Scaling up a community-based primary health care program: The Jamkhed experience

PURPOSE: To learn how Comprehensive Rural Health Project (CRHP), Jamkhed, India, scaled up its community-based primary health care (CBPHC) program.

METHODOLOGY: Case study with information garnered through participation in 1-month international course for Medical/Allied Health students, key informant interviews, and literature review of CRHP's impact and experience.

BACKGROUND: Since its inception in 1970 by Drs. Mabelle and Rajanikant Arole, CRHP have pioneered the principles and practice of CBPHC. Through Village Health Workers (VHWs) and community participation, 80% health problems are prevented or treated in villages. Health impact is well-documented, dramatic and sustained.

RESULTS: Beginning with 8 villages, by the 1990s CRHP expanded to surrounding villages and two other areas (total 500,000 population). This expansion occurred mainly by villagers' efforts, due to CRHP's emphasis on building community capacity via innovative approaches based on principles of equity, empowerment and integration. The establishment of Jamkhed Institute for Training and Research in Community Health and Population in 1992 provides various opportunities for individuals and organizations (government, NGOs, community members, students, project managers, clinicians, policy makers) to learn from villagers and staff in participatory, applied methods - over 2,000 persons from almost 100 countries and 27,000 persons from India. The Mobile Training Unit, with staff and villagers provides training throughout South Asia. Drs. Arole have served as advisors to state, national, and international health programs to incorporate CRHP's principles and experience, including India's National Rural Health Mission. Massive state-government-sponsored training programs are instrumental in this process, including training of 1,150 ashram teachers and VHWs in tribal areas in eight districts of Maharashtra (pop. 10 million), and over 4,000 health and government workers from 22 rural districts in Andhra Pradesh (pop. 60 million). CRHP's experience also informed the WHO/UNICEF Alma-Ata Declaration, 1978, and continues to serve as a model internationally in the current renewal of Alma-Ata's principles.

CONCLUSIONS: Through various mechanisms, CRHP influenced policies and practices of comprehensive CBPHC nationally and globally through training and technical assistance by villagers and staff at the Institute and off-site, and by advising government policies. Appropriate roles of NGOs are to partner with communities to pioneer, demonstrate and share alternatives for others, including NGOs and government programs and policies.