A recent project review and experience-sharing meeting with non-governmental organisations engaged in the care of HIV-affected people in Tamil Nadu was an enriching and gratifying experience for a team from the Voluntary Health Services (VHS), Chennai.
It was in 1986 that Tamil Nadu reported the first case of HIV-AIDS infection. That it had reached Indian shores made all concerned sit up and consider the implications. The response from the governments of India and Tamil Nadu together with the United States AID Agency (USAID) was comprehensive. A tripartite agreement was reached among USAID, the government and the VHS. The VHS-APAC project began in earnest in 1995, under the stewardship of Dr. N.S. Murali, Honorary Secretary, working with marginalised communities to reduce the transmission of HIV-AIDS in Tamil Nadu through the sexual route.
Changing behaviour
The concept as developed and implemented by VHS-APAC is unique. Rather than focus on traditional healthcare intervention models, VHS-APAC chose to work through education and communication paradigms that bring about changes in healthcare-seeking behaviour. With unsafe sexual practices, poor disease recognition and delays in seeking healthcare support being at the core of the HIV-AIDS epidemic, these interventions have put particular focus on high-risk groups, while aiming to bring about sexual behaviour change in society as a whole.
To this end, VHS-APAC developed a hub-spoke community healthcare management model, involving fellow NGO organisations in Tamil Nadu engaged in community-based developmental activity including healthcare. A range of tools and paradigms were developed through expert consultation processes — using manuals, flip charts, workbooks, videos, short films and so on. These were then translated to community-based NGO partners through continuous and structured field-based training. The organisations, in turn, engaged peer educators from among sex workers, men having sex with men (MSM), young adults and migrants as volunteers and built their capacity to educate others in the community. Besides, qualified social work and healthcare professionals were trained to deliver services to the community and develop skills.
As part of these efforts, NGOs were trained systematically and mentored continuously to strengthen their operating systems and processes. Recruitment, continuous training and capacity-building paradigms, quality monitoring, accounting and audit all became mantras for the NGOs in this programme, transforming them into efficient and mature community organisations. Through this emerged, organically, a management hierarchy within the participating NGOs — from field officers to project managers and project directors.
Dr. Bimal Charles, the current Project Director of VHS-APAC, observes that there are today several community healthcare professionals in India who began their careers linked to the APAC project. They have gone on to serve the government, major aid agencies and civil society at large, holding positions of significance.
Unlike other diseases and disorders — and indeed the gamut of community problems in sectors such as housing, sanitation, education, environment and livelihood development, all of which need and are the focus of community based interventions — sexually transmitted diseases pose altogether different challenges. The high-risk groups for HIV-AIDS are predominantly insular and difficult to access — female, less commonly male, sex workers (FSW, MSW); migrant workers and truck crew members, MSM, the transgender community, and so on. Each of these groups poses unique challenges.
Engaging high-risk groups
The innovative element of the project was the engagement of “high-risk group members” as community health personnel. The barriers to accessing relatively isolated but nevertheless important target audiences, were thus breached. The openness of the members of such high-risk groups, now transformed into community healthcare professionals, is refreshing. Not only do they readily identify with their own sexual predilections but they enjoy greater success in working within their own high-risk group. Indeed, this strategy of involving the target audience in community interventions is now widely adopted in the HIV-AIDS control movement.
According to civil society leaders, this structured hub-spoke model interaction has been rewarding in different ways. HIV-based community work, they say, is so challenging that other forms of community work become relatively easy to implement thereafter. Further, the high-order communication and management skills they have developed, come in handy in community work. These projects have also unlocked the potential of civil society stakeholders; school-leavers become graduates, post-graduates, even doctoral degree-holders in the process.
Further, many participants, including high-risk group members, have assumed leadership positions of significance, integrating, networking and developing community-based organisational structures. Many senior civil society members hail this model as one on which other healthcare and development projects should be based. Equally important, the model has engendered active engagement with the government at the national and State levels.
The National AIDS Control Organisation (NACO), through the Tamil Nadu State AIDS Control Society (TANSACS), has chosen to encourage and enhance this hub-spoke model of civil society engagement; pioneering government-led innovations such as master health check (MHC) and integrated testing centres (ICTC) leverage on these developments. Indeed, this collaboration between government and civil society to prevent and control HIV-AIDS in Tamil Nadu has emerged as a model public-private partnership effort in healthcare.
The response to these interventions has been tangible. HIV-AIDS prevalence among ante-natal women attending government facilities fell from 1.13 per cent in 2001 to 0.25 per cent in 2007 in Tamil Nadu. There has been a significant decline in new cases contributing to HIV numbers.
While sceptics continue to doubt these “official” figures, there is a nationwide consensus that the sexual health behaviour change intervention models developed by VHS-APAC and others with the support of government and aid agencies and implemented through civil society, have over a 15-year period had considerable social impact. Indeed, there is a quiet determination among government officials in Tamil Nadu to achieve “zero incidence of HIV-AIDS” status in the not-too-distant future. Perhaps equally important, these developments have engendered a community-based health behaviour change model that has been demonstrated to be sustainable, replicable and capable of generalisation.
Controlling life-style diseases
Health behaviour change is the fountainhead of disease prevention and health promotion. For example, behaviours that determine lifestyle diseases like hypertension and diabetes and their consequences such as ischemic heart disease and stroke, poor dietary habits and lack of exercise, begin early in life.
Health behaviour change interventions delivered through civil society are likely to play a significant role in the control of lifestyle diseases, that much-feared new epidemic, as they are in the prevention, early identification and management of infections, mental and physical disability, maternal and child disorders, substance abuse — indeed, the gamut of conditions of concern to community health professionals and policymakers.
What we need perhaps is a global action plan with health behaviour change at its epicentre. This should be conceived and led by the government and the major aid agencies; implemented through civil society organised in dynamic hub-spoke paradigms; the systems, processes, quality and standards being in-built. These should leverage on the extensive experience and best-practice models developed through work that has been done for HIV-AIDS prevention and control in Tamil Nadu. Health for all may well be achieved if it the process is democratised: by the people, for the people and of the people.
(The writer is Honorary Secretary of The Voluntary Health Services, Chennai. e-mail- esk@nsig.org)
