Our partners have significantly improved diabetes and hypertension care in Assam in the past years. With the most recent state-wide programme funded by WDF ending, local champions are now sharing their stories of empowerment in making real change in their communities.
31 May 2024 Andreea Enea
In 2021, the Health and Wellness Centre (HWC) in Bor Lalung Gaon village, located in the Nagaon District of Assam, India, faced a critical lack of necessities. It had no drinking water and no sanitary facilities.
Two years later, it underwent a remarkable transformation: the centre now has facilities for drinking water, separate toilets, a hand-wash basin, and a boundary wall.
At the heart of this transformation is the District Project Coordinator Yasmina Begum, who brought local authorities on board and formed a Jan Arogya Samiti (JAS).
Also called Joint Advisory Committee, JAS is responsible for facility management, community action, and monitoring to ensure community members can voice their opinions and access healthcare services for non-communicable diseases (NCDs).
This is just one of the many ‘stories of change’ resulting from the recently completed project in India, Strengthening NCD (diabetes and hypertension) services in Assam. The project culminates a decade of increasing efforts to improve care for underserved communities in Assam, as the third phase. For WDF, it represents the first comprehensive and fully integrated state-wide diabetes and hypertension management initiative at the primary care level, focused on strengthening the health system and empowering communities.
In a previous article, we highlighted how mobile medical units (MMUs) equipped with telemedicine technology and artificial intelligence solutions for screening and training of health workers have proved effective in improving access to care and preventing complications of type 2 diabetes for people living in hard-to-reach villages.
However, the engagement of Assam communities deserves its own spotlight. Throughout the implementation of the project, our partners collected many inspiring stories of local champions, showcasing the lasting changes communities are able to catalyse for the health and well-being of their people.
According to the World Bank, a third of Assam’s population of 31 million people lives in poverty, with 88% in rural settings. The incidence of poverty is higher than the national average, with a high density of tribal communities with limited access to healthcare across the 33 districts of Assam. The barriers to accessing healthcare among the tribal population depend not solely on socio-economic factors but on quality of services and poor transport and communication infrastructure among others, as a 2020 study shows.
Photo: Pregnant and lactating mothers join an awareness program in the Tulsijhora HWC.
The latest programme was born out of extensive consultations between WDF and our long-term local partner, Piramal Swasthya Management and Research Institute (PSMRI).
An Indian non-profit organisation, PSMRI is also a partner of the Indian government in ensuring access to primary healthcare for communities in vulnerable settings like tribal populations. Other key project partners were the National Health Mission (NHM) of the Government of Assam and the National Institution for Transforming India (Niti Aayog) providing policy advice.
‘WDF facilitated cross-learning between project teams in different countries and shared useful resources’, shares Dr Shobha Ekka from PSMRI, ‘which helped our team to examine processes and outcomes through different lenses’.
An interesting outcome has been the significant changes it brought through a community-driven, or ‘bottom-up’ approach by strengthening community action through JAS committees and peer support groups and empowering community health workers (CHWs).
Community Health Officers (CHOs) and Accredited Social Health Activists (ASHAs) in particular play a vital role in closing the healthcare gap in rural and urban areas. A 2023 article states that nearly one million ASHAs, the largest group of CHWs in the world, represent ‘the backbone of India’s primary healthcare system’.
JAS, on the other hand, are a local-level institutional mechanism under the Ayushman Bharat, the national primary healthcare reform. JAS members are health providers, CHWs, and other local stakeholders chaired by the Village Leader to ensure a hub for health promotion and a culture of active public participation and accountability for health providers, generating demand for quality health services.
‘JAS proved to be an efficient mechanism in the local context of Assam, where the administrative gap between the State and the districts, districts and blocks, and blocks and health facilities is large due to many factors like distance, difficult terrains and diverse populations’, Dr Shobha explains.
The committees have been empowered to manage the primary healthcare facilities in their villages, now called Health and Wellness Centres (HWC). This marks a shift in focus towards ‘wellness and the delivery of an expanded range of services closer to the community’ (Ministry of Health and Family Welfare India), which is mindful of the local traditions and culture. The concept of wellness is rooted in AYUSH, a traditional Indian system of medicine deeply ingrained in native culture, which makes cultural beliefs and behaviours essential to consider when aiming for sustainable change in health practices.
JAS has been a crucial resource in fulfilling the community-driven programme’s purpose in Assam. Although they did exist before, these committees were not fully functional or active in every community. The project empowered notable village members to collaborate with district NCD Cells and advocate for their rights.
‘Be it infrastructure development of HWCs or events on important health days, JAS took the lead in bringing the community needs and demands to the table’, adds Dr Shobha.
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During the project, many HWCs underwent critical transformations. One of these centres was the Phonglokphet HWC, in Karbi Anglong District.
When DPC Parikhit Chanda visited the centre in 2022, he observed that the construction was not completed, making it difficult for the staff to work there without electricity or water supply.
The local CHO was asked to contact the people responsible for the remaining work, but there was no response. The matter was escalated to the district level, which prompted the completion of the work a few days later. With electricity now available, the CHO expressed her gratitude for the District Coordinator's efforts, whose presence also improved the attendance of the staff and patients at the centre.
The Government of Assam has provided support in operationalising and strengthening JAS committees in 70 model HWCs - equal to 10% of the total centres in Assam.
The collaboration with PSMRI has also empowered local peer educators to form groups for people with diabetes that provide psychological support, increase awareness, and advocate for behaviour change and self-care. 76 peer support groups were formed, comprising 723 members with type 2 diabetes and hypertension. They have been pivotal in promoting community engagement and empowering individuals to take control of their health.
This community-driven focus of the state-wide programme in Assam has been instrumental in improving healthcare access and outcomes in underserved communities. By leveraging local knowledge and resources, and being very mindful of their valuable culture, the project was able to address local challenges and promote more equitable and sustainable healthcare.
It also ensured annual training on diabetes and hypertension of more than 2,000 CHWs on supervision and 9,900 ASHAs, and more than 600 community members as part of JAS.
On a spring day in 2023, Chirang's District Coordinator Karna Barman visited the Bishdoba HWC. As soon as he observed significantly low NCD screening rates due to limited accessibility for the villagers living very far away, he knew he had to do something.
The District Coordinator suggested screenings on specific days for nearby communities and screening camps in collaboration with the Comprehensive Primary Health Care (CPHC) team for the more isolated villages.
It did make a difference.
When an NCD screening camp took place in a remote village a few months later, ‘there was a significant turnout of community members seeking screening,’ Karna recalls. But it was a collective effort.
The camp was set at the local ASHA’s home, where ‘the CHO personally conducted blood sugar tests and maintained the necessary records’. The District Coordinator rolled up his sleeves, offering guidance and support to those who got diagnosed. ‘This proactive approach not only raised awareness but also empowered the attendees to take necessary precautions and fostered a sense of community well-being’.
Read more inspiring stories in The Champions behind Strengthening NCD Services in Assam - a book compilation facilitated by WDF, Piramal Swasthya, and Anamaya and launched at the third Northeast India Annual Diabetes Conference, where WDF was invited.
There have been many ways in which community action in Assam has truly strengthened NCD care – or enabled access to care – for its underserved populations.
• On the supply side, JAS has been able to pool funds and improve HWC infrastructure, including by renovating or creating gardens. On the demand side, the committees have driven increased awareness around diabetes and hypertension. • Regular visits from the partners at designated HWCs offered a chance to both assess the progress and quality of services and discuss and solve challenges together with local staff. • The keen involvement of the districts, religious leaders and schools, along with organising art and culture events have shown great potential for scalability. • Finally, the training offered by the Piramal team to local committees to build their leadership, negotiation and communication skills was met with a strong positive response.
With the programme ending, the success of community-driven approaches in Assam is evident.
The lessons and stories of change demonstrate the potential for a more equitable future, where local groups like JAS, the youth, and religious leaders continue to play a vital role in improving health outcomes for all.
As Dr Shobha advises, moving forward it is crucial to focus on designing culturally acceptable interventions for tribal and indigenous communities in particular, as well as on strengthening referral pathways.