Empowering women as leaders in urban slums to reduce surgical inequity in India. By Prof. Rahul M. Jindal


INTRODUCTION: I describe my team’s work in empowering women as community health workers (CHW) in urban slums of a metropolitan city of India. We conceptualized SATHI (Surgical Accredited & Trained Healthcare Initiative) as an intermediary channel through which those in need could be linked to service providers. This is an all-female work force with merely 8th grade education, living within the slums. SATHIs help patients attain benefits of health schemes, and offer counseling through which trust building, and elimination of fear of surgical procedures.[1]

THE CONCEPT OF COMMUNITY HEALTH WORKERS is well established in India. The Accredited Social Health Activist (ASHA) program is the world’s largest all-female CHWs program which was conceived to bridge the gap between community and health services by functioning as community-level health activists. Launched in 2005, there is now an ASHA in almost every village and across many urban centers who support health system linkages and provide basic health education and care. According to UNICEF, the maternal mortality rate of India has decreased from 130 in 2014-16 to 113 per 100,000 live births in 2016-18, attributed to ASHA.

SURGICAL UNMET NEEDS IN INDIA: The estimated unmet surgical needs are high in low-middle-income countries; however, few studies have been carried out in India. We carried out a community-based, cross-sectional survey of over 2,000 low-income households in Ahmedabad, India – nearly 16% of households reported getting consultation for surgical procedures over the previous year, of which almost 37% had unmet needs.[2] The findings suggested that financial constraints, and fear of surgery were the leading reasons for not availing of surgical treatment.[3] [4]India has introduced for one of the world’s largest universal health coverage (UHC), Ayushman Bharat (https://www.nhp.gov.in/ayushman-bharat-yojana_pg) which has been shown to be grossly underutilized. Implementation of UHC in India is a gigantic undertaking in a country of approximately 1.4 billion people. In addition, India has a massive shortage of surgical resources, and access to surgical care is inequitable.

CONCEPTUALIZATION OF SATHI – AN INTERMEDIARY COMMUNITY HEALTH WORKER: Numerous studies in India have shown that the uptake of various government health schemes is less than expected. Through SATHI, we aim to fill this critical gap by raising awareness, promoting utilization by education, and facilitating the process of enrolling in the Indian UHC. We also aim to provide emotional support to alleviate fear, and trust issues that might impede utilization of UHC. SATHIs also provide emergency first aid for minor injuries commonly seen in daily wage laborers, measure BP and blood sugar.

We recruited six SATHIs who underwent 1 week of theoretical curriculum about wellness, common surgical problems, and medical conditions such as diabetes and hypertension. The training is skills-focused, and delivered in an interactive way to retain participants’ interest.1 5 Teaching was followed by role play, and hands-on training to measure BP, blood sugar and wound care. An intake form and a monthly fieldwork form, performance evaluation guide, and a test comprising short questions to assess the participants’ understanding at the end of the training were also developed. We assessed the participant’s capacity to apply the learned skills through practical demonstration, and role-plays. SATHIs were paid a salary which was decided by the SATHIs themselves in consultation with our partner NGO, which was well above the prevailing market rate.

Field work entailed visiting each home using the validated ‘Surgeons OverSeas Assessment of Surgical Need’ (SOSAS) instrument to collect demographic and surgical data for each adult. SATHIs identify common surgical diseases, ensure timely referral to local hospitals, and ensure compliance with post-surgical follow-up by home visits. Identification of a surgical or medical condition during interview or after analysis of collected data triggered referral to local doctors who have been identified as willing and altruistic partners.[5] Data was entered directly onto iPads which was analyzed at regular intervals by supervisors. SATHIs are supervised by medical faculty of the Indian Institute of Public Health, Gandhinagar.5

OUTCOMES OF SATHIS AS COMMUNITY HEALTH WORKERS AND LEADERS: A pilot study was carried out by 6 SATHIs in the slums of Ahmedabad, a metropolitan city of 8.5 million people of which 20% live in dense urban slums. In total, 12 730 people from 3000 households were included in the study for a duration of 6 months. We found 10% surgical needs (n=293) out of which 57% had unmet surgical needs. Out of total surgical needs, about half of the needs were cataract and abdominal, followed by extremities and chest conditions. SATHIs were able to convert 99 patients (60%) from unmet to met needs, who underwent appropriate surgery or medical treatment.[6]

In summary, we have shown that deployment of SATHIs, all-female CHWs, with minimum education, living within the slums, could be specifically trained to reduce the burden of surgical diseases in an urban slum. Timely treatment of surgical conditions will lead to improved quality of life, longevity, and increase earning capacity of slum dwellers. In consultation with the community, we are working with to scale up the concept to 350,000 slum-dwellers in 70,000 homes of slum districts of Ahmedabad.[7] This will entail hiring, and training 60 SATHIs, while the previously trained 6 will work as supervisors. This model could be applied to other slums in India.


[1] Kranti Vora, Shahin Saiyed, Falguni Salvi, Ankita R Shah, Robert B Laverty, Mehr Muhammad Adeel Riaz, Berjo Dongmo Takoutsing, Keyur Buch, Dileep Mavalankar, Lyndsay S Baines, Rahul M Jindal, SATHI: Surgical Accredited and Trained Healthcare Initiative for task shifting in India, Journal of Surgical Protocols and Research Methodologies 2022;3 snac018, https://doi.org/10.1093/jsprm/snac018

[2] Vora K, Saiyed S, Shah AR, Mavalankar D, Jindal RM. Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study. World J Surg 2020;44(8):2511-2517. doi: 10.1007/s00268-020-05502-5.

[3] Vora K, Saiyed S, Salvi F, Baines LS, Mavalankar D, Jindal RM. Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey. J Surg Res 2023;292:239-246. doi: 10.1016/j.jss.2023.08.001.

[4] Vora K, Saiyed S, Mavalankar D, Baines LS, Jindal RM. Trust Deficit in Surgical Systems in an Urban Slum in India Under Universal Health Coverage: A Mixed Method Study. Int J Public Health 2022;67:1604924. doi: 10.3389/ijph.2022.1604924.

[5] Jindal RM. Service to Others May Be the Answer to Physician Burnout. JAMA Surg 2020 Jun 1;155(6):463-464. doi: 10.1001/jamasurg.2020.0046.

[6] Vora K, Salvi F, Saiyed S, Desai C, Joshi R, Buch K, Mavalankar D, Jindal RM. Community health workers to reduce unmet surgical needs in an urban slum in India: an implementation study. Int Health 2023:ihad072. doi: 10.1093/inthealth/ihad072.

[7] Veerappan VR, Jindal RM. Community participation in global surgery. BMJ Glob Health 2021;6(4):e005044. doi: 10.1136/bmjgh-2021-005044.

ABBREVIATIONS: Community Health Workers (CHWs), Accredited Social Health Activists (ASHA), Surgical Accredited and Trained Healthcare Initiative (SATHI), Universal Health Coverage (UHC)



ADDITIONAL INFORMATION: The concept was developed during Jindal’s Fulbright-Nehru Distinguished Chair to India (2016 & 2022).

CORRESPONDENCE: Rahul M. Jindal, MD, PhD, MBA, Indian Institute of Public Health, Gandhinagar, Opposite Air Force, Gujarat, India. E-mail jindalr@msn.com


Prof Rahul Jindal

Prof. Rahul M. Jindal, MD, PhD, MBA, MSc [Oxford], FRCS [Ed], FACS

Rahul M. Jindal is a Professor of Surgery and Global Health at the Uniformed Services University, Bethesda, and the Indian Institute of Public Health, Gandhinagar, India. He is also a Commissioner, of the Office of Human Rights, Montgomery County, Maryland. Jindal has authored 3 books and over 200 peer-reviewed articles. He was awarded the Fulbright-Nehru Distinguished Chair to India (2016, 2022 & 2024), the Ellis Island Medal of Honor, and the Carnegie Great Immigrant Awards.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None

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