My visit to Madhya Pradesh in India to explore implementing partners for the traditional community ( tribal caste) based sex workers

[Dr.Vandana P.Bhatia]

I take this opportunity to describe what I learned during a professional visit to the tribal districts in Madhya Pradesh, India. Before I embark upon the journey I would like to describe that India with its mutiple cultures, castes and communities has a caste based hirearchy which is still alive in most urban and rural India. Infact access to socio-economic and educational empowerment are rather determined by the hirearchy in many regions despite an equity based system in the country.

This visit was undertaken to explore developing interventions and identifying potential intervention partners for sex workers reported on the Ratlam - Mandsaur- neemach trucking route on the Madhya Pradesh and Rajasthan border. This is a tribal belt and consists of a community known as the Banchadas who traditionally practice sex work since more than a 100 years.Similarly there is another community the Bedias on the Sagar- Guna- Shivpuri- Gwalior- Morena belt on Madhya Pradesh and Rajasthan border who also practice sex work traditionally. The visit report below captures the reasons and needs of the communty in this region.

I started our journey from New Delhi Airport and reached Indore on Sunday 12th August 09 at 8 pm and was joined by our local focal persons form our Madhya Pradesh Office at UNFPA.There was a night stay at Indore. This was followed by early morning departure by road on the 13th of August 09 to Jhabua – Meghnagar about 150 kms from Indore. We reached the Jeevan Jyoti Sanstha a Faith Based Organsiation (FBO) with a hospital in Meghnagar for the tribal population, catering to primary health care facilities and a few specialized facilitiesavailable. Real Medicine Foundation (RMF) has partnered with Jeevan Jyoti Sanstha (JJS) to reach out to the Bhil tribes for health, literacy related issues. RMF has supported JJS to form the ART Centre, Link ART Centre (LAC) , Network of People Living with HIV/AIDS in Jhabua and ICTC under PPP all funded by MSACS. The team was received by Ms.Kaitlyn Mcquilling from the Real Medicine Foundation and Mr.Jimmy the counselor of the Positive network of Jhabua.

RMF was founded by Dr.Martina Fulkes a pediatric trauma surgeon for post Tsunami relief. It started with clinics for Post traumatic stress, physical therapy, trauma support in Sri Lanka. It then moved to Kashmir to help the communities cope with the post effects of the Earthquake. It further snowballed from disaster to disaster and reached the high poverty zones in Pakistan, NWFP, Sudan, Myanmar, Indonesia, Peru and India. It then started developing community need based health projects like mobile clinics in flood zones in Mozambique, care for Paraplegic and Quadriplegic through special clinics in Pakistan, Microfinance based initiatives in Indonesia and other regions. In Madhya Pradesh they work in the districts of Jhabua, Alirajpur, Khandwa, Korgaon and Dhar currently on ths iesue of Malnutrition among tribals in 100 village. they have identified about a 1000 children with moderate to severe malnutrition.

In Jhabua they piloted the HIV testing in every patient attending the nutrition centre. They detected 170 People Living with HIV/AIDS and developed a network in Jhabua district. Jeevan Jyoti hospital staff was trained and sensitized in Jhabua to treat and provide care and support to the patients. Jeevan Jyoti also has projects supported by Sight-Savers International since 2002 to treat and prevent blindness and provide ophthalmic care to the rural population. They also have other projects with Help age India for the ageing population.

The Positive network Drop In Centre (DIC) is in the JJS campus. They have identified 17 Transgender and 72 MSM population in Jhabua, Meghnagar and Ranpur who are living with HIV/AIDS among the 170 PLHIV. 22 of them have succumbed as they were brought in with terminal illness. The remaining 143 are living with their families. 54 of them are on ART from the Indore ART Centre and the network organizes accompanied referrals to the ART centre on a monthly basis for regular clinical follow up, supply of monthly ART, and CD4 tests at baseline and 6 monthly intervals.

Dr.Fabian Toegel with the Clinton Foundation partnered with JJS when he was doing his thesis among the tribal population of Jhabua. He then became the technical advisor of the Care and Support program for JJS. He is part of the Clinton Foundation initiative in India which works on training and sensitization of government and private medical staff on ART and clinical management of HIV.

JJS was founded in 1989 under the Catholic Diocese of Jhabua in Meghnagar 16Kms from District HQ Jhabua in MP. Earlier their tribal and social welfare programs were conducted under the banner of the Pragati Sansthan. Their aim is to see an empowered Tribal Society freed from ill health, malnutrition, lack of education, superstition, poverty and suppression, thus enjoying the freedom and self esteem. Their mission is to initiate development programme to bring about socio-economic transformation in the lives of the people, particularly the Tribal women living in the far remote areas of the society, focusing on their health, education and income generation activities.

The team collected the detailed information from the interventions in Jhabua by JJS and Real Medicine Foundation (RMF) and moved to travel to Ratlam at 5 pm.

The team reached Ratlam at 9 pm in the night and halted there for the night. Early next morning the team left for Mandsaur.

At Mandsaur the team visited the District Hospital in Mandsaur to review the ICTC, STI and RH services , the Indian Red Cross supported de-addiction centre and visited the NGO intervention – Bal Mahila Vikas Sanstha running Targeted Interventions with the Banchadas initiated under SACS in April 2009.

At the District Hospital the ICTC Senior Counselor was the District Supervisor for the District AIDS Prevention & Control Unit (DAPCU). The DAPCU is part of the NRHM & HIV convergence under NACP III. IT is headed by the CMHO who supervises the District Program Officer (DPO) , an Accountant and M&E officer. It ensures the linkages between the RH and the HIV program at the district level. Under NACP 3 the 24 hour PHCs are also added with ICTCs, STI clinics. The DAPCU is a monitoring body to ensure that the staff training under RCH program is completed, supplies are in place for STI drugs, ICTC kits , condoms and other needs. The ANM, MPW and ASHA trainings and their impact needs to be supervised. The District Supervisor mentioned that in 2008 they conducted 2027 tests of which 112 reported as HIV positive. A total of 453 positive cases were reported out of 6000 tests conducted from 2002-09. The aim with the DAPCUs in place was to increase referrals for testing from the reproductive health population, ANC population, young men and women, and high risk groups. However despite the trainings the referrals from the ANMs and MPWs for the ICTC testing and STI management is not forthcoming. There are discussions on linking referrals to incentives however that is not sustainable as a model.

The ICTC counselor also informed that although there is a high concentration of the Banchada community in the district, they usually travel to the local preferred providers in the private sector. The government had a launched a scheme for the benefit for the community . However one of the past district collector's misinterprete the scheme and broke their houses. This did not go well with the community. As a result the community avoids accessing any of the district health services as they want to avoid being identified by the government.

Another interesting fact shared by the llocals was that for a girl to marry in the Banchada community the traditional system is that the boy is asked for dowry anywhere between Rs.25,000 to Rs.100,000. The girl who is supposed to marry never enters sex work. The first daughter enters into sex work as she is wedded to the local goddess Nari Mata. However due to the reverse dowry tradition, it gets difficult to get a groom for the marriageable daughter who as they can't afford the dowry. Most men in the Banchada community do not work and are dependent on the income of the daughter who is into sex work. These men are also alcoholics and opium addicts. Mandsaur and Neemach are official opium growing belts and illegal leaking of opium in the open market leads to a lot of addiction to chasing heroine in this belt. Also Extra-marital affairs are common among men in these communities.

The ICTC counselor further took the team to the UNICEF supported 24 hour call centre for pregnant women implementing the Janani Express an ambulance service, which reaches the desired villages as and when calls are recieved on the helpline. The call centre receives 317 calls per month and there are 4 people on rotation in the centre. They have 8 hour shifts but no weekly leave sanctioned in the program. They take the leave by adjusting the shifts among each other. The counselors are paid Rs.3000/- per month. The ambulance is part of the Rogi Kalyan Samiti scheme ( Janani suraksha Yojana) where Rs.1650 is the incentive for the mothers delivering in the hospital. Rs.250/- are deducted for the ambulance service from the incentive to the mother. In case of caesarean section the ambulance also leaves the mother back to home after the post-op stay.

The District hospital also runs a De-addiction centre supported by the Indian Red Cross Society. Dr.Ojha is the Centre head and he described that heroine/ smack chasing are the common addictions among the tribal’s as it is an opium growing belt. The centre has beds for admitting the addicts for 3 weeks where thy are treated with medication , counseling, yoga and provided with meals. Bupenorphin substitution therapy is used by the centre. Dr.Ojha shared that to work with the tribal communities on the issue of sex work De-addiction among men would also need to be addressed. Only then the issue of FSW rehabilitation can be sustainable for a long term.

The team then proceeded to meet the NGO Team of Bal Mahila Vikas Targeted intervention among the Banchadas in Mandsaur. The NGP had a Banchada community member working as a peer educator and who shared a lot of details regarding the community. The NGO is a NACP III based TI project intervention in about 22 villages in Mandsaur. The NGO workers started with baseline mapping in Mandsaur and Neemach and are now concentrating their work area to only the Banchada community in Mandsaur. They have 1 counselor, 3 Out Reach workers , accountant, peer educators and Program officer. The NGO informed that in Ratlam another NGO called Samarpan was working with the communities. The population in Banchada identified was 600 FSWs among 5000 Banchada families distributed in about 30-32 FSWs per village. Most visit quacks and other private Health Care Providers (HCPs) for their health needs. During the HCP mapping the NGO identified the most sought after 20 HCPs most of them being Registered Medical PRactitioners (RMP), quacks and one of them a Gynecologist and paediatrician. They ahve had advocacy meetings with them. They further plan to train these HCPs on STI syndromic management by MPSACS. The Banchadas mainly visit HCPs for health needs of the mother and children.During the baseline community needs assessment, the Banchadas reported a demand for condoms and STI care, Reproductive care and education for children. Soem young genderation also expressed the need to come out of sex work and have access to alternate income genderation programs and or educate their children so that they can give them a better futire.

The team asked the community members the origin of sex work on how do the community members seek information/ gain knowledge.The NGO team mentioned that through the clients and exposure to television are the main sources of information for the communityi. No newspapers reach as only 1% are literate in the community.The Banchadas of the younger generation have seen some education and are now ready to get out of this practice but the mothers and grandmothers resisting their exit.

The peer educator mentioned that, Banchadas were actually Rajputs and the women were sent by Rajput kings to the military base in Mhou, to get access to the military secrets. That is how the FSW trade started and the families of the FSWs started enjoying special privileges of the Rajput kings due to their special status as secret informers. Thus its more than 100 year old tradition. It was also encouraged by the traditional practice of marrying the first girl of the family to the Goddess Nari Mata. Thus the men celebrate when the first born girl attains puberty and is considered the bread winner of the family. The men act as pimps.

The team asked the NGO if they would be fine with other NGOs / CBOs being set up in Neemach and if it was ok to approach MP SACS to plan interventions there so that the Ratlam, Mandsaur and Neemach trucking route would be covered completely. The NGO was keen to welcome other NGOs working in Neemach and was also looking forward to technical support from other partners to improve the quality of their interventions. The NGO was not visited by the TSU for any monitoring visit so far and needed monitoring support. They also needed more information on Condoms as some FSWs had heard about them and were demanding them as well.

The team then proceeded to Indore from Mandsaur at 2 pm to catch a flight to Bhopal. Due to the bad roads and rains the team was taking double the estimated time to cross the destinations. The team reached Indore by 7.30 pm. The flight was delayed by more than 2 hours as it was a connecting flight from New Delhi- Indore- Bhopal –New Delhi. It was also delayed by congestion in Mumbai.Although the roads were bad the greenery during the rains made the drive more than tolerable.

The team reached Bhopal at 11.00 pm. Next day by 10 am the team proceeded to meet and discuss the possible strategies to be put up to the MP SACS while meeting the team there. The team then had a very fruitful discussion with the MPSACS.

At Bhopal we finalised our strategies with the Real Medicine Fooundation and proposed the activities to the MP State AIDS Control Society.

The trip ended with delays at the airport and we reached New Delhi from Bhopal by 12.30 /1.00 am on the 15th July 09.


The key points for learning/ scope for UNFPA in MP SACS are mentioned in the Summary below:

There is scope for innovative interventions among the Bedia and Banchada communites for HIV prevention, care and support activities. The activities to be designed should be sustainable and community based rather than lead by NGOs. However, NGOs need to be partnered with locally to provide technical support for monitoring and evaluating the quality and impact of the interventions.

UNFPA proposes to take the lead in developing this with the potential partners RMF and JJS and the proposed intervention would be put up to the Local SACS in the next one month for both the communities. However, since there are other factors local partnerships need to be developed to address the opium and alcohol addiictions with the men of the communities, the other needs like school education and reproductive health needs of the community need to be addressed as well. Also there is a need to explore the interventions with the clients of the sex workers- truckers and migrants on the route through various partnerships at the SACS and local NGOs and private partners. Thus a holistic approach would be needed to sustain these interventions.

UNFPA proposes to develop the FSW CBO interventions and llink up RH,STI, HIV prevention, care, support interventions in the program. We further will ensure availability of male and female condoms in the program as well. Other link ups with local socio-developmental packages will be developed within the program.

We will keep the AIDS competence community posted on further progress with this initiative and welcome more suggestions to develop this challenging intervention.

I will also add up the photographs of the field visits to this blog shortly.

[rebeka sultana]

Dear Vandana,

You have brought me to India through your vivide description of madha pradesh and the tribal communities. I could see the roads, the greenaries all. I enjoyed reading your blog and learned also. To me the tribal communities, their day to day lives seems like another world, yet it is the reality. And this reality brough HIV, RH issues among other. As they are living in that belt and having the tradition of sex selling they also would be organized as a community. They have their own rules, traditions whether harmful or neutral we do not know yet. Any initiatives lead by the community would be good that I see, rather than outsiders plan for them.

While UNFPA works and partners with service providers for information, RH issues including STI managemnet, VCT, ART as it comes necessary to do so, community facilitation by AIDS Competence has great potential there. Before finalizing your programme strategy and design I think you may wish to bring one ACP coach who has similar experience to work with the tribes, for a SALT visit and reflection. What you might get from this is you will see the community through their lens and you may compare the findings with your visit that you have done by yourself as discussed above. I am sure lot of things will come out in the day light and that will help to contribute the programme.

Last week I was in Jayapura, Papua. Tribal lives are visible there too. They said ' we have been getting info on HIV for more than a decade and no one asked us what we think about HIV, what we can do for ourselves to protect' . You see...

Regards,
Rebeka

[Dr.Vandana P.Bhatia]

Thank you so much Gaston. This is very helpful! I will go through these links and get back to you for any more queries.

[Gaston]

Dear Vandana,

I understand your need. In general, this is the challenge for community-based approaches: How to make them relevant and measurable both quantitative and qualitative. Some links and ideas:

1. The self-assessment framework can function as a way to stimulate ownership, but also to measure progress over time. The community will measure its own progress. Besides this, the 'intervening' organisation can measure its own indicators on a meta-level and measure more process-related indicators. Find attached an example of how the self-assessment helped districts in Bangkok to self-measure progress on their AIDS Competence. It shows both ownership of M&E and gives quantitative data. At the same time, with good surveillance, increases in service uptake can be monitored and attributed to some extent. Our key lesson though is: let communities take ownership of the solution as well as their measurement of progress (practice 8 in the self-assessment framework). Outside organisations can strengthen their capacity to do this, but not measure the progress for them.

2. Secondly, qualitative capturing of results of community-based approaches can be very meaningful as well. We use a lot of video interviews (max 3 minutes) with testimonials. This not only provides an opportunity for illiterate people's experience to go beyond their community, but also is a great stimulus for the local response. People feel proud when you make a video of 'their progress'. See an example here:

3. Finally, several studies have investigated the outcomes of the AIDS Competence process through quantitative and qualitative evaluations. Find attached a 1-pager with extracts. The UNAIDS study specifically (coordinated by Paul de Lay) was very strong in its quantitative and qualitative measuring of outcomes. The links in the one-pager go to the full PDFs.

4. Finally, I was thinking how UNFPA plans to 'guage the community needs through a needs assessment'? An idea that works well in other contexts is to first start with a 'strength-analysis' and then explore their hopes, concerns and do their self-assessment (on HIV, reproductive health or other issues). We have learned that communities take action from their strengths, not from their weaknesses or needs. They address these by using their strengths. In many cases communities are not aware of their own potential and capacity. Outcome measurement at scale through AIDS Competence.pdfFor the framework on reproductive health, please contact Rebeka.

I hope this is helpful. I would be interested to see where the program design is going to.
1- page of AIDS & Malaria Competence evaluations.doc
Outcome measurement at scale through AIDS Competence.pdf

[Dr.Vandana P.Bhatia]

Dear Gaston,Rituu and Geoff

I am grateful for the comments and learnings shared by you all. I would also like to add, that there is study report on the HIV epidemic in Madhya Pradesh which yet to be published by UNAIDS India. Its a draft report and it has also mentioned the two tribal communities. It has probably coevered most of these issues and i am awaiting its official dissemination.
I will look at the link sent by Gaston on the Burundi experience and take lessons from it.
At this point UNFPA is developing a proposal for a Community based intervention with the local partners.

I would quickly need from the group a few more links and lessons on how to make the community based approach more meanigful as well as measurable with regards to qualitative and quantitative process, outcome and impact indicators? Also keeping in mind the mandates, UNFPA would initiate the action on the issues of sex work and then move on or add other linked issues in the intervention once the community need is guaged through a needs assesment. What I may need is suggestions, which we can effectively incorporate to make the intervention better and more sustainable.

[Gaston]

Hi Vandana, I forgot to include the link to the Burundi experience: http://www.aidscompetence.org/content/news/news_august2008/4_news_august2008.htm

[Geoff Parcell]

Wow Vandana, my head is spinning with your report! There is so much going on in this region and so many problems, but a lot is happening to help already.

A big lesson I have been reminded of is that we are all human. One of the great questions was posed by Usa Duongsa who asked us "Are we more human than them?" It is a profound question for even just thinking about it changes my attitude from service provider which makes the other person the victim to being equal. I visited the Philippines recently and one person learning the ACP process was surprised to find out she shared tastes in music with a PLHIV person. In fact she was chatting while waiting for the PLHIV to be ushered into the room. It was 20 minutes before she realized they didn't look any different, they didn't sound any different, they had similar likes and dislikes, in fact they were completely human and they were already in the room!

The other thing that ACP reinforces for me is the power of looking for strengths in others rather than looking for problems. If we look hard and listen hard for the positive points, then everyone has something to be proud of. By helping people identify those encourages them to take charge of their situation and then we can support them to respond to their situation.

You started off your report with context setting and mentioned hierarchies. I remember being in a village in Karnataka when NGOs were focusing on the vulnerability of young women. So they met frequently with the young women, approved by the elders. I spoke to a group of young men in the village. When I listened to what they had to say then they complained, "No one ever comes to talk to us!" Yet are they not part of the solution if we want to avoid the spread of HIV? Later after speaking to various groups separately we brought them together in the village hall, including elders of the village. If we give everyone a voice, if we allow everyone to say what is on their mind, then it is amazing how quickly hierarchy becomes less important in dealing with issues that are important to the community.

I'm wondering, do you have any questions for the participants in this forum?

[Rituu B. Nanda]

Dear Vandana,

Thanks for a very comprehensive report of your field visit. The region has an array of inter-linked issues - substance abuse, sex work, alcohol use, HIV, migration, blindness, gender, unemployment, dowry, extra-marital another risk of HIV, and illiteracy. I was wondering why blindness is an issue. A worrying fact is that among 170 PLHIV, 89 are MSM/TG.

The issues mentioned are plenty and have been in existence for decades. I agree with you that a holistic strategy will help address these issues. A community-driven approach where people themselves recognize their risks and apply their own solutions can prove cost-effective and sustainable. NGOs can link them to resources and services. We often see that inspite of access, especially in case of prevention services people do not avail them. You can take a horse to water but you can't make it drink.

Gaston has cited several international experiences. In 2006, local government including NACP and Mayors joined hands with UNFPA, Indonesia to apply ACP in three cities.

Here are some of my Indian experiences. As a part of Samraksha team, I was in a Karnataka village in 2007 where a group of villager elders shared this with me. They were scared of HIV and would throw out PLHIV from their villagers. The earlier cases in the village were among men who were away from the village for study or work. Mutual discussions revealed root of the problem. Due to lack of higher education and employment opportunities in the village, men were forced to go to cities. Once these men acknowledged their vulnerability and the risk they were putting their families to, they begin to act upon it. Condom usage increased in the community. When we visited the village, they had built a house for a homeless PLHIV. What a transformation in attitude!

Similarly, SIAAP (Chennai) has been applying the community based approach for some years. It used the ACP tool of the self-assessment process with an association of Women in Sex Work. When sex workers compared themselves with the general community, particularly with their family members they realized that that response to HIV had become a part of their day-to-day life. When I met such a group last year in Nagercoil I was impressed. The group is sought by NGOs to help them in condom demonstration and called upon by the villagers to settle disputes.

At Dinthar in Mizoram, it is impressive to see that the general population in the area has taken over the Salvation Army’s IDU program including its funding. Salvation Army staff are now mere visitors.

Services are most important but not sufficient. Community based approach can complement the TIs and act as a glue and bring everything together. It takes time but results are lasting.

Hope you find this useful.

Warmly,

Rituu

[Gaston]

Thank you Vandana for sharing your interesting experience here in this fascinating context. I have a few reflections:
- Regarding the de-addiction of men regarding sex-work. How do you see that happening? It is clearly not easy to change decade-long behavioural. It requires understanding and ownership of the solution. I do have one story to share about what happened in Burundi. After the SALT visits and their self-assessment, they actually changed their decade-long habit to have weddings in the evening leading to high-risk situations. Read here more

- I like your recommendation that the activities need to be community-based. There clearly IS a role for NGOs, the question is which one? For me, this goes beyond M&E, but it can be a facilitative accompaniment role where they learn and share together with the community and provide mentoring. This is the role of a SALT facilitation team, but it's not easy in practice if the NGO workers are used to a different way of working for years (f.e. bringing advice, solutions and providing incentives). AIDS Competence is one approach that is aimed at transferring these skills to the NGO workers.

- Regarding the other local factors, such as opium and alcohol. What we often see is that the community already includes this in their self-assessment or self-analysis. As they don't think vertically (disease-specific etc), they have a good overall understanding of their situation provided they are being facilitated through this process. We have to believe in their capacity to understand (and solve) their own situation. I can share a story from Papua New Guinea, where we were facilitating 'AIDS' Competence, but the young people soon found out that alcohol and drugs were the key driving factors to 'address vulnerability' (practice 5 on the self-assessment). So their action plan included actions they could take to address the drug use. They proposed to work with certain other organisations in this and the facilitation team linked them to the relevant people. Now the drug use went down with 70%, although we started facilitating 'AIDS' Competence. Communities often understand their situation very well, we just need to reveal this capacity. See a video of the youth leader here:
At the same time, other communities might not see drugs (or school or reproductive health) as a first priority. There might be more urgent things at the moment to address their vulnerabilities. It's up to them to decide and us to link them with relevant partners. For us, we need to identify their strengths from which the community will take action. These strengths they often forgot and they are not aware of them. Then it's up to the community to identify their priorities and needs. Perhaps it's not reproductive health at the moment. We need to respect that.

- So, in my experience adding a 'facilitation of local responses' component could greatly improve the results and sustainability of the program. Communities will demand themselves the services after having taken stock of their situation, their life and their priorities. They will want to take action and might ask for some support from outside. UNFPA will then be a great 'link' to the relevant organizations you are trying to partner with.

What do you think?
Gaston
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