. Piped water supply remains largely absent in rural areas and the market for it is likely as large as that for sanitation. While in other developing areas either water supply or sanitation coverage may be higher, there nevertheless remain huge gaps in almost all of these regions. Approximately 1.1 billion people around the world lack access to safe drinking water and 2.4 billion lack access to improved sanitation.</span></li></ul>

Scaling up strategy:
Stage of the initiative:

<i>Mature</i> stage.

Expansion plan:

We have successfully scaled up over the last three years. Gram Vikas has adopted a product oriented and time-bound approach in implementing water and sanitation systems, which has proved highly scalable. The water and sanitation intervention began in a pilot project in 5 villages in 1992. By March 31, 2006, 21,941 households with a total population of 122,148 have benefited from the program. During the next three-year phase from 2006-2009 we will cover approximately 38,000 households in 400 villages with water and sanitation reaching a population of 190,000. The goal is that by 2015, Gram Vikas will have covered 480,000 households and be able to cover 100,000 households per year thereafter with water and sanitation reaching 1,000,000 households and 5,000,000 people by 2020. For this, resources have to come from the government. Capacity building activities with other NGOs will expand. Workshops are scheduled for 2006 and 2007 hosted by Gram Vikas to expose other NGOs to Gram Vikas's model and processes. These workshops will serve as a starting point for forming further partnerships with suitable NGOs who themselves are in a position to scale up.

Origin of the initiative:

The initiative began as a response to abysmal health, inferior status of women and social inequality in rural communities. The logistics of the program: 100% inclusion across gender and social divides, infusion of dignity into rural people, especially the poor, cost sharing by beneficiaries and 'interference in traditional sanitation habits' generated much skepticism among donors. Through the persistence and vision of executive director and founder Joe Madiath, the program was implemented in 5 pilot villages in 1992 and succeeded to disprove all doubts. Joe has been working with marginalized people in Orissa since 1971. The successes under his leadership have improved the lives of thousands and demonstrated that NGOs are capable of large-scale projects, which reach a significant proportion of the population and influence government policy.

Sustainability
Policy change:

The most significant policy change would be the devolution of power to the local political level, called Panchayat Raj Institutions (PRIs), in water and sanitation. Correspondingly, within the annual funding allocation to PRIs, there should be sufficient funding to cover the costs of external materials for toilets and bathrooms, representing about a third of the total cost. This one time payment represents the social cost, which government should pay, and it is a far lower proportion than what the government subsidizes for urban sewage systems. Palli sabbhas (the lowest level PRIs with members from each village) should control the sanctioning and release of these funds so that communities can effectively mobilize government resources to build the infrastructure they need rather than having under-funded, poorly designed solutions thrust upon them.

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