Given the level of government apathy and the prolonged time factor, which inheres in entitlement oriented struggles, SSVK, in order to cater to some of the crucial needs of the people, also undertakes sectoral interventions like primary health care, non formal education and income generation, with an emphasis on thrift and credit operations.  Even in these interventions the emphasis has been on promoting the self-help initiatives and the limited service delivery that has been there in these interventions has been strategically geared towards demand generation at the target group level for their effective mobilization.

SSVK sees health as a critical variable in the empowering objective. Its intervention in the sector is determined by the close linkage it perceives between poor health and rampant poverty. It approaches the problem of health more in its preventive and promotive dimensions than its curative one. It believes that a heightened awareness about health will positively impact on the morbidity profile of the region thus, salvaging the poor from being hurled deeper into the trap of poverty.
The SSVK intervention districts are infrastructurally very backward which compounds the problem of access to health facilities in a state where even otherwise the quality and extent of health services available is extremely poor. The following table gives an overview of how unfavourably the state of Bihar compares with India as a whole on some of the key demographic, socio-economic and health indices:

Bihar as compared to India as a whole on some key Demographic,  Socio-Economic and Health Indices
Characteristics	Bihar		India
Demographic Indicators
Population	828.8 Million		1027.0 Million
Population Density (Population / km2)	880		324
Sex Ratio	919		933
% decadal growth rate	28.43%		21.34%
Socio-Economic Indicators
Per Capita Income (Rs.) for year 2003-04
At constant1993-94 prices	3707		10964
At current prices	6861		20292
% decadal growth in Per capita Income	~ zero		~ 45%
Proportion of population below poverty line	42%		26%
Level of Urbanization	10.5%		27.8%
Literacy	47.5%		65.4%
Health Indicators
Total Fertility Rate (NFHS 3)		4.0	2.7
Current use of modern method of family planning in % (NFHS 3)		28.8	48.5
Unmet need for family planning in % (NFHS 3)		23.1	13.2
Antenatal Coverage (Three or More Antenatal Care Visits ) (NFHS 3)		17	52
Births assisted by a doctor/nurse/LHV/ANM/other health personnel (%)(NFHS 3)		30.9	48.3
Percentage of births taking place in a health facility (NFHS 3)		20	39
Children under 3 years breastfed within one hour of birth (%) (NFHS 3)		23.4	4
Percentage of children in the age group 12-23 months extended full immunization coverage by the state (NFHS 3)		33	44
Percentage of children under age 3 who are stunted (NFHS 3)		42	38
Percentage of children under age 3 who are wasted (NFHS 3)		28	19
Percentage of children under age 3 who are underweight NFHS 3)		58	46
Infant Mortality Rate (NFHS 3)		62	57
Under five mortality rate (NFHS 3)		85	74
Maternal Mortality Ratio (SRS 2004 - 2006)		312	254

Source: Census 2001, Ministry of Statistics and Program Implementation and National Family Health Survey 3
Though the State has achieved some progress in terms of output indicators, the maternal mortality, child mortality, population growth and high incidence of malnutrition among women and children continue to be a cause of serious concern to the state's development efforts. The prevalence of certain vector borne diseases, communicable diseases, and water borne diseases is also high in the State. Besides, the health infrastructure is inadequate to cater to the needs of the people and the upkeep of the already existing facilities is challenging. There are substantial gaps in health sector infrastructure in terms of the required and existing sub-centers, primary health centers and community health centers along with shortage of manpower, drugs, equipments and consumables necessary for Primary Health Care and woefully inadequate training facilities. Other factors affecting the health status include: very high fertility rate; low level of institutional deliveries and a high level of maternal deaths; very low coverage of full immunization; low level of female literacy; and poor status of family planning programme. There is a drastic decline in the share of public health facilities in treatment of non-hospitalized ailments in both rural and urban areas. The table below highlights how, even in terms of the health infrastructure, things in the state are way below the desired level.

Health Infrastructure of Bihar	Required	In  position	Shortfall
Sub-centre	14959	8858	6101
Primary Health Centre	2489	1641	848
Community Health Centre	622	70	552
Multipurpose worker (Female)/ANM	10499	9127	1372
Health Worker (Male) MPW(M) at Sub Centres	8858	1074	7784
Health Assistant (Female)/LHV at PHCs	1641	479	1162
Health Assistant (Male) at PHCs	1641	634	1007
Doctor at PHCs	1641	1565	76
Obstetricians & Gynaecologists at CHCs	70	21	49
Physicians at CHCs	70	38	32
Paediatricians at CHCs	70	17	53
Total specialists at CHCs	280	104	176
Radiographers	70	15	55
Pharmacist	1711	439	1272
Laboratory Technicians	1711	135	1576
Nurse/Midwife	2131	1425	706

(Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI) 
Infrastructural deficiencies apart, even when these services do reach people, women in particular, often speak of lack of sensitivity and non-availability of the care that they actually require. And again, only the lowest level of services or even none at all are available to the poorest and neediest.  For poor women, waiting in long lines for medical care for a doctor to appear in a government primary health centre or hospital has an economic cost: of time and thus daily wages or earnings lost. On the other hand the ecological conditions (flood proneness of the project area), coupled with lack of awareness about health and prevalence of abject poverty, accounts for the high morbidity rate in the region. It is the poor who become the prime sufferer in a context like this. Further the systematic exploitation unleashed by the private medical practitioners, who by all means occupy a monopoly given the dysfunctional government health care system, forces the poor to take recourse to the local moneylender thereby landing them into the vicious circle of debt trap.  It is against this backdrop that SSVK has strategised its health related intervention.
The key elements of SSVK’s approach to health security include:

• Linking health security to work security.
• Women-centered health care led by local women;
• Capacity building of Traditional Birth Attendants through upgrading their skills so that they become the “barefoot doctors” of their communities and villages
• Addressing common health problems among poor families
• Promotion of health and well-being by providing access to information and education;
• Through awareness and information dissemination regarding government schemes and programmes building up an informed constituency of its target group who subsequently use their strength as organised collectives to lay claim to and access their developmental and welfare entitlements from the government.
• Emphasising self-reliance in terms of communities owning, controlling and managing their own health activities.

For its approach to show results on the ground, the key activities undertaken by the organization are as follows: 

• Mapping of the local health delivery system
• Capacity Buiding of the Health Cadre to be deployed for implementing the programme
• Capacity building of TBAs in safe conduct of deliveries, in ante-natal and post-natal care and in diagnosing and treating minor ailments
• Ante-natal and Post-natal care, including weighing, screening for anaemia, and counseling around nutrition.
• Immunization, iron and folic acid supplementation, and vitamin A supplementation, in collaboration with government services.
• Sexual and Reproductive Health Education
• Develop and operate Revolving Fund for medical contingencies through the village health committees
• Growth Monitoring of children in the 0-5 age group and nutrition counselling
• Provision of Safe Drinking Water
• Hygiene and Sanitation Education
• Preventive and Promotive health education: Integrated Primary Health Care (PHC) messages focussing on preventive and promotive health developed in alignment with  situation analysis/need assessment
• Family planning advocacy and providing information about contraceptives and making these available by coordinating with government services.
• Universalisation of immunisation in collaboration with the government
• First Aid
• Elementary curative services
• Reaching low cost, good quality and preferably generic drugs
• Linking with existing health services – government and private – especially for referral care
• Inform and educate villagers on what government health and childcare services should be available to them in order to motivate villagers to demand the services they are entitled to through forming their self help organisations (Village Health Committees)
• Strengthening the planning, implementing, managing, monitoring and evaluating skills of the village health committees
• Establish a collaborative mechanism with the District Health Office (DHO) for strengthening community management of  primary health care services 
• Develop and implement a collaborative mechanism between different actors-public health care, private health care and NGOs for enhancing the access to and utilisation of the health services
• Sensitising, motivating and upgrading the skills of rural medical practitioners (Quacks) to make them render better quality and more ethical services to the target group.

Strategies for sustaining the intervention: 

• Organisational and institutional development of the target group
• Promoting community ownership and community management of the programme
• Promoting community contribution
• ICE package for Health Education
• Optimising on the potential of the local health care providers be they the TBAs or rural medical practitioners (Quacks) through their orientation, sensitization and capacity building
• Inform and educate villagers on what government health and child care services should be available to them in order to motivate villagers to demand the services they are entitled to
• Linking with existing health services – government and private – especially for referral care
• Linking health services to insurance
• Creating income earning opportunities for the target group

In order to ensure that its interventions have the desired outreach and outcome and also remain sustainable in the long run, the organization has also perfected a delivery model which it chooses to call the health post model.  At the base of this model are two health promoters from each of the intervention villages.  Next in the tier are the Lady Health Workers (LHWs) with one LHW for a cluster of 5 villages. Next in hierarchy is the health coordinator.

Village health promoter (VHP)

2 from each intervention village trained from the existing pool of TBAs in those villages

Operational role:

• Form community organisations. In cases where a community organisation all ready exists in the village, to energise it and activate it on issues of health.
• Organise village meetings to facilitate community action when ever such a need arises
• Ante and Post Natal Care and Conducting safe delivery.
• Impart health education regarding preventive and promotive aspects of health based on observation and informal discussions.
• Assist in running the health post.
• Motivate the community to utilize the services of the health post and referral clinic in a cost efficient manner.
• Distribute vitamin A, iron tablets and folic acid to pregnant women.
• Motivate the community to avail of the immunization facility and for family planning.
• Linking with existing health services – government and private – especially for referral care.
• Under take regular reporting to update information regarding health status, health behaviour, new birth, deaths, diseases and programme implementation.
• Take part in other programmes or campaigns when ever organized.
• Acquire basic curative skills in the long term.

Lady Health Worker (LHW)
One for five villages, local to the intervention area and with minimum of Class Eight Level education and trained with the skills of an ANM. 

Operational role:

• Run health posts for 5 days in a week – each day in one village
• Meet regularly on sixth day of the week for
  • reporting on the work undertaken
  • discussing work experiences
  • type of disease prevalent
  • preventive action required general problems found during home visits
  •  identification of issues which require community action
  • devising ways of promoting nutritional levels out of local resources
• Sometimes doctors involved in the programme may participate in the meeting to guide them and also to help them improve their medical skills.
• Make home visits to mothers, children, pregnant women to conduct check ups and initiate appropriate preventive and promotive measures
• Impart nutrition education
• Identify high risk cases and refer them for specialized treatment
• Maintain records related to immunization, pregnancy and maternity history, gynaecological  and other services provided
• Use growth monitoring and surveillance of children as a tool of health education and to check stunted growth
• Inform and educate villagers on what government health and childcare services should be available to them in order to motivate villagers to demand the services they are entitled to through forming their self help organisations
• Gradually impart basic curative skills to VHPs.
• Facilitate linkages with the government and private health care system in the project area
• Submit monthly reports to the coordinator which should include, apart from day to day account of work, suggestions to improve the quality of programme.

Health coordinator (HC)

Preferably a lady with intermediate level education and trained in Health Management Skills. 

Operational role:

• Provide conceptual guidance to the intervention
• Formulate work plans
• Undertake monitoring based on feedback from the project staff
• Identify gaps in the programme and devise ways of improving it qualitatively
• Personnel administration
• Work towards linking the programme with institutional resources
• Establish linkages of health with other sectoral programmes and community development initiatives
• Regular reporting to the project director about the status of the programme.

The Health Posts to be run by LHWs have been strategically conceptualised as a time bound intervention to subserve the following objectives:

• Reinforce the credibility of the VHPs in their communities through back up support
• Enhance the self-confidence and the skill base of the VHPs through time bound hand holding leading to hands on role transference to them
• Using the services rendered at the health post as an occasion for imparting health education to the community as well as exposing them and making them aware about the range of services they are entitled to from the government health care system particularly that from the government ANM.
• Building up the planning, monitoring and evaluating capabilities of the self help organisations
• Enable the health promoters to strike linkages with the government health care system
• Create community level capacities to monitor the performance of the government health care system
• Informed access of the target group to the government and private health providers in the project area

The health post model has emerged out of a community health care programme which the organization ran from 1991 till 2006 as part of an integrated community development approach with assistance from Swiss Red Cross.  Through this health intervention SSVK could appreciably improve the health status of its target group on indicators pertaining to infant mortality, maternal mortality, child mortality, and incidence of malnutrition.  Particularly sustainable gains at the community level were the creation of a pool of trained TBAs capable of conducting safe deliveries and that of health promoters with skills of ante-natal and post natal check up and diagnostic and curative abilities for addressing minor ailments occurring in the community.  Attitudinal and behavioural change as reflected in improved dietary practices and the wide scale adoption of ORS as a response to diarroheal outbreak were the other notable gains.  Most notably the enhanced heath awareness of the targeted communities and their organization into strong collectives contributed to a marked incremental trend in these communities being able to approach and access the government health care system.

Patna - Dr. Ajay develops drug to combat Diabetes-TOI by Pranav

Aids ko jane / Aids se laren
A special booklet on HIV/AIDS endemic. This booklet provid

es primary information about AIDS. The booklet also provides information on history and magnitude. SSVK’s target area consist large number of migrant so this booklet was published for spreading information about HIV/AIDS.

Mahila ewam Purush Swasthya Karyakartaon ke liye Margdarshika
This booklet is module for the health worker. This booklet assists the health worker with primary information about health and hygiene. The booklet consist pictorial messages for better understanding.

Photos of Medical Camp in the Villages of Madhepura district run by SSVK Supported by Subodh Gupta,Bharti Kher, Nature Morte, Trident Hotel & Saffron Art

Health worker of SSVK at village Health camp in Sohrai (Madhubani) Supported by SRC Switzerland                                   Dr. P. N. Labh conducting training for health volunteers at SSVK training centre, Jhanjharpur Supported by Action Aid, UK

SSVK Medical camp in Saharsa district supported by SRC Switzerland