Comprehensive Rural Health Project
|Key people||Dr. Rajanikant Arole, Founder
Dr. Mabelle Arole, Founder
Dr. Shobha Arole, Director
Mr. Ravi Arole, Director
The Comprehensive Rural Health Project (CRHP) is a non profit, non-governmental organization located in Jamkhed, Ahmednagar District in the state of Maharashtra, India. The organization works with rural communities to provide community-based primary healthcare and improve the general standard of living through a variety of community-led development programs, including Women's Self-Help Groups, Farmers' Clubs, Adolescent Programs and Sanitation and Watershed Development Programs. CRHP was founded in 1970 by Drs. Raj and Mabelle Arole, who conceived the organization's model while on a Fulbright Scholarship at Johns Hopkins University. The work of CRHP has been recognized by the WHO and UNICEF, as well as being introduced to 178 countries across the world.
Raj and Mabelle Arole
Rajanikant Arole was born in Rahuri, Ahmednagar on June 15, 1935. Mabelle Arole was born Mabelle Immanuel in Jabalpur on December 25, 1935, daughter of a professor of Theology and Greek who taught at Duke University and in India. Raj and Mabelle met at Christian Medical College in Vellore, from where they graduated in 1959, at the top of their class. Married on April 26, 1960, they vowed to devote their new life to caring for the marginalized in rural areas. From 1962 to 1966, they worked in a Mission Hospital in Vadala, 320 kilometers east of Mumbai. After this, the couple spent four years in the United States on a Fulbright Scholarship to obtain their residency training in Medicine and Surgery, as well as a Masters in Public Health, at Johns Hopkins University. Under the tutelage of Carl Taylor, a leader in the field of community health, the Aroles conceptualized the idea of the Comprehensive Rural Health Project (CRHP) to provide community-based primary health care and development to poor and marginalized communities in rural India.
Founding of CRHP
Returning to India after their studies in the US, the Aroles decided to work in Jamkhed, a poor and drought-prone taluka strife with inequalities. The village leaders of Jamkhed invited the Aroles to visit and talk to the community about their project. After a successful visit, the Aroles decided to stay and founded CRHP in August 1970. The initial coverage of CRHP was limited to 8 villages, with a total population of 10,000 villagers.
Expansion and outcomes
In the first 25 years, the project expanded to a region of over 250,000 people. At its peak, CRHP worked with 178 villages. Outcomes were dramatic: infant mortality dropped from over 176 per 1,000 births to 23 per 1,000. Other health data also indicated substantial improvements in health in the project villages: 100% coverage of antenatal care for pregnant women and under 1% child malnutrition.
Over 40 years, CRHP has worked with 300 villages and over 500,000 people. The indirect impact of the organization is estimated to be at over 1 million people.
CRHP’s model, known in the development community as the “Jamkhed Model”, is centered around mobilizing and building the capacity of the community, empowering the people to bring about their own improvements in health and poverty-alleviation. The model has three, mutually supportive components:
“Medical doctors have started treating images rather than patients. The relationship between a modern doctor and his patient is to methodically decompose the patient, converting him into a set of laboratory findings. The ‘shadow’ patient is then reconstructed from the results of such laboratory tests as urine, blood, ECG, x-ray, et cetera. The best healers are driven not by detached scientific efficiency, but by communication and supportive human outreach.” — Dr. P. K. Sethi, the medical doctor who popularized the ‘Jaipur Foot’ in India.
In countries like India, physicians often leave the country to seek higher-paying positions abroad. Major hospitals have a limited number of doctors and nurses to care for hundreds, and patients die unnecessarily. While physicians leave the country, there are few doctors willing to work in the rural areas and healthcare suffers.
"Doctors promote medical care because that's where the money is," says Rajnikant Arole. "We promote health." The distinction is crucial to Dr. Arole, 75, who, along with his wife, Mabelle, founded the Comprehensive Rural Health Project (CRHP), known for its “Jamkhed Model”.
In 1970 the Aroles returned to India and established CRHP in Jamkhed, a small city, in the state of Maharashtra, about an eight‐hour drive east of Mumbai. The area is situated in a poor, drought-stricken area, with no industry, little sustainable agriculture and a failing market system. CRHP was created to treat complicated illnesses and emergencies. The Aroles’ reputation and education gave the project credibility and elicited support.
Their goal was to focus on diseases that were caused by malnutrition, water-borne infections, poor sanitation, and “the traditions, the taboos, and the social injustices that are meted out to certain weaker sections of our society,” said Dr. Arole.
To understand the link between poverty and health, the Aroles decided to live on the same amount of money that an average village family earned, which was approximately US $7.00 per month. By doing this, they realized that securing food and water was much more important for the people of Jamkhed, than the practice of good public health.
The Aroles reached out to donor agencies that funded food-for work programs. Citizens were employed as daily wage laborers to build dams and were paid one bag of grain per week. Health and wellness lessons, and discussions of home-based, low cost prevention and care programs to enhance children’s nutrition, prevent diarrhea, and control pneumonia were provided in conjunction with these construction projects. By providing basic medical care to workers and their children, the Aroles established an initial trust with the residents of Jamkhed. From there, the Aroles were able to start their mission of instituting trained health workers in the villages.
As the Aroles’ aim was to promote preventative over curative medicine, believing that preventative medicine would be a self-sustaining system, they decided to bring such knowledge, treatments, and means to the poor villagers and established the “Village Health Worker”. In the beginning, these women were to promote health education, prenatal care, immunization, and nutrition, however, through the following decades, their roles expanded exponentially.
It was a social experiment that initially covered eight villages and a population of 10,000 villagers. With the project’s success, the model rapidly expanded and today covers close to 500,000 people across 300 villages, demonstrating that many health problems can be prevented and controlled at the village level without the need for expensive equipment and personnel. A Village Health Worker, Arole said, can take care of 80 percent of the village's health problems, because most are related to nutrition and the environment. Infant mortality, one of the Project’s top priorities, is actually three things, according to Arole: chronic starvation, diarrhea, and respiratory infections. For all three, doctors are unnecessary.
The Village Health Worker:
The Village Health Workers were chosen from the dalit, or untouchable castes, and the Aroles requested that villages outside Jamkhed send young married women from a lower caste to the center for training. If a Village Health Worker was from a higher caste, it was believed that she may not want to work for the lower caste villagers and would not be knowledgeable about the true problems of the poor. The Aroles believed that women with families would be most able to target, treat, and prevent the problems of the average household.
The health workers' first task was to recognize themselves as people. After being selected and sent from their village, the young women began two weeks of training on the campus in Jamkhed. The Aroles' daughter, Shobha, who is now associate director of the program, assisted in some of the training. "I would ask, ‘What's your name?' and they would say the village they come from and their caste. They had no self‐identity."
The Aroles sought to empower these women before sending them back to their villages. This training continues to this day and the community of women meets at CRHP every Tuesday. Many of the original Village Health Workers, and the new trainees, return for two days to discuss problems in their villages, review what they learned the previous week, and address a new area of medicine or preventative measures.
In the beginning, all the women who came to train at Jamkhed were illiterate. Today, the majority are still so. Training methods used at the hospital employ more creative and hands-on means of conveying the facts about public health. Women are told folk stories, shown charts and graphs, study anatomy by goat dissection, and are made to write their own songs, skits, dialogues, and puppet shows to not only cement what they have learned, but to then be able to take the lessons back to their villages in a way that villagers will understand.
The Village Health Workers have said that their training motivates poor and destitute women to spend hours of their day on work that offers them no financial gain. Most Jamkhed health workers are lifers and very few ever leave, and older village health workers take it upon themselves to mentor new ones.
CRHP purposely chose women, for Village Health Workers, from predominantly lower castes. These lower caste women were invited, along with the higher caste health workers of the wealthier villages, to train together at the facility in Jamkhed. Initially, health workers belonging to the upper caste refused to sit and eat together with the low caste trainees. Over time, these caste distinctions degraded and, as a sign of unity, all the Village Health Workers stitched a huge quilt, composed of patches stitched by both high and low caste groups. At night, the women would sleep together under this quilt.
In the Villages:
The health workers were not accepted quickly. It took months or years for a village to start listening, and it was the dramatic decrease in both infant and child mortality rates that helped to cement the role of the village health worker. The women were also supported by a mobile team, established by CRHP. The team was composed of a nurse, paramedic, social worker, and sometimes a doctor. They would visit each village every week in the beginning, then less and less often, only treating the hardest cases. This team was created to not only tackle the most severe illnesses of the villagers, but to reinforce the authority of the Village Health Worker.
Village Health Workers receive intensive training from CRHP in primary health care and health promotion, including family planning, women’s and children’s health and home-birth delivery. Training is also provided in personal and community development, organization and communication skills. These workers share knowledge about health in their respective communities through discussion groups and household visits. During discussions with community members, Village Health Workers address issues such as child care, family planning (contraception use increased from less than 0.5% in 1970, to nearly 60% as on 1999), adequate birth spacing, nutrition, hygiene, sanitation and safe drinking water. They are given a small medical kit and a birthing kit. These women are capable of administering basic remedies and medications, performing safe deliveries, and detecting and referring high-risk pregnancies and deliveries to the CRHP hospital.
With the institution of these workers, there has been a significant reduction in child malnutrition, diarrhea, pneumonia, leprosy, HIV/AIDS, tuberculosis, and malaria, along with other common diseases associated with standing water from the lack of sanitation and liquid waste disposal systems.
Despite these improvement in health care, come problems with this health care worker model were encountered in the villages. Husbands would refuse to allow their wives to become a Village Health Worker or to receive treatment from one. Some women took their new-found sense of freedom and abandoned their husbands and families. In some cases, the Village Health Worker would illegally sell the drugs to the highest bidder or refuse to give treatment without payment. While women were chosen to be health workers through a town consensus, some villages refused to decide and would not accept the new model. In addition, not all women were able to travel to the Jamkhed facility for training. Often, the young woman’s town would be too far away and there would be no bus available. During the monsoon season, very few women could reach the facility at all.
Maternal and Child care:
Superstition was one of the first obstacles the Village Health Workers had to face. Infant and maternal mortality, along with many other diseases, increased because of such beliefs. To villagers in the Jamkhed area, disease came from the gods.
If a new mother died in childbirth, the child was then killed. Villagers saw the mother as unclean, and the child, therefore, unclean. Many cases of maternal death resulted from infections by dirty instruments during the delivery. CRHP trained the Village Health Workers particularly in the methods pregnancy care, such as monitoring blood-pressure and checking for anemia, and in safe and hygienic childbirth. There were other widely accepted superstitions surrounding basic nutrition for pregnant women. They were told not to eat very much, and new mothers would wait several days before starting to breastfeed.
The effect of CRHP on childhood mortality, measured from September 1992 to December 2007, showed a 30% reduction in the hazard of child death after the neonatal period for CRHP villages, as compared with villages in the control area. The reduction was significant at the 5% level. Since its conception, CRHP reduced the infant mortality rate from over 200/1000 to approximately 20/1000 (less than half of the figure for the rural area of the state of Maharashtra), with 95% being “safe deliveries” out of the 79% (data for 1999-2003) of home deliveries. A research project to measure malnutrition and illness among children under five in fifteen CRHP villages, conducted from October to December 2002, showed that malnutrition was less than 15%, while the average for India is greater than 50%. Immunization rates were 99% for measles, DPT, and OPV vaccinations in CRHP villages.
The Aroles believed that preventative medicine begins by identifying the root of the problem. Gender inequality was one of the first major targets CRHP wanted to attack. Most female villagers were married before the age of 10, started having children before 14, were beaten by their husbands (according to a 1996 UNICEF survey, up to 45% of men in India acknowledged physically abusing their wives), and eventually abandoned by them .
In each village, the Aroles asked the Village Health Worker to form an Adolescent Girls Program. The program teaches girls, ages 12-18, health education and personal development, and self-defense, and fosters discussion and creative activities in order to promote self-esteem and a sense of empowerment. As a result, more women are postponing marriage until 18, the use of contraception and voluntary hysterectomies have reduced family size, and more girls are attending school.
Additionally, CRHP helps village women to receive micro-credit loans from local banks and provides them a means to become economically independent. The loans allow the women to earn their own living, generally by selling vegetables or raising farm animals.
The Aroles chose young women as Village Health Workers to begin the process of breaking down gender inequality, but contributing factors are still heavily present—socioeconomic class, son preference, early marriage and pregnancy, and violence. Qualitative research of Jamkhed’s surrounding area has supported the success of these programs. Adolescent Girl Program members are seen to have more knowledge about nutrition, reproductive health, maternal health, hygiene, and sanitation, and are found to have healthier weights and other health indicators, as compared to non-members.
A 2010 study used qualitative methods and surveyed 18 Village Health Workers and found 6 themes consistent with a successful approach to empowering women. These included trusted sources of knowledge, effective learning methods and environment(s), qualities of effective Village Health Workers, defeating stigma, empowerment through critical assessment and community organizing, and motivation to serve.
CRHP provides ongoing education, training and support for Village Health Worker (VHW) selected by their villages. These VHWs voluntarily work with the organization to provide health education and primary health care in their villages. Currently, CRHP works with 55 VHWs in 45 project villages. CRHP also works with communities to help form groups such as the Farmers' Clubs, Women’s Self-Help Groups and Adolescent Girls/Boys Programs. Through these, project villages are able to identify their own socioeconomic and healthcare barriers, and collaborate in implementing the necessary solutions.
Mobile Health Team
The Mobile Health Team serves as a nexus between the project villages and the doctors and development personnel. The Team is composed of a social worker, a development personnel, a paramedic, two nurses and one doctor. The MHT conducts home visits to assist VHWs in more complicated medical matters, as well as collects vital statistics for healthcare monitoring. The social workers also advise on social and economic initiatives, meeting regularly with the Women's Self-Help Groups, Farmers' Clubs and Adolescent Groups.
Hospital and Training Center
The Julia Hospital is located on CRHP’s campus in Jamkhed. It is a 50-bed facility, equipped with modern diagnostic and therapeutic equipment. The hospital uses a sliding scale fee structure that provides affordable healthcare to an underserved rural population of over 500,000. Additionally, the hospital hosts weekly cataract surgeries and monthly family planning camps free of charge to the community, in partnership with private funders and government agencies. In 2010, the hospital served over 21,000 outpatients and over 1,700 inpatients.
The hospital also serves as a training facility for VHWs, as well as a demonstrative tool for students in training programs. The Training Center was established in 1994 to demonstrate the CRHP approach, in an applicable and scalable manner, to domestic and international representatives from NGOs, governments and healthcare professionals. Since 1994, 22,000 local and 2,700 international visitors have received training there. In 2010, the Institute worked with 779 domestic trainees and 186 international visitors.
2005 Mother Teresa Memorial National Award for Social Justice
2004 Dr. Babasaheb Ambedkar Dalit Mitra Award for work among marginalized classes
2003 Diwaliben Mehta Award for Tribal Work
2001 National Award for Work among Tribal People
2000 R.B. Hiwargaonkar Award for rural health service using Grassroots workers as Change Agents
1988 National Council of International Health (now known as the Global Health Council) Award
1966 Paul Harrison Award for outstanding work in rural areas
In 1989, the Aroles received a grant for two years to write a book about their experiences. Jamkhed, published in 1994, chronicles the work of CRHP from its inception. It has become a classic read for students and practitioners in the field of public health.
- Arole, M. & Arole, R. (1994) Jamkhed - A Comprehensive Rural Health Project. Macmillan Press: London, UK.
- Mann V., Eble A., Frost C., Premkumar R. and Boone P. (2010) Retrospective comparative evaluation of the lasting impact of a community-based primary health care programme on under-5 mortality in villages around Jamkhed, India. Bulletin of the World Health Organization, 88: 727-736.
- Comprehensive Rural Health Project (2011) Annual Report.
- Rosenberg, Tina (14 February 2011). "Villages Without Doctors". The New York Times.
- Rosenberg, Tina (18 February 2011). "What Makes Community Health Care Work?". The New York Times.
- The Times Of India http://timessocialawards.timesofindia.indiatimes.com/organisation_details/9784867.cms
|url=missing title (help).
- Perry, Henry. "Recognition of Dr. Carl Taylor and Dr. Rajanikant Arole as Recipients of the Gordon-Wyon Award for Excellence in Community-Oriented Public Health, Epidemiology and Practice". American Public Health Association. Retrieved 5 November 2011.
- "CITATIONS for Rajanikant Shankarrao Arole and Mabelle Rajanikant Arole". Ramon Magsaysay Award Foundation. Retrieved 7 November 2011.
- Arole, M. & Arole, R. (1994) Jamkhed - A Comprehensive Rural Health Project. Macmillan Press: London, UK.
 Singhal, A., & Chitnis, K. (2005) Community Organizing for Health: A People-Centered Vision of Health. Mica Review, 2(1), 47-55.
 Rosenberg, T. (2008). Necessary angels. Natl Geogr Mag, 12, 66-85.
 Antoniello, P., Kothari, P., Thakkar, P., & Kaysin, A. Sustainability and human rights: Village health workers training and practice. In Annual Meeting.
 Pincock, S. (2011). Rajanikant Arole. The Lancet, 378(9785), 24.
 Arole, M., & Arole, R. (2002). Jamkhed: the evolution of a world training center. Eds. D. Taylor-Ide & C.E. Taylor. Just and lasting change: When communities own their futures. The Johns Hopkins University Press.150-160.
 Gates, C., Arole, R. S., & Arole, S. (2004, November). Sustainability and significant impact through equity, integration and empowerment: Comprehensive Rural Health Project (CRHP), Jamkhed, India. In The 132nd Annual Meeting.
 Arole, M., & Arole, R. (1994). Jamkhed: a comprehensive rural health project. Macmillan Press Ltd
 Gates, C. Addressing human rights through community-based primary health care: Expanding the Jamkhed model to indigenous communities in India. In Annual Meeting.
 Chitnis, K.S. (2005 August). Communication for empowerment and participatory development: A social model of health in Jamkhed, India. In College of Communication of Ohio University.
 Chitnis, K. S. Overcoming caste barriers, mobilizing communities and achieving integrated development: Community-based primary health care experience in Jamkhed, India. In Annual Meeting.
 Thakkar, P., Kothari, P., Kaysin, A., & Antoniello, P. Community-based primary healthcare the Jamkhed Model: Overcoming domestic violence and traditional gender roles. In Annual Meeting.
 Mann, V., Eble, A., Frost, C., Premkumar, R., & Boone, P. (2010). Retrospective comparative evaluation of the lasting impact of a community-based primary health care programme on under-5 mortality in villages around Jamkhed, India. Bulletin of the World Health Organization, 88(10), 727-736.
 Arole, S., Premkumar, R., Gates, C., & Pandit, Y. (2003, November). Improving reproductive and infant health through community-based primary health care: The Jamkhed, India, experience. In The 131st Annual Meeting.
 Crandall, A. (2003, November). Morbidity and mortality among children under five in Jamkhed, India. In The 131st Annual Meeting.
 Ramsey, N. J. Empowering adolescent girls: Study based at Comprehensive Rural Health Project in Jamkhed, India. In Annual Meeting.
 Kaysin, A. (2010). Treat the with love: Empowerment of community health workers as agents of change. (Vol. 1). Baltimore : Johns Hopkins Bloomberg School of Public Health.