India has come a long way in improving its health services since the Independence in 1947. Over the years, various committees and policies have guided the action of the Government; the Family Planning Policy of 1951 and the National Health Policy of 1983 being two important ones among them.

The experience gained from vertical programmes has motivated the Government to plan actions in tune with the present demographic and health situation as well as available local resources.

One such initiative taken by the Government is the involvement of Private Voluntary Organisations (PVO) in the health promotion activity through support and guidance. Even before the Independence, India had a long tradition of voluntary action. Government has recognized the role and contribution of these PVOs in the field of health and community development. Several grant-in-aid schemes have been initiated by the Ministry of Health & Family Welfare, whereby PVOs obtain Government funding for the provision of services and the promotion of health and family welfare activities. The US Agency for International Development (USAID), has supported the Government efforts to strengthen PVO involvement. Keeping these in mind Tamil Nadu Voluntary Health Association (TNVHA) worked out a proposal for support and collaboration with the Government of India. In this article its experience in conceiving and carrying out this proposal/project is highlighted.
Tamil Nadu Voluntary Health Association is a state-level association of Voluntary Health Organisations like hospitals, dispensaries and community-based health organisations working in Tamil Nadu and Pondicherry. This association, which has completed a quarter century of service, has a membership of 463 institutions and associates with 600 others. The goal of the association is health promotion and action through networking and coordinating with voluntary organisations, strengthening of NGO activities, collection and dissemination of relevant information, lobbying, campaigning and liaisoning for health issues. Its actions are in accordance with the National Health Policy objectives for promoting Primary Health Care.

Ground realities
The strategy followed by the association stressed the need for greater involvement of voluntary organisations and the participation of rural women in taking health to people’s doorsteps. While Tamil Nadu can boast of the availability of high tech health services, equal to the west, the number of hospital beds and the state of health service in the rural areas is very dismal. For example the number of beds for 100,000 population in urban area is 238 but in rural area it is only 20. The services are also not really accessible, affordable and acceptable to people. The voluntary organisations working in rural areas also are handicapped by lack of resources, man-power, training facilities and support.
The plight of women in Tamil Nadu is no better than in other states - anaemia, malnutrition, maternal mortality, lack of health services etc. exist on the one hand, and the socioeconomic problems of dowry, low status, etc. on the other. While voluntary organisations want to work for the upliftment of women, the ways and means were not clear. These issues were discussed at the Annual General Body Meeting of TNVHA and the need for intervention was highlighted. This led to the formation of a proposal for GOI-PVOH-II grant for supporting "Integrated Project for Development of Primary Health Care and Women’s Welfare" through para professionals in rural Tamil Nadu.

A structured coordination
Unlike in other projects, where it is directly implemented by the organization, this venture was unique for its coordination at various levels. It had at the top - fund support level - in New Delhi, the Government of India (Ministry of Health) and USAID. At the next level in Chennai (Tamil Nadu) it was TNVHA, the coordinating agency and at the zonal level there were four training institutions and at the field and grassroots level the PVOs and their women volunteers.
The project had the goal to coordinate with various levels of health services to improve the health status of rural Tamil Nadu. Its objectives were to select women volunteers of PVOs and train and equip them with knowledge and skill to identify community need; to enable them to provide primary health care services at the doorstep of the local families’, to be a bridge between the people and local health facilities like primary health centre. Besides it also had an agenda to equip the women with some skills in craft which would help them to sustain themselves.

Strategies for implementation

The following strategies were planned and carried out:

• Identify and orient four voluntary organisations, one in each zone, as the zonal training centre.
• Invite PVOs to send their selected women volunteers to be trained in these centres. They will be called ‘Lady First-Aiders’.
• Conduct training of two month duration. The training syllabus to cover both health development issues as well as craft.

The zonal training centres would follow up with these LFA for 3-4 years in coordination with PVOs, even after they are deployed, through the following ways:

• Visit the LFA in their field area and along with PVOs to monitor and strengthen their activities.
• Collect regular reports from LFAs.
• Conduct review meeting for LFAs and and PVOs separately to improve coordination.
• In consultation with LFAs, conduct wayside clinics in areas where health care services are lacking.

Achievements
The project was sanctioned and the implementation started from January 1993. TNVHA gave orientation to the four identified zonal training centres and conducted consultations for PVOs in each zone. The training was started in February 1993. By 1995, twelve batches of Lay First Aiders (LFAs) were trained (300 for each zone). 118 PVOs from twenty districts of Tamil Nadu coordinated with the four zonal training centres and helped TNVHA train the 1200 para-professionals to carry out the objectives of the project. It was a unique experience for everyone involved for having come to work together for the first time. The project had outlined specific roles and responsibilities for each level of functionaries which led to smooth running of the project. Through the past four years of the coordination of the project, TNVHA has helped the project to achieve most of its objectives.

A new cadre of Health Informants
The Lay First Aiders have been functioning as health informants, by visiting families, motivating them to seek health services, coordinating with local PHCs/VHN (Village Health Nurse) to promote health and collecting and documenting vital statistics. These LFAs are not full-time workers but mere part-time volunteers. But their involvement and dedication, even when funds were not coming regularly, have inspired many, including VHNs to work more efficiently. Many LFAs helped form local Mahila Sangams (Women’s Group). These Mahila Sangams have helped in the sustainability of health activities as well as income generation.

The social status of LFAs have undergone tremendous changes. The changes in these women who hailed from remote rural areas are really amazing. From shy, unsure women, they have transformed into assured women leaders.

The periodic support, encouragement and inservice training given to them have led some of these women to even give interview in All India Radio, fight for local needs like water, street light, get IRDP loans, encourage non-formal education, etc. Few have contested in local elections with success and have even became the president or council members.

A visible transformation
The LFAs were regularly monitored and supervised by the PVOs who had sponsored them as well as the zonal training centres. The visit of the training team to the LFA field area, has not only encouraged them to work harder but also gave them a status among the villagers. The wayside clinics, occasionally helped the LFAs to identify health needs and follow them up in future. The central team and TNVHA also helped in providing the support services like giving inservice training, organ izing LFA convention and provide IEC materials to update their
information. Regular review meetings helped in improving coordination. The LFA convention, the first of its kind had boosted the image of LFA and revitalized their activities.
Health Promotion works best when the operating base of the promoters is the broadest. The LFA experiment gives lot of positive signals and hope towards bringing about desirable behavioural changes in the communities for better understanding and acceptance of improved health practices. This initiative may throw some light for similar initiatives in other areas.

WOMEN PAY A HEAVY PRICE FOR DEVELOPMENT WORK

Law is blind, so goes the saying, and it is proved time and again, with devastating effects on the victims. Social stigma, physical and mental trauma or even death are not uncommon.
Women in Orissa, like in other states, are subjected to cruelties like rape, dowry deaths and torture of all kinds. On average more than one rape is reported every day in the State which could only be a fraction of the total number of atrocities meted out to women. It is shocking that even those women who work for the emancipation and empowerment of their sisters are also not spared. The gang rape by four youth on 7th September, 1995 of two women coordinators of Women’s Initiative for Development Education (WIDE), based at Siddharth Village, Jatni, Orissa, is a case in point. (WIDE is involved in training of Tribal and Harijan women to create self-help groups for proper utilization of Government programmes). These tribal women were returning to their camp in Khuntamal village of Leikera Block in Jharsuguda district after the days work. The brutal attack took place one km. away from their camp in the jungle. The rapists photographed the rape scenes and threatened to eliminate them if they disclosed the matter to anybody and also took away the valuables of the victims.
There was the usual delay in filing the First Information Report. But once the FIR filed, the culprits were identified by the girls and were arrested by the police along with the camera and film. The medical office of Jharsuguda district head quarter hospital misbehaved with the victims and did not produce the report even after 3 days. The victims were then taken to Burla Medical College and a medical report was obtained from there. WIDE met the Deputy Chief Minister, sent letters to the Chief Minister, Prime Minister of India and many others asking for immediate action to bring the culprits to book and requested disposal of the case in 3 months, suspension of Jharsuguda Medical officer, protection of women activists in Orissa etc.
Protest rallies 2 lakh tribal women were organized in the State capital on 5th October - marked as ‘Black Day’. Several women’s organisations in Orissa and outside the State protested against the incident. They demanded a ‘rape-free Orissa’ among other genuine demands.
But cruder shocks were in store for the women. On 16th May 1998, all the four accused were acquitted by the additional sessions judge, Sambalpur, R. N Bhuyan, nearly three years after the incident. The judgment read "From the evidence on record and discussions made I found prosecution has failed to prove its case against the accused persons beyond all reasonable doubt. In the result, I hod the accused persons not guilty and set them at liberty": (Sessions Trial No. 271/54 of 95-96). Thanks to the contradicting medical opinions, witnesses turning hostile and the failure of the poor women to withstand a harrowing, insensitive cross examination and the non-involvement of the public prosecutor in the argument which helped branding them to have cooked up a false story of rape. The suffering, mental agony and ignominy of the victims had no role in the verdict.
Apart from the need for a mechanism to handle such cases sensitively, in focus is also the dignity and safety of women’s workers in this country. It should be a concern of every citizen of the country to ensure respect for women and thereby uphold dignity of the country.
For more information write to:
Women’s Initiative for Development Education (WIDE)
Siddharth Village, P.O. Box No. 9
At/P.O. Jatni 752050, Orissa
Ph: 0674 - 490516, Fax: 0674 - 490160

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