In the villages the lack of adequate health services is a huge problem, especially for disabled people and the “poorest of the poor.” In theory, Primary Health Care in India is a universal human right. In practice, hundreds of millions of people face enormous obstacles to getting the health care they need.

In India government health services exist on several levels. At the village level are the “anganwadis” or village health workers, mostly village girls with a couple of weeks training. Their skills and responsibilities are so limited that they have little credibility among the villagers. They weigh babies, fill out forms, and help rally people for immunization. However, they are taught almost no curative skills. They know less about useful medicines (most of which they are forbidden to use) than do local shop keepers or the traditional healers. They refer the sick or injured to the closest District Health Center.

But District Health Centers (the second level of service) are few and far between. Time and cost to get there, and the series of bribes or “tips” required to get service, are such that the poor often go untreated. Or worse, they use up their limited food money on transport, bribes, and (recently introduced) “user fees” (or, alternatively, on local private doctors.) As a result, their hungry children become even less resistant to the “diseases of poverty.” Thus “health care” becomes another cause of ill health, disability, and death. Health department officials concede that the services of district health centers are often inaccessible to the most disadvantaged.

At the third level are public hospitals and surgical centers in larger towns and cities. Indigent and disabled persons are legally entitled to free care, along with “entitlements” such as bus and train passes. But again, the combination of bureaucracy and corruption (bribes) deprives the neediest people. Underlying these problems is the fact that the government budgets only a small fraction of what is needed to provide the services and entitlements guaranteed by law.

An Enormous Unmet Need: All this means that in rural Andhra Pradesh there is an enormous need for low-cost, competent, health services provided by, caring health workers at the village level.

A Possible Solution: Disabled Persons as Health Workers, Backed by their Sangams

In our discussions with villagers, SERC, and the APRPRP planners, an exciting possibility arose. Why not train selected members of the disability sangams as village health workers (VHWs)? A comprehensive, participatory approach to Primary Health Care could be revived at the village level. Young disabled women (and men?) from the sangams could be trained as an upgraded version of anganwadis. Their sangam could form a back-up team for health promotion. The new anganwadis (or VHWs) could embrace preventive, curative, rehabilitative, and promotive curative aspects of PHC in a manner that could more fully protect health of the poorest, most vulnerable people. Backed by their sangams, they could involve other (non-disabled) sangams, school children (through Child-to-Child activities) and other villagers, in health promoting action. Together they could address issues such as water supply, sanitation, malaria control, tree-planting, sustainable agriculture.

This way, disabled persons would play a central role in the community’s well being. People would look at their strengths, not their weaknesses, and include them more fully.

This approach could also help bring about closer links between Primary Health Care and Community Based Rehabilitation. The “Neighborhood Houses,” might evolve into Community Based Rehabilitation and Health Promotion Centers"—as part of an empowering village-based development paradigm.

Good Health Care Reduces Poverty

Studies in India show that on the average poor families spend 19% of their family income on health care-related expenses. Costs related to catastrophic illness are one of the main events that push families that have managed to cope into absolute poverty.

Empowering communities to better meet their health needs at low cost can be an important step toward reducing poverty. In the long run it can save more money than it costs (for people and government alike).

Potential for ‘Scaling Up’

Within the self-help disability sangams in Mahabubnagar, the interest and potential exist to improve health and rehabilitation services at the village level. Such an empowering approach could help meet an urgent need of the most vulnerable people. It would also increase respect and opportunities for disabled persons. And reduce poverty.

This community-based approach could be introduced, on trial basis, as part of the Andhra Pradesh Rural Poverty Reduction Program. The APRPRP, as a state-wide program, has the necessary links to government and to the health, education, and other relevant ministries. If successful, the approach can be incrementally scaled up to include all 500 mandals under the coverage of the APRPRP. And from there, who knows?