Founder - Chairman


News & Events

AGRI-CLINIC & AGRI-BUSINESS CENTER: AWARE has been approved as Nodal Training Institute (NTI) by MANAGE (Government of India, Ministry of Agriculture and Farmers Welfare) to conduct Training in Agri-Clinic and Agri-Business for Unemployed Agricultural Graduates /Diploma Holders/similar qualification. The training is for 60 days at Pujyashri Madhavanji Agricultural Polytechnic, at Aswaraopet Campus, Khammam District.... Read more...
Integrated Rural Development Program

AWARE which is an acronym for Action for Welfare and Awakening in Rural Environment is an organization exclusively serving the tribals and socio-economically depressed groups in the Telangana region of Andhra Pradesh in India. AWARE is associated with 1,750 villages with a total population of 975,000. It seeks to create self-sustaining rural and tribal communities through a process of their socio-economic and psychological invigoration such a process of resurgence involves a complex continuum of psycho-socio-economic action. It is also inevitably geared to people rather than to projects. In AWARE's strategy of total development, health has an integral place. The present study reviews AWARE's successful experiments and experience in health care against the backdrop of its broader interventions.

The Beginning

In 1969 in a stuffy staid office, a senior civil servant put down his signature on an official letter (for the last time in a memorandum addressed to the Government, he expressed his inability to continue and tendered his resignation from the civil service.) He then walked out a free man, free to find himself and to determine how best he could serve the people, which is why he had joined government service in the first place.

A developing country like India, which has been a colony, tends to carry a colonial hangover in the form of an administration that is not always geared to look at develop­ment processes and problems from the optic of the ruled but often ends up reinforcing the power and the perspective of the ruling. Those who wish to narrow this distance can do so either from within or with a greater degree of flexibility and challenge. Mr. P.K.S. Madhavan, the bureau­crat in question, decided to take the latter route. Nearly six years later, he crystallized his search and aspirations in the form of Action for Welfare and Awakening in Rural Environment (AWARE).

During those six years, Mr. Madhavan an anthropologist by professional training spent considerable time moving around the tribal areas in the Telangana region of Andhra Pradesh. His close observation of the existing development processes affir­med his earlier suspicion that the percol­ation or filter-down theory of development was misguided. Tracking the course of government spending in the tribal region, he detected that as much as 62 percent went toward maintaining the bureaucracy with barely 7 percent reaching the tribals. An­other 5 percent were misused by the tribal beneficiaries themselves, but more discon­certingly, the balance 26 percent was misap­propriated. Retrieving tribal welfare from this dismal situation became Mr. Madhavan's fervent concern as he decided consciously to set aside the passive armchair observer's role in favor of social activism.

Around the time of this transformation, Mr. Madhavan met like-minded persons in Mr. V. Kumar and Mr. B. Babu Rao, also in search of qualitatively different horizons. The three set out together in a common cause, that of bringing development processes and bene­fits closer to the people who had ex­perienced them the least.


Telangana is the least developed of the three principal regions into which Andhra Pradesh, India's fifth largest state is divided. The neglect of both industry and agriculture has undermined Telangana's development capability. The resultant adversity has inevit­ably hurt the Girijans and Harijans more than others. While exclusion from the develop­ment process is common to both, the Harijans suffer additionally from covert or overt social ostracization, a stigmatizing cul­tural legacy from which the girijans are fortunately free.

The Girijans in Andhra are around three million and constitute around 6 percent of the state's population. Consisting of 33 tribal groups, they live in 'scheduled areas' or those designated as tribal by the govern­ment. The 8 million harijans represent 15 percent of the state's population.

The envisioned aura of a stress free, close to nature tribal life has invariably to be juxtaposed against grimmer realities. The steep hills with their poor soil and the ever present threat of erosion, the conven tional methods of cultivation, the lack of agricul­tural production technology, the virtual ab­sence of alternate sources of livelihood, recurrent floods and crop failure together cause food and income shortages which accentuate want and its debilitating impact on the quality of life.

Health parameters specially get under­mined through adversity. The incidence of maternal death during childbirth is high as are infant and child mortality. In the absence of the cushioning effect of minimum health and nutritional wellbeing, even minor dis­eases easily acquire the momentum of epidemics causing preventable loss of life. Life expectancy among the tribal population where AWARE elected to work is barely 40 (as compared to an average of 54.4 es­timated in 1980 for India) which is a com­ment on the health backwardness of the region.

The ecological context of harijans is somewhat different. Geographically, they are not restrained or isolated on settlements. But owing to centuries of social discrimin­ation, they are a socio-economically and psychologically submerged and ostracized group who remain have-nots in a very real and brutal sense.

When AWARE decided to take up cudgels on behalf of these two groups, it was fully cognizant of the complexities of the task it was contemplating and the infinite chal­lenge it posed.

Objectives and Strategies

AWARE was born in November, 1975. Unlike some private voluntary organizations, which seek to set up a gamut of direct services, AWARE decided to take on an indirect role of sensitization or generating awareness in order to improve the utilization of services already in existence. To end this, awakening became its principal modality.

As a secular socialist democratic republic, India is constitutionally wedded to the prin­ciple of development of all in pursuit of which explicit constitutional safeguards, pro­tective legislation and ameliorative socio­economic programs have been ado­pted. Yet, as performance has indicated nationally, human resource development much more than capital formation is the keystone on which the development arch must rest. Unless the potential of the human being for whom the development process is intended is itself released, there can only be a dismal gap between the proclaimed egalitarian objectives and the inequitable reality of development. To help unleash their power and potential, AWARE decided on a process of empowerment of people. Through social education and awareness AWARE would jolt the people out of their apathy and try to mainstream the developmental outcast groups in psychological as well as material terms.

"It is the basic strategy of AWARE." says its chairman, "to awaken the people, to make them identify their own problems and to prepare them to devise their own solutions and plan of action. The oppressed must not only recognize that they are oppressed but must also be aware of what they can do legally, peacefully and constructively, to overcome their oppression.”

The unit of AWARE's concern is thus obviously the individual and that too, the one who is the poorest among the poor. The individual, however is a part of the family and the community. In the rural Indian context, it is the wage that is the nodal point of the community and must be assisted to become the nerve centre of all develop­ment. AWARE's organizational strategy con­sequently is riveted to the village and to its potential as a microcosm that can gradually be simulated elsewhere at the block and the district levels. In that sense, AWARE is pledged to start its endeavours from the ground up rather than await the psychological and material gains of development to percolate from the top.

AWARE's objective simply stated is to increase the equity of the Tribals and Harijans in the business of development. Through their psychological empowerment, it seeks to attack the culture of submissiveness. Socio-economic interventions are to minimize poverty. The strategies deployed are three-fold.
  • Psycho-social mainstreaming of the Harijans and Tribals.
  • Higher production directly benefiting these two groups and
  • More even distribution of resources for better co-existence of people.
Although direct services, both social and economic are necessary, the essence of AWARE's strategy lies primarily in educ­ational and organizational programs which end the voicelessness and powerlessness of the groups who have been silenced and debarred from their share of the sun for centuries.

To do that AWARE builds an organiz­ational system that can function autonom­ously but at the same time can also interact, interlink and network with other systems and structures in pursuit of the objective of creating self-sustainable rural and tribal societies the process involves specifically:
  • Creating organizations or associations of people at various levels (villages, and taluka or block levels) to represent their own interests and causes.
  • Supporting such organizations and their members to have access to devel­opment resources and available through government.
  • Phasing out once the organized popul­ation has reached a level of articulation and autonomy.In that sense, the transitory nature of AWARE's engagement is evident and is aptly conveyed through its spirited slogan “Awareness must stay. AWARE must go.”

AWARE's modalities are in a sense, in­direct. They are aimed at devising systems that can furnish a basis from where the target population can itself take off. Their ultimate objective is to create alert, sustain­able and autonomous communities and to reach them to a point where they can function on their own stream without further catalyzing help from AWARE or another group. In support of this objective, the specific methods include developing:
  • An awareness building and organiz­ation program
  • An income and employment generation program and
  • A basic needs program
Awareness Building and Organization

Awareness is generated through various means such as informal discussion, non-formal education, group meetings consist­ing of gram sabhas (village meetings) and maha sabhas (mass meetings), audio-visual shows and radio talks. The focus is on subjects of topical relevance such as agriculture, animal husbandry, community health, rural marketing, rural organization and representativeness of such organiz­ations, legal position on the rights and entitlements of the tribal and harijan popul­ation and practical difficulties in getting the larger rural community to accept those entitlements as legitimate.

Institution building entails creating a knowledgeable and motivated cadre of workers who can act as agents of change. Village-based training camps are conducted at which, information regarding develop­ment infrastructure and the rights and privi­leges of the weaker sections in the rural society are shared. Camps are also held on specific themes such as training in modern agricultural methods, rural marketing, knowledge of administrative structures, rural leadership and community organiz­ation and training for barefoot workers legal/medical/veterinary and other. At vari­ous camps, over 93,000 people have been trained so far and functional education has been made available to considerably more.

Another forum for training is the Community Education Centre(CEC). Each of these CEC is man­aged by a community organizer, trained by AWARE, who works in a selected village and sensitizes the community to its own pro­blems, potentials and capacities. The focus is on building the capability in the people for perceiving and solving problems. The issues that are talked about are elementary but crucial—land and water use, grazing rights, caste inhibitions and atrocities, status of women, shelter, food production, consump­tion practices, and so on. The centre also tries to generate interest in adult literacy, and assists school drop-outs and children who labour on farms and elsewhere with reinforcement coaching. There are currently 844 villages in which such centres are oper­ating with a daily attendance of nearly 34,000.

In creating an institutional and a leader­ship base, the following sequence of action is generally followed. AWARE organizers seek out a village and generate sufficient awareness and interest to form a village association. In consultation with the village association and aided by AWARE, an action plan for the village is drawn up. The plan aims at total socio-economic and psycho­logical development of the village. For an initial period of around five years, AWARE maintains its presence in the village through its workers and organizers after which it slowly begins to phase out once the village community becomes self-reliant and the village society believes that it can take over the responsibility of further planning and implementation of village development activities.

Withdrawal constitutes the last phase in AWARE's cycle of intervention. It amounts to discontinuing the regular presence and support of the Cluster Development Officer (CDO) appointed by AWARE, and his re­placement by the local CDO, an independ­ent appointee of the village or cluster of villages. It is recognition by the community of its self-reliance and capability to act on its own behalf. Normally, it takes 6 to 7 years of support from AWARE to reach the stage when AWARE can recede entirely. Such a stage leading to its withdrawal has actually taken place in about 200 villages.

As a result of this strategy, AWARE is able to limit its direct involvement to villages in the initial stage and take a back seat in those villages, which have taken off on their own. The philosophy of AWARE and its way of working are thus being disseminated through AWARE's direct or indirect pre­sence, in 1,750 villages at a time embracing a total population of around 9,75,000.

Economic Production

Agriculture is the fountainhead of rural livelihood and any effort to add to tribal and harijans earning potential has to be firmly rooted in agricultural development. With that in mind AWARE supports an irrigation program through which wells are dug, deepened and improved, minor irrigation works such as tanks and check-dams are undertaken, lift irrigation and pump sets are installed. Soil conservation and land leveling activities are promoted and suitable agricultural implements are provided for better farming. These are collectively owned by farmers' groups and village associations. Better seeds and fertilizers are also supplied. A very modest beginning is being made in animal husbandry with which neither the tribal nor the harijan is conventionally fam­iliar. During a visit to a tribal settlement, goat sheds and poultry farms are seen which are a response to AWARE's recent initiatives.

Marketing has always been a channel of rural exploitation. AWARE therefore en­courages its target communities to set up cooperative marketing systems through which farmers can buy and sell their pro­duce and also familiarize themselves with marketing procedures and financial man­agement. For the landless population who have no access to regular agricultural in­come. AWARE has set up small-scale cot­tage industries involving the making of baskets, leaf plates, shoes, and pottery.

A promising economic activity is AWARE's work with the rural youth. The need to engage them in appropriate skill training and trades, which are relevant to their own environment, is key inspiration behind AWARE supported vocational training. An impressive instance of such activity is the Rural Vocational Training Centre set up exclusively for tribal youth at Aswaraopet in Khammam District. Since 1980, the centre has been able to annually train 140 tribal youth as carpenters, fitters, diesel mech­anics, welders and electrical mechanics. These trades are required directly to service the needs of the tribal economy and to meet the recruitment requirements of industrial plants that are beginning to come up in the neighbouring areas of the tribal belt. Train­ing that is conducive to employment keeps the sons of the soil rooted to their native habitat stemming the usual push towards urban migration. Thus, AWARE tries to en­sure the conservation or retention of human resources. Keeping the centre's clientele exclusively tribal amounts to reverse dis­crimination but AWARE has never felt shy of projecting its bias openly in favor of the tribals and the harijans. In fact, it made an agreement with government to run the cen­tre conditional to the latter's acceptance that it would cater exclusively to tribal youth.

Basic Needs Program

This program focuses on the essentials of living. It encompasses community health, women and child welfare, and community development. To fit the peculiar ecological and sociological needs of the region AWARE has taken on two additional activ­ities:
  • Disaster and cyclone relief, and
  • Legal assistance for the weaker sections including the rehabilitation of bonded labourers.
Both these have been chronic problems in Andhra Pradesh. Cyclones and floods are a common feature, which dislo­cate normal life and set the clock back several paces. People's resilience, indefatigability, and the timely and constructive help from external sources such as AWARE is routinely able to muster, help the uprooted clusters of tribal settlements in the disaster hit areas to revive their socio-economy. AWARE's disaster relief planning is generally accurately timed and appropriate. It is occa­sionally also preemptive. In a recent flood at Bhadrachalam, AWARE's team of rescue workers led by its chairman was the first to reach the site and mount relief operations as the river waters were starting to swell. The impact of such assistance is tremendous by way of confidence building. The goodwill thus earned stands AWARE in good stead when embarking on health and develop­ment projects with longer gestation, entail­ing less visible gains and at times even less acceptable changes in personal habits and social mores.

Bonded labour which is a modern eu­phemism for slavery, is as integral part of the Telangana scene as nature's ravages. For decades and maybe even centuries, the resource less tribal or harijan is entrapped through intimidation and economic pressure to pledge his time and labour to a resourceful land owner. AWARE is committed to help these hypothe­cated souls. Through its team of legal offi­cers, consultants, social investigators and barefoot lawyers, AWARE restores unlaw­fully occupied land to the people, and the people to their freedom. So far, over 60,000 acres of land, which had been lost through unfair transactions, have been regained and some 5000 bonded labourers have been released and rehabilitated. AWARE is quick to clarify that all this has been done legally with utmost regard to due process. Such an approach confers legitimacy on social change as well as on social justice endeavours.

Environmental development is a logical sequel to AWARE's involvement with the land through its people and an integral part of its community development activity. Eco­logy is beginning to grip public attention in developing societies especially, only rec­ently. AWARE recognized the unmistakable value of environmental nurturing and pro­tection very early, fully appreciating that survival depends on nature. One segment of its activity therefore focuses on social fores­try and promoting an understanding of the need to preserve and plant trees. Other supportive activities include horticulture and sericulture.

Community development does not extend only to the environment. It also relates to aspects of collective community life such as building of an access road, a public well, the village drainage system, a biogas plant, a community centre, and so on. The deci­sions to implement such activities are taken by the community for its own benefit. They fit the availability of funds as well as the needs of the people and their level of conscious­ness. If food appears higher in the people's priorities, then that is where the community development efforts are focused. Where employment figures next, that is taken up as the centre of the group's attention. If health figures low among the community's felt needs, no unnatural push is given by AWARE to hasten a community to take on health ventures. Community development therefore amounts to a community developing itself in accordance with its own perceptions of what it needs and what it is capable of doing to fulfill that only a felt need should trigger off a development response.

A major focus of AWARE's community development program are women and children. In the development processes, women traditionally have lagged behind. Among tribal and harijan women, the ad­ditional disadvantage of belonging to a socio-economically depressed class reinforces this intrinsic handicap. AWARE has fought to empower women to counter their handicaps. Through motivational camps, mass mahila sabhas (public meetings for women) and setting up of exclusive societies serving the interests of women including mahila mandalis (women's groups), AWARE is beginning to get women to participate in their own development, and even more, to break out of their shell. Today a young tribal woman is able to go to a bank to demand a loan, or a group of harijan women can physically block the illegal occupation of land by the better-off sections.

Other welfare interventions entail com­munity cooperation and participation in helping the aged and the infirm, destitute and widowed women, and orphaned and neglected children. No matter how deprived, a population is still able to collectively meet the basic needs of its weakest members. AWARE encourages an informal concept of social security that is financed and man­aged by the community for its weaker sec­tions. In essence, this amounts to the poor assisting the poorer.


The welfare of women and children and of the community has a strong health dimen­sion. It is this realization that is behind the health promotive endeavours of AWARE. Its health philosophy is designated by the words Jeevana Shravanti which means life's flow. AWARE looks upon health as a conti­nuous life sustaining force, a concept which is difficult to sell in a milieu where actual rather than probable sickness decides the merit of medical consultation and treatment.

The turnaround in this traditional ap­proach came quite unexpectedly in one of AWARE's earliest health projects. Following a cyclonic disaster and fearing a cholera epidemic, AWARE undertook mass immuniz­ation. In addition, it set up a wayside clinic to treat hundreds to patients with a wide range of diseases directly attributable to the cy­clone such as palpitation, stiffness of legs, diarrhea, tendency to miscarry among women, loss of milk among lactating mo­thers and other overt and covert signs of trauma deprivation.

At the end of about four months, after the work arising from the cyclonic dislocation finished, when AWARE considered closing its health clinic the user population could not bear the thought. With their enthusiastic support AWARE decided to convert the clinic into a permanent community health centre. The centre was formally inau­gurated almost a year later at Chinnapuram in Krishna district on 5th January 1979. Despite their depleted economic condition and meager incomes, the people contri­buted toward the partial maintenance cost of the centre. Thus, at the behest of the community, a one-time emergency relief operation was converted into a sustained health activity.

Even after this happened, AWARE did not deliberately impose a preventive bias on the health centre's activities. It focused its efforts primarily on curative care which was the felt need of the community and which commands high visibility. As a doctor atta­ched to the health centre observed, "Here we experienced that the community's pre-­eminent health need is for curative care and cannot be dismissed as irrelevant." Sub­sequently AWARE slowly expanded the scope of the program to include the preventive aspects as well.

Along with its scope, the program coverage also expanded. Using the Chinnapuram centre as the base camp, a mobile clinic program was developed as a result of which every village within a radius of 20 kilometers was visited every alternate day.

Gradually, the centre started addressing the key public health problems in the 15 villages within its jurisdiction with a view to eliminating the causes of ill-health rather than merely curing disease. Field analysis led to the conclusion that scabies, pyoder­ma, herpes, diarrhea and amoebiasis were the more common diseases that occurred due to water pollution, and consumption of unsafe water. Diseases arising from severe under nutrition were common in about 90 percent of the children. Around 37 percent of the female population suffered from anemia.

Recognizing that many of the health com­plaints in the population were the outcome of unsafe water, creating an awareness of the benefits as well as sources of clean water became the focus of preventive ac­tion. AWARE realized that its own responsi­bility lay in educating the people on the merits of clean water and environment. The actual task of creating the sources of clean water and environmental sanitation facilities would be best left to the government. Never­theless, by pressuring the local government to dig wells and build drinking water tanks and drainage systems. AWARE ensured that every village in the Chinnapuram health centre area has a source of clean drinking water as well as drainage facilities.

In the four years since its inception, the Chinnapuram community health centre has treated around 80,000 patients. The people themselves, apart from donating the initial cost of purchasing the land on which the centre stands, have contributed a sum of over ` 1 Lakh towards the cost of medi­cines. This is evidence of the community’s continued belief in the efficacy of the ser­vices rendered by the health centre.

The health canvas of AWARE is spread over several campuses. Chinnapuram is possibly the earliest and the remotest, being over 400 kilometers from the state's capital--Hyderabad. There are other com­munity health centres located at Padkal (70 kilometers from Hyderabad in Mahaboobnagar district), Naidupet and Narayanapuram in Khammam district (about 200 and 300 kilometers respectively from Hyderabad).

All these centres are engaged in promot­ing a similar concept of community health. Each centre (except the one at Kunavaram) has a 30 bed base hospital. The services rendered include:
  • Curative health care
  • Preventive services including health educ­ation
  • Training of community health workers and paramedical staff to serve as health educators, and to work in the health outposts
  • Health and nutrition camps
  • In addition, each community health centre (CHC) has its own focal activity— environmental sanitation in the case of Chinnapuram and Narayanapuram, leprosy in the case of Naidupet, and training of health workers and health education in case of Padkal
The base hospital serves as a nucleus of the health care system. It combines the functions to a referral hospital with medical research, monitoring and training. There is provision for collating health information of the project area and updating it by routine surveys. Community surveys deal with per­sonal, community and environmental health aspects.

The practical experience and knowledge gained from treatment and survey work serves as a useful resource for developing health education and training materials, which reflect the local health context and needs peculiar to the project area. Health education and training, curative care, and diagnostic work thus reinforce each other and are seen as a continuum.

The training program aims to create a team of health workers from among the illiterate tribal and harijan women and occa­sionally men. From among them, those who meet the criteria eventually serve as auxiliary nurse midwives (ANMs). The team of workers include dais (Traditional birth attendants), village health workers and paramedical workers. The major thrust of the training is on preventive health care. Mother and child health, nutrition, vaccination and sanitation are the main areas of concentration.

Unlike some private voluntary agencies who take a guarded stance on the worth of health camps. AWARE regards these as effective rallying points for promoting its health objectives. Camps organized around the prevailing priority health needs such as, nutrition, vegetable growing, clean water, diarrhea prevention and treatment, personal hygiene, eye care, vaccination, identification and treatment of tuberculosis and leprosy. The camps are run by AWARE's medical staff aided by the general (nonmed­ical) project staff, and organized with the cooperation of the village associations. When such bodies are traditionally en­gaged in broader development endeavours take on health care, it has the practical effect of establishing health concerns as an integral part of development and as one of the responsibilities of the community.

AWARE is convinced that it is only when health programs backed and im­plemented by the people that the goal of health by the people, and for the people can materialize. AWARE aspires eventually to create self-sustaining health societies, aptly expressed by its idealistic slogan 'health without a doctor’ in pursuit of that goal. AWARE places as much stress on the healthy as the sick. Recognizing that dis­ease prevention and health promotion are two sides of a coin, AWARE spotlights pre­vention as a fundamental ingredient of its community health programs.

In disseminating knowledge for prevention of ill-health, AWARE's democratic bias is clearly seen as its belief is that medical and health knowledge should not be concen­trated in a few hands or rest exclusively with the professionals. Primary or basic know­ledge of health can and must be shared by the entire community. In AWARE's communi­cation channel thus, the message does not stop at the level of the community health worker. It has to transcend the worker and be absorbed, imbibed and internalized by the community. AWARE is also trying to instill a sense of accountability to the health worker for the state of health of the com­munity. Such accountability takes its inspiration from the practice in ancient China where the doctor was paid as long as his client was healthy and lost his pay when the client fell sick. Health education, monitoring and care, and improved health status of the people thus become interde­pendent outcomes of the community health endeavour.

Staffing and Training

AWARE's staffing pattern is elaborate, it has a head office with a chairman and around two dozen full-time staff, and facil­ities for computer processing, account keeping and auditing. For its various programs, it has about 200 full-time field staff who are graduates and postgraduates there are engineers, doctors, lawyers, geo­logists and professionals from a host of other disciplines. In addition, it has 400 rural organizers, 800 part-time village organizers and a volunteer force of 25,000 drawn from the project villages. Almost all staff work beyond the normal 8-hour workday. Nearly all days of the week but compensation is linked more to their own sense of idealism than to the modest amounts that AWARE can manage to offer.

The apex functionary of the health program in each CHC is the director aided by an assistant director. These are medical doctors with specialization in preventive medicine. One of the two doctors is exclus­ively in charge of the health education program as well as training, assessment and review activities, and health care is en­trusted to the other doctor. These functions are assigned on a rotation basis. The doc­tors are aided by three tiers of health workers consisting of paramedical workers or community health workers, village health workers, and dais.

Paramedical workers are trained for six months during which they acquire the basic knowledge of medical assistance including first aid, treatment for simple diseases, han­dling emergency cases before the doctor can be reached, aftercare and follow-up and maintenance of health records. On comple­tion of training such workers can manage a health outpost or shelter and function as medical 'extension' workers.

The village health workers are nominated by the village associations they are trained for a month at the base health centre. To be nominated, no formal qualifications are re­quired except the ability to absorb and transmit simple health messages, speak clearly, and nave the self-confidence to work on their own. Training of these workers touches on identification, prevention and treatment of seasonal and other common diseases, personal and environmental hygiene, malnutrition and other aspects. The training of dais focuses additionally, on safe delivery, prenatal and postnatal care and immunization. Training is conducted through casual informal conversation slides, picture cards, and songs or theatre.

During a visit to the centre in Padkal district, a group of tribal women health workers is seen around the campus. They have come for refresher training, which takes place every six months. They represent all age groups above the minimum requirement of 25 years. Seethamma was earlier a dai (midwife) and feels that her ignorance regarding hygiene and tetanus led to many more casualties, commonly arising from infection. With the knowledge and expe­rience gained through AWARE, she is now able to prevent maternal and child deaths. Antenatal and postnatal care, nutrition, pre­vention of tetanus and other diseases through immunization, all these are better comprehended both by her and by the community who sponsored her for this re­fresher training. Others echo Seethamma's positive experience. Is there any visible im­pact of their work? Yes, their own personal lives are safer and cleaner, and their com­munities have upgraded their health status considerably. In most cases, as the women themselves contend, their functioning as health workers has the blessing and support not only of their villages and hamlets but also of their spouses.

Although principally a health meeting, the scope of discussions is deliberately kept wider to encompass health and develop­ment aspects. Muthamma recalls how she and her children were bonded labourers and AWARE liberated them, organizing them to acquire land and gain access to the well, both factors which drastically transfor­med her life. She regards working for her community's wellbeing and service with AWARE as a modest return on the invest­ment made in her by AWARE. Another woman health worker, Kantamma speaks of the evils of drinking and how, after renounc­ing liquor, her spouse and she is much better adjusted and able to cope with life's business with dignity. She feels that equal health is as much a right to be demanded and earned as equal wages and equal terms of work.

Lakshmi specializes in delivery cases. She has learned some and practiced much with AWARE and now feels more confident of her skills. Largely as a result of AWARE's in­sistence on the team approach, she has no professional tensions vis-à-vis the Dai and often functions in consultation with her. The two dais (midwives) in the refresher course independ­ently confirm the above cordial working milieu. They seem well adjusted and confi­dent of their new skills.

Bhudevamma provides a soulful finale to the trainee narratives. She notes how owing to her active participation in the village association, she was nominated by the community to attend the refresher training course. The leaders in her village told her, "Go and learn about diseases so that you can let others know." The simplicity and direct quality of the commandment is elevat­ing so is its relevance to a health care program pivoted on awareness of people.

In that exclusive female gathering of health workers, one cannot but help notice a solo masculine presence. He is an old man. He had worked as president of an AWARE sponsored village association for eight years during which time he actively orga­nized the harijan families. He is now in charge of the women health workers as a health motivator. He uses many devices to motivate the workers, but a favorite is singing. Suddenly, in the midst of the hot sleepy afternoon, he begins a health song. Slowly, word by word, beat by beat, the group of trainees join in and the hall becomes resonant. The song covers the key themes not health in isolation, but of health as an integral part of development. As an apology for the rich original verse and flavor, the text is recapitulated below:

In the bottle we lost our health and wealth and pledged our souls in bonded labour
Then the change came and a desire to right the wrong
The awakening which grew from neighbor to neighbor
In village after village, from neighbor to neighbor.

Leafy vegetables are good, so eat them; Vaccinations help, so take them
Without antenatal knowledge and care what will come your way are death and despair.
What is leprosy, do you know it's not fatal; without proper shots it's tetanus that is lethal
Avoid the darkness and the loss of life ;Awaken to knowledge that is your birth right.

In the verse, there is a reference to intoxic­ation. De-addiction is a prime target of AWARE's health work. The entire culture of AWARE, from the chairman down to the community workers is ascetically fixed in a Gandhian stance against drinking. Liquor has been the bane of Indian life. It eats into the meager resources of low income families and causes men to inflict brutalities on women and children. AWARE has trained rural volunteers particularly women to stimulate concerted action against alcohol­ism. As a result of this effort, as AWARE reports, the entire harijan and tribal popul­ation in 1200 villages has stopped alcohol consumption and ensures that there is no resumption of drinking through stringent collective monitoring. The economic and psychological advantages from not drinking are sworn to most vociferously by the women who see a distinct upgrading in their status.

Linkages between health and develop­ment and the 'economics' of health are fostered by AWARE in all its operations in various ways. The CHCs for instance, are encouraged to become economically self-reliant by setting up income generating projects like agriculture, animal rearing or dairying. Income from this helps to defray the cost of running the medical centre. At one health centre, leaf plates and inexpen­sive saris are made. Considerable space at this health centre is devoted to sericulture, an activity that is hoped to make the project self-sufficient.

The health workers are offered similar incentives to become self-reliant. During the initial two years, they receive a small re­muneration from the project. This is followed by a loan to commence some income-generating activity such as poultry or weaving.

The involvement of the medical discipline with the process of development is the crux of the AWARE methodology. Treating people is only one of the CHCs functions. By disseminating health knowledge, the CHCs must also become 'community information centers’. Furthermore, by taking an active part in community development activities they are expected to serve as 'community action centers’. This integrated approach permeates the medical functionaries as­sociated with AWARE and affects the very manner in which the doctors heading the CHCs and leading the AWARE health teams conduct themselves. During a visit, the med­ical team does not confine itself to health issues. Sitting inside a villager's mud hut or cattle shed, or simply under a shady tree, the visiting doctor may initiate a discussion with the assembled men, women and children. Often the topics discussed are wells, land, schooling, poultry, diseases that are con­tracted by chickens, and finally, health of the community. Watching this interaction, a feel­ing grows that community medicine is com­munity development. The mystique and aloofness of urban medicine seems to pale the comparison to this dynamic networking of health with life. As a visitor to one of AWARE's CHCs has aptly noted, "Here in these villages, one gets the impression that health care is integrated into the lives of the people and is not treated as a separate entity" and that in a fundamental way "health and life are seen as one."

Although each of the CHCs set up by AWARE would in itself make an independent case study, in the present narrative, two CHCs are briefly described in order to de­monstrate AWARE's talent for pioneering ground breaking modalities.

Naidupet Community Health Centre

The CHC at Naidupet focuses on the problem of leprosy. It is not a feeding place for the leprosy affected, or a centre for their free treatment, boarding and lodging. Its emphasis is more on creating an under­standing and acceptance of the disease through education, survey, detection, treat­ment and rehabilitation of leprosy cases and of their families. A receptive, sensitive and constructive climate is created for facing leprosy with knowledge and a sense of responsibility, and not compassion alone. In AWARE's terms, rehabilitation does not mean creation of leprosy colonies but rest­oring the leprosy patients to their villages and society with the full knowledge, under­standing and acceptance of the village.

The 'reclamation' process is based on the acceptance by the village of its joint moral responsibility to take care of every leprosy patient. Enough compassion and a sense of identification generated in the villages around Naidupet for them to contribute towards medication costs for treating leprosy, and to imbibe and practice the message that the leprosy patient is not to be shunned or renounced.

These attitudinal changes did not come about overnight, AWARE's involvement with leprosy began quite by accident. One day, while driving along the road leading to Naidupet Mr. Madhavan noticed a group of families gathered together under a cluster of trees mourning over their burnt down huts and hamlets. Enquiries revealed that this is a common method of hounding out leprosy-affected families from any neighborhood.

This is when AWARE decided to fight this process of exclusion by offering a facility where the hysterical fear of leprosy could be slowly and scientifically demonstrated to be unfounded. That all leprosy is often not infectious and that only the lepramatous type is danger­ously infectious are facts unknown to the vast majority of people. Among the identified cases, according to AWARE, only 15 percent are lepramatous. Most of the burnt out cases are not dangerous, and every disfigured person is not a conveyer of infection.

As theoretical messages, these pieces of information are hardly original. AWARE's uniqueness lies in the manner in which it chose to disseminate them through de­monstration. A health centre was set up jointly for the treatment of lepers and the general public, initially this effort misfired as the general patients refused to show up for consultation and care. AWARE then decided to demonstrate its beliefs more openly. It began to host meals cooked by leprosy patients. Public functions were held and festivals were celebrated at the centre where the city fathers and key public figures came and ate the food cooked by cured and noninfectious leprosy patients. AWARE staff and leprosy patients began to travel tog­ether and sit across the table for discussions and for meals. Disfigured but cured leprosy victims were appointed as watchmen, sweepers, watermen, compounders and medical aides at the centre. Gradually the general patients started attending the out­patient clinics. Eventually, they accepted inpatient care and soon the Naidupet CHC began conducting minor operations, deliv­eries, and offering other forms of domiciliary care to the general population.

For the able-bodied leprosy patients, an agricultural farm was set up on seven acres of land that is now self-sustaining. Sheep rearing, towel making and bandage cloth weaving are other trades through which leprosy patients have been effectively re­habilitated. In this manner, about 100 pa­tients have become self-reliant. AWARE does not stop its involvement with serving only the health needs of the patient. In the hamlets that have sprung up around the Naidupet campus, here are young men and women who are entering into marriage with one of the marrying partners being a leprosy victim. There are older couples whose children have left the colonies to get married, to stay in student hostels for further studies, or to work. AWARE’s helping hand is unmistakably present in most of these cases. AWARE’s more rewarding moments have come from a turnaround in the social acceptance by the community of leprosy victims. To quote an instance, residents of two AWARE villages invited some recovered leprosy patients and their families to settle down in their villages and they have pur­chased goats for them to help start a new chapter in their lives.

In the treatment of leprosy AWARE is experimenting with alternate therapies. Magnet therapy has been introduced and a laboratory has been opened in the CHC to study its effect on the leprosy patients. AWARE is also exploring the efficacy of transcendental meditation in reducing men­tal stress among leprosy victims.

Motivation has been a key factor in the success of the Naidupet experiment. A cadre of health motivators were recognized to be of indispensable value by AWARE which set up education and training as integral parts of the CHC. To educate and motivate the community, the health centre relied not only on its own cadre but also on women's clubs (mahila mandalis), mothers clubs, religious singing groups (harijana mandalis), youth clubs and caste elders. The involvement to such a variety of groups reinforces AWARE's core message that the delivery of health care is not an exclusive function of the medical profession.

Kunavaram Floating Community Health Centre

If innovative methods are a yardstick, AWARE's boat hospital or floating CHC operating out of Kunavaram village is a winner. In the rugged Bison Hill range, on either side of the river Godavari, AWARE has a novel strategy for reaching health care to the Koyas and Konda Reddis—two key tribal groups. Living in 300 odd villages along the river, these tribals have been boycotted for decades both psychologically and in terms of service infrastructure. There are neither roads nor any other means of easy access through the Bison Hill terrain. The only communication possibility and one which AWARE grabbed eagerly was the mobility offered by the river. It decided to set up a floating hospital. The Government of India and the state government were per­suaded by AWARE to finance the cost of a mobile health program located on a launch. The hospital floats on the river every day. Beginning at 7 a.m., it touches five centres on one of the banks each day. The medical crew halt overnight at a place called Kolhur and the following morning, the cruise is resumed with the boat stopping at another five centres located on the other bank. The boat has facilities for minor operations, inpatient care, and a laboratory for urgent diagnostic work. There is a doctor on board who is aided by the Assistant Nurse Midwife and a com­pounder. The crew is efficient and knowled­geable in boat maintenance and repair. A talented cook turns out delicious local cuisine. Over the years, Prakash Rao one of the sarangs (boatmen) has acquired enough medical savvy through formal and informal learning to be engaged as a para­medic. He had the chance to see one of his children being delivered in the boat hospital and that too, in the midst of a fuming Godavari.

The boat berths on the riverside at a designated place. Outpatient services are delivered on the boat except to the aged and the infirm that are unable to come person­ally and are therefore, visited in their homes by the roving medical team. The tribals come down the slopes to get immunization, first aid, prenatal and postnatal check-ups or general health services. Routinely, before the outpatient clinic is held, the doctor and his crew climb up the steep hillside to a health 'shelter' or 'outpost'. Here, some of those who live within the jurisdiction of the outpost (8 villages) gather to talk with the doctor and his team of village health worker, the motivator, the midwife. AWARE's development project staff, leaders of mahila mandalis and youth mandalis, caste elders, and a mix of women, men and children—all sit together to go over any pressing problem in health or other fields. Women speak freely of their hassles not only with the lack of medical facilities but with socio-economic programs, the availability of loans, the problems of debt, irrigation or seed supply, repair of dwellings, cattle, poultry, and pre­valence of malnutrition.

At one of these meetings at Sriramgiri, Mr. P. Raghavaya a paramedical worker began with a discussion of unhygienic foods. He went on to discuss scabies and how the lack of personal hygiene causes it. The benefits of immunization against polio and other diseases were emphasized next and finally, he spoke of smokeless cooking stoves. The presentation was participative and encouraged those assembled to supplement what Mr. Raghavaya was saying. Later, a group of midwives explained to the visitors how AWARE had brought safer birth practices to the tribals. Since the villagers did not know how tetanus is caused, many cases went undetected result­ing in loss of life. Now that loss is prevented, deliveries are generally safer also because the primitive instruments such as sickles, arrows and heavy stones used for cutting the umbilical cord earlier have been merci­fully replaced with the modest sterilized delivery kit provided by AWARE.

According to Seethamma, immunization is accepted by many more expectant women today than before. AWARE estimates current immunization coverage at two of its CHCs at around 40 percent as against 4 percent initially. Suramma, who is a village health worker (VHW), confirms Seethamma's (midwife) assessment of the changing health habits and status of the villagers. An old woman, she explains her desire to assist AWARE as the least she can do for those who have set out to help her people. "I want to help them to help us." says Suramma with a touching directness and a dignified mix of gratitude and pride.

The boat repeats this shelter drill ten times during a 24-hour period. Through each shelter or outpost, the population of eight villages is expected to be covered, in all, through 10 outposts, 80 villages or a total tribal population approximating 40,000 is intended to be reached. Each shelter is manned by a paramedical worker and is regularly visited by the floating health cen­tre. Bicycles and mopeds are being slowly added to ensure mobility and outreach for the health shelters. A country boat is also provided at each health shelter for trans­porting patients to the base hospital at Kunavaram in case of an emergency. With six beds, a labour room, a minor operation theatre, a clinical laboratory and a training centre, the base hospital is equipped to act as a referral centre.

Each of the 80 villages has a trained VHW to meet the first aid needs of health and family welfare services. In addition, a trained midwife is expected to be available to each of the 80 villages. The recruitment of midwives has not been easy. At present, there are 30 of them who are serving the 80 villages on a cluster basis. AWARE is conscious of this shortfall and is making a vigorous effort to fill this gap.

The two teams of doctors oversee the health shelters, supervise the midwives, village health workers, and paramedical workers and manage the floating health facility and base hospital. Assisting the doctors are ANMs who are locally recruited women who have received six months' training with AWARE. There is also provision for a health program officer (a position yet to be filled) with a background of health educ­ation to assist the health education activities in the Kunavaram project area.

Even with two teams and their supporting staff alternating, life on or off shore can never be easy. But Dr. Subba Rao, presently in charge of the Kunavaram CHC, speaks softly of deeper compensations and of pro­mises to his health constituency. Sitting in his inspiring presence, with the contours of the Bison Hills silently backing the cou­rageous little hospital boat anchored in the shimmering waters, the poignant truth of Robert Frost's lines comes alive:

The woods are lovely dark and deep. But I have promises to keep,
And miles to go,
And miles to go before I sleep.

As a qualified medic, Dr. Rao is hardly naive to or unaware of the market value of his skills or those of his colleagues. In fact ten doctors have left the scene since he joined but he has stayed on, despite grave personal difficulties in terms of housing and other amenities of life possible in the modest setting of Kunavaram.

There are additional contingencies, which one must learn to cope with. Over a year ago, when the base hospital and referral centre set up by AWARE at Kunavaram stood submerged under 20 feet high water, Dr. Rao and his team ran the boat as a major rescue and flood relief operation, AWARE won formal recognition in terms of a state award for helping to rescue over 20,000 stranded victims of flood. Soon after the flood waters receded, the team was engaged in reclaiming the health records and equip­ment from the water-soaked CHC. After a year later, there are no visible signs, nor sorrow over what was lost or what could have been. Along with the tribal hamlets and the rest of the landscape, the CHC stands resurrected in total defiance of nature's intimidating power.

Organizational Revamping

Organizationally, AWARE's evolution has passed through two distinct stages. In the earlier phase, it began as a conventional vertical set up with a pyramidal structure. Accounting for a few persons on the top with the grass root workers forming a bulky base. Around 1984 within 5 years of its existence, its pyramidal structure began to experience operational cramps. AWARE may have been slow to appreciate its own atrophy but experience open critical forthrightness of its const­ituency. Some people from a community which AWARE had sensitized and empo­wered discovered that AWARE was losing its activist's healing touch and was becoming just another bureaucracy.

Instead of turning a deaf ear, AWARE's central office listened to this illiterate but knowledgeable group, and in fact provided a scribe's services to document their agit­ated perceptions, which was tabled and widely reviewed by AWARE staff. The outcome was a decision to reclaim the organization from its operational maze. After closeting themselves for several weeks in self-evaluative introspection, AWARE came up with an alternate organizational model, based on the cluster approach.

In the revised approach, both geographic areas and substantive functions have been consolidated into more cogent administra­tive and functional units. A set of 20 villages are now grouped together to form a cluster. The villages are headed by village orga­nizers (VOs) and the clusters by cluster development officers (CDOs) who report to area coordination officers (ACOs) who in turn, are placed under zonal officers (ZOs). At the end of 1986, there were around 120 VOs, 99 CDOs, 17 ACOs and 3 ZOs. Below the CDO level, there are about 9,900 village workers and volunteers who serve as moti­vators and activators at the local level. They work in close cooperation with the village associations catalyzed by AWARE.

The VOs are responsible for the motivation and guidance of volunteers at the village level and assist in implementing the projects. The CDOs plan, activate and monitor AWARE's programs in the concerned villages, they are assigned definite targets in terms of project amounts to be raised locally. These are expected to match AWARE's grants in the ratio of 70:30. The ACO is principally responsible for over viewing the development of the program and its coordination. He has no financial or administrative responsibilities; those are entrusted to the regional offices.

The central office has total organizational charge. Under the leadership and personal supervision of the chairman, a core group operates consisting of the Chairman, man­ager, program officer, project director and zonal officers. This core body decides all policy matters.

All these administrative levels are linked together in a two-way communication chan­nel which works exceedingly well on power­ful human transmitters. The Chairman has the unusual knack of being able to quickly relate a problem to a person and the person to a face. He lived amongst the tribals and mixed with them closely before feeling con­vinced of the need to set up an AWARE type program. He has not allowed that first imprint to leave his mind. His vigilance keeps the bureaucratic cobwebs away from AWARE. Mr. Kumar, the project director shares the absorptive and the retentive power of the Chairman and can readily recall and retrieve relevant pieces of inform­ation to serve as building blocks in decision-making. He attributes AWARE's strength to its solidarity and to the clarity of perception at every level of the organization regarding AWARE's principal mandate. Where the message is clearly comprehended down the line, an organization and its personnel pose less risk of going wary. In AWARE, the message travels up, down and sideways with equal facility. Human transmitters, how­ever, can only function well with mobility. They cannot afford to transfix themselves in some remote point of reception; such a permanent spot does not exist. It has to be identified each time in every territory and that is why both the Chairman and the Project Director are perpetually on the road trying to learn and to transmit AWARE's message.

In independent discussions, both empha­sized the ability not to compromise as the most valuable strength of an organization. The objectives must be clear, and once set one must not go alter them, never agreeing to compromise either on the means or the ends. In support of this, AWARE can quote convincingly from its own experience. For instance, AWARE began with and has stuck to the tribals and the harijans- its exclusive target groups. It has successfully withstood the compulsion of various pressure groups to broaden its canvas and is not prepared to risk dilution.

Yet that uncompromising quality is tem­pered with a judicious dose of self-analysis and self-criticism. If AWARE or its staff are wrong, they have the courage to say so. Where they do not detect the wrong and others do, AWARE is more than willing to review, to discard and to start all over again. This flexibility makes it receptive to new ideas, modalities and motifs. A proof in evidence of such open-mindedness is the administrative turn around in its organizational culture when it switched from a tiered to a cluster model. The structural overhaul mounted in re­sponse to the anguished call of the rustic tribal, and not because of a fancy assess­ment from a pricy five star management consultancy.

Many of the preceding traits can only be the outcome of soundly decentralized pro­gramming, budgeting and enforcement strategies. AWARE is de-centered, it thrives in several centres, each operating within itself as an autonomous organism, but organically linked to the body corporate that is AWARE.


AWARE regards funding as a subsidiary activity to its programs. It shows a sense of autonomy in its fund raising and adopts an approach to raising its funding needs that is relatively carefree. AWARE's stake­holder, to borrow a corporate expression are the people. Once they understand that an intended program is in their interest, AWARE believes that they are capable and nearly always successful in mobilizing sup­port to finance the proposal. It relies heavily on people's human as well as capital re­sources to support the running of its programs.

Whereas nothing would satisfy AWARE more, nor honor it better than to have an entirely popularly funded program, the reality is substantially different. Forty per­cent of its annual budget of around ` 40 million (` 1 = US 8 cents approx) is raised from overseas funding sources, another 25 percent come in the form of credit from banks like Industrial Credit and Investment Cor­poration of India and district level govern­ment agencies. People's contribution (as payment for services rendered) approxi­mates 24 percent, which is four times as much today than just two years ago. Grants from central and state governments ac­count for 5-6 percent. The balance 5-6 percent comes out of a revolving fund set up by AWARE and from income generating projects.

Overseas funding has been a source of some anxiety and criticism as well as sus­picion in India but AWARE has no fear that this aspect could be used either as an index of AWARE’s invisible ownership by vested external interests or compromise its autonomous nature in any way. AWARE stresses its intrinsic right to make decisions freely regarding its operations.

Keeping in view the existing felt needs; AWARE's sectoral disbursements as a per­centage of its total budget of 115.6 million rupees for 1984-86 are as follows:

Health 4.4
Economic and agricultural programs
Social education and community 12.8
Release of bonded labourers
Cottage Industries
Marketing justice
Women's development 3.5
Field staff maintenance 3.5
Central administration
Total 100

Once funds are received and budgeted, AWARE is very cautious in ensuring ac­countability and efficiency through careful auditing aided by computerized process­ing. AWARE continuously monitors where money is going, why, for how long and how much, Is it met by the receiving party with matching amounts? Is the actual rate of spending as per schedule? What is the absorptive capacity of the receiving com­munity? Except in rare cases, AWARE's grant in aid to any project does not amount to more than 30 percent of the total cost involved. The balance 70 percent is raised locally through government or other means including direct contributions by people.

An unusual working characteristic of AWARE is its low operating costs. Salaries of field and central office staff amount to less than a tenth of the total budget, which is well below the 30-40 percent operational cost generally associated with private voluntary agencies, and an even higher proportion estimated in respect of government spending.

Cooperation with Government and Non-Governmental Agencies

AWARE sees itself as reinforcement to government. It accepts that government provides the principal framework for the processes of development. Its own role is to give the people a nudge to use the govern­ment infrastructure and to benefit from it. AWARE's staff operate closely with their counterparts in government. Occasionally, relations tense or sour, when the people aided by AWARE push the state machinery too hard. Allegations doubting AWARE's credibility or questioning its mandate are made every now and then in the state legislature or outside. AWARE leaves it to the people who know its worth to defend it. In a recent episode, when certain allegations against AWARE were reported in the local press, hundreds of AWARE's illiterate sup­porters gathered to adopt a resolution, and conveyed its text to the local media, categorically denying the alleged flaws in AWARE's set up and approaches.

AWARE has generally experienced a sound rapport with the non-governmental sector. It is a grantee of several well-known private voluntary outfits such as NOVIB (Netherlands Organization for International Development Cooperation), ICCO (Inter Church Coordinating Organization for De­velopment Projects), CAA (Community Aid Abroad).

Its major counterparts, however, are the people. There is a box office quality to AWARE's capacity to draw crowds. At any point in time, virtually within a moment's notice, AWARE can organize small, big or massive assemblies of people known popularly as sabhas (councils) and mahasabhas (grand congregations); they have become a familiar motif of AWARE. Although its larger rallies are uncannily similar to political meetings as an organization, AWARE is pledged to secular, apolitical behavior and harbors no aspirations that rivet its survival and entity to the ballot box.

Impact and Achievements

AWARE's achievement in its work with the tribals and the harijans is to be measured not only in terms of the number of wells dug or milch animals distributed but in its vision of a tribal and harijan population that is strong, united, courageous and patient and is able to cope with its own requirements and liabilities through more intelligent use of its own resources and those of the govern­ment or the system.
In a narrative of health, AWARE's wider horizons cannot be justly dealt with. Its larger achievements are on the other hand capsule alongside.

In terms of human resource development, AWARE's performance is particularly impres­sive. It has trained a cadre or task force for rural development consisting of a group of 200 graduates and postgraduates. More than half of them are cluster development officers who live in the project villages and work with a sense of dedication and commit­ment that is now internalized and is no longer dependent on AWARE.

Through an unusually stringent screening and initial training procedure, which tests out the physical and moral strength of the trainee, AWARE is generally successful in recruiting worthy and reliable staff. As the training proceeds, those with weaker will or purpose but not necessarily less ability, flake out. According to the Chairman, who personally conducts the training and breaking-in drill, lasting over several exacting weeks, almost 60 percent of the trainees drop out. What remains is the stuff with which AWARE's dreams are translated into reality.

Specific to health, although AWARE ope­rates several health centres, the impact of its health action can be reviewed only in rel­ation to two centres (Naidupet and Padkal) for which longitudinal data are available. AWARE's achievements along key health indicators over the period 1979-86 where the comparative data show that AWARE's preventive approach is succeed­ing. Health inputs by way of immunization, antenatal and postnatal care show an im­pressive enhanced coverage from below 10 percent to between 40 to 50 percent. The outreach of institutional care and of trained health workers has also improved starting with meager levels, the coverage of health services currently encompasses be­tween one-third to one-half of the project population.

To some, this rate of expansion may seem neither dramatic nor noteworthy but given the constraints of tribal ecology, and the skimpy health base of the tribal and socio-economically submerged classes AWARE's health performance is substantial.

Strengths and Limitations

AWARE's strengths arise mainly from its human rights approach to health. AWARE views health as a legal right of the people and not as service or charity rendered unto them. It also perceives health as a funda­mental duty. People are not merely moti­vated to use a service where it exists or to demand one where it does not but are encouraged and expected to get involved in the development of the health services.

AWARE expects people to organize them­selves not only to demand the health to which they are entitled but also to ensure that such health is equitably enjoyed by every person in the community. This approach fits in with AWARE's optic on overall develop­ment. According to its Chairman, "develop­ment must be seen as an 'unfolding' of people and humanization of personal and group relations."

In AWARE's terms, a comprehensive health care program should make it possible for each individual in the commun­ity to attain the highest level of health in a given situation and within available resources.

The holistic concept of health is a nece­ssary complement to the above view. AWARE, like many of its cohort agencies, believes that health and life are interdepend­ent and integrated. Factors that affect the quality of health range from food, shelter, work, and education to general living con­ditions. All these must develop synergistically for the people to become and remain healthy.

There is another kind of desirable synergy, which is between the individual and the community. The health of one is interde­pendent on the health of the other. A successful health program recognizes how the two impact on each other and therefore creates a basis for individual and collective initiative towards better common health. This is the essence of the equity clause in AWARE's health jurisprudence.

AWARE's conceptual as well as practical strength lies in rooting health and develop­ment functions firmly in people. People's support and accountability for their health is a product of their own understanding or awareness. Creating that awareness is a core function. Once awareness is created the spectrum of health action that follows has to run the entire gamut (from prevention and treatment to health promotive work). The infrastructure for the delivery of health care has likewise to develop a strong vertical axis running from the base hospital or referral centre to the health centres and sub- centres, health outposts and shelters, community based services, and home care. The human resources deployed for health care should also range from health professionals to paraprofessionals, auxiliary and middle level workers, and those trained from the community to expand health's outreach.

Knowledge (viewed as program in­telligence and not only awareness) has a key role to play at various stages in AWARE's health program. It precedes the creation of the health program in that a need has to be specifically felt before any health activity can be launched. Knowledge also figures prominently at the implementation and monitoring stages. AWARE lays great stress on efficient and reliable health in­telligence and control. Detailed health in­formation on the project population is gath­ered and routinely updated. Very recently AWARE has computerized the socio­economic and health profiling of its target population, which facilitates an estimation of the health and socio-economic status of a family or community. This, in turn provides an informed basis for programming. It also aides decision-making for scalingup,sus­taining or phasing out program operations.

A convincing outcome of AWARE's health approach has been an attitudinal change in the population it works with. Within a very short period, tribal and harijan communities have cast off their suspicions of modern medicine and eagerly sought help in up­grading their health status. This change, however, has not meant any disruption of the conventional resources or methods of health care. AWARE deliberately does not discourage use of traditional medicine. It is sensitive to the wealth of wisdom and de­monstrated success of reliable primitive re­medies. As the doctors at Naidupet and Kunavaram clearly affirm "We are anxious to ensure that the traditional healer and healing science do not disappear due to the advent of our health program. We are interested in testing the efficacy of traditional medi­cine. This fits in with our overall objective of achieving development without de­struction of the digeneous culture."

AWARE extends the same blending ap­proach to staffing and personnel develop­ment. In the AWARE service structure, the medical cadres are at par with the non­-medical that is the development cadres. The doctor is encouraged to look upon himself as a head of a CHC but also as a peer of the area or cluster development officer. Both are expected and encouraged to blend their talents for achieving a com­mon objective—that of promoting self-sustainable rural societies.

Nevertheless, there are loose ends as in the Kunavaram CHC's outreach program that require to be tied up. The supervisory element needs strengthening, linkages with health posts, particularly those located in the interior are still fragile. The contact of the head office with the Kunavaram CHC is also sporadic and AWARE is applying itself to over­come these constraints.

In independent evaluations of the func­tioning of AWARE's CHCs (conducted jointly by Government of India, National Institute of Health and Family Welfare and USAID or those carried out by joint teams from NOVIB and AWARE), there is concern expressed on the slow and unsatisfactory recruitment of medical staff at all levels. Recruitment has to rely heavily on locally available people given the stresses of working in remote rural and tribal regions and the reluctance of out­siders to move and live there. For the same reason, elaborate norms in respect of a hierarchical supervisory chain, or a more formal content and manner of training can only be of academic value and have to be set aside in favor of informal, improvised training, and supervisory methods, which cut across conventional bureaucratic tiers.

More genuine anxieties are those arising from inadequate monitoring and health intelligence activity, which is crucial to gauge the performance of the program and its principal actors. Another area of concern is the absence of a health education function­ary, someone who not only can animate and activate the health team to carry out health education activities but can also motivate the non-health cadres to work as extension workers for health. To quote from one of AWARE's evaluations, “This organization has a large network of functionaries at village level, cluster level and even at area level for carrying out other developmental activities in the backward areas. There is a large scope to link the activities of all these function­aries with those working for health so that the total welfare of the community can be looked after."


AWARE's rich and diverse experience points to a few key lessons. The most striking is that AWARE stands behind and with the people and not ahead of them. It tells the people that it is there and energizes them to act on their own behalf, it brings very few pre-conceived notions on programs and priorities and allows the community's needs to dictate the choice of program. In fact AWARE itself did not start with a blueprint in mind but, as it notes in one of its documents, allowed experience to be its teacher. The intervention cycle as if exists today, is the product of actual field experience gathered during the past decennium. Unless adequate recording, analysis and documentation back this conceptual and operational spontaneity, it could be a disadvan­tage in the long run. An in-house evaluation carried out jointly with NOVIB has in fact pointed over this lacuna. AWARE is cognizant of a distant point in time when an excess of happenings could well defy intelligent as­similation and deciphering of experience. To counter that, it is giving greater attention to intelligence gathering, documentation and dissemination aspects.

People's ability to make informed choices is the real basis for their successful develop­ment. This is another lesson demonstrated by AWARE. As an organization, it seeks mainly to make people aware that some­thing is wrong with their lives. The people are then expected to find out what is wrong, what causes the wrong, and to work out the solutions. In that process if health appears sequentially later as a felt need, AWARE is the last to push it upfront. Even within health, each target population identifies which as­pects of ill-health bother them more. Those aspects become the focal points of the CHC. In all cases, the focal areas of intervention reflect the people's perceptions and as­sessment of their own health status, rather than AWARE's primer on public health.

Up scaling, is a constant concern at AWARE, as its Chairman notes, there is no feeling that it is anchored to a particular state or region, but only to a particular target group. Wherever such target groups abound, and are receptive, AWARE is willing to move there. This search for similar pastures has taken AWARE to other parts of India where its workers are dissemi­nating its modalities for changing the de­pressed classes' equation with rural society. As of now, AWARE has four tribal development projects in Orissa two in Tamil Nadu, and one each in Karnataka, Kerala, Uttar Pradesh and West Bengal. Although under the overall charge of AWARE Hyderabad, all these projects operate essentially autonom­ously. What holds them together is the commonality of their objectives—to attack poverty and cultural bondage, and to re­quire of development processes, greater uni­formity and parity.

Related to its decision-making capability is the principle of accountability. AWARE is clear that it is not obliged to render any help. It does so only because people are willing to work alongside AWARE to make the society and the system respond better to their needs. This message is easily caught and appreciated by its target population who realize that AWARE is there only so long as they are willing to work with it and testify that its worth. Expressions of people’s support of and belief in AWARE are strong and recurrent, they are also soul stirring. On the day when the floating hospital was inaugurated, for instance, AWARE organized a people’s meeting. A massive crowd showed up when the chairman announced the grants received from government and other sources to operate the boat hospital, and emphasized the need for mobilizing more funds those present came up with an amount which was seemingly small (a bare ` 5,600) but deeply meaningful as an index of the community’s involvement. The biggest note or money bill collected that day was of the denomination of ` 5, which meant that most people put into the collection whatever they had on them. Many of them had donated their return bus fare and had to trudge home several miles.

AWARE is particularly anxious to emphasize that an organization is answerable to the people. For this reason, it cannot afford to be impervious to their changing needs. When an organization becomes big, the focus shifts to the stability and continuity of the program, then often people tend to become less important, and the organization’s own interest becomes primary. “Constant introspection and self-assessment are necessary to avoid this lethal tendency,” notes the Chairman. “The programs we implement,” says Mr. Madhavan, “must not be for us but for the people”.

The merit of this approach may be indisputable but it leads to predictable tension vis-à-vis donor agencies and even with the government bureaucracy who would prefer to see AWARE adopts a more copyrighted approach to this programs and to their funds but AWARE is uncompromising in respect of people’s supremacy.

The net indirect result is also AWARE’s own autonomy, with slightly over halt its funds coming from overseas donors, one cannot help but wonder at the real extent of AWARE’s operative freedom but AWARE shows no concern on that behalf. It does not feel in the least bit inhibited with its sizeable dependence on donors. To AWARE and to its donors, it is crystal clear that the money is for the program and furthermore, that the people are the stakeholders with overriding powers to decide how the money is to be utilized.

Specific to health, AWARE’s lessons can be summarized: its perception of health is holistic, it is also participative and redistributive. AWARE’s target communities grown in all respects, synergistically, in accordance with their own collective ability, but with concern for all individuals and most of all for those who are the least well off. AWARE has successfully socialized community health and medicine and used both to the advantage of the tribal and the harijan population.

A final lesson is the one concerning the cult factor, like any other successful voluntary organization, much of AWARE’s strength is tied up with the personal charisma of its leadership symbolized in the Chairman. The doubt whether AWARE without him would be as effective is conveyed to him and to other staff very often by visiting observers. But neither the Chairman nor the AWARE team show any consternation on that account. The conviction seems to have settled down deep into all levels of AWARE that the chairman is only one of the links and not the fastener in the human chain that binds AWARE. In the final analysis, the survival of AWARE depends not on the chairman but on the people who are its true leader.