Empowering Communities for TB Control: The Swasthya Karmi Yojana in Rajasthan

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Project Details

Category: Healthcare
Project Title: Swasthya Karmi Yojana – A Tribal Health Transformation Model in Rajasthan
Department or District: Tribal Area Development Department, Udaipur
State: Rajasthan
Start Date of the Project: 1st January 1996
Website: https://tad.rajasthan.gov.in/

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Tribe(s) that the Project Covers: The project predominantly covers Scheduled Tribes residing in the tribal sub-plan (TSP) areas of Rajasthan, including remote and underdeveloped districts as well as the Sahariya tribal region.

Keywords: Swasthya Karmi, TB Control, Tribal Health, DOTS, Women Empowerment, Community Health, Public Health, Maternal and Child Health, Behavior Change Communication, Tribal Development, SWACH

The Swasthya Karmi Yojana is a pioneering public health initiative by the Tribal Area Development Department of Rajasthan, launched in 1996 through the SWACH Project. It aims to tackle the serious health challenges, particularly tuberculosis (TB), in the inaccessible tribal regions of the state. The initiative is a shining example of a community-based, women-led health intervention model that blends cultural sensitivity with modern treatment protocols. By training local tribal women to serve as health workers (Swasthya Karmis), the project seeks to bridge the healthcare gap in areas where formal systems struggle to reach. These Swasthya Karmis have since become key agents in delivering essential healthcare, raising awareness, and fostering trust within tribal communities.

The Project

Swasthya Karmi Yojana functions on the premise that health interventions in tribal regions must be locally driven and culturally embedded. Under this initiative, village women are trained and appointed as Swasthya Karmis to monitor and assist tuberculosis patients using the DOTS (Directly Observed Treatment, Short-course) method. These health workers are not only responsible for identifying TB cases but also play an instrumental role in maternal and child healthcare, immunization, family planning, malnutrition intervention, and health promotion. Operating across eight districts, the project has grown to include over 4,300 trained Swasthya Karmis who reach more than 70 lakh people.

Problems that it Intends to Solve

The project was conceptualized to address several pressing issues in Rajasthan’s tribal districts. One of the most urgent was the high prevalence of TB, particularly in remote villages that lacked accessible healthcare services. Compounding this was the issue of low health awareness and widespread cultural beliefs that resisted modern medical intervention. Poor literacy, especially among women, led to low community participation in health initiatives. Additionally, the remote geography, poor road networks, lack of electricity, and limited communication platforms made healthcare delivery logistically difficult.

What was the Need

In many tribal regions of Rajasthan, state healthcare systems failed to reach the last mile. The tribal population, especially women and children, suffered from avoidable illnesses due to delayed diagnosis and lack of care. TB was a serious concern, as many patients went untreated due to stigma, inaccessibility, or ignorance. Traditional beliefs and mistrust of government systems only exacerbated these problems. There was a clear need for a community-integrated model that used local women as frontline health workers who understood the language, customs, and concerns of the community they served.

What Hindered its Introduction

Despite the evident need, the implementation of the project faced early resistance. The foremost hurdle was geographic: many villages lacked basic transport infrastructure, making them hard to reach for any kind of intervention. Technological constraints, including lack of electricity and internet, further isolated these areas. Social challenges loomed large as well. Women in tribal societies were often not allowed to leave their homes or participate in community decision-making. Convincing them to take up leadership roles required years of awareness efforts. Furthermore, due to low literacy rates, there was a severe leadership vacuum, making it hard to find capable women to train as health workers.

Process Followed for Implementation

The project was implemented by the SWACH unit of the Tribal Area Development Department in partnership with the Health Department and UNICEF. It began with identifying villages most in need of intervention. Swasthya Karmis were selected by the villagers themselves, ensuring community trust and ownership. The selected women underwent rigorous training provided by medical officers and SWACH personnel on topics such as TB identification, DOTS protocol, maternal and child health, immunization, and nutrition. A behavioral change campaign, the Village Contact Drive (VCD), was initiated to promote health awareness and reduce resistance to institutional care. The project also set up a structured governance hierarchy, including a Chairman, Director, Project Manager, and District Coordinators to monitor and supervise field operations.

• Involvement of NGO
  • UNICEF played a significant role in shaping the training modules and providing technical support, particularly in maternal and infant nutrition (MIYCN). It also supported the design and deployment of the Village Contact Drive to create behavioral change across target areas.
• Involvement of Community
  • The community was central to the success of the program. Not only did they nominate the Swasthya Karmis, but they also actively supported the initiative through cooperation and participation. This ownership helped break down cultural barriers and enabled widespread acceptance of the program.

Solutions Implemented

To address the TB crisis, the Swasthya Karmi Yojana adopted the DOTS methodology, wherein each health worker ensured that patients took their medication on time and followed up regularly. The health workers facilitated TB screening at local health centers and provided nutrition support in the form of 3 kg of sattu per month. In addition to TB, Swasthya Karmis took on auxiliary roles in immunization drives, first aid, maternal counseling, and sanitation awareness. They supported ANMs and Anganwadi workers to create a more integrated health delivery mechanism.

Details of the Coverage

Starting in Udaipur district, the initiative expanded to Dungarpur, Banswara, Pratapgarh, Sirohi, Pindwara, Rajsamand, and Baran. It now covers approximately 70 lakh people and employs over 4,300 Swasthya Karmis. The Sahariya tribal region alone has 239 trained workers under this scheme.

Innovation and Unique Features

What sets the Swasthya Karmi Yojana apart is its community-centered design. By selecting women from the same village, the program ensured cultural compatibility and trust. These workers were not outsiders but insiders who could navigate local customs and build confidence. The program also functioned as a livelihood opportunity, offering a monthly honorarium and travel allowance, thus empowering women financially. The integration of nutrition, family planning, immunization, and hygiene under a single outreach worker made the program cost-effective and multidimensional. The use of VCDs and IEC materials like flipbooks helped spread awareness in low-literacy settings.

• New Approaches: Tech integration, capacity building, culturally sensitive methods
  • While technological integration was minimal due to infrastructural limitations, capacity building was central to the project’s success. Swasthya Karmis received training in SBCC (Social and Behavior Change Communication), record-keeping, and public health counseling. Culturally sensitive approaches, such as allowing the community to select their health workers, enabled the program to function effectively in traditionally conservative societies.
• Co-creation: How tribal knowledge or leadership shaped the solution
  • The community’s role in identifying and empowering their own women to serve as health workers was key to the project’s success. Traditional knowledge and lived experiences of the community were respected and integrated into training and awareness campaigns.
  • Over time, the program expanded its scope to include maternal and child nutrition, water and sanitation awareness, and pandemic response. Special training modules were introduced during COVID-19 to adapt to new health challenges. The program evolved from being TB-centric to a more holistic community health intervention.

Challenges Faced Before Implementation

Internally, finding literate and willing women to be trained as health workers was a major challenge. Externally, poor connectivity and deep-seated cultural practices delayed acceptance. These were mitigated through focused awareness drives, gradual community engagement, and constant encouragement by Swasthya Karmis, many of whom became local role models.

Challenges Faced During Implementation

Coordination issues among health teams and difficulty in standardizing data reporting posed internal challenges. Externally, resistance from men and older generations, particularly around topics like women’s mobility and institutional healthcare, continued. Mitigation included engaging male community leaders and using offline monitoring tools where electricity or internet was unavailable.

Outcomes

• Quantitatively, the project has recorded 6,133 TB patients undergoing treatment and 4,552 completing treatment as of October 2022. More than 4,328 Swasthya Karmis have been trained and employed, creating sustainable livelihoods. Qualitatively, the program has transformed attitudes toward healthcare, empowered women, and fostered community responsibility for health outcomes.
• District Coordinators were appointed to oversee both office operations and fieldwork. Data from health workers is reviewed by TB officers and SWACH personnel to ensure compliance with protocols. Training refreshers and community feedback loops enhance accountability.
• Primary beneficiaries include TB patients, pregnant and lactating women, children under two years, and the broader tribal community. Indirect beneficiaries are the Swasthya Karmis themselves, who gain respect, income, and agency through their work.

Replicability / Scalability / Sustainability

The project is highly replicable due to its low cost and community ownership. It aligns with national schemes like Ayushman Bharat and NTEP and can be expanded to other districts or adapted for different diseases. Its sustainability is ensured by integrating it into the state’s health systems and providing livelihood to workers.

• The program integrates with government policies through its alignment with the National Tuberculosis Elimination Program and maternal-child health frameworks. Coordination with ANMs and ICDS strengthens policy-level linkage.
• The program operates on a modest budget, with a proposed expansion cost of Rs. 30 crore. Honorariums are low but impactful, ensuring long-term affordability.
• The success of the pilot in Udaipur has led to its adoption in seven additional districts. Its participatory model of governance and grassroots execution make it ideal for replication in similar rural and tribal geographies.

The Swasthya Karmi Yojana represents a transformative model of public health intervention tailored specifically for the unique socio-cultural and geographic challenges of Rajasthan’s tribal communities. Initiated in 1996, the project successfully leverages local knowledge, community trust, and women-led grassroots mobilisation to address pressing health issues, particularly tuberculosis (TB). With over 4,300 trained Swasthya Karmis reaching more than 70 lakh tribal residents across eight districts, the program has shown tangible health benefits and intangible social empowerment, especially for women in conservative settings.

What sets this initiative apart is its participatory design—where community-selected women serve as both healthcare providers and change agents. Their deep cultural familiarity bridges gaps that formal healthcare systems often struggle to navigate in tribal areas. The inclusion of behavior change tools like the Village Contact Drive (VCD), integration with government programs like NTEP and Ayushman Bharat, and focus on maternal and child health make the initiative both comprehensive and cost-effective.

Globally, community-based health models have proven successful in low-resource settings, such as the BRAC model in Bangladesh and Acción Comunitaria por la Salud in Peru, which similarly emphasise local health workers and community trust (WHO, 2017; USAID, 2021). The Swasthya Karmi Yojana’s alignment with these global best practices highlights its potential replicability across similar socio-economic contexts.

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