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Conference Report: Reproductive Health & Child Care Project in Jaipur, by JKSMS & MdM Conference Report: Reproductive Health & Child Care Project in Jaipur, by JKSMS & MdM Document Transcript

  • 2011 Conference Report Innovative Approaches toImproving Health in Slums Organized by, Jan Kala Sahitya Manch Sansthan Médecins du Monde
  • http://www.jksms.org http://www.medecinsdumonde.org 2
  • Innovative Approaches for Improving Health in Slums A thematic multi-session one-day Conference Inaugurated by Shri Aimaduddin Ahmad Khan (Dhuru)Honorable Minister of State for Health and Family Welfare, Rajasthan Organized by JKSMS & MdM On 4th April 2011 At OM Tower, Jaipur, India Report Compiled by: Roma Kaur Rana, Communication Specialist Umesh Sharma, Project Coordinator, JKSMS 3
  • ContentsForeword ............................................................................................................................................................................... 5Executive Summary ............................................................................................................................................................. 6Conference Background .................................................................................................................................................... 7Areas of intervention .............................................................................................................................................................. 7 Target population .............................................................................................................................................................. 7 Project Objectives ............................................................................................................................................................... 8 Philosophy ........................................................................................................................................................................... 8 Intervention Methods ........................................................................................................................................................ 8 Results ................................................................................................................................................................................. 9Welcome Address ............................................................................................................................................................. 10Inaugural Address .............................................................................................................................................................. 12The Necessity of Raising the Level of Health Knowledge in Slums....................................................................... 14 Panel Members .............................................................................................................................................................. 14Anaemia, Malnutrition and Vitamin Deficiency in Slums: The Unspoken Issues ................................................ 17 Panel Members .............................................................................................................................................................. 17Institutional Deliveries: Overcoming Obstacles in its Popularization ................................................................... 24 Panel Members .............................................................................................................................................................. 24RHC Conference Recommendations ........................................................................................................................... 26AnnexuresConference Agenda..............................................................................................................................................................27Conference Images...............................................................................................................................................................29Conference Media Coverage...............................................................................................................................................33Conference Attendees..........................................................................................................................................................................38 4
  • Foreword After almost four years of implementation, the present conference represented probably one of the most important milestones of the Reproductive Health and Child Care project. It all started four years ago, when Médecins du Monde and JKSMS decided to team up in order to respond to one of the most challenging health situations faced by the city of Jaipur: the extremely high level of maternal and child death in slums. Indeed, though the ―pink city‖ counts plenty of medical institutions (private and public) and though numerous schemes are available for themost vulnerable, it is a fact that slum dwellers tend to avoid frequenting the medical institutions. If it istrue for common illness, it is also the case at the time of pregnancy.The first phase of implementation of the project was ―bumpy‖: slum dwellers were reluctant to listen,understand or even participate to our activities. Who could blame them? Health behaviour in slums hasbeen inherited from centuries of tradition and especially the nomadic culture which prevailed in the slumdwellers communities until recently. And it is well known that nomads only rely on themselves, theirfamily or their community. This attitude has been reinforced all through by the lack of consideration andgreat despise they often get from the environment surrounding them.After month and month of project implementation involving the pregnant women, their friends andrelatives, changes were noticed: more and more women were willing to deliver at the hospital or to gofor the Ante Natal Check-up. It was probably due to a better understanding by the communities ofpregnancy related issues and schemes available. Or maybe was it also because, for the first time, thesemarginalized communities had been listened, respected and accepted for what they are.Capitalizing on its success, the project did not stop there: in order for the project to be sustainablebeyond its end, it was also important to train volunteer, within the community, to act as health worker.We call them the Community Health Workers: they dedicate some time to help other women dealingwith health issues. A second step towards sustainability consisted in advocating the cause of thevulnerable population living in slums as well as organizing events where awareness of the general publicand key stakeholders will be raised. The conference was one of these events meant at gathering people,informing, proposing, exchanging and debating.As Pandit Nehru said, ―Ignorance is always afraid of change‖. This is what this project is all about: fightingignorance, creating knowledge, bridging the gaps between vulnerable communities and medical institutionand last but not least, giving hope. Willy Bergogné General Coordinator Médecins du Monde 5
  • Executive SummaryThe Report highlights presentations and discourse which took place during the Conference on 4th April2011 in Jaipur on ―Innovative Approaches for improving Health in Slums‖ organized by Jan Kala SahityaManch Sansthan (JKSMS) & Médecins du Monde (MDM). This one-day Conference, an integral part of thepilot-project to share best practices with State Health policy makers, health workers and Non-profitorganization working in the field of health in Rajasthan, was inaugurated by the Minister of State forHealth and Family Welfare, Shri Aimaduddin Ahmad Khan and consisted of three panel sessionscomprising of stakeholders like health practitioners, academicians, State Health representatives and slum-dwellers (beneficiaries) themselves. The report highlights key points of the papers presented, outcomefrom panel discussions and best practices established during the project and approved in the Conference.The project intends to support policymakers in drafting appropriate policies as well as facilitateimplementation of policies & directives in the slum communities to ensure optimum results. The mainobjectives of this conference were:1. To present the findings of the baseline survey in selected slum areas2. To initiate an open discussion on project findings3. To create strategies for health improvement in less-privileged communitiesNearly 100 participants representing NGOs, State health department, medical profession, academia &media gathered at the conference to discuss present health policies, participation of slum-dwellers inState-sponsored health programs, general health awareness in the slums, prevalence of malnutrition inmothers or children and exchange ideas and suggestions on pertinent health issues. The conferenceopened with a plenary session followed by three panel discussion sessions covering the following topics: 1. The necessity of raising the level of health-knowledge in slums 2. Anaemia, malnutrition and vitamin deficiency in slums: the unspoken issues 3. Institutional deliveries: overcoming obstacles in its popularizationWith the release of Census 2011, which revealed that more than 50% of women in Rajasthan cannot reador write and almost 0.65million girls are missing, there couldn‘t have been a better time to organize thisconference and bring forth such findings that are proportionally related to literacy rates. Low literacyrates can affect general health knowledge which could affect the rate of institutional deliveries in acommunity. In the absence of institutional deliveries, births often go unregistered which does, indirectly,impact the instances of female foeticides in any community.The conference was unique in the sense that there was an active participation of the beneficiarycommunity. Women representatives from the project area sat through the conference and shared theirstories with the participants. The conference highlighted the inadequacy of existing communication &advocacy methods used by State Health departments and some other NGOs in slums because of lowliteracy levels and cultural trends prevalent there.. Therefore, the need to develop communication toolsthat will work with these communities was stressed by the speakers and supported by all participants. Asa best practice, JKSMS tabled the proposal to use Street Theatre and other innovative approaches to reachout to the illiterate and vulnerable masses. 6
  • Conference BackgroundThe Conference was organized as a milestone event of the pilot project on Reproductive Health and ChildCare (RHC), initiated by JKSMS and supported by MdM, in 11 slums of Jaipur to bring health knowledge tolow-resourced communities. During the past three years of the project period, JKSMS and MdM haveutilized various innovative strategies to reach out to the beneficiaries and create a means for sustainablehealth development. The conference provided a platform to share best practices from the RHC projectwith the attendees and now, through this report, to many more in the field of grassroots development. The project is implemented in Jaipur by Jan Kala Sahitya Manch Sanstha ( JKSMS). A non-profit organization founded in 1983 by a group of enterprising social activists, JKSMS works with vulnerable women and children across the state of Rajasthan for their development. JKSMS believes in democratic values based on secularity and community participation at all levels. The strategic aim of JKSMS is to ensure active involvement ofchildren in all issues that are pertinent to their existence and progress. It strongly advocates the right ofevery child to have a full-fledge childhood, where the children have the right to existence, protection,development and active participation in their growth and self respect. To implement the Reproductive Health and Child Care project, JKSMS is supported by Médecins du Monde (MdM), an international humanitarian organization providing medical care to vulnerable populations affected by war, disease, famine, poverty or exclusion. Originally established in France in 1980, the Médecins du Monde network now extends to 16 countries in Europe, Asia and the Americas. MdM‘s work depends on efforts of nearly 3000medical and logistics professionals who volunteer their time. Although MdM‘s primary aim is to providemedical care, its work goes further to ensure long-lasting effectiveness.Areas of intervention11 slums located within the municipal city of Jaipur (Akbar Road, Amar Nagar, Bagrana, Bambala, ChokhiDhani, Galta Gate, Goner Mode, Idgah, Luharon ki Basti, Railway Station, Pratap Plaza). These slums areall, except for Railway Station, in the vicinity of Jaipur. Only two slums among those previouslymentioned, are authorized slums. The others are not with the consequence that access to electricity,drinkable water as well as social services and schools is an issue.Target populationThe target population in this project is 5000 inhabitants in 11 slums of Jaipur including almost 1250women of reproductive age. 7
  • Project ObjectivesTo improve the health situation of the target population with a focus on pregnant women, pregnancyrelated issues as well as children below five years by encouraging the utilization of the private and publichealth services. By doing so, the program intends to participate in the Indian efforts to reach theMillennium Development Goals (MDG) implemented by the United Nations, and especially the objectives4 and 5, related to child health and maternal health.PhilosophyIn order to maximize the outreach of the project and foster the condition of its sustainability, all theactivities were developed with a high degree of involvement of the community. In addition to themainstream initiatives (community meetings, group/individual interactions), other innovative communityparticipation methods were implemented for the first time in Jaipur such as the utilization of traditionalstory-telling tools (Kawad box), theater performances : ―oppressed‖ method and community mapping.Intervention MethodsWith the view to attain the project objectives, several activities have been implemented: These interactive sessions are led by the Social Worker whenever Health Education Sessions he/she is feeling a need to emphasize on a particular thematic withthe goal to deliver key messages and answer audience‘s questions. The duration of the sessions variesgreatly according to the subject matter and community participation. Specific groups (husband, mother-in-law, local priests and so on) are sometimes targeted to deal with particular problems. Social Workers provide useful advice during interpersonal meetings Interpersonal Counseling or group sessions. In both cases, topics are chosen by the participantsthemselves. During these sessions, different visual tools are used such as posters or drawings created bySocial Workers and/or in some cases by members of the community (children), pictures frompubications, IEC posters, preventive tools (according to the topic) and so on. Meeting are organized in slums by the community on important subjects Community Meetings related to their particular community. It is a good way to increasecommunity participation and let them play a role in their development. Capacity -building of CHW CHW or Community Health Workers are recruited in each slum to encourage community participation in the RHC project. Theyhelp spread disease-prevention messages and accompany people to the medical facilities. In addition tothe principle of ―peer education‖, voluntary CHW are trained to gradually take over the work-load ofSocial Workers. In this case, the objective is not to ask them to fulfill the duties of the JKSMS SocialWorkers but to create the conditions of sustainability of the program with minimum external support. 8
  • Results As of As of As of Dec08 Dec09 Dec10 Evolution of % institutional deliveries 32% 41% 45% Evolution of % Dai deliveries 56% 49% 45% Evolution of % home deliveries 12% 11% 10% Evolution of % of birth with the mother completing 3 ANC 24% 46% 69% Evolution of the % of baby going through NBC 11% 24% 31% Evolution of the % women going to PNC 8% 9% 34% Evolution of the % of pregnant women covered by a Birth Preparedness Plan 62% 70% 76% Evolution of the % of participation of male to health awareness session 19% 31% 34% Evolution of the % of institutionalized deliveries getting the JSY scheme 33% 55% 61% Evolution of the % of deliveries getting the JSY scheme 11% 22% 28% Total number of live births 128 125 155 Total number of child death in the project slums(0-6) 31 20 10 Number of immunization encouraged 214 321 416 Total Number of Health Education Session 73 147 772ANC: Antenatal careNBCPNC: Postnatal careJSY: Janani Suraksha Yojana (Pregnant Women Safety Scheme) 9
  • Welcome AddressBy Shri Kamal Kishor, General Secretary, JKSMSHonourable Minister of Health and Family Welfare, Shri Aimaduddin Ahmad Khan, Dr. Asha Pande,Emmanuelle Ferblantier DSouza from the Embassy of France in India, Isabelle Hainzelin from Medecins du Monde, Janet Chawla of Matrika Foundation and dear participants, I would first take this opportunity to welcome you all, on behalf of JKSMS, for sparing your valuable time to participate in this conference, especially honourable Health Minister, at a short notice. As you know our conference is focused on improvement of health in slums and therefore, we will be talking about the health issues of people living in the slums of Jaipur. Before we begin, I would like to share some information about JKSMS and its work. JKSMS was launched in 1983 by a few of us friends, studying at the University of Rajasthan, as we decidedto work for the underprivileged and backward people of the society to bring them into the mainstream.Today, as we walk proudly into our 28th year, the organization has progressed manifold. We are workingin three main areas: Children, Health & Livelihood. Let me first share with you about our work withchildren on the streets or in slums. We are working with almost 7000 such kids through 11 institutes forstreet children, two shelters homeless children: Apna Ghar & Mamta Apna Ghar, where we take care ofchildren‘s health, education and professional development until they are 18 years old and when we areconvinced that they can fend for themselves and assimilate respectfully in the mainstream society. Apartfrom this, we are running two counselling centers at the Railway station. In 1999, JKSMS establishedprimary schools in 19 slums with the help of five UN agencies and local community. After runningsuccessfully for 5 years, these primary schools were finally handed over to the local government althoughJKSMS counsellors and facilitators are still working in those schools to facilitate relationships betweengovernment, staff and children for smooth operations. We are also running a 1098 child help-line numberwhere we provide help within 30 minutes of receiving a phone call from any child in need.Talking about health, our most recent project was Reproductive health and child care in 11 slums where weimpacted 5000 women and children through our work. Our ongoing projects include AIDS/ HIVprograms with tribal people in 12 districts of Rajasthan including Ajmer. Over the years, we have realizedthat in order to make development sustainable, we must ensure livelihoods in the communities we work.Therefore, since 2001 we made Sustainable Livelihood our major thrust area. As a part of this program, wehave worked with 20,000 artisans who work in the costume jewellery industry in Jaipur, through JJADE (Jaipur Jewellery Artisans Development Enterprises) program of SEEP Network. We help them in theirtechnical upgradation and marketing knowledge by collaborating with the American organization, SEEP 10
  • Network. The state government & UNDP have both accepted the Samode Town Livelihood Project as a model “JKSMS has received two national project and the model is being replicated in 178 other awards for its work on generating villages around Rajasthan. While continuing to explore livelihoods for vulnerable communities: livelihood possibilities further, we have worked for Best NGO in income Generation by generating agriculture livelihoods for which we received Indian government in 2007 & CNBC’s two awards in the area of Water Harvesting. JKSMS is also Best Income Generating Project actively encouraging craft-based livelihoods: one in Bassi award for Samode town where almost near Chittorgarh- by helping local artisans to continue 25 % population of the town was working on wooden handicrafts like Kawad; and another in helped through livelihood generation.” Udaipur- by encouraging miniature painting artists in theme, color or design development and marketing strategies. Collectively, JKSMS is working in nine different cities with27000 artisans for their sustainable livelihoods. The organization has received 11 awards so far inrecognition for for this work. At this point, let me make an honest and sincere confession, JKSMS and itsbeneficiary communities have made progress only through your continued support and blessings.I would also like to make a quick mention about our focus on social mobilization in all our projectsbecause we strongly believe that until we reach out to the most marginalized of the communities who areleast developed and bring them into mainstream population; until we make them aware aboutdevelopment and let them assume responsibility for their progress, there won‘t be any sustainability inour efforts and results. Therefore, we emphasize on social mobilization- on getting the communitiesinvolved in what is being done for them. To this end, we use Street Theatre or Nukkad Nataks as they arepopularly called in India. JKSMS has its own theatre group called Caravan theatre. It is an excellent tool toreach out to the uneducated people who don‘t have access to other information mediums. We have beenexperimenting new techniques like Theatre for the Oppressed People in collaboration with internationaltheatre professionals. Caravan Theatre‘s popularity has travelled far and wide in the world. We have aresource centre in the town of Rainwal where we hold training programs for other organizations orindividuals who would like to use Street Theatre in social mobilization. Today, JKSMS boasts of six StreetTheatre teams within the organization.In the end, I would like to share with you that through all these efforts, we are trying to create a newleadership in less-privileged communities in Rajasthan for the past 27 years. These are mostly minoritiesor marginalised communities. We can now see a new ray of hope as these people are coming forward toparticipate in their progress. They are the new Change Agents.Once again, in profound appreciation, I must say that all this has been possible through the huge supportwe have received from various government departments and our partner NGOs along with the localcommunities. Let me take this opportunity to thank all of you, Honourable Minister, esteemed dignitariesand dear participants for your gracious presence and continued support to JKSMS.Thank You.Kamal KishorGeneral SecretaryJan Kala Sahitya Manch Sansthan( JKSMS) 11
  • Inaugural AddressBy Honorable Shri Aimaduddin Ahmad KhanMinister of Health and Family Welfare,Government of Rajasthan, IndiaDistinguished dignitaries and dearparticipants,Reproductive Health is a major cause ofconcern in the present health care systemin our country which impacts the generallifestyle and future growth of our society.And, it is most needed where it is lacking:the vulnerable population that is affectedby poverty and illiteracy, the slum-dwellers.All and more important the governmenthas taken up the cause of reproductiveand child health at the grass root level.The factor which most affects the reproductive & child health in slums is the lack of awareness of thegovernment sponsored schemes and basically problems of hygiene, nutrition, healthy lifestyle etc.Anaemia, malnutrition and vitamin deficiency are the most prevalent in slums. The Government ofRajasthan has taken various steps to compete these with more effective and active involvement of NGOs.I‘ve been informed that this conference would mainly focus on three issues: mainly the need of improvinghealth problems in slums, anaemia, malnutrition or vitamin deficiencies and promoting institutionaldeliveries in slums.I‘m really happy to learn that the government‘s concern for reduction in IMR & MMR is finding room inthe thoughts of NGOs and their endeavour. Rajasthan has an infant mortality rate of 63/ 1000 live birthsas against the national rate of 53/1000 live births. However, in the rural areas it is 68/1000 live birthswhereas in the urban area it is 39/1000 live births. We have to bring it down to our Milleniumdevelopment goal of 27 and this is where the rural NGOs become all the more important by providingtechnical support to the people living in the backward areas, making available the resources to thegovernment and spreading awareness about various government schemes at grass root level so that thebenefits of these schemes can reach them.I‘ve been informed that JKSMS, along with MdM, France, organized street plays, one-on-one discussions,group discussions, hospital tours and other publicity campaigns to enlighten citizens of the slums aboutgovernment health care facilities. The government is committed to making improvement in the publichealth system in the rural as well as urban areas. And we strongly feel that reproductive health and childcare has an important role to play in raising the bar on health conditions in the state. 12
  • Over the years, rapid urbanization has led to ahaphazard rise of slums in and around Jaipur. While we “The combined efforts of JKSMSare becoming stronger economically, it is sad to know and the Government of Rajasthanthat child mortality rate and sex ratio is not getting have reaped fruits. Women havemuch better. Women in the slum areas are still fightingfor basic survival because of poor health and economic become more aware and moreconditions. children are brought-in toI felicitate the efforts of JKSMS and MdM in carrying on participate in the vaccination drives.this research in the various slums of Jaipur district. Lately, more and more womenThese efforts will go a long way in bringing awareness have come forward to volunteer.about health, hygiene, institutional delivery, child care Women have been taken forand eliminating social evils prevalent in the societyamong the underprivileged. hospital tours so that they are not scared to visit or take their childrenI‘m happy to know about the emergence of CommunityHealth Workers in these slums. The two organizations to a doctor. I’ve been informed thathave indeed taken a very positive step in bringing health JKSMS and MdM have succeededawareness into the very homes of the people who have in making this awareness campaignlong neglected the need for good quality of life. I take fruitful.”this opportunity to appeal to all other NGO‘s workingin this field to re-enforce their efforts in bringingawareness in slum areas especially to educate children about basic health & hygiene. Our children are ourfuture and if we want to empower our future, we must ensure that they have a safe, progressive andhealthy childhood.I congratulate the organisers on this occasion and believe that this will further pave way for improvinghealth in slum areasGod bless you all. Jai Hind!Aimaduddin Ahmad KhanMinister of Health and Family WelfareGovernment of Rajasthan, India 13
  • Panel OneThe Necessity of Raising the Level of “I had never imagined myself sittingHealth Knowledge in Slums in such an intellectual gathering and Panel Members sharing my story and that my story was even worth being heard. I am illiterate but JKSMS approached me to work with them as a Community Health Worker. I faced opposition but that didn’t deter my enthusiasm to help this project. I have understood how can I play an important role in bringing health awareness to my community despite my lack of education.The Session was opened by Dr Bhupendra Sharma, the head of PSMdepartment who was moderating the panel discussion, with an When I began working with JKSMS, Iintroduction to the low levels of health awareness in slums and didn’t know anything about the state-existing efforts made by the government and NGOs. He presented the funded health facilities available to us.first speaker: Alia, a Community Health Worker from Idgah Slum area Gradually, I started visiting clinics andin Jaipur district. Alia shared her story with the participants highlighting health centers. Now, when Ithe issues in her neighbourhood such as lack of interest in accessinghealth facilities or learning about hygiene. She faced opposition from accompany pregnant women orboth, her family and community when she began supporting the cause mothers, I am able to communicateof maternal health and child care in the project initiated by JKSMS & their problems to the doctorsMDM. It wasn`t easy for her to convince pregnant women in her area confidently. It feels good to be ato consult doctors in the health centers. Most families preferred to change-maker, even if it is just for mycheck with the Traditional Birth Attendants (Dai) who were neither little neighbourhood. “educated nor totally aware of health and hygiene criteria for safepregnancy and delivery. However, with persistence and determination,Alia was able to win the support of both her family and community,especially as she succeeded in generating some income by volunteeringto help women in the neighbourhood. For each visit to the healthfacility, she charges a nominal amount of ₹5 whereas for the deliveryat the Health Center, the mother gives her ₹200 out of the ₹1000 shereceives from the government. Thus, the project has created healthawareness while empowering women in the community to create asupport structure and a unified front for the cause of reproductive Alia Khan Community Health Worker, JKSMS 14
  • health and child care. Alia is just an example from dozens of Community Health Workers who are now working in these slums; their training and activities supervised by JKSMS to ensure sustainable development. The second speaker in the session was Dr. R.P Jain, Reproductive & Child Health Officer with the Medical and Health Department of the Ministry of Health and Family welfare of Rajasthan who began his talk by stating the definition of Reproductive Health as accepted by the socio-medical fraternity: ―...a state of health in which people are able to reproduce and regulate their fertility......‖. He pointed out that Rajasthan fares really low when it comes to health awareness, especially Reproductive Health & Child Care. Dr. Jain further elaborated on the various State-sponsored schemes like Yashoda scheme which is not being accessed by the general masses in the slums. He emphasized the need for proper communication strategies that will help regularize fertility among the underprivileged. The final speaker in the first panel was Umesh Sharma, the Project Coordinator at JKSMS for RHC project with Médecins du Monde. Mr. Sharma has an in-depth understanding of the issues faced in the slum areas as he has been working on several development projects in urban slums. The presentation was an eye-opener for the participants as he shared the baseline survey findings of the project area. Mr. Sharma went on to expose the sad state of health affairs in these areas since the authority‘s general approach towards health awareness has been rather informative instead of educating. REPRODUCTIVE HEALTH & CHILD CARE: Project strategies & Approaches Umesh Sharma, JKSMSWith the objectives to raise health awareness, scale up community participation and foster linkages betweenslum communities and government services, the project employed five main strategies: 1. Avoid replicating efforts of other organizations 2. Encourage slum-dwellers to visit medical facilities 3. Sensitize slum-dwellers to appropriate hygiene standards 4. Focus on reproductive health & child care only 5. Create Community Health Workers from within the communityThe project employed various innovative approaches like:  Increased community participation  Innovative outreach approaches (Kawad, Theatre etc)  Mapping medical facilities  Individual counselling  Educating about government medical facilities These approaches have taken the form of best practices as they got the women and children interested in convincing their families to become conscious about their health and hygiene. The end result was that communities, who were earlier openly resistant to any kind of state interference in their reproductive health or child care, now support and participate in government policies and schemes. 15
  • Kawads- the traditional art of story-telling in RajasthanEducating Women in the Slums Medical Mapping for the CommunityStreet Theatre to Engage the Community Group Discussions & Awareness Sessions Images from the Project 16
  • Panel TwoAnaemia, Malnutrition and VitaminDeficiency in Slums: The Unspoken Issues Panel MembersWith the first session focused on raising the level of health knowledge in slums, the second sessionhighlighted the need for immediate intervention in the slum areas because of various unspoken issues likeAnaemia and Malnutrition. Most of the times, health workers or surveyors do not record some of theunderstated but critical health concerns which have long term effect on reproductive health and childcare. This session, chaired by a very senior academician from the medical fraternity of Jaipur: Dr. TP Jain,succeeded in bringing attention to pertinent topics like mineral and vitamin deficiencies and the innovativesupplements recommended by academicians. In countries like India, micronutrient deficiency, especiallyiron, is most prevalent among children. Besides culminating into anaemia, the consequences of irondeficiency are grave which affect the health as well as quality of life of the nation as a whole.The first speaker to share her thoughts, research and recommendations was Dr Beena Mathur fromUniversity of Rajasthan‘s department of Home Science. Dr. Mathur highlighted key statistics aboutmicronutrients deficiency among women, especially pregnant women or adolescent girls. She revealedthat the statistics are worst in the slums because of poverty and illiteracy. In her presentation, shepointed out that because malnourished children suffer from an under-developed brain, lower immunityand physical deformities or decreased stamina, they face higher levels of unemployment when they growup. She elaborated on the collective impact of malnutrition saying that it could lead to a huge populationbecoming an economic burden on the society as they could be incapable of fending for themselves. Sheinformed the participants about government-run programs like ICDS Program, National Vitamin Aprophylaxis Program, National Nutritional Anaemia Control Program, Iodine Deficiency DisorderPrevention Program, to name a few. However, the slum population refrains from participating in theseprograms because of obvious reasons like lack of communication and awareness. Emphasizing, theimportant role that NGOs like JKSMS & Médecins du Monde can play in eradicating Malnutrition fromslums, Dr. Mathur then recommended Leaf Concentrates as an effective solution to micronutrientdeficiency. Leaf Concentrate’s Molecular Composition 17
  • Leaf Concentrates from Alfalfa are rich sources of, Iron, folic acid and beta carotene or pro-vitamin A,good quality protein, other vitamins, fats and minerals.COMPARITIVE CHART: Spirulina, LC & WMP Nutritive Value of Leaf Concentrate Spirulina Leaf Concentrate WMP** Nutrients Value/100g basisNutrientsMoisture 3-7% 8% 3% Energy 344 Kcal Protein 60gProtein 55-65% 50-55% 26% Fat 22.5gLipids 4-7% 9-10% 26% Carbohydrate 12.5gpufa* (w3) 1,8% (1,0%) 6,4% (4,8%) 0,9% Carotene 86700ug (0,2%) Folic acid 330.0ugCarbo-hydrates 15-25% 10-12% 38% Iron 99.0mgMinerals 7-9% 13-14% 8% Calcium 1865.0mgFibre 4-7% 1-2% - Phosphorous 604.0mg*PUFA: Polyunsaturated Fatty Acids**WMP: Whole Milk PowderDr. Mathur further shared the research that was conducted in a slum in Jawahar Nagar, Jaipur where3%Alfalfa leaf concentrate was incorporated in the meals of the experimental group. The group comprised ofchildren aged 3-6 yrs and their initial haemoglobin levels, weight, height and morbidity profile wererecorded. For a duration of two years, there were quarterly follow-up and monitoring. The results wereas follows: The results showed a significant increase in the Hb levels of the experimental group while they decreased in the control group. The difference between the two groups Leaf was statistically significant (p<0.01). Concentrate The morbidity profile of the as a experimental group improved while Micronutrient remaining unchanged in the control Fortifier group. The anthropometric measurements did not show a significant difference between the two groups. Dr Beena Mathur University of Rajasthan 18
  • The second speaker in the session was Dr. Mukta Arora who began by talking about the general efforts that are being made to manage malnutrition, highlighting government schemes like Integrated Child Development Services (ICDS). Launched in 1975 by the Ministry of Women & Child Development, ICDS represents one of the world‘s largest and most unique programmes for early childhood development with a strong focus on: - Improving the nutritional and health status of children in the age-group 0-6 years - Laying the foundation for proper psychological, physical and social development of the child - Reducing the incidence of mortality, morbidity, malnutrition and school dropout - Achieving effective co-ordination of policy and implementation amongst the various departments to promote child development - Enhancing the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.With reference to key findings about the health benefits of Leaf Concentrates & Spirulina, Dr MuktaArora pointed out the role of NGOs in supporting initiatives through the adaptation of research &recommendations into the implementation of policies & directives of government programs like ICDS.She elaborated on the current directions by Supreme Court that food supplementation distributed inAnganwadis (State-sponsored Day Care Centres) should not be sourced from contractors. Instead, suchfood should be procured by Self-help groups or community-based organizations in the area. While thisdirective is a positive step in strengthening SHGs, the flipside is that such food lacks any kind ofmicronutrient fortifiers. Dr. Arora suggested that NGOs can play an important role in educating thecommunity-based organizations or SHGs about naturally-available micronutrients and their integration infood products provided at Anganwadis.Through this recommendation, Dr. Arora stressed the role of convergence of different governmentinitiatives with non-profit efforts in effective malnutrition management. Next, she gave the example ofASHA Sehyogani who can pursue community mobilization to fight malnutrition. The final speaker in this session was Manish Jain who is the Head ofMission at Action Contre La Faim, India Chapter. Manish Jain enlightenedthe participants about the various terms used to describe varying levels ofmalnutrition like hunger, malnutrition, acute malnutrition, MAM & SAM. MAM: where the body is seriously undernourished, starts losing weight,and is at increased risk of infection. For the body to recover, MAMneeds treatment using food that is high in energy and nutrients, otherwiseMAM worsens to SAM.SAM: a stage when the body is so undernourished that the immune system becomes ineffective and maininternal control systems shut down. This is when people die. This requires urgent medical treatmentand therapeutic food. Types: Marasmus, Kwashiorkor and Marasmic Kwashiorkor.Chronic Malnutrition: a condition that lingers on for a longer period, or result from several bouts ofacute malnutrition. A consequence of an inadequate diet often combined with an infectious disease.People can die prematurely, can contract infections or have their growth stunted. It stops childrenreaching their full mental and physical potential. 19
  • Talking about different cases of malnutrition, Mr Jain also shared that in some cases over-nutrition couldalso be termed as Malnutrition. He cited the figures for Rajasthan that 7.3% children are severely acutemalnourished which means almost 6,20,000 children in the state. Nearly two million children under fivedie every year in India – one every 15 seconds – the highest number anywhere in the world. More thanhalf die in the month after birth and 400,000 in their first 24 hours. These are the unfortunateimplications of malnutrition.Mr. Jain not only talked about the implications of malnutrition but also the reasons leading to thisunfortunate situation. He pointed at the lack of exclusive breastfeeding in Rajasthan, customary burial ofcolostrums, load of mother‘s responsibilities other than child care. He summed up his presentation bycalling attention to the ways to fight malnutrition:  All lives are equal and children should not die of reasons for which remedies are known  Further build malnutrition in societal and political agenda  Community empowerment  Prevent and treat  Increased nutrition surveillance at district levels for better targeting  Strengthen human resources and institutional vigour  Innovate-in-delivery: openness to learning and adapt to local contexts. ‗…reject-accept-innovate- adapt…; deliver-the-innovation  Increase use of MUAC  On treatment of children with SAM: think of other solutions to improve the coverage, timeliness; - community based management of malnutrition (CMAM) where 85-90% children with SAM can get treated  Not only manage from within, but managing across through concerted actions 20
  • Manish Jain then focused on the issues arising from maternal and child under-nutrition which is quitecommon in underprivileged communities like slums. As indicated in the figure above, Mr. Jain alsodescribed the various reasons leading to Maternal and child under nutrition like disease, low dietaryintake or simply household food insecurity. He summed up his presentation by calling attention to theways to fight malnutrition: Mr. Jain finished by sharing that there are shortcomings in the ICDS scheme aswell due to which the results are not as good as one would expect and hence, the Non-profit outfitsshould continue to play their role by bringing in nutritionists at the centres and conducting regular follow-ups with beneficiary families. Dr. TP Jain, as the moderator of this session, complemented the speakers for bringing research into the conference in a lay-out that can be easily understood by the participants. He urged the participants that these findings should be translated into change in present policies and implemented in the field. About the hurdles faced in policy implementation in low-resource communities, Dr Jain revealed that people are used to ―expecting from the government but not acting on their own‖. In his concluding note, he strongly disapproved the present trend among beneficiaries of being excessively dependent on non-profit organizations and government bodies instead of inculcating accountability for their situation and acting with self-respect. What is needed is Behavior Change whereby people become aware of their own responsibilities in maintaining good health in their families and hygiene in their neighbourhood. Instead of saying, “ what can you do for me?”, let them say “how can I improve my family’s situation?” Organizations working for development need to focus on changing health & nutrition behaviour of the community by introducing knowledge and positive changes instead of plain material help. Dr TP Jain 21
  • Street TheatreNukad Natak or Street theatre, a form of theatrical presentation in outdoor public places with minimalprops or theatrical frills, is deeply rooted in Indian traditions as a form of grassroots communication topropagate social and political messages. JKSMS has been using street theatre extensively in its projects toreach out to the beneficiary communities and create social awareness. The biggest advantage of Streettheatre is that it breaks formal barriers between the actors & spectators by approaching people directly.In the case of JKSMS street plays, the team likes to involve the audience in discussing the issues and pin-pointing solutions. The final component of the second session was one such street play drawing theparticipants‘ attention to various social challenges in implementing institutional deliveries in illiterate orlow-resourced communities.With Aditya Sharma of JKSMS leading the performance, the rest of the team comprised of social workersand project executives of the organization. They enacted a scene from a rural family illustrating howwomen have to fight age-old traditions in order to bring changes. The focal point of the play was whenthe spectators were no more mute spectators but participating actors! Aditya asked questions from theparticipants as to how they would like to pick up roles in this play and make changes. This kind ofexercise helps change people who are taciturn props to become key players in improving socialsituations.1 Depicting negative family roles in institutional deliveries 22
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  • Panel ThreeInstitutional Deliveries: Overcoming Obstacles inits Popularization Panel MembersThe third and the final session in the conference was focused on an important aspect of reproductivehealth: pregnancy and deliveries in a hygienic and healthy setting. Dr K.K. Sharma who is a MedicalConsultant at JKSMS and has been supervising the medical components of this entire project onReproductive health and Child care was the moderator for this panel discussion. The session broughtforth the story of an indigenous birthing attendant turned trained birth attendant and a change-maker: ShardaDai; as well as some indigenous birthing tips by Janet Chawla, founder of Matrika.The session opened with the motivating story of Sharda Dai where she shared her own experience ofhow she started early in life as a traditional midwife but later became a trained Community HealthWorker. Sharda Dai learnt about indigenous delivery-facilitating techniques from her grandmother in thevillage. As a traditional birth attendant, Sharda used to provide health care, support and advice during andafter pregnancy and childbirth, based primarily on experience and knowledge acquired informally throughthe traditions and practices of her community. The primary focus of Sharda‘s work was to assist womenduring delivery and immediate post-partum. Occasionally, she would help with household chores too ifthe family needed so. When JKSMS social worker approached her to learn about the health facilitiesavailable to pregnant women, she was a little hesitant. However, the social workers continued to interactwith her and over a period of time, Sharda was convinced that she might have a role to play in improvinghealth outcomes in her slum because of her access to community and the relationship she shared withwomen in her neighbourhood. Her contacts were valuable for the JKSMS social workers because theslum women were otherwise unable to access government facilities on their own. Sharda underwenttraining to learn about health care, hygiene, government facilities and responses to birth complications.Now, she has emerged to be a confident birth attendant and community health worker. She prefers totake her clients to the hospital for routine check-ups rather than judge their situation independently.Sharda Dai confessed that she had never thought earlier that her work was so important to help reduceperi-natal mortality but now, at the conference, she has realized the value of her role in the society. Themoderator, Dr Krishna Kant Sharma applauded her efforts, saying that CHW like Sharda or Alia have thepotential to become change-makers in healthcare of low-resourced communities.The next speaker was the renowned social worker and founder of Matrika, which advocates traditionalbirth techniques practiced by women around the world for centuries. Expressing her delight over JKSMS‘s 24
  • initiative to start an open dialogue to discuss options of optimizing healthbenefits through maternal health and institutional deliveries, Janet advocatedthe need to build bridges between indigenous and biomedical systems toenhance health care in both rural and urban settings. She began by sharingher thoughts: ―My basic advocacy point here is that we must understand thesophistication of indigenous women‘s ―body knowledge‖ and not just solelyrely on a delivery of services approach—delivering western-orientedbiomedicine. Health is not a deliverable, nor are there quick-fixtechnological solutions. We hopefully can build bridges between indigenousand biomedical systems to enhance health care in both rural and urban settings.‖ Janet went on to shareher inputs on Dai‘s knowledge and practices from two perspectives: Best practices‘ and ‗Evidence-basedBiomedicine in US and Europe & Text-based Ayurvedic indigenous medicine.  Dais (traditional Birth Attendants) use the following practices which are currently accepted as state of the art ‗evidence-based‘ practices during childbirth:  Encouraging movement during labour, not restricting or enforcing to lie down  Allowing easily digestible food and drink throughout labour if the mother desires  No Prenatal preparation: (shaving and enema usually given in medical facilities)  Continuous presence of a supportive person during labour  Massage, encouragement and other comfort techniques  No routine episiotomy—even with first babies—rather the massage and support of the perineum  If the mother is able to sit for an upright or squatting position for birth  No premature cord-cutting…allowing the pulsations to stop before cutting. (Traditionally dais throughout the subcontinent would cut the cord only after the placenta is delivered)  From the Ayurvedic point of view both dais practice and Ayurvedic text reflect the following principles and therapeutics:  Warmth: During both labour and post-partum the use of warmth/heating is essential. Hot drinks, heating herbs, warm oil rubs, warm room are all used to stimulate labour and comfort the mother. Postpartum use of warm compresses to contract uterus, warming and sweet food and drink, a warm room, keeping legs together to prevent hava/cold from entering vaginal area.  Oil: Used during labour for massage, sometimes mother is given a drink containing ghee, oil is used to lubricate the birth canal for smoother delivery. Postpartum full oil massage is given with special attention to the head. Heating substances such a gur, gond, nuts are given to ‗cleanse‘ the body of ‗impure blood‘ or substances which need to be expelled.After these two wonderful talks sharing personal experiences and traditional wisdom on birth-facilitation,the final speaker and moderator of the Conference, (Col.) Dr KK Sharma highlighted findings from thebaseline surveys before the commencement of the project and how the solutions were planned for thehealth issues in the community in his presentation and advocated the need for Institutional deliveriesespecially in hygiene-lacking slum areas. He elaborated on slum conditions, discrimination against womenand other problems in these areas. Dr Sharma enlightened participants about the results of the pilotproject. There has been a marked improvement in the mortality rate and reproductive health of thecommunity now. 25
  • RHC Conference Recommendations I. Non-profit organizations can play an important role in filling-up the gap at various stages between government Schemes and implementation results II. Government scheme information can be disseminated to the uneducated people by grassroot communication strategies using experience and skills from non-profit organizations. III. Traditional tools of communication like Kawad can be used for rural outreach. IV. Participatory Theatre can be an effective tool in mobilizing uneducated communities and should be an integral part of communication strategies targeting illiterate population. V. Communities need to be made aware of natural supplements like Spirulina or leaf concentrate’s role in micro nutrition. VI. Spirulina/leaf concentrate products could be marketed/distributed in undernourished communities through self-help groups thereby providing livelihoods to many others.VII. Replicating CHWs for sustainable health programs by sensitizing, mobilizing & training potential CHWs though National Urban Health program with the help of experienced non-profit organizations.VIII. CHWs or community participation in planning process of any scheme or program before its launch is important IX. Women should be able to make a conscious decision regarding their preferred facility/ environment when it comes to birthing/delivery. X. Skilled birthing attendance should be made available regardless of where the delivery takes place. 26
  • ANNEX 1: AGENDA of the Conference Innovative Approaches for Improving Health in Slums OM Tower, Jaipur Agenda Day 1: 4th April 20109:30 Inaugural Ceremony: Lighting of the Lamp9:40 Welcome address by Kamal Kishor, General Secretary, JKSMS9:55 Introduction to Medecins du Monde by Willy Bergogne, General Coordinator, MDM10:10 Film Presentation: Reproductive Health & Child Care in Slums by Umesh Sharma10:30 Address by Hon. Shri Aimaduddin Ahmad Khan, Minister of Health & Family Welfare, Raj.10:50 Thank You Note to the Chief Guest, by Dr. Asha Pande, Vice-President, JKSMS10:55 Tea Break11:00 Opening of 1st SessionThe Necessity of Raising the Level of ―Health Education‖ in Slums12 pm Open discussion & Recommendations1 pm Lunch2 pm Opening of 2nd Session Anaemia, Malnutrition and Vitamin Deficiency in Slums: The Unspoken Issues3 pm Open discussion & Recommendations3:30 Street Theatre by CaravanTheatre Group3:45 Opening of 3rd Session Institutional Deliveries: Overcoming Obstacles in its Popularization4:30 Open discussion & Recommendations (Tea & Refreshments) 27
  • Program Details Session 1: The Necessity of Raising the Level of “Health Education” in Slums Moderator: Dr. Bhupendra Sharma, PSM Department Panelists: RP Jain, RCHO, Jaipur Alia Khan, Community Health Worker Umesh Sharma, Project coordinator, JKSMSSession 2: Anaemia, Malnutrition and Vitamin Deficiency in Slums: The Non-Spoken Issues Moderator: TP Jain, RVHA Panelists: Dr. Mukta Arora, UNICEF Manish Jain, Head of Mission, action Contre la faim Prof. Bina Mathur, University of RajasthanSession 3: “Institutional Deliveries: Overcoming Obstacles in its Popularization”Moderator: Dr. KK Sharma (Retd. Colonel), Medical Consultant, JKSMS Panel: Janet Chawla, Matrika Foundation Dr. Akhilesh Sharma, Health Sociologist Sharda , Mid-wife/ Community health WorkerDay 2: 5th April 2010 9:30 am to 12:00 pm Field Visit (Idgah & Bagrana) Facilitated by RHC Team 28
  • Annex 2: Glimpses of the Conference 29
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  • Annex 3: Media Coverage 35
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  • Annex 4: Conference Attendees (Arranged in alphabetical order)Nos. Names Organizations Designation 1 Aliya Khan JKSMS CHW Idgah 2 Alka Sharma JKSMS Social Activist 9898638496 Aimaduddin Minister of State for Ahmad Khan Health and Family 3 (Dhuru) Government of Rajasthan Welfare Amarjit Singh 4 Rana Sikh Educational Board Director 9829055819 ranaamarjit@gmail.com Social Worker Railway 5 Bhanwar Singh JKSMS Station 9351409328 6 Chanda JKSMS CHW Toll Tax Bambala 7 Daksha Parashar JKSMS Jt. Secretary 9982628100 8 Dr. Asha Pande JKSMS Vice-President 9829055717 ashapande@hotmail.com 9 Dr. B.D. Acharya State Health department Medical Officer 98299304711 Dr. Bhupendara 10 Sharma SMS Medical College Professor of Medicine 9414718374 drdpl979@gmail.com 11 Dr. D.K. Sharma Department of PSM Senior Demonstrator 9166973143 Dr. Dharmpal Senior Demonstrator 12 Bishnoi SMS Medical College (PSM) 9636585959 Dr. Dinesh Additional 0141- 13 Dwivedi SMS Hospital Superintendent 2351712 14 Dr. K.K. Sharma JKSMS Medical Consultant 9413134038 colkks@gmail.com 15 Dr. Kamal K Bajaj State Health department CMHO (retired) 9314504060 kamalbajaj@gmail.com 16 Dr. Kusum Garg SMS Medical college Assoc. Professor PSM 9460271172 drkusumgarg9@yahoo.com 17 Dr. M.P. Sharma PHOD, PSM Professor & Head 9929110045 sharmamaheshprashad@gmail.com Dr. Narendar Health department, 18 Kumar Sharma Sanganer SMO, BCMO 9314966083 Dr. Nirmala 19 Sharma Resident Doctor PSM department 9784405605 20 Dr. R.P. Jain RCHO M & H Department 9829122232 rpjjpur@yahoo.co.in 21 Dr. S.D. Sharma Superintendant 9414278442 sdsharmajp@yahoo.co.in 22 Dr. S.N. Mathur (QI) ICDS Consultant 9460068713 23 Dr. Simple Gupta MSM Medical college 2nd Year DPH 9468599383 simplegupta@Yahoo.co.in Dr. Sudhakar 24 Sharma SMS Medical college Senior Demonstrator 9950989143 sudhakar_143@yahoo.com Dr. Sukhwant 25 Singh Department of PSM Resident Doctor 9462238207 Rajasthan Voluntary Ex-Professor Medical 0141- 26 Dr. T.P. Jain Assocciates college 2580507 27 Dr. Vimla Jain Mahila Chiktsalya Supperident Hospital 9414047721 Dr.Sweta 28 Tikkiwal SMS Hospital Resident PSM 9252311297 Emmanuelle Child Protetection & Ferblantier Inter-country Adoption 29 DSouza French Embassy in India Officer 9718498858 0141- 30 Ganpat Acharya Child Welfare Committee Chair Person, CWC 2000804 31 Govind Pareek M & H Dept. IEC Public Relations Officer 9828012352 govindpareek@gmail.com 38
  • 32 Isabelle Hainzelin MDM Responsible of Misson isabelle.hainzelin@laposte.net33 Jaya sashi Sharma JKSMS Social Activist 9799693265 dnavajyoti@gmail.com34 Jyoti Sharma JKSMS Social Activist Kailash35 Chaudhary JKSMS Social Activist 969409104736 Kamal Kishor JKSMS General Secretary37 Karan Dudda Saarthak Consultant karan@saarthakindia.org38 Komal Varma JKSMS Social Activist 969409103439 Kumkum Sharma JKSMS Social Activist 969409103840 Laxmi Madhukar JKSMS Social Activist 935118988441 Lokesh Sharma Dainik Navjyoti Reporter 902441311042 Mamta Prajapat ICDS Workar Angan Badi 766512247043 Manish Jain ACF Action Control la Faim Head of Mission India 9711200379 hom@in.mission-acf.org44 Manju Sharma JKSMS Social Worker Idgah 9928651489 Mathura Prasad45 Sharma JKSMS Social Activist 969409103646 Maya Laporte JKSMS MDM France maya.laporte@laposte.net47 Mishra Ji JKSMS CHW Bagrana Mrs. Nidhi48 Sharma ICDS Angan Badi 941478822549 Mukesh Kumar JKSMS Social Activist 9694091016 Nahid50 Mohammed Saathii Traning Officer 9314532436 nahid@saathii.org Narendra Kr51 Mahawar JKSMS Social Activist 969409102752 Neetu JKSMS Social Worker Bhagrana 9929338979 Poonam Chitransh Education &53 Dhamniya Welfare Society GNM 9461500855 Social Worker Choki54 Prabha Sinha JKSMS Dhani 9829705541 Prabhakar55 Goswami I India Director 9414048817 goswami10@hotmail.com Prof. Beena PG Dept. Raj. University Of56 Mathur Home Scince Professor, Nutrition 982836648457 Raja Ram JKSMS Social Activist 9694091020 Access Development58 Rajesh Jain Services Vice President 9414249226 rajesh@accessdev.org59 Rajesh Sharma JKSMS Social Activist 988756981660 Rajish Verma JKSMS Social Activist 931420842461 Raju Sharma JKSMS Social Activist 988700960162 Ramesh Paliwal Taabar NGO Jaipur Director 9829850566 paliwalramesh@gmail.com63 Ramesh Sharma Taabar NGO Jaipur Project Manegar 9462100211 Communications64 Roma Kaur Rana JKSMS Consultant 9829055819 romakaur@gmail.com65 Rekha Sharma JKSMS Social Activist 9694091033 Social Worker Khirni66 Sangeeta Jadon JKSMS Phatak 995035053867 Sanjay JKSMS Social Activist 950955618168 Smt Sanno JKSMS CHW Bagrana69 Santosh Saini JKSMS Social Activist 960242322570 Satyen VHAI Represention 0941407644971 Shanu Kanwar JKSMS Social Activist 9694091012 39
  • 72 Sharda Dai JKSMS CHW Bagrana73 Kusum Nair Department of PSM PHM 982918609674 Rukmani Dai Dai/ Retd. Nurse 950955618175 Sourash Sharma Sewa Sandesh Director 9413376076 Sudharkar76 Goswami I India Coordinator 992839459877 Suntia Sahu JKSMS Social Activist 805291326578 Sushila Yadav JKSMS Social Activist 998221508179 Umesh Sharma JKSMS Pro. Coordinator 9929070085 b_i_t_t_o_o@yahoo.co.in80 Vijay Sharma FXB India Surksha Consultant 9351308920 vijay1659sharma@yahoo.co.in81 Vikram Singh JKSMS Social Activist 992923572482 Willy Bergogne MDM Gen. Coordinator 09717799917 genco.india@medecinsdumonde.net For more information on the RHC project, visit http://www.jksms.org or http://www.medecinsdumonde.org 40