**6. Community mobilization**

The DCM is involved in providing services to 100 villages in the Wardha Block since 1985. Based on the experience over the years, we promoted various community-based organizations (CBOs) and built up their capacity for promoting health action in the community. Initially, we interacted mainly with the village panchayats (local bodies) and once we developed a good understanding with the panchayat, we started promoting the CBOs. Over the years, two important CBOs have been promoted and they are described in the following sections.

#### **6.1 Self-help groups (SHGs) of women**

In the initial years, we used to visit the villages while delivering the health education in the community. We noticed that every time we visited the community, a different set of people gathered. Hence, we decided to develop women self-help groups on the guidelines of the National Agriculture Bank for Rural Development (NABARD). These groups are informal groups and do not require any formal registration, however, number has to be restricted to 20 members. In the initial years, we spent a considerable time using SHGs only for economic empowerment of women and to provide them relief from the moneylenders. These self-help groups collect token monthly subscriptions from the members and utilize the collected amount for internal lending. Once the groups have a certain amount of money, then banks provide them a formal linkage by which they are eligible for bank loans to undertake small income-generation activities. Over the years, these SHGs have been proved as a good example of microfinancing at the community level. Once these groups were

financially stabilized, we started introducing health agenda in their activities by providing them with relevant information in a phased manner. At present, the DCM has nearly 300 self-help groups in the field practice area and they are promoting health actions on various health and health-related issues in the community.

#### **6.2 Adolescent girls' group (Kishori Panchayat)**

The members of self-help groups prompted to help adolescent girls who do not have proper information related to menstrual hygiene and are suffering rampantly with anemia. Accordingly, we started organizing community-based adolescent girls' groups known as Kishori Panchayat. These groups are mainly involved in adolescent to adolescent health program. They have been oriented toward various adolescent health issues, maternal health, child survival, environmental health, and family life education as well as on reproductive tract infection (RTI)/sexually transmitted infection (STD)/human immunodeficiency virus (HIV) control. These girls in turn also trained their peers and younger adolescent girls in the villages.

Later on, we have developed these girls' groups on the basis of activities of the Rashtriya Kishor Swastha Karyakram (national adolescent health program). At present, we are linking these community-based adolescent activities with the school-based adolescent health programs to ensure sustainability. Additionally, two adolescent health resource centers have been developed at our rural health and training centers at Anji and Bhidi, which act as reference centers for both the community-based and school-based adolescent health programs.

#### **7. Community-owned health clinics (Kiran clinics)**

Mahatma Gandhi Institute of Medical Sciences, Sewagram, is committed to provide accessible and affordable health care, primarily to underprivileged rural communities. In the community health needs assessment (using quantitative, qualitative, and participatory methods) in 60 villages, the findings emerged that the delivery of primary health care was available at the Primary Health Centre (PHC) or sub-center level but not at the village level. Villagers had to travel a long distance for seeking primary health care even for the basic ailments and it costed them a lot. Apart from the direct health expenditure on consultation, medicines, or investigations, patients had to forego their daily wages and spend on transportation. The VHNSCs of the respective village recommended to establish a village-based clinic to cater to the unmet need of providing primary health care at the village level, especially directed toward the marginalized, poor, and vulnerable section of the society—women, children, and elders.

The Kiran clinics were started in selected villages under the Community-Led Initiative for Child Survival (CLICS) program in 2004 to meet the health needs as defined above. The precondition set by the Department of Community Medicine (DCM) for partnering with the VHNSC to establish a clinic was that at least 60% of the population of the village should contribute to the village health fund. This was done to ensure the financial sustainability of the clinic in the long run. Apart from providing curative services, preventive and promotive services are also provided through the clinic. It is an attempt to overcome constraints that affect access to care like the distance, transport, and availability of services of the basic health-care facility.

Usually, services given under any research project will stop after the project ends. Kiran clinics have sustained through community ownership for a period of more than 15 years, which is a testimony to the simple but robust and transparent management and reflects the "Value" the community gives to the clinics. One key learning is that the community does not really expect free health-care delivery but are willing to pay minimal cost, provided services are of desired quality and are able to cater to their needs.

Quality health services are provided in the Kiran clinic. One diabetic patient showed his satisfaction saying, "Doctors and sister give psychological support along with quality treatment. I am 100% satisfied with services given at very low cost." [12].

In our field practice area, 23 such clinics have been established. The cost comparison in terms of the doctor's fee, cost of drugs, transport, and lost wages has been strongly in favor of the Kiran clinic (approximately, 64 rupees at the Kiran clinic vs. 390 rupees for treatment outside the village which is a savings of almost 350 rupees).

In the Kiran clinic only, generic drugs are being purchased and made available to the patients at a no-profit, no-loss basis to ensure affordability. Apart from organizing the clinic, the VHNSCs also ensure the quality of services at the clinic. Again, the DCM supplied them with a tool in the form of a quality assurance (QA) checklist, which covers a number of quality parameters from the presence of health-care providers to adequate infrastructure and logistics, including drugs. The charges and the cost of treatment for the patient are also under scrutiny, as is the client satisfaction based on simple exit interviews. To top it all, it also looks into equity issues whether the clinic manages to reach out to the disadvantaged and marginalized in the community, including the women and children.

The Kiran clinics also act as hub for health promotion by providing growth monitoring, antenatal care, and screening for hypertension and diabetes and also provide support in the organization of the Village Health and Nutrition Day (VHND) at village level. Thus, it offers a promise for new and innovative health initiatives.

The community is engaged at every stage (planning, implementation, and evaluation) in the functioning of Kiran clinics and has been able to successfully run the clinics for the last 15 years. The committee has flexibility and authority to make necessary changes in the functioning of the clinic, for example, addition of new services, registration fees, drug price and incentive to village volunteer, etc. Over the years, the committees have taken several decisions to improve the services through these clinics as per the demand of the community; for example, addition of new services like treatment of noncommunicable diseases and other health promotion activities.

Community dialog, voluntary participation, empowerment of people, and involving them in decision-making have been crucial for ensuring ownership. One member of the VHNSC expressed her gratitude saying, "It's my pleasure to work for community. It gives nice feeling to me. Even if I am not doctor, I am able to contribute for improving health of my village."
