Health Promotion Around the World: Focus on the Voluntary Health Association of India

Introduction by Gabriel Oguda, Edited by Gabriel Oguda and Emily Fisher
Contributions from Ms. Bhavna Mukhopadhyay & Ms. Seema Gupta, VHAI
and Rahel A. Oyugu, Programme officer, African Institute for Health & Development

Background

The world is increasingly becoming a smaller place, not only because of rise of sophisticated technology, but also because of the rapid population growth. Among the notable countries that have raised eyebrows in population explosion is India. According to the 2011 population census, India’s population now stands at a whopping 1.21 billion – “more people now live in India than in the United States, Indonesia, Brazil, Pakistan and Bangladesh combined” (Available from http://www.bbc.co.uk/news/world-south-asia-12916888). This phenomenal population increase demands an equal and concerted scale-up of healthcare service delivery with a focus on improving the quality of life of the Indian people.

Among the organizations that have been on the forefront of empowering the people of India from both the community and policy perspectives is the Voluntary Health Association of India (VHAI-India). VHAI is a non-profit, registered society formed in the year 1970. This federation began from a meeting with 25 individual leaders and has grown to 27 State Voluntary Health Associations. It links together more than 4500 health and development institutions across the country making it one of the largest health and development networks in the world. VHAI advocates people-centered policies for dynamic health planning and programme management in India as well as initiates and supports innovative health and development programmes at the grassroots with the active participation of the people.

Indeed VHAI’s efforts to make an impact at and from the community level to the global level have not gone without notice. Among notable initiatives that VHAI is credited with includes facilitating the setting up of an Independent Commission on Health in India with the aim of assessing the current health status and problems in health care delivery in the sub-continent.

Based on these achievements, health promotion experts have been keen to exchange ideas and borrow from VHAI’s continued positive track record in the health promotion arena. This month, we asked Bhavna Mukhopadhyay and Seema Gupta, members of VHAI, about what has made their efforts successful. In addition, we asked Rahel A. Oyugi, programme officer at the African Institute for Health and Development, about her trip to India and experience with VHAI, to discover some lessons Africa can learn from VHAI.

We began by asking VHAI members:

1. When VHAI first started, how many partners were involved?

The VHAI network had its origin from a meeting on 13, January, 1969 in Bangalore. Twenty five leaders of Christian hospitals got together for five days of creative thinking on the question – what to do for the millions of people in the villages who would never enter the doors of their hospitals? There was a need to reach out health services to the people as expensive hospital-based curative care offered no permanent solution to the people’s problems. It was agreed that health was much more than medical care, and individuals as well as communities had a critical role in health care.

In order to operationalise the idea and to foster greater cooperation among the various health care agencies towards this cause, the group decided to establish a secular , nonprofit and charitable registered society by the name Coordinating Agency For Health Planning (CAHP) operational at the national level.

CAHP started functioning from a one room office in South Delhi with a staff of three people from 6 March, 1970. People’s power was a key priority area from day one; however, to channel this power, it was essential to bring various civil society groups under the umbrella of State Voluntary Health Associations. Beginning with Bihar Voluntary Health Association and later, Tamil Nadu Voluntary Health Association, other state-level bodies gradually began to take shape.

Turning the vision into VHAI – In 1974, fifteen State Voluntary Health Associations of India (State VHAs) unanimously decided to federate into Voluntary Health Association of India (VHAI) replacing CAHP giving it a secular dimension. A new organizational structure comprising of a General Body with State VHA representatives, a Governing Board and an Executive Director to manage the activities was worked out. All the initial programmes were geared towards VHAI’s mandate to promote a vigorous community health movement in the country.

2. What has the organization done to strengthen growth of partnerships in India?

While VHAI is a federation with State VHAs functioning independently as autonomous bodies with their own Governing Boards and Executive Directors, we make a point to ensure that constant communication with all the state partners and member organizations at the community level is maintained. We assist State VHAs in planning and managing their activities with technical and finance resource support to the extent possible and through implementation of joint public health programmes. Specific, need-based capacity building workshops are organized at national level where many state partners participate regularly. Technical inputs are also given frequently in the form of resource materials, VHAI publications, latest media and policy-level updates, new partnership options in the health sector, to enable them to be updated in public health matters. In addition, involving state partners in joint programme planning and implementation helps them to extend their outreach to remote and neglected areas while strengthening the community health workers’ network.

VHAI continues supporting various State VHAs in the following aspects:

• Supporting and where possible, reviving not-so-active organizations

• Providing publicity through national and international coverage to the activities on the VHAI websites – www.vhai.org and www.rctfi.org as well as the bimonthly journal ‘Health for the Millions’, published by VHAI’s sister concern – the Health for the Millions Trust
• Keeping them aware and updated on important public health issues preventive approaches on tobacco use, bird flu, swine flu, disaster management, etc.

• Initiating partnership programmes in different areas of public health and development

• Involving the State VHAs in various projects implemented at the grassroots

• Giving regular inputs on fund and partnership prospects and introducing state partners to national as well as international agencies

• Recommending them for recognitions and awards and facilitating their participation in international training and exposure workshops

• Capacity building in terms of training, campaign, advocacy and human resources

• Providing immediate financial/technical support during natural calamities

• Following up and actively supporting project proposals submitted by state partners to the Government of India at the central level

• Developing, translating and printing of publications

As a regular annual event, VHAI organizes the Annual General Body Meeting to discuss the concerns of State VHAs and further build on their capacity in the area of health and development.

3. How do you choose your partners?

VHAI makes efforts to primarily build partnerships with like-minded national and international organizations working in health and development who have credibility in their respective domains. VHAI has always strived to focus its objectives and activities based on the needs of the community. We are not a donor-driven organization, so we are able to identify our priorities and choose partners based on the health and development needs of the country.

4. What have been some of your greatest successes of Public Private Partnership (PPP)?

a) VHAI – Arunoday Project: A Journey in Partnership and Innovation (State of Arunachal Pradesh, India)

VHAI has been managing five Primary Health Centres (PHCs) under the Public Private Partnership (PPP) project of the Government of Arunachal Pradesh and National Rural Health Mission (NRHM). The project was initiated in January, 2006. All the Sub Centres under these five PHCs are also managed by VHAI. As confirmed by several reports, the PPP project of Arunachal Pradesh has emerged as a model for delivering better primary healthcare in rural and remote areas, in which VHAI’s contribution holds significant importance.

Managing CHCs – With an impressionable success achieved in managing the five almost dysfunctional PHCs, the State Government handed over the management of a Community Health Centre (CHC) in Deomali, Tirap district to VHAI from 1 August 2009. VHAI deployed several qualified doctors, including specialists, and placed the nursing and paramedical staff as per the Memorandum of Understanding.

With all these efforts in place the healthcare delivery has improved significantly; almost four times after the takeover (refer graph-1). Now the hospital meets the norms to become a first referral unit (FRU), since the operation theater (OT) and related facilities are in place.

VHAI received the management of the CHC in Deomali w.e.f (August 2009)

• HIV/AIDS Control – VHAI has been implementing three Targeted Intervention Projects (TIPs), in collaboration with the Arunachal Pradesh State AIDS Control Society (APSACS). VHAI is one of the only organizations that has employed HIV-positive persons in its projects to end the stigma and discriminations associated with HIV/AIDS.

b) Regional Resource Centre – VHAI
The concept of Regional Resource Centre (RRC) is a milestone in the partnership between the government and the non-government sectors. Implementation of this concept is a step towards decentralisation of the Mother NGO scheme of the Department of Family Welfare, Ministry of Health and Family Welfare. RRC-VHAI has been instrumental in providing technical, managerial and coordination support to the district and block level NGOs as well as State Governments for an effective implementation of the RCH programme in the four states of Rajasthan, J&K, Delhi and Uttaranchal. It facilitates and promotes constant dialogue between NGOs and state governments and provides technical assistance and capacity building support for a range of programme management and technical intervention areas to the state NGO Committee, Mother NGOs / Field NGOs.

c) HIV/AIDS Programme
Link Workers Scheme – VHAI is implementing the Link Workers Scheme in collaboration with National AIDS Control Organisation (NACO) and Madhya Pradesh State AIDS Control Society under the Global Fund support. The Scheme covers four ‘A’ category districts (see NACP guidelines), Balaghat, Panna, Dewas & Harda. The Scheme is envisaged as a short term intensive scheme focusing on HIV/AIDS prevention and target beneficiaries are female sex workers (FSW), men who have sex with men (MSM), intravenous drug user (IDU), vulnerable young men, vulnerable women, people living with HIV/AIDS (PLHWHA) male/female and other vulnerable children (OVC).

Significant Milestones:
• VHAI has successfully acted as liason with allied departments and coordinated with the State health authorities, M.P State AIDS Control Society and NACO for smooth and effective functioning by channelizing and managing resources such as finance, material and human resources.

• Completion of mapping and rapport building exercise in 100 high prevalence villages.

• All identified potential link workers have been trained and have created second line volunteers to sustain the services initiated through the scheme, since both the link workers and the volunteers are local residents.

• All four districts have established formal service delivery mechanism and regular review and meetings are taking place from VHSC to district level health planning.

d) Tobacco Control
VHAI is one of the pioneers in tobacco control at the national level, leading campaigns to reduce tobacco use especially among vulnerable populations, like women, youth, marginalized and children while advocating for strict enforcement of the Tobacco Control Act, 2003. Currently, VHAI is implementing an intensive and widespread campaign focusing on policy and media advocacy, increasing tax on tobacco products, creating smoke free settings and monitoring compliance of the tobacco control law. A number of landmark activities and developments have taken place in recent times, which have further strengthened the tobacco control campaign in India.

National and Sub-National Advocacy Initiatives

Tax increase on tobacco products, including bidis

VHAI and our and stakeholders have been sending representations and appeals to various State Governments for raising tobacco taxes. Due to joint efforts by civil society representatives, this year, the Governments of Rajasthan, Gujarat, Himachal Pradesh, J & K, Assam, Kerala, Tamil Nadu and have increased tax/VAT on tobacco products with the objective of reducing tobacco use and generating additional revenue.

Advocacy on pack warnings on tobacco products: Section 7 of the Indian Tobacco Control Act (COTPA), 2003 provides for pictorial health warnings on all tobacco products as per given specifications. However, pack warning rules could not be implemented till 2008 due to various administrative, political reasons, interference and continuous pressure from the tobacco Industry/lobby. Since 2007 till 2009 and again later till May 2010, the implementation of this law suffered constantly either due to political and industry influence. HFM Trust, the sister concern of VHAI filed a Public Interest Litigation (PIL) in 2008 against the Union of India and the tobacco industry, for non-implementation of the pack warnings. Through the case proceedings it has exerted continuous pressure upon the Government of India to act in the interest of public health and protect the health of its citizens. As a result, the Supreme Court directed the Government of India to implement the health warnings from 31st May, 2009. Pictorial warnings, began appearing on all tobacco product packages in June 2009. Further, as per the latest Government notification (May 2011), stronger pack warnings are expected to be implemented from 1 Dec 2011.

State and District-level implementation of Section 4 & 6 of COTPA Act

VHAI’s Partnership Against Tobacco (PAT) & Action for Policies, Politics, Legislation and Empowerment (APPLE) Project – Phase III (launched in December 2010) aims at effective implementation of Section 4 & 6 of COTPA Act, 2003 in collaboration with the State Government and key stakeholders in 10 districts of 5 different states of India. This act will build a strong, rooted and participatory campaign for tobacco control. Successful project interventions at these settings would lead to the declaration of these districts as ‘Smoke Free’.

Smoke Free Initiatives through PPP:

• Kottayam, in the state of Kerala was the first announced district to be smoke free (September 27, 2008) through the joint efforts of Government, civil society and the community.

• Sikkim was declared smoke free on World No Tobacco Day (31st May 2010) by the Government of Sikkim. It is the first state of India to go smoke free with the active support and involvement of multiple stakeholders.

• Following the footsteps of Sikkim, on 2nd October 2010, the Chief Minister of the state of Himachal Pradesh declared its capital Shimla, a popular tourist destination located in the hilly mountains, a smoke free city.

• Bhubaneshwar, capital city of the state of Orissa, also known as the “City of temples”, was declared smoke free in September 2010.

World No Tobacco Day Campaigns

Apart from the above, every year, VHAI and WHO-Country office, India and Ministry of Health and Family Welfare organize campaign activities to observe World No Tobacco Day on 31st May across different settings. World No Tobacco Day is usually used as an ongoing campaign to advocate on critical concerns of tobacco control. It is also an opportunity to strategically position all the crosscutting issues of tobacco control in the agenda of key stakeholders including policy makers, bureaucrats and elected representatives. On this occasion, VHAI and its State Partners conduct a broad range of activities across all states focusing on the theme of the year – in 2011, it was FCTC, particularly pack warnings and smokeless tobacco. Each year, the activities include mass rallies, media sensitization programmes, street plays, mobile road shows, public awareness programmes, community meetings, which witnessed the participation of policymakers, Governmentt personnel, enforcement agencies, women, media, youth, children, medical and para-medical staff, management institutions, civil society agencies and community-based organizations.

e) Collaboration with World Health Organization

In the year 2010-2011, VHAI entered into two on two publication projects with WHO-SEARO, New Delhi.

1. The first project on Innovations in Primary Health Care in the SEARO region has been completed. This publication, Glimpses of Innovations in Primary Health Care in South-East Asia was conceptualized, developed and produced by VHAI. The book gives a brief overview of some of the best practice experiences in the delivery of primary health care in the Member States of the WHO South-East Asia region. It showcases some of the important projects, programmes and groundbreaking innovations in Primary Health Care currently being implemented in Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor Leste.

With the formal release of the publication in Chiang-Mai, Thailand, at a regional conference attended by the Chief Executive, VHAI, the project was successfully able to share successful models and practices from various South-East Asian settings with policy makers, international agencies, researchers, social activists, programme personnel and civil society for wider learning, experience sharing and forging the way ahead.

2. The second project, currently in development by VHAI, is on developing an effective Self-Care handbook for as a capacity building tool for community healthcare workers and volunteers.

3. The Regional Meeting on Health Care Reform for the 21st Century was organized by the South-East Asia Regional Office of WHO at Bangkok from 20-22 October 2009. The meeting was attended by the Chief Executive, VHAI, who provided significant inputs to some of the objectives.

g) MICRODIS Project

The MICRODIS Project has 19 partners from 13 countries and is coordinated by the Centre for Research on the Epidemiology of Disaster (CRED)-Université Catholique de Louvain, Brussels, Belgium. The outputs of the project include an evidence-base on impacts, field methodologies and tools for data compilation, impact models, and integrated vulnerability assessments. VHAI is one of the two community-based organizations in this consortium.

There have been many more successful examples of public private partnerships as well as achievements due to collaboration with State VHAs and like-minded organizations.

5. What have been some of the struggles of PPP?

The main challenge in PPP initiatives is to change the conventional mindset that NGOs should not be just recipients of support grants/fund to implement the programme activities, but should be pro-active partners from the overall strategic planning and programme development stages and further down to the implementation stage.

• In PPP programmes, at present, effective participation of beneficiaries and their involvement in the planning, designing, implementation and monitoring of the programme is not present or encouraged at all levels.

• One of the key challenges in PPP is accountability – there is still lack of complete clarity as to who is ultimately responsible for the delivery of efficient, effective and equitable services. There need to be clear coordination mechanisms across various departments within the Government as well as the implementing agencies. The roles, rights and duties of all partners should also be outlined clearly and unambiguously.

• The project design must have a bottom-up approach. The top down or linear model will not be sustainable in the long run as there needs to be an equal involvement of all stakeholders to ensure the participation of direct beneficiaries.

• In most PPP models even today, the partner who enters with the financial resources sets the priorities. The other partners are left with the responsibility of implementing the programme, meeting the challenges and delivering the outcomes. The beneficiaries/target audiences have little say in the whole exercise. This needs serious reassessment. Resource sharing is a crucial component of stakeholder participation and all partners should have stakes and responsibilities. Policies should be in place to address how poor and marginalized beneficiaries can also be addressed as stakeholders.

• Bilateral national and international agencies can play an important role to decrease the gap between government and non-government organizations. Despite the best of intentions, Government models, due to paucity of staff, resources and bureaucratic procedures, are not equipped to work in concert with the community in the way nonprofit organizations and community-based organizations can.

6. What are the lessons from your PPP experience that other countries could use?

VHAI has had several successful experiences in PPP programmes as mentioned earlier. Whether it is Project Aparajita, working with the local populations like fisher folk and artisans in the areas of rehabilitation, health, education and livelihood following some of the worst disasters; the Poorest Area Civil Society Programme (PACS) “Parivartan” project, aimed at poverty alleviation in some of the poorest areas in the country or our other programmes, our experience has led us to believe that the community has the ability to identify, plan, implement and evaluate their developmental needs.

An effective PPP programme model helps people realise their potentials, know their rights and utilise their collective-strength while fighting against poverty, illiteracy, corruption, disaster, tobacco, access to healthcare or other socio-economic problems that they have been faced with for generations. VHAI models have given emphasis on lateral implementation platforms, strengthening Village Development Committees (VDCs), activating the local-self-governance system through PRIs and other community representatives, using Right to Information to access information from the Government on issues of public interest, empowering women through Self-Help Groups and bringing development-related information closer to the community.

In PPP, effective governance is the key at all levels. Here, apart from Government agencies, NGOs should also practise governance within themselves. The development concept should be initiated from the grassroot level and that is only possible when the local government takes active participation in the overall development process. For example, in India, local bodies like Panchayats can play a strong role. The perceived gap between Government, international funding agencies and NGOs can be eliminated, if the initial planning process involves the civil society organizations.

Building NGO Capacity and Providing Institutional Support: As a pre-requisite to any PPP programme, training should be developed for capacitating all the participants – GO-NGO, beneficiaries and the international agency, if involved:

  1. In the process for the preparation of the training module, there should be an equal involvement of personnel from all the partners as well as the community for a more result-oriented process.
  2. After the training, there should be a system to facilitate the way forward, along with an assessment of the technical assistance required, followed by the development of a workplan/roadmap for programme implementation.
  3. An arrangement of regular meetings and strategy workshops should be worked out through the programme, to strengthen the capacity of the NGOs and the community to discuss forward strategies and to make way for course-correction.
  4. Staff exchange programmes and exposure visits within the country and outside should be the other key components.

Interview with Rahel A. Oyugi, Programme officer, African Institute for Health & Development (Kenya)

Rahel first learned about VHAI when she was living in India. Community Health Volunteers would come to the nearby poor settlements to educate residents on health promotion activities. She discovered that they had been trained by VHAI to advocate for better health among the low caste communities. Later, she became involved with VHAI through her work with the African Institute for Health and Development (AIHD), who had been working with the IUHPE and VHAI. Through these efforts, she was invited by the VHAI 2007 to visit India with the main aim of learning and sharing the various health promotion experiences in their programmes. She describes this visit as an eye-opener: it guided her towards active health promotion participation through integrated community action.

1. On their website VHAI states they are “…one of the largest health and development networks in the world.” Do you agree with this statement, and why?

YES! VHAI is a federal movement. Their work is evident at the community level as intended. This is quite a feat, as India is a sub-continent with a large population; however, VHAI’s presence in almost all Indian states, its duration of operation since 1970, and the large number of institutions affiliated to it have ensured its place as one of the largest networks. The ownership of its own printing press will for a long time ensure sustained advocacy and voice for their activities in public health.

2. How do you feel that VHAI contributes to health promotion activities across India and South East Asia?

VHAI is the core of Health Promotion activities in India. All projects are designed using an integrated health promotion approach, through a social determinants lens which looks at health holistically. VHAI advocates for people-centered policies for health planning and programme management in India. They support innovative health and development projects at the grassroots and encourage active participation of the people. Through their work in New Delhi, VHAI has enabled poor communities to have access to clean and safe water, to learn about the proper use of toilets and hygiene with their target groups being school-children. The children have also formed their own community forums where they address issues of health that are affecting them. Because of the community investment and inclusion of community members at all levels, there is a strong sustainability component of the programs initiated.

3. What health promotion lessons did you learn that are relevant to the development of Health Promotion in the continent of Africa and other developing nations of the world?

Health and development are closely linked, and active community action participation plays a key role in achieving its goals. Africa could take many steps forward by governments making it a point to encourage and embrace active participation of the community in all decision-making processes.

4. What is the single key aspect that you want to see incorporated in African health promotion programs?

Empowerment at the grassroots level through advocacy and education- I see this as fundamental to making sustainable changes.

5. How effective were VHAI’s use of partnerships? What did they do to help facilitate the growth of partnerships?

VHAI enjoys good relations with its partners. Through these partners VHAI has been able to institute some cost effective, preventive health care initiatives with accountability practices within the health care sector. VHAI has been at the forefront of policy development and initiates talks with the government to influence policy implementation. Through networks and doing what is right, they have a foresight in predicting forthcoming health promotion related problems through evidence –based programs, with accurate success. 

6. What lessons from their use of partnerships could other countries use?

The sustainability mechanism that is embedded in each program for self-reliance is most important for countries to learn from in the designing and implementation of health promotion programs.

7. Are there any specific programmes or activities that caught your eye that you feel if adopted can help in the growth of health promotion across Africa?

Establish a MOVEMENT! One of VHAI’s partners, SEWA, have a movement for a cause and their eye-catching motto is “we are poor but many.”

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