Women and Community-Based Organizations in the Public Health Care: Exhibits from Kerala Volume 53- Issue 1

Biju T¹*, Jithendran S², Sanu F³ and Ammu S⁴

• ¹Professor of Commerce, University of Kerala, India
• ²Assistant Professor of Commerce, Government College, India
• ³Research Scholar of Commerce, University of Kerala, India
• ⁴Research Scholar of Commerce, University of Kerala, India

Received: September 12, 2023;   Published: September 21, 2023

*Corresponding author: Biju T, Professor of Commerce of University of Kerala and formerly District Mission Coordinator of Kudumbashree Mission who bagged the recognition of Best District Coordinator of Kudumbashree during 2015-16, India

DOI: 10.26717/BJSTR.2023.53.008332

Abstract PDF

India, one of the most populated, developing countries in the world was surprising the rest of the globe in containing and fighting the fatal millennium’s social distress- the Covid 19. It has inflicted huge stress on healthcare systems which is both capital and labour intensive. Density of population of the country has increased the challenges manifold. The panicky migrant workers and the related issues on return have put the state administration really at a fiasco. Kerala, a state in the Indian Union was inadvertently chasing all such issues as a miniscule of developing statehood. Despite an exposed demography of diaspora spread all across the globe, it has successfully maneuvered the ASHA worker as a chosen representative from Kudumbashree in fighting the pandemic through institutionalizing the ASHA worker and Kudumbashree. By leaps and bounds the state had fought the battle for containment of pandemic and proved successful. Subsequently, there were multiple layers of assistance at the time of crisis using the capacity of localized information, skills on social relations and customized approach to the destitute, women and children, who are otherwise hard to access. The initiatives have been applauded internationally as a success, with Kerala serving as a role model for the rest of the world and providing yet another example of women’s empowerment. It has set a better model for community participation through administrative decentralisation in all the three phases of containment, spread and vaccination. The model also got acknowledged in the sphere of sustainability and community participation.

Keywords: Kudumbashree; Community Based Organisation; Sustainability Participation; ASHA worker; Administrative Decentralisation

Abbreviations: SPEM: State Poverty Eradication Mission; ADS: Area Development Societies; NHGs: Neighbourhood Groups; CDS: Community Development Societies; ASHA: Accredited Social Health Activist; NRHM: National Rural Health Mission; RTIs/STIs: Reproductive Tract Infections/Sexually Transmitted Infections; ANC: Ante Natal Check-up; ORS: Oral Rehydration Therapy; IFA: Iron Folic Acid; DDK: Disposable Delivery Kits; WHO: World Health organization;IEC: Information, Education and Communication

Sarvodaya means “welfare for all” ensuring betterment of human life and fulfilment of all basic needs of all human beings (Mahatma Gandhi). Equitable deliverance of health care facilities is a challenging task for every populous nation. Public Health Care needs precedence over all other issues in State administration for all nations globally and particularly for developing countries. The widespread availability of medical insurance and allied financial corporations for citizens means that the Healthcare sector is not of a major concern for developed states. On events of medical emergencies, developed states have no glitches in streamlining the resources. However there is a felt dearth of funds, facilities, infrastructure and professionals in the communities of developing states (Kasthuri [1]). The density of population in Indian context strain the existing medical infrastructure along with its inherent weakness. Under the ferderal system the state can always wait for grants and orders from the Government but when it comes to the question of health, time component is very significant. To increase the efficacy of such systems WHO is advocating community participation for the provision of better health care to rural masses (WHO [2]). Intervention in the form of community participation is a sustainable effort of an equitable and bottom-up approach to healthcare, that is proven effective in optimizing health interventions for positive public health impact (Haldane, et al. [3]). At this juncture, community participation emerges as a self-reliant system and has the power to save lives, especially during a panic-laden pandemic period. The State of Kerala in Indian Union has set a better model for community participation through administrative decentralisation in all the three phases of containment, spread and vaccination (Babu, et al. [4]). The hallmark of Kerala’s administrative decentralisation is the transfer of public service delivery institutions to Local Governments. The important institutions transferred are Schools, Dispensaries, Public Health Centres, Community Health Centres, Hospitals, Anganwadis, District Farms, Veterinary institutions, pre-matric hostels for Scheduled Castes, etc. There is an increasing concern on the performance of these allied Institutions, especially health centres of Local Governments (Vijayanand SM [5]). The Covid-19 pandemic period also pinned the importance of health centres and their quality requirements. During the pandemic, a series of initiatives has been marshaled to protect rural India from spreading panic and containment of Covid 19. The Kerala model of management and containment of the pandemic was much praised. The state put forth a replicable model of community participation for public healthcare through the female agency -Kudumbashree which is assisting the state in executing the ideas and practices. Kudumbashree, a Community Based Organisation, is the poverty eradication and women empowerment programme implemented by the State Poverty Eradication Mission (SPEM) of the Government of Kerala (Kudumbashree [6]). The role of Kudumbashree in the State of Kerala in Indian subcontinent cannot be undermined due to its unique initiatives especially in the context of pandemic. It offers a spectrum of innovative practices along with the health and law and order personnel in the state. The output is commendable achievement with respect to reports on epidemic management amidst members’ vulnerable exposure with migrant workers from different parts of the country. The present paper highlights the role and effectiveness of Community Based Organization- Kudumbashree in building a self-reliant rural health care system.

Kudumbashree- A Women Empowerment Initiative

Sociologists of all times have highlighted the role of women in bringing social changes and its effectiveness. Kudumbashree is the poverty eradication and women empowerment programme implemented by the State Poverty Eradication Mission (SPEM) of the Government of Kerala. It is essentially a community network that covers the entire State of Kerala. It consists of a three-tier structure with Neighbourhood Groups (NHGs) as primary level units, Area Development Societies (ADS) at the ward level, and Community Development Societies (CDS) at the local government level. The Kudumbashree network by 15th October 2022 had 3,09,667 NHGs affiliated to 19,470 ADSs and 1070 CDSs with a total membership of 46,16,837 women (T Biju, et al. [7,8]). Kudumbashree membership is open to all adult women, limited to one membership per family; therefore, it represents almost 46 lakh families in Kerala or a cross section of Kerala. This Community network of almost 46 lakh women is also to be recognised as the real heroines behind the Covid 19 control activities designed and implemented successfully by the State Government. The paper is organised to highlight the performance of Kudumbashree units and ASHA workers specifically as a participative community health care program in a contingency mode. It pinpoints the operational area of Asha workers and initiatives of Kudumbashree in assisting the fight against pandemic.

ASHA Workers

Innovative institutional arrangements are capable of delivering quality governance as in the case of cooperative movements in Rural development for capital formation. As we focus on the Public Health Care, the role of Accredited Social Health Activist (ASHA) is one of such innovative systems. It is a community-based health activist. In India, under the National Rural Health Mission (NRHM), an ASHA is a lady selected and appointed to each and every village in the nation. The ASHA will be chosen from the respective village and will report to NRHM. They are trained to act as a link between both the society as well as the public health system. ASHA should always be a village woman who is married, widowed, or divorced, and preferably between the ages of 25 and 45. More than 90 percent of ASHA in Kerala are from the Kudumbashree fraternity (WHO [9]). ASHA’s capacity building is viewed as a continuous activity. They would have to go through a number of training events in order to gain the essential knowledge, skills, and confidence to fulfil their tasks. The major tasks of an ASHA are encouraging universal immunisation, referrals and escort support for Reproductive & Child Health (RCH) and other health programs, as well as the building of domestic toilets, etc. The service of ASHA is purely voluntary in nature and they will be provided a very nominal amount to meet expenses. Every ASHA is supposed to be a fountainhead of community involvement in public healthcare programs in her area, armed with information, and a drug kit to provide first-contact healthcare.

ASHA will be the primary point of contact for any health related needs of the poor, particularly women and the children, who have difficulty accessing health care services. She would foster healthy habits and give a minimal package of curative care as necessary and practicable for that level, as well as timely referrals. ASHA will impart community members the knowledge on health determinants like nutrition, basic sanitation and sanitary practices, healthy living and working environment, information on the current healthcare system, and the importance of using health and family welfare facilities on a timely basis. She would also counsel women on topics such as birth preparation, the importance of a safe delivery, breast-feeding as well as supplementary feeding, immunisation, contraceptive methods, and the mitigation of common infections such as Reproductive Tract Infections/Sexually Transmitted Infections (RTIs/STIs), as well as child care. ASHA will motivate and inspire the community and make it easier for them to access health and health-related facilities like immunisation, Ante Natal Check-up (ANC), Post Natal Check-up, supplementary nutrition, hygiene, and other government provided services, which are available at Anganwadis/ sub-centres/ primary health centres. She would also serve as a principal agent for vital provisions such as Oral Rehydration Therapy (ORS), Iron Folic Acid Tablets (IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Contraceptive Pills and Condoms, and so on, which will be made accessible to all habitations (Anonna Dutt [10]).

In short, an ASHA worker is a pivot in community health care of Rural India so much as a machinery of liaison of the Government to make the issues of access seamless to the vulnerable. ASHA workers have become an important part of the government’s pandemic responses, with most states relying on the ASHA network to screen people in containment zones, test them, and transfer them to quarantine centres or assist with home isolation. The role played by ASHAs during pandemic was properly recognised by WHO. It is admitted that an ASHA cannot operate without proper institutional backing at the village level. There comes the role played by Kudumbashree through its Community Development Societies, ensuring support of the Local Self Government Institutions and other related health care systems. An ASHA has an incredible data base on the localities as she hails from the same village as her turf. She also has incredible flexibility in operation in the neighbourhood as she is from Kudumbashree. An ASHA has incredible access to the aged and ailing as she is equipped with such social skills from training for interpersonal relations. One of the reasons that makes the Kerala Model, a replicable one among states in the Indian union is the efficacy which is exhibited through a multi layered approach for syncing bottom-up approach with state machinery. Although ASHA workers are presented through the National Rural Health Mission (NRHM), the state administration could assimilate the capabilities of Kudumbashree members as a feeder point for recruiting ASHA and reinforcing the administrative decentralisation process.

Journal of Covid -19 Strike and the State of Kerala

India, the second most populous country and the largest democracy in the world, really fought to its core against Covid 19 pandemic with the rest of the world. With the apprehensions of community spread, the country addressed the crisis with utmost care. On January 30, 2020, the first case was reported in the state of Kerala, where a medical student from China’s Wuhan University had come on vacation. There were subsequently two more reported cases in this state. Kerala had the most cases when Prime Minister Narendra Modi announced the first nationwide lockdown. Almost 100 days into the pandemic, the state had done exceptionally well in containing it. In the above-mentioned period, Kerala managed to keep down its infection rate, garner a high rate of recovery, and maintain a vanishingly small death toll. To be more specific, it managed to keep the rate of spread to 0.1%, the lowest of any state with more than 500 confirmed cases. The measures taken by Kerala attracted the attention of the entire globe (Menon, et al. [11]). Several international publications, including the Washington Post, BBC, The Economist, The Guardian, Al-jazeera, and the Tribune, have covered the success in controlling the epidemic. Community-based organizations’ strong support was the driving force behind the early days of the pandemic’s containment success. Community participation in public healthcare was proved once again.

Obviously, the state was likely to garner this advantage thanks to early detection through widespread testing, thorough contact tracing, strict 28-day quarantine for those on the contact list and for those from abroad, and monitoring of the same by district level bodies with the assistance of Local Bodies and community organizations. Former UN Secretary and current parliamentarian Tharoor [12] made the astute observation that “Kerala’s COVID-19 response emerged from a template that long preceded the current crisis.” While observing the measures taken by the Government in the State and its enforcement, they were highly pro poor and very humanitarian at the needful hours; for example, it has allocated significant resources to public-health infrastructure; devolved power and funding to village-level bodies; and above all, established a social system that promotes community participation and public cooperation. The contribution by health workers ranging from an efficient pool of doctors, committed nurses, medical students, health inspectors, pharmacists, biotechnologists, community health workers were all remarkable. Meanwhile the police force of the state, fire force, local bodies and other community organisations also played a significant role. It is interesting to note that the Prime Minister of India has urged all of India’s states to adopt Kerala’s model of community kitchens to feed migrants, those in quarantine, the homeless, and government employees working to combat the spread of the Covid-19 virus. Almost all of the government-announced preventative measures in Kerala have been carried out with the help of a prominent group that has made available the power of its women. In reality, this power enables the government to swiftly announce and implement a variety of measures, all the way down to the grass-roots level. Kudumbashree Women’s Network of Kerala is this formidable group.

Kudumbashree in Popularising and Partnering ‘Break the Chain’ Campaign

In response to the government’s “break the chain” campaign announcement, Kudumbashree took swift action. Special NHG meetings were held in roughly 3 lakh NHGs across the state to disseminate information to the populace at large. In addition to providing time bound information to all of their members through WhatsApp groups, the families were educated through these special meetings on the importance of social distancing and personal hygiene in preventing the disease. To ensure that the 22 million members of NHGs stayed aware of the government’s instructions regarding Covid-19 during the lockdown, Kudumbashree organised them into 3 lakh WhatsApp groups.

Kudumbashree and Mask Making and Sanitizer Production

In the initial days there were reports on acute shortage of masks from many parts of the world. The intervention of this women’s force allowed Kerala to triumph over this challenge. The Women Kudumbashree members produced reusable Single layer as well as double layer cloth masks with cotton fabric. Centaury cotton is mostly used for the production of single layer masks and poplin cotton is used for double layer masks. Production of simple hygiene protection products like mask and sanitizer was a key challenge at some point of time during the pandemic where the enterprises encountered with shortage of raw materials. Moreover, abrupt price hike of raw materials and huge demand worsened the situation. However, the units of Kudumbashree tactically overcame all these difficulties with their experience and readiness to be at the service of the society. Many hundreds of Kudumbasree units responded to the rising demand for masks in a full-scale warlike fashion, just as a few drops of water add up to a mighty ocean. Kudumbashree women have also begun producing hand sanitizer at 210 of their own units. Kudumbashree’s intervention in this case prevented exploitation in the form of inflated prices for hand sanitizer and face masks. When called, the Kudumbashree women admitted that the chemistry departments at nearby universities helped them out with some of the technical aspects of making the hand sanitizer. The Kudumbashree women of Kerala provided invaluable assistance to the state government from the get-go. Through their micro-enterprises, Kudumbashree women have begun producing face shields for use by healthcare workers treating patients infected with Covid-19. As the government exhorted its citizens, “we are with you, we can overcome,” the women members were reassuring their fellow healthcare workers of this sentiment.

Kudumbashree in Support of Children

In the State, Kudumbashree Micro Enterprise units were entrusted to produce and supply Nutrimix, the nutritional food supplement to children through Anganwadis. Even though the Anganwadis were not functioning, the teachers of Anganwadis along with Kudumbashree volunteers ensured the supply of nutritional food to all children. 1583 metric tonnes of Nutrimix were supplied through all anganwadis during the lock down period. The 239 Nurimix units had ensured the uninterrupted supply of Nutrimix to children despite of the month long lock down (Athira M [13]). Kudumbashree Gender help desk, Snehitha along with the Community Counsellors - trained and placed from among Kudumbashree women, provided counselling service to children during the unprecedented lockdown period.

Kudumbashree for the most Vulnerable Groups to Covid 19

The Kudumbashree women volunteers were working with elders, mentally retarded children and other destitute families of the state, which enabled the government to focus on other areas. Kudumbashree was conducting Information Education and Communication campaign to inform the NHGs that elderly people should take special care to prevent the pandemic from the very beginning itself (Jacob [14]). 786 committed community resource persons were working in the field of quarantined elderly care. They were repeatedly contacting the elders who were quarantined and ensuring supply of food and medicines to them. Kudumbashree through its 270 BUDS institutions – the schools for mentally challenged children- was rendering commendable service to the society.

There were 154858 destitute families in Kerala with 144339 elderly members with above 60 years of age. 2500 women resource persons were engaged in contacting and looking after the affairs of such elders. The women resource persons had ensured that they got food from community kitchens, medical care from Primary Health Centres, on timely basis. Besides all these, essential services like food and medicine were given to the needy through the local self-government body. In addition to meeting their basic material requirements, the recipients also received counselling and other related services to help them overcome behavioural and lockdown-related psychological issues. (Ministry of Rural Development [15]).

Kudumbashree on Call Counselling Assistance

The trauma inflicted by the covid 19 was not confined to treatment or indisposition, it caused a surfeit of mental agony and stress. This was largely due to the isolation in quarantine, emotional breakdown, work related issues and delinquency in adapting to the new order. Through 360 women community counsellors of Kudumbashree, counselling and mental support were given to those in need to counteract various mental issues faced by them in relation to Covid-19 and lockdown. Through the community counsellors, Kudumbashree ensured that those who needed medicines receive them and that the support through Snehitha Calling Bell beneficiaries-the scheme designed to support women and children suffering from abuse and atrocities against them at home- are being provided, through the cell operated at the Collectorate, activities related to community kitchens are being coordinated, mental support to elderly community are being provided etc. An organisation of the poor women of the state empowered the women of the state to fight against all such atrocities against them and against their children. Thereby, Kudumbashree marked their presence in all walks of life.

Kudumbashree and Sannadhasena for Government of Kerala

The Government of Kerala has started a volunteer portal named “Sannadhasena Portal”, to enlist volunteers to co-ordinate various Covid-19 related activities (Samoohika Sannadhasen [16]). The government formed the pool of such volunteers, provided training and instructions to them by the district administration. More than 50000 Kudumbashree women immediately started working as Sannadhasena volunteers. This was in addition to the Nirbhaya volunteers of Kudumbashree working with the Police department, The Community Development Society Chairpersons of all the CDSs in the State, The Area Development Society presidents in all ADSs of the state etc. In fact, Kudumbshree agency had not left any stone unturned in helping the government machinery to orient the society to the new normal.

Kerala was indeed placing a new community model to the developing world that through network in community organization and trained ASHA, a pandemic could be effectively contained in a given space and time. It is a model out of social engineering par excellence. The media all over the world apprised the measures taken by Kerala in its public health care system and covid containment, terming it as the Kerala Model. When we observe the execution of all well praised measures in the State of Kerala, it is understood that the main pillar behind the successful implementation of all these measures were the women in Kerala. This includes the nurses, doctors, police personnel and all who were combating the virus’ threats. The 46-lakh women army of Kudumbashree is with the government and the society in all respects. They are enriching the public health care system of Kerala in multiple facets, not only physical health care but also addressing the mental health aspects too. This list of activities performed by the poor but powerful women army of Kerala cannot be ignored, when state the success of Kerala in Covid-19 control. The Kudumbashree Women of Kerala puts across a narrative to the rest of the world during the pandemic and beyond, voicing out loudly ‘empower your women, they will fiercely and meticulously shield you, your family and your nation’.

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