Participatory Reflection on Community Health RF-COM-H-1 PART 1
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- Title
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Participatory Reflection on Community Health
RF-COM-H-1 PART 1 - extracted text
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Gooa H \A
-i•
Participatory Reflection on Community Health
at the Tibetan settlements in Karnataka
particularly Mundgod.
The Deputy Secretary (Health) of the Central Tibetan
Secretariat at Dharmasala,
l*ledica*l7 /Qf'f iCiers of
Settlements in Karnataka and the CMC team had an
initial brainstorming session in November 1988
on this issue. This was followed by a visit to the
17 •
Mundgod Settlement by two members of the CMC team
to obtain first hand impressions of the prevailing
status. This
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. .
culminated in a report containing
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observations and possible options for action in the
follow up meeting with all the above participants.
The community participates in decision making and pays
a substantial amount towards the maintenance of the
hospital. However, there were some features unique
t
to their health efforts:
a.
The ’refugee’ status of the population and
the attendant cultural and socio-economic problems
ranging from dilemmas of preservation of their culture
in ’alien1 surroundings to integration into the
present ethos and search for income generation towards
survival(eg large mobile population of sweater sellers).
■yr? /££
COMMUNITY HEALTI
CELL
Ref. N© CRC:54:89
Date: .2..MAR...1.2.8SU,______
Lok Swas
b.
47/1 St Mark's Road
(First Floor)
Bangalore 560001
lya Pc
A higher susceptibility to some diseases like
tuberculosis in spite of adequate efforts towards
controlling the problem.
c.
The essentially Buddhist approach towards all
forms of life and acceptance of diseases as pat of
their ’Karma’.
d.
A large percentage of population of the ’Lamas’
accepting a monastic life devoted to spiritual
endeavour while remaining uninvolved with the problems
of the lay populace of the settlements.
e.
The problems of integration of the Tibetan Traditional
medical system with the Allopathic model prevalent in
the settlements.
I
The options that evolved towards a more community
health oriented approach were:
a•
Stregthening of community based activity and
creative re-orientation of the available resources to
focus on a larger range of primary health care problems.
b.
Various avenues of better management of the tuberculosis
control programme.
c» Fostering of good cultural and traditional
practices in maternal and child health care.
d.
Appropriate medical/administrative action to
tackle the health problems of the large mobile
sweater sellers population.
e.
Education for health at school, pre-school and
non-formal levels..
f. A holistic planning for health by integrating
Tibetan Medicine and avoiding duplication of health
efforts.
g.
Promoting involvement of youth/youth clubs,
wome n/uortien 1 s
clubs and the Lamas especially in
preventive and promotive activities of primary health
care.
h.
Continuing education, regular staff development
programmes, up-dating of the hospital library
were considered essential for cortinued orientation
)
towards community health.
Areas of study were identified with a view to
improving the health of the community.
COfv\ H
WORKSHOP ON COM>'UN I COTTON
held at Central Tibetan Secretariat, Dharamsala
24th - 28th October 1988.
Participants: 23 Community Health Workers from settlements around
India.
Workshop Co-ordinator: Mr Padam Khanna, Voluntary Health Association
of India.
Group discussion between Health Worker participants on the first day
of the workshop produced the following account of the shared and
individual problems experienced by the ealth Workers in their everyday
work.
We share this here, to lend encouragement and support to all the Communi
Health Workers, in recognition of the problems you encounter and the
hard work and dedicated service you give to the community, in order to
strive for better health for all Tibetans.
1. Lack of education among community can cause misunderstandings,
even after repeated explanations.
2. Language problems - faced in Bir settlement, with camp of new
arrivals from Tibet , who may be speaking Amdo or Kham dialect or
with Chinese words inbetween.
3. Blind faith, where people consult lama before CHW and may go to
private Indian medical officer if lama recommends it. This can
damage credibility of CHW. Most problems here are with people wtyo
have recently arrived from Tibet. Can only try to prove by example.
4. Antenatal care: some CHWs lack training in this regard and therefore
have difficulties. Dehra Dun area has this problem. Some settlements
find that local Indian doctors/hospitals will not take an interest
in filling out the CHW*s record card on each mother. Some misunder
standings among the mothers, e.g. that they think the Tetanus Toxoid
vaccination is given to make their labour easier. The ideal situation
is to teach mothers ante- and post-natal care in antenatal period,
and repeat post—natal care after baby is bom, e.g. while mother stil’
in hospital or during home visits.
5. Breast feeding. ^*alks on this work best when mothers need the infor
mation,i.e. are pregnant. If not concerning them at present time,
will not listen so carefully.
-MhiTT"
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6. Family planning: "If we have fewer children. who will there be to fight
the Chinese?”
7# Under-Five Clinics: parents cannot always attend regularly because of
work commitments. For this reason, not every child gets all its
vaccination doses when it should, one CHW finds that offering to give
the family something for an underweight child will make parents
attend clinic regularly, e.g. food supplement, iron tablets.
8. Practical problems: Bir experiences a lack of water supply, which
prevents proper teaching on sanitation, personal hygiene, etc.
9. Health education2 CHWs feel need for new materials, as people get
bored with the same old flash cards, slides, etc. and thus do not pay
proper attention.
10. Health talks must vary with seasons and seasonal diseases to make
them relevant, e.<g. seasonal variation in malaria, diarrhoea, conjunctivitis. If not relevant at the time, people do not want to listen.
11. People continue to take more interest in health cures than in the
prevention of disease.
12. Defaulters or lack of compliance: if people go to local doctor, he may
charge a lot of money for drugs, e.g. for TB. People cannot afford, so
they stop taking them. Then they may go to CHW, but doubt that the CHW
can cure them when the local doctor has been unable to cure them - as
they see it.
13 • One CHW has to pretend the same drug (aspirin) is different,
by giving
patients different brand names and shapes of the same drug. Otherwise,
the people think he only ever gives out the one drug and they do not
trust it to work for everything.
14. If there is a good relation between the CHW and the local District
Hospital, the CHW gets a better supply of vaccines^ etc. if relations
are not so good, there can be little co-operation and theCHW1 s-werk
is harder.
15a Some CHWs experience great difficulty in covering the distances
involved between camps, carrying all their equipment with them. One
example is Simla area - 1,200 people in two different places far apart
from each other and only one CHW. She finds people are unwilling to
attend clinics because the distance is too far.
16 . Nutrition: people are poor so CHWs can only recommend nutritious foods
if they are very cheap. Tibetan diet is not balanced, depending on
availability and general reluctance to eat vegetables (although younger
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people are usually better in this regard).
17. More acute TB problem among new arrivals from Tibet, e.g. in
Sera monastery at present, there are 4 TB patients from Mysore and
24 TB patients who are new arrivals from Tibet.
18. People may continue to go to local doctor, even if not very happy
with his work, out of habit or because they -know him or because he
cured them once in the past. Difficult to change people's attitudes,
and especially to make them accept advice and suggestions of CHW.
19. One CHW finds it is sometimes necessary to create a rumour, e.g. abo
cholera in a nearby place, in order to get people to listen carefully
to health talk on diarrhoea.
20. If people are reluctant to attend health talks, one idea is to
advertise a movie video evening show, and when the people are there,
to show a health fi^i first.
21. CHWs generally feel people’s attitude to health care is improving,
e.g. more people using Oral dehydration Solution now, and more
interest taken in health.
22. There is a need to improve the family economy, as a broader aspect
of health. Mrs. Takla also mentioned at this point that the issues
of sanitation, water supply, family economy are known to the
Administration, and that the newly formed Planning Council is looking
into these matters now, with the aim of in time solving these problem.'
G.OM H K 3
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TENTATIVE PROGRAMME FOR THE PROPOSE SEMINAR-CUM-WORKSHOP
ON INTEGRATED DEVELOPMENT PLAN FOR TIBETAN SETTLEMENT,
_______ MUNDGQD, NOVEMBER 13TH. & 14TH., 1988
November 13, 1988:
(Sunday)
8.30 a.m.
Chairman: Dr. A.K. Basu
Welcome Sc Introduction By
South Zone Development
Coordinator, Bangalore
I
8.40 a.m.
Key note speech on the
relevance of the Master Plan
Mrs. Greta Jensen, Hon.
Secretary, ApTT Trust - UK
9.10 a.m.
Human Resource Development
traditional and modern
technology - Initiator :
Dr. A.K. Basu, Executive
Director, Society for Rural
Industrilization, Ranchi
10.00 a.m.
Topic open for discussion
10.30 a.m.
TEA BREAK
10.45 a.m.
Re-organisation of village
layout plan - Initiator :
Prof. R.L. Chakravorty,
Regional Planner, Adviser to
the Government of West Bengal
11.15 a.m.
Topic open for discussion
(Contd.2.)
(2)
11.35 a.m.
Eco-Development - Initiator:
Prof. Madhav Gadgil, Head,
Centre for Ecological
Sciences, Indian Institute of
Sciences, Bangalore
12.40 p.m.
LUNCH
1.30 p.m.
Land and Water Management Initiator : Prof. I. Dey,
Secretary, Society for Rural
Industrialisation, Ranchi
2.15 p.m.
Subject open for discussion
3.00 p.m.
Harnessing of Underground
Water, Maintenance of borewells,
etc. by Mr. B.S. Bahadur,
Geologist, Department of Mines
and Geology, Government of
Karnataka
3.30 p.m.
Topic open for discussion
4.00 p.m.
Agricultural Diversification
with emphasis on organic
farming-initiator : Dr. J.V.
Goud, Vice-Chancellor,
University of Agricultural
Science, Dharwar
4.30 p.m.
TEA BREAK
(Contd.3.)
(3)
4.45 p.m.
DISCUSSION
5.15 p.m.
Horticultural Development
with particular emphasis on
growing Mango, Coconut,
chikku, cashew nut, etc.
Initiator; Dr. Jaya Prakesh,
District Horticultural Officer,
Sir si
5.45 p.m.
DISCUSSION
7.00 p.m.
FILM ON TIBET
8.30 p.m.
DINNER
8.00 a.m.
Chairman; Prof. Madhav Gadgil
I
November 14, 1988:
(Monday)
Industrial Development Initiators - Dr. A.K. Basu,
SRI, Prof. J.s. Arwikar,
Principal, Engineering
College, BiJaipur and Dr.
Balgopal T.S. Prabhu, Regional
Engineering College, Kerala
9.00 a.m.
Topic open for discussion
9.45 a.m.
Energy - Initiator :
Mr. Tency Baetens. Executive
Director, Centre for Scientific
Research, Pondicherry
(Contd.4.)
(4)
10.15 a.m.
TEA BREAK
10.30 a.m.
DISCUSSION :
11.00 a.m»
Animal Husbandry Development
with special emphasis on
cattle breed improvement
technics and care-initiator:
Mr. Dorjee Namgyal,
Secretary, Kollegal Dairy
Farm
12.00 p.m.
DISCUSSION
12.30 p.m.
LUNCH
1.30 p.m.
Consolidation of Seminar
discussions. Planning for
Phasing, Action Plan, Budget,
sources
5.30 p.m.
THANK YOU TEA
!
South Zone Development Coordinator
Bangalore
COfA. H I-
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(N. X.)
DOEGULING TIBETAN SETTLEMENT MUN^Wpir''''--------------------------------- TiBETAN SL
On behalf of the Tibetan Settlers, I would like to take this
opportunity to welcome the experts in this Workshop Cum Semi by the CfwincTl
Cwm rT 1 /
7 fnr_S
for Sin
me a f f a i r-s ,
nar being organised bv
=fnmA
Dharamsal a,
»pdn snr-e-d by Appropariate Technology for Tibetans in this
i
settlemen t,
»
This Settlement was established in the year 1966, where a total
land of 3922.28 acres of Vergin forest land were distributed
to A302 settlers, at the rate of 32 guntas to the adults, 20
guntas to the minor below 12 years and 2 acres to three monks.
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Bachangi Dam was constructed in 1979 with a view to faciliate
irrigation to some part of the Tibetan Agricultural land, as
such about 1000 acres of Tibetan land were developed for irri
gation and the same were distributed at a reduced rate of 24
guntas to the adults and 12 guntas to the minor,
The entire
land to the extend of 3055.28 acres of cultivable land were
reallocated to 3093 lay adults, 1097 minors and 600 monks of
this settlement later, We have 9 villages, two Lama Camps
and a home for, ^an d Infirm people. Presently, we have a total
population of nearly 9000.
We have two Hospitals, one Allophathic and another Tibetan Medical Centre to meet the Health
needs of the people. We have a Central School for Tibetan^ and
it has two Branches.
These schools are under the Management
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of Central Tibetan School Administration, N ew Del hi .
*
tive Society:
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This settlement has registered a Co-op.Society in 1967. All
the Settlers are the members of the Society. It has a managing
Committee being elected in the general body meeting.
The
Representative of Council for Home Affairs, Dharamsala is the
Chairman of the Society,
The Management of the Society meets
as and when felt to
jcuss
□cuss the major issues and it would be
executed by the Co-op.Secretary.
The main activities of the
Society is to supply fertiliser, seeds and agricultural implements and other farm requisites in adequate quantity.
It faciliates to own or hire godowns to store their products and
arrange for its marketing and to provide other developmental
activities to improve the economi c condition of the farmers,
This Society has the following units: 1.
Handicraft Centre
Con t d. • . 2
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2
!I
1
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2.
Workshop and Tractor Section
3.
Consumer Shops and Fair Price shop
4.
Flour Mills
5.
Dairy and Demonstration Farm
6.
Truck and photo Studio.
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1.Handicraft Centre:
This Centre besides keeping the traditional skill alive,
T1
also gives a gainful employment to the members.
It
It gives trai
nings to the interested people of this Settlement. It is on e
of the highest paid centres in the South Zone.
The Centre’s
1
finished products are being marketed through the Tibetan Chari
table Trust Handicraft Exports division, New Delhi.
2.
Workshop and Tractor Section:
It gives facility of tractorization to the farmers, It also
carries out the complete overhauling and repairing work of the
tractors. Minor motor parts are also manufactured. Major
ploughing work of the fieldfare carried through this section.
3.
Consumer Shops and Fair Price shop:
Through this Section, we make available all domestic needs
of our Settlers at a most reasonable rate.
1
4.
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Through this Section, the society helps the members in grin
ding the flour and it has a rice shelling unit to help the
Settlers.
5.
♦
Flour Mills:
Dairy and Demonstration farm:
Through this Demonstration unit, the techenical feasibility
and economic viability of the a new agriculture are tested
before it is adopted by the farmers,
Series of demonstration
had been carried out by cultivating paddy, maize, vegitables
I
etc. but due to lime and heavy soil, it does not come out satisfactorily.
A Dairy farm was introduced to motivate the farmers
to replace their local cattle with an improved variety.
As a whole the Tibetan Co-operative Society makes all the ef f orts to provide more employment at a better wage/salary to our
Con t d . . . 3 . . .
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employees, for instance this society provides highest wages
to our weavers in our handicraft centre compared to other
centres in south, but it is still low compared to the income
they get from the sweater business. Hence our people prefer
to go for sweater business.
To curve this drastic population
drift to sweater business, this society needs more working
capital on soft loan basis inorder to provide more facility to
the members.
f
To conclude, I am extremly happy that this workshop cum
Seminar is being conducted here to discuss on the Draft master
Plan and to give solutions to the various problems that the
I firmly request the experts and speciSettlement is facing.
■
lists to come out with concrete viable action plan for a
substainable and integrated development of this Settlement.
i
MR. GYALTSEN CHOEDEN,
Represen taive of Council
for Home Affairs,
Dha ramsala, H.P.
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Com h i S'
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EV22 LUA TI ON _ E.SPORT_ 0N_ TU 0E.RC ITLOS ISC ONTROL PRO J ECT
2r_P2^!IH^S_TIBETAN_S}3TTLEijSNT_HOS:PITAL, MUNDGOD
IWK^CT.lON:
Doeguling Tibetan Settlement is the biggest Tibetan Refugee
Distiictriof1K4;7tl’nSi!'UHted
■;und£°d Tal,1k of North Ka'nara
the ihbhaL
2? l-ndl?- Before the resettlement of
hl! h. ! '
’ tdejantll-e •■•■’rea was a thick forest which now
has been converted into 4000 acres of farming land.
nfG1vh^’!3triS in trls ■!3attlement live in 11 camps/villages and
of whicn two are Lam.. Camps/villages. The first Tibetans
to arrive in this settlement was in 1966.
The main
occupation of the settlers are farming, carpet weaving and
a few of them do sweater selling during the winter season.
According to the first demographic survey conducted by the
hospital, it was reported that the population was approxi‘'^ound 9000 (excluding the floating population), but
of late Tinetan refugees from Bhutan have also been resettled
m taxs settlement.
In the beginning, a small dispensary w.-s started by the settlers
however the present hospital vzas constructed in the year
year 1969
1969
;?nd an extra floor was aoded in 1986. The hospital though
ne
supervision of the Tibetan Department of Health,
at the local level it has an Executive Committee, headed by
the settlement Representative
--------- j as the Chairperson, the medical
officer as the Jxecutive Secretary and eamp leaders of the
settlements as its members•
The facilities 'vailable at the settlement hospital are;
1 ) iatern?;’.
2) Dental
3) Eye
nd Child Health
h) Laboratory
5) X-ray Service
6) Community Health Drogramme
7) Immunization
8) T.3 Control Project
9) Minor Surgery
10) Health Education
It is a 40 bed hospital with both out patients and in patients
facilities -tr*
— separate
*
~
nd3 1has
wards for males and females
and
also a separate ward for T3 patients.•
)8ve for two Indians,
the hosnitnl personnel including the doctor are Tibetans.
tuberculosis .CONCOOlLOJECr:
'Che Department of Health of Central Tibetan .Secretariat was
set up in the fall of 1981 by His Holiness the Dalai Lama1 8
Governmant-in-exile. The top priority of this new Department
nreis to look a fter the health problems of the Tibetan refugees.
1
The Tibetans in India have not been immune to Tuberculosis and
infact Tuberculosis is in epidemic proportion among the
population. Studies have shown that incidence of Tuberculosis
?.mongst the Tibetans is a.tleast
times the Indian population.
Therefore, seeing the urgency of the Tuberculosis problems
amongst the Tibetans, one of the very first task of the Depart
ment of Health was to bring incidence of Tuberculosis under
control.
- 2 Control ^ojJc\sfine3oJthWInd'L^
Tuberculosis
ance from 1 BREAD FOR '.tfOIW*
rWlth flnancial assistControl Project otToegXv nb^ SD ' Th! T"<>«e«K>rt.
in July 16, 19.34.
S -ibetcfn Settlement was started
’Of1'!”
beleoted
syllabus
similar'to on'lubfrculoeis,
th-t of
nDel9k the
hos
Pital.
The
sale
with was
Aore^mphasis
HosP
it31
’' Dharam-
be‘uht^rKrm!:l:S,™l^rotSuc^Sl^’1eaCh °f «» —"W
md their role in the health delA±lr re^ectiv° camp leaders
was explained. Community health c°nAysystem at the settlement
camp fter consulting with thi A /
'Vore set-uP in *ftch
branch bispc-nsnry of^he hospital
Also a
c -hospital was opened m village No. 6.
and thetpa?ents°r’on°nciPcheOWprbeen°nSt-the
children
camps. The first cr-chZ X ™
a n SeTt up in a11 the nine
occasion of H.rT. The Dalai
6’ 1976 on the
noration. The Community Health ^£0rty-first birthday comnrefor the under five clinic and nl ce f^
^inf these creches
the community esneciallv thp mn+-£S f°
education of
structure t the DoIruliL ^A ? henS;^The health infrathe creat goes to thf Hosfit^l ’
\S Very good and
hospital’s Executive C^ret-'v D?&™tlve Co™ittee. The
The
serving the Doegulinr Tibet-1 s2a^g Norbu has been
years as its debtor? [lbetan Settlement for the last nine
EVALUATION:
!
__
i g
s^carried out from November
Dnwn n-i
?n
request of Department of Health i by Mr.
cwa., Diploma m Community Health Management.
GOALS:
O noeluliJ/^b^n^r^-?^ strengths ™d weakness of
1) To deejr.®rlb4
hospital's Tuberculosis Control Project
son?:1^"^ XgST”* *4» ’nd t0 ”aas“re “o
aIM:
To assess the errioiency of the functioning of the programme's
activities.
OBJECTIVES:
1) fo determine the efficiency of Case-finding,
To determine the coverage of under five children with
BCG inmunization,
A) To determine case -holding
....
rate for the registered TB
; Patients at the hospital
4) To assess the effectiveness of i *
the Health Education
on Tuberculosis amongst the school
children
---- and
---- 1 general
public.
- 3 TOOLS A;\D IN.-i-.’UMTNTS USED FOP THE .EVALUATION:
1 )
’'
'
.
structured questionnaire
2) Interview
3) Observation
4) TB patient's record cards
U.jILDF.^yORD3 USED FOR .EVALUATION :
1) Co mmunity Health Jonkers’ IB Treatment Register
rj Laboratory Technicians
-- .j sputum test Register.
METHODOLOGY:
Sample size of the survey- 200 families of the general population
- 25 .school children from the local school
SAMPLE DE3IGN:
M
TOOLS C0N3TRUCTUNEP:
Keeping in mind the objectives of the evaluation
a set of
under rive chlldrfn^uraj,^""-^0^^ °f
FRE-T iiSTIHG:
L JS
PrePflred questionnaire was not done this
fworkability was already tested during the Delek
1986lt31 3 Tuber’culosis Control Project's Evaluation in October
m
PROC :X'UR.E OF D.aTa COLLECTION:
Rapport building was considered very important by the inverstigator to collect accuaate information. The purpose of the
survey was explained in detail to each of the respondents.
_he community health workers played an imporiint role here.
However, when the name of Department of Health was used, the
respondence welcomed the survey.
All the questions were administered in Tibetans.
ANALYSIS OF THE DATA
DEMOGRAPHY:
The total population of the sample survey at Doeguling Tibetan
settlement, Mundgod was 12J6. The age ratio of the area in the
study showed a high proportion of under five children (13.27%)
and unproductive age group between 0-15 years of the population
■.yas
.he other unproductive age gruup i.e. over 61 years
is b.1%. The remaining population consist of 55.13%, which
contributes to the productive age group.(see fig. No.1)
fhe study also shows that the
ratio among the sample group
9-q7 females ner 1000 m'jles,. aex(see
fig. No.2)
H&uTH tJJUC/.TTQN:
j’or the success of any health
programme,
health education
activities is an important factor^
'
done by means
and ete^5^^ t-’lks’ flask-cards,
fl*^-^rds, slides, posters, films
cin< etc.
o ..ducate the c- ------ - *
•"~2?rn?u
nJ;ty,'
the’ talk
hospital
staff
should be able to give some
sort
of all
health
’ r~The
-rained eight community health workers in1]?^
. hospital
-tnce November 1'8/^ the hospital's co..,
community health workers
nave been reguiariyn. bowing flask-cards
-ommunity both on '^B and general health. and slides to the
according
the findings of the evaluation,
53.5‘^ of the
prevent^ nndhf^ ^ys ^nd ^.ns'how
Tube^ulo^is
can be
answer. (seedfif’5No.Wwere
J)e nOt
t0 P
rovide a satisfactory
not 8ble
able to
provide
I
I
y* —
hob th ' a0 r??nond®nt
general public, 89X received
some
tha^tbZv d?JLOn/rO? th® bosP1^1 personnel
rmd
11%
expressed
that they did not.
(See Fig. No. 4)
caused by unhylienic^ondftZons"!Sd^mSinF^S^^a^ 3%^
= ns“fr on’the fS?eaa“fe?30fhS^v™de^
g;:K'd''1^1’0'1S"
sign and symptons of TB in’adults. (se^fig? NoS) It^s'heSv
cJ?°blofX(feeOfig?No^h8) 91 % °f thS resPondent’sa:i-d TB is
Tile preventive methods being tuken by the respondent's family
to control the spread of TB sre by not allowing other members
of nt he family use the s.?me ><cups,spoons
plates, which amounted
to Ji ;-ind 18.83 expressed to coyer the-and
mouth
when coughing.
Only 30.4'3 were not able to provide postive answers.
(see’fig. No, 9)
BCG Immunization:
There are two methods commonly used for the estimation
covara ge. The 8„pll„s methoa
method. In this evaluation study
sampling method that was
aonlied iw-Q
w s represnet:.tive random sample on a house to house
basis forr the
tho presence of BCG scars.
The under five BCG c~- -r^te, of Doeguling Tibetan Settlement
rate wns 96.37 and 3.7X did not’have"the scar.(see fig.Nor10)
^ccordingto the place of immunization, 95*17^ of the under five
cnildren immunised in the hospital and 4.9^
otherside.(see fig“
- 5 -
A _ A J22L 9 21A ALL AL A ARC b-os i s
I
fCentr-.l School for Tibetans, Mundgod)
/
fteAl SvAtivS SdSVs'e^ ?r°sr?+ira" °n ^ercuiosis
c. Udp.-n' on r 7 mF ■
F- g0?1;;r 1 Public ■
dmjnist^rPd
fuvj th-t the .•aiov-Lv.>po0n
hotter then the general SSblic.
°F to find the school
hf103 '10118 a<: t:v't used for
w a very encouraging to
S
SCh°Oi Cllildren Wo-s far
Ic-'eyer^ the
ch )ol children’s knowledge on
s only 2/{..
< said it w s <
caused by worries
c a u s e d b y K<-. > r m r.
fig. -io.l'i)
c-oiQ it was due to one's karma.
O-■ of th? children Ln the
<----the sample
sample O
groun
□ :> iho rraventlm of tntuborouloLs
8 /know
. ‘ the various methods
fi™ SG O
lOOOO;! •salons
O-f-pective
S10?? wu,
villages.
(see fig, w0. b and1^)
rr
to the question wither T.B wr-s e« communicable diseases
11 j Me ?'•_ students ■
agreed, (see fi^ No. 15) it was interest
-Mr- to know that
rePlyi"S that TB W3S curable
if one t kes full course of^r^t
of treatment. (see fig. Mq. ;7)
^;tthee£ho0l0chnflXSinnthr^ sy?ptoms of TB in adults, 60%
^rroct ^wS'r?’ (se^Rg/wo. I?? 6
t0 glve
.-i. ■ g . ■ gu of the students who were
r-mdonly selected for
this ov tuition . tudy w s 1g years.
-2 LaLjSF T.U: J TUP?:
1 )
Since no-rroper
?----- records -..nd statistics "/ere being- maint
in ted t th<? hospital, < 1.
, the investigator's objective
nuicber one end three'could
— ---- not be achieved satisfactorly.
■idP^^WliCl._OF THS I'R PfiQGR
1 )
fol-f-owlng cards and register;
register;
Patients treatment card.
fb.)
ily Record Ctnrd.
(c)
ter TB Register.
a’) Tn the sputum test register separate columns
should. .Maintained.
^he community her- LCh workers should br giv-n
more support
ri.nd eacour ^?ement both by the
.,
,, leaders 'and the
-be community,
5) uo ¥ o-inion of the
community on tie community health workers.
rt.arH OF p.iz
’OGR ,< 43:
s“’1C%jhb/dronn?r0hPr0je3Ct W?S started 1* November 1084, they
-ctl °4t
F F the ^^'?^nCe °f th2 73 Patents in the
7
,
Fiv h
the Pf ’3erit’ during the time of evaluation there
h ■ '•iornxim1! p tients, of which only three were sputum oositlve
«<n
?Mgullne
-ttC:
6 ;N:
1) 'its tistic* 1 work need to up-grade us soon -'<s possible.
2) Community health workers should be given conts-j.nt
encourag.)ment, ■■s they are
'I'e vthe back bone of the TB
control project and also the general health care of
the community.
.8 1the findings show that the health
education of the
school children on ?3 w.-s amusingly good. Therefore,
if rore ho-1th educ tions vere given to them, they
could become means of
to carry these he. 1th education mess ges to their parents ^nd near ones. T}lere by
bring an improvement of he 1th and awareness in the
community.
- 7 TCI.Sl'RIBJTION OF
SWLE
^ig. 'Jo. i .
F
gr O u ‘0
9-5
i
6-10
1 1 -15
1 6-.-0
2i -r25
'16-50
.5 i -35
56-40
4 < -45
46-50
71-55
56-60
--- ^4--'potal
■la le 'Female ’
-------- —___
i 80
I 65
92
j 55
1 44
/ 39
I
I ztQ
■ 84
1 65
62
■
1 34
- 31
45
31
I x5
,! 92
I -'+5
648
| 588
Total
^4
f>2
66
6?
. 25
I 31
I 28
55
‘ 26
i
I
I
100
r Male
13.?-7
1 0,89
12.70
O.50
7.52
5.91
5.18
7. ‘>4
5.35
5.40
4.6i
4.20
8.10
---------------
1^36
1
■ LEjL.i< tip
Tig. ’- o. ? .
—
I sex j.Humber i 0 ere ent
648
. Female 588
I------------------i Total '1236
Percent
164
1 794
1 57
IT?
93
'IO
■
BY AGE BY SEX
100.00
!
Sex ratio
5P.43
907.41 per
47.57
1000
------------100.00
r|W
"MW
Fig, No. 3.
n--------------
Answer
Yes
No
!---------i Tqtal
1
; Number
Percent
I 1586
96.30
3.70
I
I
164
-I 100.00
H
f
rd
O.JDOtJTS 4L7I9G RECEIVED HjiLkLTH EDUCATION
Fig. No. 4,
5
1
newer
j Humber
Yes
•
j Percent
89
No
178
22
j Total
< POO
100
1 1
1
l
I
- 8
ai3^I3UTI0^ -EiJS^KHWSNrs
XUJ3i®culojis. 4
swar
KPo^/Li^Gg
-___ 1______
'• 3.rms
3 m ok'inf;
Tarma ’
-Poroent
46
J
60
I
nd
/oorie^
o [dee
nxleties
conditions
24.00
3.50
1 .60
31 .30
18.80
20.80
1
“H
I
I
192
^-8.
iuOWi-
o. 6.
'O.
!
I anower
r
i
'■umbor 1 -ere ent
4 ------------- ^,.
I
165 1 32.50
5 !
2.50
■■•To
No Idea
i
i _ 50 ' 15.00
Total
'■’().
I 100.00
200
I
7.
!---------------
r
Answer
fes
?T o
?
i
Number
■r-
-------- - ---
!
Percent
'63
■J
200
r—
--q
1 00
I
Tot - 1
31:50'
68.50 f
•7ig. "o. 3.
. ns'vor
l
dumber
aercont
------ -----------
I---------------
fes
182
91
’’o
”0 Ider
IS
I
*
?otal
200
i
9
i oo
9
^niDSNT„-XaWire TO_^iS£iZCION OF SPR&xP
^4—474
i
let hod 3
J.------------------------------------------------------ - -----
•’ercenTj
!^core
; 2-■ l.Lo-yirif] oth-r jw-nb
of tho
i
ir‘o.N uain^ the
cans, spoons nd nlates.
5/ covering the ■nouth when cou^hin*
<y not slitting r-’/erywhere
I
By living iaoleted
j '0 Idea
51.10
57
18.80
5.10
1 't
. 70
,-70
10
29
60
JO-.. 40
-r 3
197
i.. nn
1100
00 7!
I
ot -1
61
i
--------- 1-------------------1-------
MI CTION st. TIB
"Vsvi47~R0P0PT . .ilD. QjiaCXiN
G JLQH .SC.-.R'.'
[/Mr
Fig. '-■o. 10.
• nsW'jr
i
i
Yes
dumber I Percent '
Vo
b
►--------------------
i
Tot-1
|
‘
'
!
3.70 J
t ".’3d
158
164
: 100.00
i^^JUI^afC-CCORFl:^
Fig.
s’o.
2UO:3_OF.J - -iUNIZnTION
; 1 .
“
-
r------------
‘
ns’’'er
I
1
1
Humber i Percent
1 56
f—
To
—4
Tot- 1
- -
95.10
8
i
4.90
16^
I
100.00
;
2 2 i -2222? 2 2 N' 3 f 1 g u r e s
— -—1 u.,3 uKUJLQ j.LS .
rig.
'
.’o.’?.
nsw^r
Yes
To
r-----------i
'Cotai
I
I
!'Tuaber ■ Percent I
+
19
i
76
6
I
2/^
100
I
I
- 10
lilSTg
OF Q.QS
?o -2P Q 2.P C' i 0
i■——lSUTIfW
—---------------------- . QNDEN
------ •*•-•-•*••>.■■■
TO HA 7 [ Nc.
-----------------
_LL
ig. No. 15.
1 nsw.jr
.'timber
‘•10
-total
L+
84
i6
25
100
^13^ 13UPEON .JF_??r^)jNDZNT_g
C USZS Or TUB-IPCULOSIS.
Fig. ^o.
‘
hTi
Percent
,?1
1; 3
( ?•i •
'-V lJL£ijG£ ON
Tn umber j
answer
Y:':rcent
J Oorms
9
J .: »n.irig
j
Poking
3
I -'orri.js
■'orri.js t ''nxieties j 19
j frtih/gi-?nic conditions 6
i No [^.3,-.
24.32
,
8.10
51 .14
16.22
L57
I Totnl
j_________
100.00
i
I
xiLi^iL-j££I ? ; of PbS?OriLNNT:L_T<CCO.PD L->;C ;?0 THE IP KN OW LEE GE ON
>—L
U 3ORCUI OS IS.
Pig.
'o. 15.
"* ------------
ns’vor
''r. -J 3
.. r
Number i .v er cont
25
i 00
25
1 00
i
No
! Total
fflauaflUM
aWmMW
7ig.
‘’o.
16.
nswor
Number | P /rcont
Yes
No
15
hot-i
25
10
j
60
40
i 00
i
i
j.
- 11 -
EUXMBUrIOK_OF..£L/G e. TILSIri JCNOrfLEDGS
ja
Q’'. ■rUfl.^RCUL.OSIS.
‘
----------17.
n 'r o r
Dumber > ?arcoat
^5
1 00
I
|
■o
r?otc 1
1
100
25
‘IQ xPRgJEiiTIfyOF
Fig. "o. 18
1-------- “T*--------
I Methods
I Nu’nbor I Percent
-------------------
) By not allowing other members
I of the family from using the
so tic cups, snoons, plates and
• etc.
By covering the mouth when coughing 14
i By
Bp not spitting
slitting everywhere
overywher
1
1
By living in isolation
9
!
. Mo Idea
3
T
?otal
1
41
r £ M £]
! 34.15
i-------- '
3^.15
I 2.^3
2.43
j 21.95
I 7.32
7’32 I
t--------- i
; loo.oo '
P L
r
i
Date
Invent
♦J ov. 1 )86 i
j Sth
! Journey to /and god
i 7th
• L'ifscussion with Dr. Poss a n g N o r b u la .
; 8th
I Discussion with CBW,, visit to CHW’s centre and
I
! going through hospital records, registers,etc.
I
I ?th-15th I Community Sample survey.
h 6th' nalysing
n?lysing data
II 7th
j Rest Day
13 th
. School s\mplu(CST above class VI to X) Morning
| class for CIP, meeting with settlement Representative
i ?'nd in fator with ^r. Passang Worbu la.
loth
| Class for CT,f in the morning
j
Loft Mundgod in the afternoon.
I
|
- 12—
DISTRIBUTION OF POPULATION OF fHS SAMPLE SURVEY ACCORDING
TO
AGE AND SEX
r
A 0 E
I
66
r
MALE
61-65
FEMALE
—I
.J
A
G
3
) 56-60
“1 51-55
i
M
i—
Y
U6-5O
E
A
R
3
I
|--------
1 U-li5
r
36-hO
__
i
: 31-35
i
26-30
i
4
21-2^
1
I
16-20
I
i
11-15
i
I
.6-10
I
1“
I
7
6
5
U
3
2
I
0
I N
o-5
0
I
2
PERCENT
3
5
6
7
- 13 R33P0ND3NT3 KKOWLEDGZ ® CAUSES OP' TUBERCULOSIS
\
2U $
18.8%
Germs
Unhygienic
conditions
...
/
.1
'
31$
anxieties
/
t
Smoking
/
20,8$
No Idea
Worries
I
Under Five Childfen’s Immunization status: BCG
96.3£
!
i
I
3.2%
- / J.
YES
M 0
-III-
\
—
RESPCNDENT'S KNOWLEDGE ON PREVENTION
OF TUBERCULOSIS
;
■>---------x
I
i
i
_____ __ b
_____ J
YES
NO
RSorONDaWS HAVING HAD HEALTH EDUCATION ON TUBERCULOSIS
89 %
I
II
|
. y
YES
NO
-15■ -S'-!OC.
Kro/LEDG2 OI' CAUSES OF TUBSFC’^OSIS
51. W<
*
I
i
I
2h.32;s
8.10^
16.22%
i
I
germs
smoking
!
1...L
worries/anxieties unhygiepe !
SCHOOL CHILDREN't, KNOWLEDGE 0!J SIGNS xV® SYMPTOMS OF TUBERCULOSIS
60 %
I I
i
l
I
I
I
Uo %
l
i
I
I
I
I
I
I
—
i
I
YDS
-16SCHOOL CHILDREN'S KNOWLEDGE ON PREVENTION OF TUBERCULOSIS
I
I
2U t
\
N 0
/
/
76% y 3 3
<
CHILDR3T TfflO HAJD
SEEM
HEALTH EDUCATION GIVEN BY HOSPITAL STAFF
16 «
N 0
8W
YES
#
B
<• .7
X
o
0
^ETM i’
0-4
UiMjje c
’ A
e CM
lh^
l°|£(o
«..,s,..,7.
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PH
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
piC T» O Ns
I. HOSPITAL
A. General
The Doeguling Tibetan Resettlement
A well equipped library and current medical periodicals
Hospital has 30 beds. Its average
will help in updating of medical knowledge especially
occupancy rate is 6-8 beds. It is well
in the area of community health; it will also be useful
equipped with X-ray, Laboratory, ECG
to the para medical workers in strengthening the
and other necessary equipment. The hospital
primary health care activities.
has adequate facility for performing
minor operations. It has specialist
4"
facility for eye problems with the help
of a local opthalmologist. The hospital
dental
has acquired the necessary/equipment
for future use.
The hospital services are well utilised
Administrative routine to include visit to these
by nearby 5 villages and 2 lama camps.
villages by competent staff on a regular schedule -
There seems to be under-utilization by
could be considered.
4 distant villages due to transport problems.
2
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
The hospital is self-sufficient for
water and sanitation.
There is large out patient load with
Separate TB follow up clinics on specified
general and tuberculosis follow-up cases
days in addition to the already allotted
Saturday afternoons could be considered.
Record keeping is up-to-date. It is
Adequate record keeping to reflect the amount
adequate for the TB control programme only.
of activitiy being undertaken in the areas of
The Hospital follows the National
primary health care such as MCH, under—5 care
Tuberculosis Programme regime.
etc., could be started.
A good referral system with the Medical
A formal arrangement with the Medical College
College Hospital at Hubli for specialist
Hospital, Hubli and the National Tuberculosis
services not available except on the
Institute, Bangalore, to be considered.
personal liaison of the medical officer.
3
OBSERVATIONS
RECOMMENDATIONS/POSSIBLESOLUTIONS
B) Staff
The medical officer is overloaded with
It may be a good idea to induct additional
preventive, curative and till recently
manpower support for community health activities.
administrative activities at the hospital
level.
An administrator has joined the health
team recently.
The two trained staff nurses are fully
A trained community health nurse is required
involved with hospital out-patient and
for better utilization of MCH and under—5
in-patient activities and are unable to
activities by the community.
devote time to community health.
C) Administration and funds
The budget of the hospital is prepared by
a Committee consisting of the Representative
of the Settlement, Village Leaders and the
Medical Officer.
4
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
About 25% of the funds are met by the
Health Tax, Bed Charges and OPD Charges
at presents Free treatment is given to
deserving patients.
It is proposed to collect further 25%
from the same resources. This community
participation will meet a major part of
the health budget apart from TB Control
programme.
Decisions are made with the participation of
the community (represented by the leaders)
with adequate flexibility for the medical
officer’s functioning in medical matters.
The percentage of patients on second line
1. Ensuring that all Tibetan Settlers
treatment showed 35.0% in 1985; 32.1% in
approach their own health centres or
1986; 36.2% in 1987 and 28.68% in 1988 (upto Nov)
the nearest District Tuberculosis Centre
5
OBSERVATIONS
RECOMMENDATIONS/POSSIDLE SOLUTIONS
The cause for this is the starting of
to enable the standard treatment policy
second line treatment at private clinics
to be followed.
and other centres which do not follow
2. Consider mobile health worker with
the National Tuberculosis Programme
first line drugs; even if the diagnosis
recommended regime. A standard treatment
is made by the private practitioners.
policy in all the settlements in accordance
treatment to be followed should be as per
with the National Tuberculosis programme
the National TB programme.
is being implemented.
3. Links with local practitioners/organizations
From the statistics provided^ it is
could be established for following the NTP regime.
noticed that more than 31% of the proposed
4. Consider training of mobile sweater sellers
budget for TB and Primary Health Care
for tuberculosis programme.
programme is earmarked for anti-tuberculosis
5. Employer of the sweater sellers may be
drugs in view of the high proportion of
requested to take action as in 1-3 above
cases being on costlier second line treatment.
on detection of tuberculosis cases.
and the inability of the District Tuberculosis
6. Check if second line drugs with CMS-I
Centre to supply these drugs. This cost is
are cheaper, details of which are being sent
despite the fact that all other health care
6
RECOMMENDATIONS/POSSIBLE SOLUTIONS
OBSERVATIONS
activities are being met by the
to Doeguling Hospital.
7. A
community itself.
t
.. •
There is no definite staff development
Taking this up as a policy matterwill enhance
and continuing education programme
the skills of the team in perfoming their
as a policy in the South Indian
work more effectively. In addition, regular
settlements.
meetings of the staff, discussion of health
and related problems^ training of staff
not individually but as a team, will further
strengthen their team work towards providing
/•
Detailed studies of disease incidence/
prevalence are not being done due to
lack of funds for this activity.
primary health care.
w
7
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
II. COMMUNITY HEALTH
A. Water supply and sanitation
Adequate potable water is available from
Overflow and sullage water can be utilised for
borewells within walking distance.
kitchen gardens.
Collection and storage of water is
Proper health education of the community in this
unhygienic
area is needed.
Sanitary facilities for excreta and
Propagation of the concept of atleast community
waste disposal are grossly inadequate.
latrines to be considered.
B. General hygiene
Concepts of general hygiene, especially
Health education to alter the habits which were
oral and personal is poor.
not harmful in their homeland of Tibet but are
conducive to spread of diseases in the present
circumstances is required.
8
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
C. Maternal and Child Health
Immunization coverage is good*
Breast feeding is promoted as part of
the culture. Birth weight of newborns
is above average.
Pregnancy is usually diagnosed after
The services of a Community Health Nurse will
5-6 months. Hence the critical period
help improve the situation.
of MCH care in the first and early
second trimester are not availed of to a
full extent
Abortions are not reported and home
Awareness building programme (through community
deliveries are conducted by elders
participation' to elders who conduct deliveries
in the family who are untrained.
could be organized. Concepts of hygiene etc./
could be included in the programme.
Since prevalent cultural practices appear to
9
OBSERVATIONS
RECONMENDATIONS/POSSIBLE SOLUTIONS
be adequate in producing healthy children,
child
maternal and/health needs deeper study especially
antenatal practices in order to foster good
traditional practices.
D. Health Workers
The health workers are well trained.
Health workerscan be trained to handle minor
motivated, sincere and capable of handling
ailments and given some drugs for it thus reducing
responsibility. especially in TB control
the hospital out-patient load.
programme. They were given adequate on the
Additional work with more incentives to be
spot training by the medical officer for
considered for health workers to ensure
TB control, MCH care and Health Education.
committed primary health care.
They are occasionally utilized in hospital
care in place of nurses in addition to above.
In order to ensure replacement of staff easily
tegular training programme for health workers
There are 3 drop outs out of the original 8
could be organised.
health workers trained and the replacement
The services of part time health workers could
workers are yet to be fully trained.
10
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
The younger unmarried health workers
be considered; they could be selected from
are not well accepted by the community
amongst school teachers/staff of cooperative/
yet.
staff of handloom weaving centres etc,, who
are likely to be permanent residents of the
settlements.
E. Villages 1,2,3,5 and Lama Camps 1, 2
Majority of TB cases are found in the
mobile population of sweater sellers
especially those coming from major
cities. Many people affected by TB
belongs to the age group 15-35 years9
while in Lama Camp 1 under 20 years and
above 55 years are affected. It is
believed that the higher incidence rates in
monastries is due to newcomers from Tibet.
Cases on second line treatment have been
11
OBSERVATIONS
initiated on treatment elsewhere.
Females show a lower incidence compared to
males.
(observations pertaining to other aspects
of health are as recorded in previous
paragraphs.)
F. Nunnery
It has 25 residents and is clean and
well maintained. Adequate water and
sanitation facilities are provided
to it. Since it is next to the hospital,
the inmates utilise its services well.
RECOMMENIiATIONS/POSSIBLE SOLUTIONS
12
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
G. Homes for the oldf infirm and destitute
They have been provided with adequate
More community health worker’s activity
water and sanitation facilities. However,
especially in the field of hygiene is required.
general and personal hygiene in the general
Participation of community to be sought to
section is poor. It is better in the
take care of those who are unable to help
Lama section.
themselves.
H. Tibetan Medicine and Astro Institute
It aims at revival and popularisation of
Integration of activity with the allopathic
traditional system ofmedicine. According
system and more so in the direction of providing
to the Medical Officer, its theoretical
primary health care to be considered.
principles are similar to Ayurveda.
Imparting some skills to health workers and
Source of medicine is centralisedat its
utilising them would strengthen their efforts.
HQ in Dharmsala.
No local/herbal/home remedies propagated
It could play an important role in taking over
which can be easily made at home.
of hospital over-load of out-patients wherever
possible.
13
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
The institute is staffed by a senior
Comparative clinical trials of treatment
doctor and two trainee doctors. They conduct
for chronic diseases using both allopathic
home visits and treatment on request.
and Tibetan systems can be initiated at
the settlement levels.
!• Representative of the Settlement
Mr G Choeden was very concerned about the
Screening of settlers returning from their
mobile population of sweater sellers since
prolonged stay outside to spot TB cases
a. they constitute the younger generation;
could be considered.
b. they are unable to learn any skills; and
(other suggestions regarding
c. they are the major source of the
TB as in
tuberculosis problem.
above).
It will be good to involve the health team
to introduce health aspects in all the social/
economic activities of the settlement.
14
OBSERVATIONS
RECOMMENDATimS/POSSIBLE SOLUTIONS
Mr Choeden invited us to speak at a
>•
Seminar-cum-Workshop on INTEGRATED
DEVELOPMENT PLAN FOR TIBETAN SETTLEMENT
AT MUNDGOD.
During the discussions here, it was
noticed that "health" did not form a part
at all of their "Human Resource Development"•
This was pointed out and stressed by a
member of our team.
J. Cultural and Social factors
Community eating and drinking habits
Health education to create awareness of the
from common plates and glasses is
adverse health effects in the present conditions
prevalent.
to be organized.
15
OBSERVATIONS
RECOMMENDTIONS/POSSIBLE SOLUTIONS
A traditional barley brew is consumed
by many though alcoholism does not seem
to be a problem. Smoking and chewing of
tobacco are not common while using of
snuff is widely prevalent.
There are no organised health promotive
Community participatory activities to be
activities like youth clubs, community
considered.
reading rooms/libraries, play grounds.
games etc.
K. Schools and School Health
There are 3 central schools: one upto
higher secondary (XI std) and two
/.<• A
U41
are primary schools.
There is no regular system of school
Regular school heath check ups and
check ups and health record maintenance.
recording could be undertaken.
The doctor has noticed a very high
Health and hygiene/sanitation to be made
16
OBSERVATIONS
Recommendations/possible solutions
a part of school curriculum.
There are 9 creches with under 5 children.
These places can be used for education of
Some of the personnel are trained in the
mothers in health, hygiene and nutrition
Montessori system. Mid-day meals.
aspects of children.
supplementary nutrition and growth monitoring
are done here.
There are no regular formal/non-formal
adult education classes.
The drop out rate at middle school level
is very high.
Regular adult education classes to be considered.
17.
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
COMMENTS NOT COVERED ABOVE
From the available statistics, the following
is noticed.
a. The Crude Birth Rate shows a decreasing
A detailed study of these statistics
trend in the settlement population.
from hospital and community records
will help in formulating a more meaningful health
programme for the future, especially since this
settlement has a large monastic population and
also an old age/destitute home which may account
for the present interpretation of statistics.
b. The crude death rate is mainly due to
old age and destitute home accounting
for it.
c. The infant mortality. neonatal mortality.
maternal mortality, and mortality by
cause could not be calculated.
18
OBSERVATIONS
RECOMMENDATIONS/POSSIBLE SOLUTIONS
d. The high rate of BCG immunization is
due to the fact that all settlers under
19 years of age were immunized in 1985
and more newcomers into the settlement.
e. The in-patient and out-patient attendance
has decreased while the referrals have
increased during October 1988 due to the
absence of the medical officer.
AREAS OF STUDY
1. A thorough study of the trends and pattern of Tuberculosis in Tibetan settlements in Karnataka.
2. Comparative study of the relation and impact of agriculture, dairy farming and other
socio-economic activities on health in the different settlements in Karnataka.
3. A study of the child bearing and child rearing practices of the Tibetan community.
19
4. A study of the training needs and training in areas of MCH/under fives and school health.
5. Study of utilization pattern and scope for integration in community health practices of the
Tibetan system of medicine.
CYC^
THE ABOVE STUDIES, BY THE HEALTH TEAM THEMSELVES
4
EFFECTIVE STRATEGY FOR THE FUTURE OF THE SETTLERS.
. ENABLE-^VeLV^NG--eF, A MORE APPROPRIATE AND
A
SUMMARY
as
--- 4--------------
-tLyThe Hospital is very well equipped.
at^the- eypeTTse of a
(r ^V\A» £ fVS; V\=C
very well conducted tuberculosi
h‘x«4 f» <‘KXicA.t< rr
-a<
— The community participates
e
programmesAneed more attention,
The aspects of primary health care being implemented are not adequately projected
v**
in making democratize decisions and pays for most of the primary health » >
needs apart from the tuberculosis programme. 7^oo
•
<
Considering the high cost of TB control programme, various avenues of better m®agement have been
h-'.
|-k’c,1Z
20
explored in the report. The suggested study will help in pointing out an appropriate course of action.
Health education in addition to appropriate public health engineering works will help prevent many
minor illnesses and promote primary health care.
Good cultural. traditional practices in maternal and child health care can be fostered after an
adequate study in this field.
_ The health worker services are commendable in the tuberculosis control programme and can be extended
• to other areas of primary health care.
The large mobile population appears to be the main source of disease especially tuberculosis. An
appropriate administrative and medical approach is to be evolved to tackle this problem./^
/
Integration of Tibetan Medicine at all levels with the prevailing system will prevent duplication of
health efforts.
Health promotion practices to be introduced at pre-school, school and non-formal education levels
including regular health check ups and record maintaining.
/
D
/7>
* 'Vuvvn
n. rljc i ci
DEMOGRAPHIC DATA OF MUNDGOD SETTLEMENT
421. Total Population
♦
Males
Females
2. Total Area of Settlement
3. Number of Villages
9658
5788 (includes Lamas - 2400)
3870 (includes Nuns
25)
3000 Acres
9
4. Number of Lama Camps
5. Nunnery
2
1
6. Home for Aged
1
7. Number of Creches
8. Number of Schools
9
9. Cooperatives
10. Banks
11. Post office
-
3 (1 High School, 2 Primary
Schools run by the Cent
ral Government)
1
2
1
12. Transport facility
2 Government Buses to
Mundgod daily
13. Main Occupation
Agriculture
14. Seasonal Occupation
(3 to 7 Months)
Sweater selling ( more than
60% according to the
Representative)
15. Other Occupations
Carpet Weaving/Handicrafts/
Dairy
\\0
G
I U A ly
COMMUNITY STATISTICS
I
1985
1986
1987
1988
(till Nov)
Crude Birth Rate
(1981 - Indian- 33.2)
16.21
12.0
11.33
6.41
Crude Death Rate
(1981 - Indian - 12.5)
8.62
9.78
8.14
4.34
Under - 5 Population
741
(8.52)
764
(8.59)
696
(7.66)
717
(7.42)
141
107
103
62
MG
<1(4;
- as % of total population
(Indian - 15%)
—— 0-1 Population
11t)
^3
IMMUNIZATION
STATISTICS
1985
1986
1987
1988
(till Nov)
4
T-
B.C.G
(Good Coverage, see comments)
D£T
OPV
1st
2nd
3rd
Measles
Boosters
I
II
<5^
%
20
10
4
108
102
106
93
83
69
81
74
55
46
82
113
115
Nil
Nil
119
91
79
21
45
43
HOSPITALS
I
1985
1986
1987
1988
(till Nov)
i
-
Total Outpatients
25,960
21,862
21,536
14,418
Total Inpatients
612
696
625
484
Referrals
11
8
4
19
Average Stay in
Hospital
(Days)
9
9
9
9
(
Uc
2^
It
*
MOTHER AND CHILD HEALTH
1985
1986
Ante-natal Clinic
attendance
1059
Hospital Delivery
1
1987
1988
895
864
308
36
39
24
30
Home Delivery
63
39
33
31
Outside Delivery
45
25
28
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4
PLANNERS' APPROACHES TO COMMUNITY
PARTICIPATION IN HEALTH PROGRAMMES:
THEORY AND REALITY
by Susan B. Rifkin*
Introduction
Concern with the people who receive health
services rather than those who provide ser
vices has gained increasing importance over
the last twenty years. By the mid-1970's, the
experiences of the national health care pro
grammes of countries like China and of many
church and non-governmental organizations
(NGOs) gave birth to the concept of Primary
Health Care (PHC). Defined as "a practical ap
proach to making essential health care univer
sally accessible to individuals and families in
the community in an acceptable and affordable
way and with their full participation", PHC is
the strategy propagated by the World Health
Organization (WHO) as the means by which
"health for all by the year 2000" is to be
attained.
Community participation is seen as the key to
PHC. It has reached a prominent place in health
care strategies in many countries and program
mes for a number of reasons. These include:
1) increasing evidence is being provided to
show that medical technologies are less impor
tant for health improvements in large com
munities than what people do and can do for
themselves; 2) economic planners increasing
ly are convinced that development is more a
result of an investment in people (in their health
and education) than in machinery, and efficient
* Susan Rifkin is currently coordinator of the Asian Communi
ty Health Action Network (ACHAN), formed in 1981 to pro
pagate, popularize and pursue a philosophy of community
health, to facilitate the exchange of information, materials
and personnel among its members and to help initiate, sup
port and sustain community health work among NGOs in
Asia. Prior to this, Ms Rifkin was a researcher on community
health for the Hong Kong Christian Council and an associate
of the Center for Asian Studies at the University of Hong
Kong. CMC has published two of her works: Health Care in
China, an Introduction, 1974 (out of print) and "Health, the
Human Factor. Readings in Health, Development and Com
munity Participation" in CONTACT Special Series No 3, June
1980, of which she was guest editor.
use of this investment is possible only with
community involvement; 3) health care ser
vices are being misused and underused, a
situation it is thought possible to rectify by in
volving clients in decisions about the develop
ment of these services; 4) the problems of in
justice and maldistribution of health resources
can be addressed as lay people, especially the
poor, develop, maintain and control their own
health programmes.
Community pardcipation in health care has
raised many assumptions and expectations
among health planners. One is that community
people are a great untapped resource potential
which, if mobilized, can contribute to the
scarce pool of existing health resources to ac
tually reduce the cost of health care by pro
viding additional manpower. Another is that
communities are homogenous entities which
are able to agree upon a course of action which
would enable a more equitable distribution of
existing resources. Also, planners expect that
health is a prioriry for community people, who,
thus, will be motivated to spend their precious
time and energy, especially scarce among the
poor, to improve services and care. Finally, it is
expeqted that community people want to par
ticipate in their own health care because they
wish to serve their communities and to have a
part in decisions which affect their daily lives.
In the 1970's, the belief in and the rhetoric
of community participation in health care
mushroomed. Inspired by the alternative health
care models anc the increasing concerns of
social justice, heath care planners, particularly
in the less developed countries, looked to com
munity participation as the panacea for pro
blems of scarce resources, unequal distribution
of resources and medical domination of health
policies. How rea were these expectations?
The answers to these questions now are begin3
. «r*
^33
-
H
Integration of Vertical Programmes in Multi-Function Health Services
Preconditions, Limits and Potential of Integration
Bart Criel and Vincent De Brouwere
December 1995
Cm-*-—
J
*
«
Introduction
The concept of integration has been the subject of differing interpretations. For example, during an
international conference on the prevention of HIV and AIDS1 the concept of integration was much
discussed in the sense of the integration of services in the execution of a programme, or in the sense
of greater collaboration, or indeed a fusion, between two programmes (for example a programme for
the control of sexually transmissible diseases and a family planning programme). Little consideration
was given to the integration of certain programme activities in the package of activities provided by a
polyvalent (multi-function) service. There is a need, therefore, to clarify these problems.
This paper seeks to contribute to the debate by discussing the concept of integration and the
operational implications of integration. For this purpose we base our discussion largely on the study
and experience developed by the Public Health Department of the Institute of Tropical Medicine in
Antwerp in the course of its history and on a review of the literature on the concept of integration.
The concept of integration which we propose to discuss in this chapter therefore concerns the
activities included in programmes in multi-function health services. After clarifying the terminology
and the conceptual framework in which we understand integration, we shall discuss the potential and
the limits of integration. We shall then consider the problems encountered when the integration of
certain activities involved in vertical programmes is decided on, and we shall attempt to formulate
the preconditions of integration and the practical questions which must be answered if integration is
to have a chance of succeeding.
Theoretical considerations
It is important to establish clearly the definitions of certain terms which will be used in this discussion
of integration (Kegels, 1992).
Vertical structures
Vertical programme
A vertical programme consists of a coherent package of activities designed to deal with a
single health problem or a group of linked health problems. The content of a programme (the
package of activities and tasks aimed at dealing with a particular problem) is the result of a
technical analysis based on a vertical approach. The creation of a programme is the result of
a political decision which ipso facto recognises the importance (epidemiological, economic,
social, cultural or political) of the health problem and thus justifies the establishment of a
specific administrative structure to be responsible for the management of the programme.
1 USAID Conference on Prevention of HIV/AIDS, Washington, August 1995.
1
Thus a vertical programme may be established to manage more effectively the control of a
particular disease (for example leprosy or tuberculosis), to manage a group of linked health
problems (diarrhoeas, acute respiratory infections), to manage the health problems of a
particular population (problems associated with maternity), to structure existing activities
(e.g. vaccinations) or new activities (in the AIDS context, for example), etc.
Vertical structure
A vertical structure is a health structure staffed by specialised (monovalent, "single-function")
personnel highly qualified in a particular field who are responsible for dealing with a single
health problem (or a limited number of problems). Very frequently (but not always) a vertical
structure operates on a periodic basis; it may remain centralised or may operate in a
decentralised fashion (for example with mobile teams). The establishment of a vertical
structure for the control of a particular health problem ought (at least in principle) to be the
result of technical consideration and analysis.
Horizontal structures and integrated health care services
Horizontal structure
A horizontal structure is defined as a health structure in which a multi-function staff,
responding to the needs felt by the community served, is responsible for dealing with a wide
range of health problems. A horizontal structure is decentralised and operates on a
permanent basis.
Integrated care
Integrated care means that the care provided in curative, preventive and health-promotional
activities is offered by a single operational unit. (A distinction can be made between
integration of care in time and integration in space3).
Integrated health system
An integrated health system is a system in which all the elements of which it is composed
(basic health services, referral hospital, etc.) are organised and coordinated in such a way
that they constitute a single entity with a common objective. For example in an integrated
district health system the activities of the health centres and the referral consultations at the
2 Though not necessarily with a formal specialist qualification.
3 Integration in time means that all services are available at the same time, so that at each contact with the service a patient can
have access to any type of care. Integration in space means that all services are provided by the same team but at different points in
time (for example curative consultations in the morning and preventive consultations in the afternoon).
2
hospital are coordinated with the object of improving the health of a well defined population
living within the administrative boundaries of the district.
Integration of the health activities of a given control programme
This is the result of a decision to have particular activities, decided on in the context of a
programme, carried on by staff working in horizontal structures, accompanied by a transfer of
responsibilities. Integration thus implies a decentralisation of both administrative and
operational responsibilities (Mercenier and Prevot, 1983; De Brouwere and Pangu, 1989;
Feenstra, 1993). We can thus talk of administrative (or structural) integration and operational
(or functional) integration (Mills, 1983).
Relations between basic health services and vertical programmes
In a district health system multi-function health services are organised in a network of health centres
associated with primary-level hospitals. Structures of this kind can be called horizontal. In many
developing countries the running of a health centre is in the hands of a nurse or medical assistant
heading a small team. In other developing countries and in most industrialised countries health
centres are headed by generalist doctors.
The health policy option considered by the authors of this paper sees the health centre as the first
point of access for patients to a formal health formation, lying at the very heart of the health system
(Figure 1). The health centre has comprehensive responsibility for the patient, to which it gives effect
by offering a minimum package of continuous, comprehensive and integrated care, covering
curative, preventive and health-promotional activities. It is at this level that all relevant information
concerning the patient is archived and brought together.
Figure 1: Operational structure of health services
The care provided by health centres is fundamentally characterised by its potential for developing the
interaction of human and relational aspects between the service and the community it serves much
more than by the technical level of the care provided. In other words the quality of care is defined not
only by reference to technical performance but also in terms of its capacity for communication
between health care staff and patients, the accessibility of the service, the degree of continuity of
care offered, etc.
3
There is a dynamic equilibrium between the offer of integrated care and the "need" to structure
certain forms of care through vertical programmes. It will depend on the emergence of new health
problems, the level of resources available (in terms of the qualification of health personnel and of
equipment and supplies) or on political preoccupations at national level.
• structuring of existing activities
A multi-function health service may decide at a particular point in time to structure all the
various tasks which it offers for dealing with a particular health problem in a programme, with
the object of improving its effectiveness and/or efficiency. For example it may decide to draw
up a programme for structuring its measures for dealing with diabetes, high blood pressure or
acute respiratory infections.
• Establishment of new activities under new programmes
New programmes may have been established because of the appearance of new problems,
either on a national (AIDS) or a local scale. The basic health services are then alerted to the
new problem and staff are trained for the complex of tasks which they will have to integrate
into their activities in order to deal with the new problem.
•
Transfer of activities from vertical structures to basic health services
At some point it may be decided, for good reasons or for bad, to dismantle a vertical
structure and transfer its activities to basic health services. This was the case with
tuberculosis after the dismantling, in some countries, of networks of specialised dispensaries.
It is also regularly attempted in the arrangements for the treatment of lepers, when the
activities run by vertical structure are transferred to basic health services.
•
Transfer of integrated activities to vertical structures
Conversely, certain activities run by basic health services may on occasion be transferred to
a vertical structure which is considered more appropriate.
The discussion on integration may thus be approached from two complementary points of view, each
the mirror image of the other:
on the one hand, from the point of view in which integration is considered the normal state of
affairs and discussion centres on possible preconditions and reasons for de-integrating, that
is to say removing a particular activity from the package of activities of a multi-function
service of first contact and making it the responsibility of specialised personnel. The question
4
then becomes: when should de-integration take place? In what circumstances is the multi
function health worker, the generalist doctor, no longer the most suitable person to organise a
particular activity?
on the other hand, from the point of view in which discussion centres on the question: when
should an activity not previously integrated be integrated?
Conceptually, the former point of view is more coherent, since it consistently sets the multi-function
health service (for which the various health problems to be dealt with are on each occasion only
relative priorities) at the heart of the health care system. From this point of view a multi-function
service is, until proof of the contrary, the one best placed to run a particular activity. De-integration
then becomes the exception for which a case must be made.
The second point of view, however, can claim to be more in line with reality as it frequently presents
itself today; and this is broadly the point of view adopted in this chapter. This reality is the situation in
which, whether we like it or not, many health activities are compartmentalised: that is, are not
integrated. It is perhaps partly the consequence of a vision of health, still too fragmentary and
selective, in which the relativity of each health problem is not realised. In this point of view discussion
will centre on the arguments which would justify a transfer of activities previously carried on by
vertical structures to multi-function health services.
Potential and limits of integration
In certain circumstances, and for certain activities in a particular programme for dealing with a health
problem, the integration of that programme in multi-function health services may be an appropriate
strategy for making the services offered more efficacious, more efficient and more equitable. This is
not, however, always the case. Integration, therefore, is not an end in itself (Mills, 1983).
Integration is justified only when some benefit is to be expected: that is, when it is more
advantageous for a particular health problem to be made the responsibility of multi-function health
services. This benefit must, therefore, be spelt out and supported by argument. The justification for
integration then becomes a crucial question. The answer must be based on technical and not on
ideological grounds.
The rationale and motivation of integration must be of a positive nature: integration should be
undertaken to bring about an improvement - for example because the handling of cases will benefit
from a comprehensive and integrated approach, or to achieve early detection or the proper carrying
out of treatment (Lehingue and Urtizberea, 1985; Walley and McDonald, 1991), or because
integration will improve the accessibility of services (Dharmshaktu, 1992; Courtright and Lewallen,
5
1992), or because it will reduce any stigma that may be attached to some particular health problem,
etc.
In reality, however, it is not uncommon to find that the underlying rationale of integration is not
demonstrated (Dechef, 1994) and it is simply taken for granted that integration is better; nor to find
that the rationale is of a negative order. As an example we may take the situation (regrettably very
common) in which integration is decided on because of a lack of resources to maintain a vertical
structure (Tonglet et al, 1990; Wamdorff and Warndorff, 1990). In such a case integration is a
makeshift solution, decided on unilaterally by the managers of the vertical programme, in which
multi-function health services are manipulated rather than used to take advantage of their
potentialities.
The problem is not to integrate programmes, but rather to integrate activities or even tasks in a
programme (Figure 2). From this point of view integration is not a standard operation, carried out at
constant speed and intensity whatever the context may be (Bainson, 1994). It may be more
advantageous to integrate an activity in certain situations than in others. Integration is thus not an all-
or-nothing question. And it does not mean that the vertical programme should disappear (Mercenier
and Prevot, 1983), or that specialised personnel have no longer any part to play (Loretti, 1989;
Tonglet et al, 1990; Feenstra, 1993): quite the contrary.
Figure 2: Integration of programmes versus integration of activities or tasks
Problems encountered in the process of integration
Integration is a process which meets with considerable resistance from the staff concerned
The various members of staff concerned by integration may, in varying degree, oppose it (Feenstra
and Tedla, 1988; Bainson, 1994). This resistance may be technical, conceptual or human (Mercenier
and Prevot, 1983).
6
Resistance by specialists
Specialists may fear a decline in the technical quality of the health care provided. They may also be
afraid of losing power or losing their control over the running of the vertical programme and its
content (Huntington and Aplogan, 1994). For integration is more than a mere operational
decentralisation of activities in space, from a specialised and centralised structure to a decentralised
and multi-function structure. It involves a real transfer of responsibilities, rights and duties to the
"horizontalists", the staff responsible for running multi-function health structures.
However a situation in which certain activities or tasks in a given vertical programme are always
carried out by the central level of a system is not necessarily in contradiction with a policy of
integration. Let us return to the example of the tuberculosis control programme in Figure 2: there is
no contradiction between the fact that the diagnosis of tuberculosis is still made at the central,
specialised level and the situation in which a decentralised multi-function health structure has overall
responsibility for the care of patients. In this situation the multi-function health structure uses the
specialised service in the same way as a generalist uses a laboratory to have his examinations
carried out. The centre of decision remains at the point where arrangements for the comprehensive
care of the patient are made.
Resistance by the providers of funds
If the management of resources is to become the responsibility of horizontal structures there is a real
risk of problems in the supply of those resources; for very frequently the resources supplied by
international fund providers are rigidly linked with budgetary items earmarked for financing precisely
specified elements in vertical programmes. Their management by multi-function health services, for
which this health problem is only one among many, makes it likely that some of those resources will
be used for other activities which have little connection with the particular problem for which the
resources were offered by these bodies.
The providers of funds are disinclined to support this kind of situation, not least because it could have
a negative effect on the raising of funds; for funds are increasingly being raised through the media,
for which it is necessary to have a single, simple - even simplistic - message, inevitably isolated from
its context.
Moreover these strategies designed to generate funds make it necessary to offer those who give
money tangible results in the short term which justify the use of the money given (in terms of health
care coverage, for example, or the number of human lives saved); and this is evidently not a realistic
objective, at least in the short term, for the integration of activities included in a vertical programme.
7
Resistance by the "horizontalists"
There may also be resistances within multi-function health services for social and cultural reasons.
Integration may be rejected by the staff of a multi-function health service because social disapproval
or the stigma attached to a particular health problem would lead the population to object to the
mixing of patients with that problem and other patients. This perception is, of course, dynamic and
will change with changing values in society.
Integration may also meet staff resistance because of the overload of work which it involves4.
Integration can thus have an upsetting effect on the operation of multi-function health services
(Unger, 1991).
Resistance by patients
The integration of arrangements for handling a health problem in multi-function services may also
have implications for patients in terms of the loss of privileges: for example the loss of free treatment
fortheir particular problem5, or the loss of other advantages (e.g. gifts of food6), etc. Evidently these
patients will take a poor view of this and will tend to oppose a process of integration which will make
them "normal" patients just like the others.
Patients may also oppose integration if they see the multi-function service as a second-best to a
specialised service.
There is a price to be paid for integration
There is a price to be paid for integration in terms of technical efficacy, resources (guides and
instructions, basic and continuous training, equipment and recurrent costs) and in terms of
organisational changes. The price to be paid is linked with the relative importance of the health
problem for which integration is to take place among all the various problems of which people are
conscious, about which they complain and which they bring to the multi-function health services
(Table 1). For example when an immunisation programme is integrated there may in consequence
be a fall in coverage.
4 A situation in which the frequency of a problem is (still) high, involving a substantial increase in work load for multi-function staff,
could be a deterrent factor in the introduction of a process of integration of activities for dealing with that problem.
5 In the Belgian Congo leprous patients sometimes objected to being offered the prospect of cure. A former leper then became an
individual like any other patient and lost such privileges as free health care, exemption from taxes, free accommodation, etc.
(personal communication from H. Van Balen).
6 This is the case, for example, in Uganda with AIDS patients.
8
Table 1: Differences between the approaches of managers of vertical programmes and managers of
horizontal services
One sacrifice which must be accepted is a fall in the technical quality of the services provided (at
least in the short term). By definition, a health worker in a multi-function health service (for example
a generalist doctor or a health centre nurse) will never have the technical competence of a specialist
in a particular field. And of course if this were not so the specialists would have no raison d’etre.
Integration is thus not always possible even if it is desirable. Techniques, instruments and tasks
which are integrated should be designed in such a way that they can be used by multi-function staff.
It is necessary, therefore, to prepare and circulate guides and standardised instructions suitable for
multi-function staff, who will frequently have only limited qualifications.
Perhaps the most immediately visible cost of integration, at least in the short term, is the cost of the
training programme for multi-function staff (Ross, 1982). The cost of an initial programme of specific
training can of course vary very considerably between one problem and another. There are also the
costs of the continuous training of multi-function staff (mainly the cost of supervision), particularly in
the short term; for these costs can be very considerable during the first phase of integration, which
makes more intensive supervision necessary.
Integration can also increase the recurrent costs of a multi-function health service (Bredo, 1991).
Again, these costs will vary considerably between one problem and another, and it is difficult to
quantify them. For example it might be necessary to buy specific drugs or additional equipment for
multi-function services. It may also happen that the costs associated with the general logistics of
multi-function health services increase because of integration, or that it becomes necessary to recruit
additional staff to cope with the increased work load.
Some of these costs may, however, be recovered if the specialised vertical structures are
discontinued.
9
Preconditions of integration
Basic health services must be functional
There is no point in integrating when multi-function health services are not operating properly. How
can you integrate in something that isn't there?
How will integration work when the overall performance (both technical and relational) of multi
function health services is poor? Clearly the success of integration in these circumstances is very
doubtful: a vertical structure may then be completely justified (Roos and Van Brakel, 1994).
However, if we are to be able to answer this question properly we must take account of the context:
• What resources are consumed by the vertical structure?
Have the costs involved not become too high? The resources - or some of the resources allocated to the vertical structure (which is concerned with only a single problem) could in
actual fact be used to increase the functional level of the multi-function health services
(which have to deal with a variety of problems) if it is really a lack of resources that is the
principal cause of their dysfunction.
In other words, the functional level of multi-function health services is a variable and not a
constant.
Integration may offer an opportunity to invest in the overall functioning of multi-function
health services7.
Integration may be a means of enhancing the prestige of the service and thereby increasing
the satisfaction and motivation of the staff of multi-function health services8. An interesting
hypothesis to test would be to see whether a marginal benefit of integration is to trigger off
the development of multi-function health services (even though this is not the principal
objective of integration). It could improve the ability of multi-function health services to
respond to the wide spectrum of problems presented by the population (Loretti, 1989).
Is there advantage in having a monovalent (single-function) vertical structure concerned with
a single problem in a context in which the functioning of multi-function health services is
poor? This can be justified only insofar as such a health problem is so common and so
7 For example resources for regular supervision may become available.
8 For example the decision to equip health centres with microscopes under the tuberculosis control programme. The microscope
can be used for purposes other than the diagnosis of tuberculosis. An improvement in the ability of multi-function health services to
respond to problems with additional technical capacity can increase the confidence and the credibility of these services.
10
serious that its control can be felt by the population as a real improvement in their wellbeing
(for example epidemics of very serious problems such as African trypanosomiasis: Kegels,
1992).
Integration should be decided on at an appropriate time
• Integration when the problem has become less common: too late
Frequently integration is decided on because the problem has become less common9. This is
what we have called a ’’negative motivation". In a situation in which the frequency of a health
problem is steadily falling the marginal cost of a specialised service becomes increasingly
high: a stage of decreasing return has been reached.
The managers of a vertical programme may then decide to integrate because the unduly
high marginal costs of the specialised service become unacceptable to them (and to the
providers of funds)10; but not (necessarily) because the staff of the multi-function health
services would really be offering a "plus", a significant improvement in the quality of care.
In reality a situation of low prevalence may be a reason for not integrating, since:
the specific work load of the multi-function health personnel could be so low that they would
not see enough patients with this specific problem to maintain their technical competence in
handling the problem. For example, how can (non-specialised) staff be expected to identify
correctly a new case of leprosy if leprosy has become a very rare problem in the community?
In the long term it is the credibility of the multi-function staff that is called in question, and
there is then a risk that the community may lose confidence in their abilities. In such a
context integration would have clearly negative repercussions and the managers of the
vertical programme would have no difficulty in demonstrating that integration was a failure.
a problem which has become rare may no longer be a need felt by the community11. As a
result it will be difficult to secure their participation in the process.
9 Most of the literature on integration refers to the problem of leprosy. It is notable that for most authors the main argument for
deciding to integrate is precisely an epidemiological one (i.e. a fall in prevalence).
10 Very high marginal costs could in fact be justified in a situation in which the health problem could be eradicated: that is to say, a
situation in which a permanent impact can be hoped for (as was the case with smallpox). They would be less justified in a context in
which the very high costs have to be carried indefinitely. For example it will never be possible to "eradicate" the demand and the need
for family planning services.
11 This will depend, of course, on the type of problem and on the sub-groups of the population mainly affected by the problem. For
example diabetes is a relatively rare health problem in many developing countries, but it affects older people, who are an influential
group.
n
*
the staff of multi-function health services will have little incentive to take a training course for
a rarely occurring problem12.
To integrate in a context of this kind may form a serious handicap for the staff of multi-function health
services at the very beginning of the process of integration. This may also be the case when it is
proposed to integrate the activities for dealing with a problem which has just emerged and is still
relatively rare: it may then be too early to decide on integration.
• Integration in a situation of emergency: is there any benefit?
An emergency situation calls for a rapid response. Multi-function health services do not seem
the most appropriate facilities for handling a situation of this kind.
The rapidity of response will be determined by the load of routine work falling on these health
formations and on the amount of work required to deal with the emergency. For example it
will not always be possible or acceptable to stop all their routine activities in order that they
may deal with the emergency. Moreover multi-function health services will often not have the
appropriate means to do this work properly. And finally it would be necessary to evaluate independently for each such situation - what additional benefit there is in using multi-function
staff (rather than specialised staff) to deal with a particular emergency situation13.
Integration involves a transfer of decision-making power to multi-function health services
Integration may involve the disappearance of specialised health care structures, but not the
elimination of the programme and/or the specialised staff, at the most centralised levels of the health
system. As noted above, the establishment and the existence of a vertical programme is a political
decision reflecting the fact that a given problem calls for particular attention (even if the problem is
not a need felt by the population14). A vertical programme, therefore, may not depend on specialised
vertical structures: whether or not specialised vertical structures should be used, and at what level of
the health system they should be operational, are questions the answers to which lie in the technical
field.
Integration involves administrative and operational changes at the level of multi-function health
services, since there is no point in integration unless the multi-function health services have been
12 World Health Organization. Report on a consultation on the operation of leprosy control in the context of primary health care.
MOS/CDS/lep/86.3.
13 For example, what would be the specific contribution and the benefit of having multi-function staff involved in dealing with
cholera? In the case of cholera there is an urgent need of people skilled in such essential techniques as rehydration and intravenous
perfusion. No other particular technical skill is required. A hospital auxiliary may very well be the most competent person.
14 For example a decision to establish a vertical family planning programme may be founded on macro-economic or demographic
motives.
12
given the means to deal adequately with the problem, taking account of the level of qualification and
work load of their staff. Integration will necessitate - in varying degrees - supplementary training,
appropriate instruction manuals, closer supervision, etc. This implies that the managers of the multi
function health services must have sufficient administrative authority and operational control: it is
very difficult to achieve successful operational integration unless there is concomitant administrative
integration.
A practical example which illustrates this point concerns supervision. Most of the work and studies on
integration stress the importance of supervision. One important question, however, remains (Smith
and Bryant, 1988): who should carry out the supervision? the specialist or the manager of basic
health services? what are their respective roles?
If there is operational but not administrative integration, there is a danger that a situation like that
shown in Figure 3 may arise, with various specialists visiting multi-function health formations to
supervise activities carried on at that level under a specific vertical programme. There might thus be
several specialised supervisors supervising different programmes, possibly leading to overlaps and
contradictions which become a source of confusion for the staff being supervised. The main concern
of specialised supervisors is to check that their particular programme is being properly carried out.
There is then a real risk that the multi-function structure may be seen as an appropriate instrument
for developing the activities of each programme in relation to their particular objectives and that the
multi-function health care unit will be used to serve the purposes of various specific programmes.
Figure 3: Supervision in the context of operational integration without administrative integration
Administrative integration means that the managers of multi-function health services are responsible
for supervision; they will monitor the quality of health care in general and not merely the quality of the
handling of a limited number of health problems (Mercenier and Prevot, 1983). A situation in which a
multi-function supervisor follows the various activities carried on in a health centre is not in
contradiction with the involvement of a more specialised supervisor at a particular time, provided that
the multi-function supervisor is a person who appreciates when and why it may be appropriate to
seek more specialised expertise and what particular expertise is needed (Figure 4). Not only is there
no contradiction in having a specialist associated with the arrangements for supervision: it would be
foolish not to use him when appropriate.
13
*
Figure 4: Supervision in the context of operational and administrative supervision
Integration calls for a remodelling of objectives
Integration entails a redefinition of the objectives of the programme. Instead of aiming at a relatively
short-term epidemiological impact, the objective should be to offer an appropriate response to the
suffering15 of patients. The integration of control activities in multi-function health services can clearly
form part of a policy whose objective is to have an epidemiological impact, for example in terms of
reducing the incidence of the problem; but this should not, and cannot, be the prime objective of
integration. Nor would it be right to impose an epidemiological impact as the objective to be achieved
by integration (Criel, 1992).
The corollary is that the absence of impact on the frequency of the problem after integration does not
(necessarily) mean that the policy of integration has failed.
The framework and the criteria for the evaluation of integration must therefore be adapted. The
results expected from a policy of integration must be clarified from the very outset and must be
clearly formulated. Multi-function health services cannot be expected to achieve results which it is
impossible for them to achieve; moreover it is fundamental that the specific characteristics of the
potential contribution to be made by multi-function health services to the control of a given health
problem should also be recognised and developed.
Conclusion
Integration cannot succeed without a dialogue between specialised staff and the staff of basic health
services.
A dialogue between specialised and multi-function personnel is necessary from the very beginning,
so as to promote the best possible mutual understanding between two different logics:
The logic of the system of multi-function health services is to respond in an appropriate
manner and in a dynamic perspective to the needs of the population16 without the imposition
of any specific target from outside17.
15 We consider this suffering expressed by patients as a demand.
16 Where the health problem in question has only relative priority.
17 Since the achievement of any such target may interfere with locally defined priorities or even be opposed to them.
14
The logic of the system of specialised services is to achieve quantified and relatively well
18
defined objectives in the control of a particular health problem .
A dialogue is also necessary to appreciate the specific characteristics of the other partner's potential
contribution. A rational discussion on the sharing of activities and tasks between specialised and
multi-function staff can then take place.
Even if the two logics differ it is undeniable that there are sufficient overlaps between the two
systems in terms of objectives: both of them desire to improve the care provided to patients.
Sufficient common ground exists to initiate the dialogue. The starting-point should be what is
common to the two systems and not what distinguishes them from one another. Both systems should
benefit from integration: if this were not so, integration would yield little result or would have negative
effects on multi-function health services, or both.
As has been shown above, it is important to organise a discussion between specialised and multi
function services on a technical basis and not on an ideological basis or on the basis of institutional
arguments. In that case there would be a real risk that each partner would cling to its own positions,
and the result would be a service of poor quality of which the patient would be the first victim.
Before contemplating the integration of the activities of a programme in the basic health services it is
essential that every health service manager should ask himself the following three questions: Is it
advantageous to integrate? Is this the right time to integrate? Is it possible to integrate?
18 Once the vertical programme has been established its sole function is to deal with a given problem. The idea of priority,
therefore, has no relevance.
15
References
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Leprosy Review 65:376-84.
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Courtright P, Lewallen S. 1992. "Considerations in the integration of eye care into leprosy care
services". Leprosy Review 63:73-7.
Criel B. 1992. "L'integration de la tuberculose dans les soins de sante primaires: ou en sommesnous? [Editorial]". Annales de la Socfete Beige de M6decine Tropicale 72:1-3.
De Brouwere V, Pangu KA. 1989. "[The flexibility of an integrated health service in the campaign
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Dechef G. 1994. AGCD, editor. Appui a l'integration des soins de sante mentale dans les structures
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Dharmshaktu NS. 1992. "A project model for attempting integration of leprosy services with general
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Feenstra P. 1993. "Leprosy control through general health services and/or combined programmes".
Leprosy Review 64:89-96.
Feenstra P, Tedla T. 1988. "A broader scope for leprosy control’’. World Health Forum 9:53-8.
Huntington D, Aplogan A. 1994. "The integration of family planning and childhood immunization
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"Homme-Sante-Tropiques" tenu £ Poitiers du 14 au 17 juin 1990 et des assises et ateliers "HommeSante-Tropiques", Poitiers, 15-16 avril 1992, 15-16 octobre 1992 et 1er octobre 1993. Brest 25 mai
1993. Ed. Jacquemin JL. Poitiers. Association "Homme-Santd-Tropiques". pp. 85-89.
Lehingue Y, Urtizberea JA. 1986. "[Tuberculosis control in Malawi. Time distribution of cessation of
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Exotique et Filiales 79:259-65.
Loretti A. 1989. "Leprosy control: the rationale of integration". Leprosy Review 60:306-16.
Mercenier P and PrSvot. 1983. WHO, editor. Guidelines for a research protocol on integration of a
tuberculosis programme and primary health care. Geneva. World Health Organization.
WHO/TB/83.142. p. 1.
Mills A. 1983. "Vertical versus horizontal health programmes in Africa: idealism, pragmatism,
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Roos BR, Van Brakel WH. 1994. "Integration of vertical projects into the basic health services: an
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Ross WF. 1982. "Leprosy and primary health care". Leprosy Re view 53:201-4.
16
Smith DL, Bryant JH. 1988. "Building the infrastructure for primary health care: an overview of
vertical and integrated approaches". Social Science and Medicine 26,9:909-17.
Tonglet R, Eeckhout E, Deverchin J, Bola N, Kivits M, Pattyn S. "[The evaluation of an anti-leprosy
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Tonglet R, Pattyn SR, Nsansi BN, Eeckhout E, Deverchin J. "The reduction of the leprosy endemicity
in northeastern Zaire 1975-1989". European Journal of Epidemiology 6:404-6.
Unger J-P. 1991. "Can intensive campaigns dynamize front line health services? The evaluation of
an immunization campaign in Thies, Senegal". Social Science and Medicine 32,3:249-59.
Walley JD, McDonald M. 1991. "Integration of mother and child health services in Ethiopia". Tropical
Doctor 21:32-5.
Warndorff DK, Wamdorff JA. 1990. "Leprosy control in Zimbabwe: from a vertical to a horizontal
programme". Leprosy Review 61:183-7.
17
Tables and Figures
Table 1: Differences between the approaches of managers of vertical programmes and managers of
horizontal services
Figure 1: Operational structure of health services
Figure 2: Integration of programmes versus integration of activities or tasks
Figure 3: Supervision in the context of operational integration without administrative integration
Figure 4: Supervision in the context of operational and administrative supervision
18
Table 1:
Differences between the approaches of managers of vertical programmes and
managers of horizontal services
Manager of a
vertical programme
Manager of
horizontal services
an approach by health problem: a vertical logic
an approach by service: a horizontal approach
an epidemiological objective
a social objective
methodology: a rational approach, top-down
methodology: a response to needs felt by the
population
the problem has a character of absolute priority
the problem has a character of relative priority
evaluation centres on a reduction in frequency evaluation centres on a reduction in human and
social suffering created by health problems in
of the given health problem
general
tendency towards maximalisation
tendency towards optimalisation
19
Figure 1: Operational structure of health services
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Figure 2: Integration of programmes versus integration of activities or tasks
VERTICAL PROGRAMME
activity 1
activity 2
activity 3
activity 4
activity 3
task 1
activity 3
task 2
activity 3
task 3
activity 5
A programme is made up of a a group of activities; an activity consists of a series of tasks.
In the above diagram activities and tasks in bold type are integrated; the others are not.
Activity 3 may be taken as an example. In the vertical programme of tuberculosis control one of the
activities is the passive detection and treatment of cases. It may be decided to integrate the detection
of suspects in multi-function health services (task 1), and also the treatment and follow-up of patients
diagnosed as tuberculous (task 3), but not the diagnosis (task 2). One of the reasons for not
integrating this task might be that there are not sufficient resources: for example no resources for the
purchase of a microscope in the multi-function health services. The diagnosis could then be made by
a specialised service, and the patient could return to the health centre for treatment and follow-up.
Certain activities in a programme should not be integrated unless there are solid reasons for doing
so: for example quality control, epidemiological surveillance, fundamental research, etc. These
activities also require the involvement of specialised personnel.
21
4
Figure 3: Supervision in the context of operational integration without administrative
integration
Specialised
supervisor 2
Specialised
supervisor 1
Specialised
supervisor 3
activity B
q
O
O activity C
activity A
O
Specialised
supervisor
O
o
O
o activity D
o
Multi-function health structure
Figure 4: Supervision in the context of operational and administrative supervision
Multi-function supervisor + specialised
supervisor
activity D
activity B
O
O
O activity C
activity A
O
O
activity D
O
O
O
Multi-function health structure
© Oxford University Press 1997
HEALTH POLICY AND PLANNING; 12(3): 193-198
(S O (V\ H
.
Viewpoint: Public versus private health care delivery:
beyond the slogans
DANIELE GIUSTI,1 BART CRIEL2 AND XAVIER DE BETHUNE2
'Comboni Fathers, Matany Hospital, Moroto District, Uganda, and department of Public Health,
Institute of Tropical Medicine, Antwerp, Belgium
In most settings, a 'public' health service refers to a service which belongs to the state. The term
'private' is used when health care is delivered by individuals and/or institutions not administered by
the state. In this paper it is argued that such a distinction, which is based on the institutional or adinistrative identity of the health care provider, is not adequate because it takes for granted that the
..ature of this identity automatically determines the nature of the service delivered to the population.
A different frame of classification between public and private health services is proposed: one which
is based on the purpose the health service pursues and on the outputs it yields. A set of five opera
tional criteria to distinguish between health services guided by a public or private purpose is presented.
This alternative classification is discussed in relation to a variety of existing situations in sub-Saharan
Africa (Mali, Uganda, Zimbabwe). It is hoped that it can be used as a tool in the hands of the health
planner in order to bring more rationality in the current altercation between the public and the private
health care sector.
Introduction
There is a growing interest in increasing and improv
ing co-operation between the public and private sec
tors in the field of health care delivery, particularly
in the developing world. A range of different explana
tions for this boost in interest can readily be iden
tified. For a start, the already scarce resources for
health care are dwindling yet further and linkages
with the private sector may raise additional resources.
There also is the gradual acknowledgement of the
need to develop a systemic approach to health care
d
ry. The private sector is an important actor in
thio system, and can, under certain circumstances,
substantially contribute to a consistent development
of health systems.
health managers towards matters outside their con
trol. The private health sector has often grown in
dependently from the public health sector and is rarely
taken into account in health planning scenarios.
This has been the case in Uganda where the non
governmental sector, which generally has been in the
forefront of the development of primary health care
initiatives and which accounts for about 65 % of the
current primary health care delivery in the country,
is rarely taken into account by the District Health
Teams in their planning exercises. On the other hand,
there is often in the private sector an excessive
jealousy for its own independence, with a disregard
of policy guidelines, aversion to evaluation, and
hostility towards regulative measures.
Our field experience in sub-Saharan Africa con
fronted us with the rigidity, and even the strong
emotions, that often tend to colour this debate on
co-operation between the public and private sectors.
The relative lack of rationality and objectivity in these
discussions has contributed to a state of affairs where
the concerned interlocutors clutch at their respective
positions. It is common, and even natural, to notice
a certain diffidence among civil servants and public
It is increasingly evident that co-operation between
the public and private sectors is a must in a systemic
view of health service provision and in order to avoid
expensive and useless duplications. In this perspec
tive, it becomes important to move towards an ever
progressive integration into the health system of all
elements accepting a ‘public’ rationale of operation.
But the definition of ‘public’ is, at present, somewhat
hazy and needs focusing. The purpose of this paper
194
Daniele Giusti et al.
is to contribute to a proper definition and understand
ing of the terminology. We acknowledge the limit
ation of this paper to the specific context of
sub-Saharan Africa. We intended it to be this way,
since we believe the misconception to be stronger in
that part of the world than elsewhere.
The confusion: what is the meaning of
public and private?
In our view, one of the major stumbling-blocks in
the process of understanding is the lack of consistent
use and interpretation of the terminology public and
private, be it conscious or not. We think attempts
merely to answer the questions ‘what is a public
health service?' or ‘what is a private health service?'
would reveal the heterogeneity of views on the mat
ter. The purpose of this paper is precisely to present
some thoughts on how these very words ‘public’ and
‘private’ are used and to attempt to clarify’ what con
tent they should refer to. We think that the develop
ment of a more coherent vocabulary’ is a necessary’
step in the broader process of co-operation between
public and private sectors in the field of health care,
or in any other social field for that matter.
In the majority of situations, the definition - both im
plicit and explicit - of a public health sendee refers
to health care institutions belonging to the state. In
sub-Saharan Africa, health care delivery is often sup
plied by private individuals and/or institutions whose
ownership and/or administrative guardianship is not
the state. In that case, the term private is used. It is
generally understood that the public health sector
should be supported by public money and protected
by a series of privileges regulated by law, while the
private health sector should operate on private fund
ing, obtained through fees, donations or other means
in the arena of a market oriented provision of service
and of competition. This understanding is based on
the assumption that the private sector is homogeneous
and financially self-sustaining whereas, in reality,
a remarkable heterogeneity exists in the private/
non-govemment sector (DeJong 1991; Green 1992;
Zwarenstein and Price 1990; Smith 1989).
Generally, when the sendee is rendered without
lucrative purposes the specification ‘not-for-profit’
is added. The term ‘non-governmental’ is used to in
dicate organizations offering sendees without profit
making purposes, and whose ownership and/or
admimstrative guardianship is not the state. We think
that a distinction between public and private based
on the institutional or administrative identity is not
always adequate in dealing properly with the variety
of existing situations.
The limits of this classification can be exemplified by
the mushrooming number of non-governmental organ
izations operating for outright or hidden lucrative pur
poses. At the same time, there are public sendees
which operate, to varying extent, on a lucrative basis,
even if the intensity and the sometimes radical
character of this shift in rationale within public
facilities has not necessarily been the result of the
planned choice of policy-makers. Examples of such
shifts are the situations of some government hospitals
in Zimbabwe and Uganda. In both countries, m
1
officers are allowed to develop private practice in
tandem with their responsibilities and tasks in the
hospitals. In the case of Zimbabwe, this measure is
part of a broader effort aiming to attract national
medical officers into the public sector in a context of
massive brain-drain to neighbouring countries or to
the private sector. In the case of Uganda, it grew out
of a legitimate concern to increase the revenue of
national doctors beyond the extremely low level of
government salaries. In both countries, government
officers are allowed to use the hospital infrastructure
and hospital resources for treatment of private patients
who pay them a fee. but without recompense to the
hospital.
The gloomy prospect is one of governments ending
up subsidizing - with tax-payer money - a private
lucrative sector where basic measures of quality con
trol are lacking and with a poor accessibility for lower
income population groups. A “two speed' health care
system becomes a real threat - the same government
would instead deny subsidies to private institutions
striving, but finding it increasingly difficult, to
T
financially accessible services, often at lower
s
than those observed in public institutions.
The core of the matter really is that the adjectives
private and public refer to the institutional or ad
ministrative identity of a given health service, taking
for granted that the nature of this administrative iden
tity' automatically determines the nature of the service
that is actually offered to people. In a time of reform
of many health systems, with decentralization as a key
element, this assumption can no longer be justified.
If a distinction between public and private needs to
be made, we think it cannot be based exclusively on
the institutional set-up of a given service, but rather
on the objectives and the output of that sendee.
Public vs. private health care delivery
Maintaining a distinction between public and private
on the grounds of the administrative identity will only
perpetuate confusion, prejudices and discrimination
(positive or negative but. in either case, inadequate
to the changing context). In Uganda for instance, the
non-govemment sector (mainly Church-related notfor-profit organizations) has been able to achieve ac
ceptable levels of health care delivery in some very
remote and insecure areas of the country and in en
vironments characterized by important social and
political unrest with a de facto absence of the state.
Nevertheless, the posting of national doctors to these
institutions has become very difficult because of uncer
tain career and training perspectives for those who
d- “e to work in them; nurses trained in NGO
is, which are formally recognized by the national
Nursing Council and the final examinations of which
are supervised by government officials, can make their
way to the government service only with great
difficulty; no or very little government subsidies are
being allocated to NGO facilities which are considered
by District Health Teams as falling outside their scope
of responsibility, even when their importance for the
system is openly recognized. The (private) status of
these NGO not-for-profit hospitals, and the consequent
refusal of support for them from government sources,
clearly has hindered long-term development efforts,
both for the NGO and for the state.
Such a distinction will hinder the dialogue between
the different components of the health system at a time
when each one’s contribution and co-operation is
necessary. Indeed, in the light of decentralization
policies implemented in many developing countries,
the institutional set-up of many decentralized ‘public’
health services is far less clear-cut. In the past all public
health services, with few exceptions, belonged to and
were financed by the state, represented by the Ministry
o
ilth. Today, there is a trend towards decentralizt« ownership and management by local communi
ties, co-operatives, administrative districts etc.
Such a trend can be exemplified by the case of the
network of community health centres (‘centres de sante
communautaires’) gradually put in place in Bamako
(Mali) from 1989 on. Former rural community-based
experiences in the public sector served as an inspira
tional basis for young medical doctors who could not
be hired by the government and who remained,
jobless, in the capital of the country. With some initial
external help, three or four health centres were
organized so as to offer basic curative, preventive and
promotional services. The owners of the facilities were
195
members of community associations created for the
purpose and the aim of these health centres was to pro
vide health care to the subscribing members through
a system of cost-recovery. Later, a ‘second’ genera
tion of centres was put in place with virtually no ex
ternal help other than small in-kind loans by existing
centres. These new centres built up their revolving
drug fund through the initial voluntary work of their
employees. Several of them acquired grants from
different donors, but only at a later stage.
The government played a promotional and regulatory
role by considering these centres as active partners in
its health development efforts. The existing centres
constituted the starting point for geographical health
coverage maps drawn up by the urban district teams.
They also received small subsidies in kind from the
government, especially for immunizations and family
planning services. Their revenue was tax exempted
and they were granted a special license to sell generic
essential drugs. This suppon was provided in the
understanding that the health centres themselves would
not generate profits.
The debate on the status of these institutions is still
ongoing. Legal texts have defined both the govern
ment’s and the health centres’ responsibilities, but the
way the centres were put in place and the pressure
from unemployed health workers in Bamako indicate
that some of the attention has been diverted from ±e
equitable provision of health care to the raising of
revenue, mainly to hire additional staff.
An alternative classification?
What really matters to the health planner and to the
public, are the contents, the quality and the costs of
the package of services offered. For planning and
evaluation purposes, and for the allocation of the
meagre resources available, it is important that a clear
and explicit declaration of intent, or mission statement,
of the health care institution exists, so that the output
and accessibility of these services can be evaluated.
In an era of rapid change, it is also necessary to
evaluate over time how, and to what extent, the per
formance of each health care institution fits the mis
sion statement. Hence, we propose a different frame
for the classification of health services based on their
declared objectives and on their outputs. From
thereon, a dichotomous classification in health services
with respectively a public or private purpose can
be proposed. More specifically, we propose a set of
Daniele Giusti et al.
196
administrative guardianship and/or
institutional identity of the
health service
purpose the
health service
pursues
Figure 1.
public
private
public
a
b
private
c
d
I
Classification of health sendees according to their purpose and their administrative status
criteria for the classification of a health institution in
the category of ‘public’:
• A social perspective: a concern to enhance people’s
well-being and autonomy in a perspective of human
promotion. In the case of health sendees this more
specifically means contributing to people’s realiza
tion of a socially productive life, in a climate of
dialogue between all implicated parmers and in har
mony with the prevailing overall socioeconomic
development.
• Non-discrimination: a concern to offer people
accessible and quality health care without
discrimination whatsoever with regard to race, sex.
religion, political affiliation, social status, income
level etc. This is not in contradiction with a positive
discrimination of specified population groups,
deemed to be in particular need of health care (e.g.
women, children, disabled people etc), or with a
focus on specific health problems in the frame of
vertically organized health programmes (e.g.
trypanosomiasias control programme, family plan
ning services etc).
• Population-based: a concern to take responsibility
for, and to be accountable to, a well-defined
population for its health care delivery. This
accountability could be based on a contract with
the population, specifying the mission statement of
the service or institution.
• Government policy guided: a concern to comply
with government health policies for the level of care
provided and to fit in a broader masterplan. Should
any different views arise with regard to official
policy, then it is necessary that they be argued,
discussed and, when possible, formalized in official
agreements between the health institution and the
national health authorities.
• Non-lucrative goals: a concern not to reduce the
purpose of the sendee to profit making. This does
not, of course, mean that good working and living
conditions would not be a right for staff, nor that
the sendee must be run at a loss. On the contrary,
it is desirable that any service be self-sustained (this
is not always possible; it is even virtually impossi
ble in the case of district hospitals) and that its staff
can work in acceptable conditions. In any event,
in order to preserve the public purpose of the ser
vice, profits made should be reinvested in the same
service or in other activities of social interest in
agreement with the concerned population.
These criteria, which are currently being tested .
*
context of district health care delivery in Uganda, do
not exhaust the variety of possible criteria identifiable
in other contexts. Nonetheless, they provide an
instrumental framework which could be used to assess
the purpose of health services rather than the
administrative/institutional set-up only. Both perspec
tives can be represented in a simple two by two table
(Figure 1).
The four cells of this table can be exemplified as
follows: a corresponds to National Health Service
(NHS) hospitals in the United Kingdom (although the
current reforms of the NHS represent a gradual shift
from a to b); b corresponds to most church-related
<
Public vs. private health care delivery
hospitals in Uganda: a shift from a to c is taking place
in many government hospitals in Uganda and in some
government hospitals in Zimbabwe; and d corresponds
to the situation of many hospitals in the USA. The
relative strengths of the actors involved in the environ
ment of the health centre of Bamako will determine
whether these centres end up in categories b or d, or
remain somewhere in between.
■*
It is clear that the variable ‘purpose’ does not com
pletely fit the nature of a dichotomous variable: indeed
it covers a range of intermediate situations in the wide
spectrum from public to private. The same comment
holds for the administrative guardianship as well.
I
e 1 is thus an oversimplification of reality. We
nevertheless think that it is useful to illustrate our point.
If governments agree and accept the rationale of this
classification according to the very purpose of the ser
vice, then it would allow them to achieve more
accuracy in targeting their support to health care in
stitutions and organizations - both government and
non-govemment - who serve a public purpose. The
case of designated district hospitals in Tanzania or
Ghana illustrates that it is possible to define consis
tent policies. In the case of Uganda, it appears that
many (but by no means all) of the non-governmental
and church-related organizations would sufficiently fit
the criteria defining a ‘public’ service. This classifica
tion could also be helpful to distinguish organizations
in the present mushrooming of private practices
throughout the developing world: it may help to
separate the com from the wheat. A consistent policy
would then be to support those organizations and in
dividuals that pursue a public mission, and not only
those that fit a given administrative status.
(
elusion
We have argued that a distinction between private and
public based on the institutional set-up of a given ser
vice is not always adequate in defining the very nature
of the service offered, the latter being of paramount
importance to the health planner at any level of the
health system. For example, many private hospitals
and health centres in developing countries operate
according to a rationale which could be defined as
public; at the same time, lucrative goals are being
introduced into public health services which,
eventually, endanger their adequacy, relevancy and
accessibility. An operational definition of what could
be considered to be a public health service is still lack
ing. This is not without consequence at a time when.
197
on the one hand, most governments are (or have
become) unable to respond in a satisfactory way to
the health needs of people, and where, on the other
hand, the contribution of the private sector is called
upon more and more.
This paper attempts to identify some operational
criteria which would enable services to be distin
guished according to their public or private rationale.
These criteria do not necessarily fit each situation, but
they can open up debate among health planners aiming
to bring more rationality into the current altercation
between public and private. They may also bring the
various actors beyond the slogans and to a constructive
dialogue.
What could this classification be used for? In opera
tional settings public administrations could use these
criteria to identify elements in the health system which
need to fit the rationale of public-oriented health ser
vice provision. It should not be impossible to develop
from these criteria some simple indicators, both quan
titative and qualitative. In Uganda, for example, the
criteria ‘population based' and ‘non-lucrative goals’
are progressively being used to identify those elements
of the health system eligible for integration and,
sometimes, for partial financial support. But there is
definitely a need for further research: the set of criteria
need to be tested in a variety of different situations
and precise indicators need to be designed so as to
render the whole process less of a theoretical exercise.
References
Dejong J. 1991. Non Governmental Organisations and Health
Delivery in Sub-Saharan Africa. Working Paper. Population and
Human Resources Department. The World Bank.
Green A. 1992. Planning for Health. In: An Introduction to Health
Planning in Developing Countries. Oxford Medical Publications:
p. 77.
Smith K. 1989. Non Governmental Organisations in the health field:
collaboration, integration and contrasting aims. Social Science and
Medicine 29(3): 395-W2.
Zwarenstein M, Price MR. 1990. The 1983 distribution of hospitals
and hospital beds in the Republic of South Africa. South African
Medical Journal 77: 448-52.
Biographies
Daniele Giusti. MD, DTM&H, MPH. has worked in Uganda from
1978 to 1982 as a Medical Officer and later as Superintendent of
Kitgum Government Hospital. From 1983 to 1986 he specialized
in infectious diseases at the University of Milan. In 1987, he was
198
Daniele Giusti et al.
appointed Medical Superintendent of Matany Hospital, a private notfor-profit hospital in rural Uganda. In 1993 he was apppointed Ad
ministrator of the same hospital. He currently maintains this post
and is also involved in the establishment of policy guide
lines for the integration of different health care providers at district
level.
Bart Criel, MD. DTM&H, MPH, has worked for 7 years in Zaire
in the Kasongo and Bwamanda health districts as a Medical Officer
and District Medical Officer. He is currently a staff member of the
Department of Public Health (DPH) of the Institute of Tropical
Medicine in Antwerp, Belgium. His research field is
mainly the organization of district health services in sub-Saharan
Africa with a special focus on health financing issues.
Xavier de Bethune, MD. DTM&H. MPH. has overseas experience
in Primary Health Care projects in Zaire, Guinea-Conakry and Mali.
For almost four years he was PHC-Adviser to the regional Medical
Officer of the city of Bamako. He presently does research and training
in the Department of Public Health (DPH) of the Institute of Tropical
Medicine in Antwerp. Belgium, mainly on the development of PHD
systems in urban settings.
Correspondence: Dr B Criel. DPH, Institute of Tropical Medicine,
Nationalestraat 155, 2000 Antwerpen. Belgium.
_______—
Com H <
0277-9536/92 S5.00 + 0.00
Copyright (© 1992 Pergamon Press Ltd
Bcri Med. Vol. 35. No. 4. pp. 409-117 1992
in Great Britain. All rights reserved
I1?
■
$
;-«l
i
SECTION E
I
CULTURAL INFLUENCES IN COMMUNITY
PARTICIPATION IN HEALTH
■
Linda Stone
Department of Anthropology. Washington State University, Pullman, WA 99164-4910. U.S.A.
■
•18
_
“
the
to ‘community participation. A loo a
P
> factors jn health care systems than on cultural
programs has come to be seen as relying moiincreasing emphasis on political factors or power
factors within lo^‘c0”m™“n hea th agencies, governments, and various levels of national health care
Systems5^hese"ti^^w questions'for community health programs and the strategy of
community participation.
Key words
immunity participation. Primary Health Care, culture
thinking about the relationship between culture and
Bnning in the 1970’s, the widespread adoption of
health development. In accounting for successes or
feary Health Care (PHC) policies among develop- failures in community health programs, these trends
KBnations spurred a new interest in the role of
include (1) greater emphasis on structural factors in
"'ultural factors in health development. PHC was, health programs than on community cultural vari
■ ’A
iter all, designed as a way to deliver at least minimal
ables, and (2) increasing emphasis on political factors
Bth care to poorer, more remote rural segments of
lEation to people whose lifestyles and modes or power relationships.
This paper outlines what I see as the major phases
^thought were considerably different from those of
in the definition of the role of culture in health
'
.J- JBtem outsiders or educated, urban elites working
—
development, with particular attention to 'commu
■FY OftMal health planning and administration. In nity participation'. This is followed by a discussion of
U. : . these rural areas. PHC sought not merely to intro- some new questions and challenges for community
duce a new health technology but to bring about health development raised by recent perspectives on.
/
wX; substantial changes in the health behavior of local
the role of culture.
;
people. Even more significantly, PHC was to adopt
y
the strategy of ‘community participation whereby
^Communities identify their own health needs and
CULTURE AND HEALTH DEVELOPMENT:
CHANGING PERSPECTIVES
'^assume responsibility for their own health develop| Stent. For the effective introduction of PHC. knowl
An early period, from roughly the 1940’s to the
edge of and sensitivity to the cultures of these
early 1950’s, was an optimistic era in which develop
OMcipient’ communities came to be seen as essential.
ment, including health development, was defined as a
Kghn the 20 years since these ideas were being formu” / overcome with the introduction
there have been innumerable efforts to discover set of problems easily
of Western knowledge and technology. Local culture,
a how and in what ways cultural factors influence the
if considered at all, was considered irrelevant to
; creation of and participation in community health the development process. Peoples m Third World
v^t’fdgrams in developing countries. Although much
countries would naturally accept and adopt‘superior
\ : interesting and potentially useful knowledge on this
knowledge and technology. This is what Foster [1
( f
Jhpic has accumulated, even more striking is that over referred to as the ‘silver platter model’ of technical
f
decades, the professional definition of the assistance, which as he pointed out, was not only
A'lc of culture in community health development has
ethnocentric but failed in fact to work. Yet, as naive
, & ?■■■' .k^^U’Sed and continues to do in ways that tell us as
and ethnocentric as this approach may have been, it
■
, .S'about the ‘culture’ of health ‘developers’, and
did hold to an image of Third World rural persons as,
.. -Wthis culture influences health programs, as about like ‘us’, rational. Like us, they would naturally opt
••'■’’’b&^ajtures of the Third World communities that
for better health care and so would accept what we
■
advocates seek to transform. This impression is
knew to be the means toward this end.
|(the outcome of certain recent trends in the
%
409
Maa
z'-/
rr.'
•'4
•11
■'T - ■
i
410
If
liil
I■
ml-i
■W;
Linda Stone
^ger being tak«
Recognition of the failure of this approach, and within which the oia ana new oi neann care'shot^f'
be integrated. In this perspective, ‘culture’, far./fi-^■ Embersincreasing knowledge of the complexities of inter
Oftegarding
being seen as an obstacle, was viewed more
national development, eventually led to a whole new tically and more positively as a potential resource^^ ^Rcially to the
era of development thinking, marked by new phrases
that tradi
health development. Perhaps the clearest expre?.^^I
such as ‘basic needs’, ‘new directions’, ‘felt needs’ and
B-^tild
discoura
'
reaching the ‘poorest of the poor’. This period ap of this view came in the many programs around
more
and
pears to have reached its peak in the late 1970 s. It world which attempted to recruit local mid-wives
------—
people c
other
types
of
indigenous
healers
into
PHCyp^
'
was considerably favored by new policies of particu
also
1— automatically ^eu’fv:;®|orld aS in lhe
lar donor countries and international agencies, such grams. This attempt was articipation.
''I md medical op
promoting community participation.----------------'
as the New Directions Legislation in the United
In some cases the tension between these two poifA "
his staten
States Foreign Assistance Act, and the World Bank’s
of view was felt
pi > 1:
increaf
felt within
within health
health programs.
programs. Corcil
Corcfl-fM
new ‘Poverty Oriented’ programs. The PHC move
reported
a
Haitian
program
where
traditionalmore
iment itself was officially endorsed by the World
were already dispensing modern Oral Rehydrat^n
;J J scientific me
Rehydi
Health Organization (WHO) in this period [2]. The
Therapy. The healers sought active cooperatipn’with ■W&ditional and
whole thrust of this new movement appears to have
the _..uuo
public koaith
health nffiriak
officials, but
but the
the latter.
latter, who saw <
been increasing concern with all aspects of the lives
traditional healers as themselves a problem and £ • ' | Where mo<
of the truly poor and needy people of developing
source of national embarrassment, did not|want
t Affordable an<
countries who were to be the beneficiaries of develop
lave shown
to cooperate with or legitimize the work of loyal
ment efforts. Their voice was to be heard and their
Eternal poin
healers.
.
4
health programs were to be ‘culturally appropriate
While these two views’of the role of cultWjgg^B Modern and
[2, p. 23). Moreover, community participation, an
Jteople find
health development were being expressed during tius :
idea that had been around much earlier, now loomed
^■ Adjustments;
period, a considerable amount of research in lociL;
as an essential development strategy. In order for this
communities of developing countries was taking' Mfepsnrt to b
to be realized, or stimulated by outsiders, knowledge
Belsch’s stu
place. The results of this research have
of local social structure and leadership patterns was stimulated new thinking about the role and powex^?
^tions in 1
■iabiowed how
mandatory.
.
culture in both health programs and commu»ft|^
With regard to health development and PHL in
.iestem me<
participation. Before outlining these recent perspec-^ g
particular, there were in fact two somewhat different
feingle
ind
as the major
views of the role of culture during this period. One tives, I will discuss what I see
AH of thi
of research on
culture
and
community
on c------- —
view, held primarily by planners and health project
lonsfcp ■‘■^KOtetors, in
developing countries. They involve the relatra
personnel, saw culture as a set of ‘beliefs’ and cus
traditional and modern medicine, the'issw rf tong
8
toms' which were potential ‘obstacles’ to the intro between t------—i _i. ---------------- | Traditional
of the cultural relevancy of PHC to local com
duction of new health measures and ideas [1]. A
die obstacl
ties, community participation, and the
•MeO' success or
second view, sponsored primarily but not exclusively
•>
by social scientists, saw ‘culture’ in the realm of assessing program success.
■ regarded a
The relationship between traditional and
health as ‘local knowledge’ (indigenous medicine) on
MWlanners aF
the one hand, and local ‘strategies’ for securing health medicine
^■Hictors [1].
care on the other. Both groups, however, tended to
With regard to traditional medicine,
regard local culture as fairly static.
1 an ‘integrationist’ perspective, suppo^ffl g|^&idely ki
These two views carried different implications for adopted
jScroaftronien’s
the inclusion of traditional medical practitione^^^^
^^^^msistant
health interventions and for the notion of community
the use of local remedies in PHC. Some repo
Mn worn
participation. The first, ‘culture-as-obstacle’ view use of traditional practitioners in new healtti^m|
stressed that a particular culture needed
under grams, especially the use of local
"c'o”uM to
be be
'designed
| mid heal
snee in T
stood so that a health program (------ -- been very positive. However Velimiro
I
able for v
in such a way that local people would be more
highly critical of integration, claims that a
likely to accept it. The inherent truth and superiority integration of traditional and modern medicuw^^^ iWere not
Wives ve
of modern medicine and modern health education
not taken place anywhere in the world, an
were central to this view; the problem was to get
WHO has retreated from encouraging iThe culti
the medicine and the messages ‘out there' and ac report. although concurring that a rea u*
cepted. The local Third World peasant was no
Altho
has not occurred, claims that mternat.ona
longer seen as rational and eager for change but as
f^ous
be!
agencies show a "cautious but mcrea_
|jJS obstr
‘ignorant' and ‘tradition-bound’. Local beliefs were
accorded to traditional healers" [7, p.
Jseen as largely ‘wrong’ by the yardstick of scientific
kK far mi
Some anthropologists have been skep •<«
medicine and public health. Some way would have to
ation
use in PHC of traditional practiuoncrs I J- or
be found to discourage these ‘wrong’ beliefs and
- ->IC la
less so for use of traditional birth atten
practices, but to do so, one should at least know _ _ _____
t.-ontmonte nf mental illUCSS [
E^.Pn
_________________________ ________
.g-’
Bl
■
I
I
about them.
The second view of culture which focused on local
knowledge and health care strategies saw ‘culture’ as
a much broader ideological and behavioral context
while, Foster [9, 10], claimed that me uc—
use of traditional curers may never n
resolved since truly ‘traditional’ medical p
>v
ac
-WWW■
1
411
Cultural influences in coiimmunity participation in health
system of referrals linking health workers, clinics and
JL being taken up by new generations in sufficient hospitals. But in practice, what most poor people of
developing countries actually encounter m PHC
. , ■r/ne indigenous medicine, another concern, health education and preventive services.
^Mlv to the ‘culture-as-obstacle’ viewpoint, has
Nearly every observer has recognized that rural
Kat traditional medical beliefs and practices
people of developing countries, like people every
where, are overridingly interested in good quality
-1
curative services and are not very interested> in receiving health education or preventive medica advice
17 8 10 141. It is further not just potential clients
Rtedical options [11]. Foster summed U up
who are focused on curative services but community
opuvno i
health workers and others delivering PHC, since they
• i 1977:
his statement in
convinced that economic and social realize that their own credibility, status and prestige
\ • gain i•nrreasinglv
mcreasmgiy
determining the use or nonuse rest directly on their ability to dispense medicines and
—
« are more important
medicine than is the belief-conflict between offer cures. At the same time PHC is founded on th
^jcientinc i*—
medicine [9. p. 529],
idea that modern health education messages (cove W g^onal and modern
accessible, ing environmental sanitation, oral rehydration, nutnBiere modern curative services
used.are
Many studies tlon. family planning etc.) would, if followed be f
j-ordable and effective, they areas
are u where, from an more effective m ra.smg health standards than would
r
shown that even in areas
theory and principles of CUrative services. In addition, tie w 0 e
■temal point of view, the 1
"
'
1 ment in part grew out of the concern that extension
medicine
do conflict, local
“fem and indigenous
of "making” their own cognitive of good quality curative services equitab y t roug W Bumente and/heir own ways of ‘integrating
■ ’ their' out an entire nation would be far too expensive for
o
s.
'■
31$
' •
o<i'
< ■
■■
ii
this
developing country governments.
xal
But this raises a serious contradic 1
' d
.ing jg fe/inXu/ “ew^uinea [12], for example^
is supposed to foster community parbcipa ion and
Bied how the Ningerum people have mterPr^ wherever possible assist local communities to defne
their own health needs and initiate ways of meeting
“ stem medicine in a way that brings it in line with the/ At the same time PHC has already set i s own
parameters around both the needs ot the people^and
*^®^Wfcs in medicine or other areas of life, are no the range of possible means of meeting them. Thus
the essence of PHC can contradict the whole spirit of
stop ,
Ifc’regarded as important to health program. a genuine, grassroots community particpation [7,8].
issue
Bditional medical ‘beliefs’ may no longer be seen as
Health planners may assume that even if local
lunF;
** ,obstacles
once were;
^-the
theyat the same time, the
■ i are more interested in curative services
n of ■
Access or failure of health interventions is joday communities
they will still be responsive to health education. Yet
and modern options,
Kdrt to both traditional t and modern medical
:r&r. £
Z 3&es
•U
'I
n
y
T Fa7 ., - ' -
_____ _
Prxilll T“ A
fcsssrsssa
factors [1]. To cite one example among many. Justice
HFhas shown how disregard of fairly simple and
3H
B. . .
j cultural expectations concerning
jrtiflg 7:^.
idely known
roles resulted in the failure of Nepal’s
sand " .‘i'
Omen’s i-—
- —. In this case, urst ant Nurse-Midwife Program,
Dfthc
deliver
maternal and
ban women were trained to
al communities. Yet
have
-•:■ ■ ‘child health services in remote rur;
id culturally unacceptzhois
since in Nepal it is socially an<
nuiric
/ ' able for women to travel and live alone these women
ie has .
/.were not well received in rural areas and
at were them-
-iM
■pr^nty’, but that local people may see it as frankly
Relevant to their health needs and concerns. In one
case in Nepal, village people expressed disappoint
ment and even anger when they saw that their new
village health workers would only be giving them
health advice [8].
.
This problem is further compounded by the man
ner in which educational activities are implemented.
/ /any programs the new health messages are
delivered as flat statements whose medical truth is
somehow beyond question, with no attempt to inte
teven ^/// selves very unhappy with their assignments.
grate the content of the messages with indigenous
raS
V'
cultural relevancy of PHC in local communities knowledge or concepts [8. 15]. Nicher [16] and othe
have argued for a more creative use of appropriate
hcaWi < IX^Sjthough cultural factors, and particularly indigeanalogy’ or using cultural metaphors and analogies
value .
• nous beliefs about illness and curing, need not be seen to effect a closer ‘fit’ between local health concep s
^Obstructing the introduction of modern medicines, and modern health messages. Though not wide y
of
.*« ■ tl
ofth«
■' if. a far more serious issue arises when we consider the used as yet, this approach has met with positive
hough
' -feonship between local cultural context and what results in health education efforts [17 81 .
or fjf
largely has to offer, namely health education
The problem of relevancy is well >llu"
Mean:,.
. and preventive services. Theoretically, PHC was
Nabarro and Chinnock’s [19] discussion of the PHC
ver the
/
some curative services—very simple ones at nromotion of growth monitoring of children.
to ht
lowest levels, using community health workers,
Although outsiders recognize this as a low-cost and
:e is na
X ;
access lQ more SOphisticated services through a
HI
OB
sp
wo
©
9
flw
__’ ____ ‘ WS
412
||lw
nl
Me
fee/
gli
II
II
II'
II'
Linda Stone
‘appropriate technology’ for monitoring the health
status of children, parents in rural communities are
quick to realize its limitations: “Growth monitoring
is not useful if those who identify growth faltering
cannot do anything about it’’ [19, p. 945]. This study
also points out that growth monitoring has been
intensely promoted even though little is actually
known about the impact of different interventions on
children who have lost weight. The study further
concludes that the promotion of growth monitoring
has not
hzc
net encouraged peoples' participation in health
care-
""J
... people from the community ... actually decide
health programs they think should be undertaken and^ll
health staff, agencies and/or the government to prnvjdffilSl
expert knowledge and/or resources to enable the activiri^W
be pursued [23, p. 14],
lash
As Rifkin notes this is often the ideal of he|
Pr°grams, but in fact this level of participation $9
rare
ly achieved.
rarely
achieved. Her
Her point,
point, however,
however, isis that
that proje|
need 10 specify, realistically, the level of participa1|
« 56 *ref
order
they are aiming for rather than to phrase progS
objectives in terms of vague concepts and ideals!
Whatever enthusiasm initially surrounded the! B W order. Vv
js vital tc
corporation of community participation into PH(
Community participation
, tbe- com
lost investigations by social scientists have in the*Q^
formed
Perhaps no other development concept has been decade suggested reserve |and
and caution.
^
caution. Many
Many invf
investp||
begin. E
more thoroughly, consistently, and fervently advo- £ators have pointed out, for one thing, the nai^H '■
' transfon
cated than that of ‘'community
community participation
participation'.’. Prob- fallacy
fallacy of
of assuming
assuming a rural ‘community’ to be’a&l
lems with participation are widely recognized, but homogeneous entity, full of persons sharing commoafi I,: should i
. similar <
this idea, unlike other development fads, has stuck, inte
rests and
interests
and oriented
oriented toward
toward mutual
mutual cooperatioSl
czz
primarily for three reasons. First, local governments t[20,25.
20' 25* 26
J- In
26],
In sorne
somecases
casesefforts
efforts to
to structure
structurecomm^B L involven
see it as more cost-effective than alternative ap- nit
y inv
olvement in
(through
locaM
nity
involvement
in health
health programs
p
:
. emplc
proaches that would draw more heavily on scarce Jhealth
'
committees, community health workers, etcj!
. of peopl«
'? purposes
state resources [20, 21]. Second, both common sense became enmeshed in local politics and powj
■
and may
and innumerable field experiences [22] tell us that struggles between factionalized and competitive interl
- others in
those development projects in which local people est groups [27, 28].
gp [20, p. 61
Others are concerned that the rhetoric of commil
themselves are somehow actively involved are, other
things being equal, going to be more successful. nity participation can be used as a substitute fort
& Assessir.
Third, the concept is morally consistent with the government responsibility in public health [20] or
It is t
principles of equality and self-reliance that have a mask that shields national and international in-1 ■jr-; 1|: g health f
guided international development philosophy over equalities of wealth and power, which are the reall
Bsome g=
the last decade. It is little wonder that community causes of poverty and ill-health in the Third WorlJ
■J
f-'as met
participation quickly came to be seen as a corner [29, 30]. In this sense community participation can
k AH by
stone of the PHC movement.
seen as a double-edged sword. On the one hand it can9
But re
But just what community participation should be phrased in such a way that it calls for empower<
PHC
p
mean and how it should work have remained prob ment of the poor [31]. But on the other hand, theW
of
villa
lematical. In actual projects around the world, any concept of community participation can too easily be
and ot
thing from semi-forced local contributions of money manipulated to deflect responsibility away from those
of cove
to revolutionary seizing of power has been discussed who truly have power, ending up as yet another
ance ir
in terms of ideals of ‘participation’. Rifkin [23], slogan which, however ironically, promotes current® E
interve
borrowing from the Cornell University Rural Partici- Polit
’cal and
economic
structures
of inequality.
Other
researchers
have
questioned
the local rele-J ‘111 i
Wha
pation Project [24], has recently helped clarify
C
.
.
examplwhat participation can mean in the field of health vanC'V of the concept of community, r
participation.
--------£---------- __iIn
progra
care by distinguishing different ‘levels’ of partici an early survey of health programs in Hong Kong, fl p
already
pation. Minimally, and most passively, people can Indonesia and the Philippines. Rifkin concluded that « .
ence tlparticipate in the benefits of a health project, by,
Community people who are involved in community health 1
mation
for example, receiving health services or education.' activities tend to see the programs as extensions of medical 1
progra
At a second and deeper level local people may services and tend to want responsibility to remain in the ‘fl r
the use
hands
of
the
medical
profession
[32,
p.
1494],
?
participate in program activities. Examples would
Nicara
be local contributions
. of
. . land,
,. . , labor
, or money- for
Similarly Brownlea [33] pointed out that not all S :
tory rt
a health facility or 1
7 uiS V.SUming r°leS CUItUreS Va,ue ,ocal Participation in decision-making “
pation
as rural health workers. A third level involves for health activities. My study of a participatory
Whe
implementation, where local people assume manage development project in Nepal [26] suggested that the
B
broadt
rial responsibilities in a program and decide how
Scurrent focus on community participation appears to
wide E
certain activities are to be conducted. A fourth level be an attempt to promote the Western cultural values
|
factor;
concerns program monitoring and evaluation. But of equality and self-reliance (values not shared by the fl l|
suppo
in all these levels so far, local people are still not local population), while ignoring alternative values fl t
suppli
involved in program planning or in translating their and perceptions of how development might work in fl B
makin
own felt needs and interests into a true ‘grassroots’
rural. non-Western societies of developing countries.
deterr
development. Only a fifth and final IpvpI
1
z-i iinai issue concerning participation was
questi
that
articulated by Madan, who wrote, “participating
can a
K
1
I
I
K
At thI
* JSR
Cultural influences in community participation in health
J
^^^fenunities are ■made', they are not ‘born’"
n argued that it is unrealistic to
:'tfiKp.619].
Madapeople
’
that local
in developing communities
the resources, organization, expertise or
take the kinds of actions outsiders want
in the name of community participation.
.,.:'-®?-Sr:see
” 133] likewise wrote that participation has
'ced’ (with power, knowledge, and skills)
P40
• for it’to'be'
to be more
more than
than mere
mere tokenism.
.1'.;?. va orde
• t perhaps even more caution is in
^HK
ferf-^werhave
t<’
413
their resources and activities in the interest of com
munity health? Some particular problems within this
issue are discussed in the next section.
CULTURE AND HEALTH DEVELOPMENT:
recent perspectives
As a result of research and field experiences a new
mode of thinking about the relationship t>etw<*n
culture and community health had emerged by he
1980-s and has continued to the present. Among th
We have heard that community participation factors that influence the success or failure of PHC in
t0 community development. Now we hear that general and community participation in particular
mnStv must be rather profoundly trans- this mode places primary emphasis on polifeal
•WSXfore even participation can realisticafiy relationships and processes [40]. Local beliefs
But according to whose values should this practices regarding illness and curing are in tins
' ' ■fev^fomation be encouraged (or in whose image mode seen as flexible, changing, and in and of
■ •£d 7 community be ‘made’?). Madan raises a themselves, not very powerful as 'obstacles to adop
his comment that community tion of new ideas and practices. What now loom n
' • ■ r s>mi,ar concern Wlth
'
the foreground are local cultural ideas and insti
i
involvement can be
tutions which govern the acquisition and mampuihemistically the manipulation
j
emploved to describe eupl
a ion of status, power, and wealth. This perspective
and technocrats for
be for the people’s good- thus focuses on structural factors of health systems
conceived by these and the ways in which these interface with local social
an infantalizes people and political structures. The idea of 'cultural influ
.
ences on health programs shifts away from an exclu
sive focus on the local culture of village peoples to a
V,$&sessing program success
much broader concept which includes the culture o
as 'Wbkft L easy to find faults and failures in community health organizations and health bureaucracies, or
»- W’^health programs. Discussing success is more difficult even of ‘international development itsel
| | Some general impressions of the success of
,
This new emphasis on power and politics carries
two important implications for the understanding of
the relationship between culture and communi y
health programs. First, it encourages an encompass
ing framework within which all levels of a health
system can be simultaneously incorporated^ Inter
-'I 4;bilviilage health worker programs
national relationships between developed and devel
|; iandKithdr countries [36] indicates
ose
T fqgcoverage and cost-effectiveness but poor Perfor™- oping countries can be included as can relationships
U■
<77 ih terms of quality of health care and health
between agencies such as WHO and local govern
ments, internal relationships between governments
I /"■WhlTare^more often reported in the literature are and health ministries, and so on down to the levels ot
' ‘r ’Ju!
..
specific successful strategies used wtthm health centers, community health workers, rural com
elej
^ms. Thus, to give a few examples beyond some munities and finally to the 'poorest of the poor .At
tng.|..
^already mentioned. Griffiths [37] described the differ- each level there are struggles for power, status and
that.:;
:
that use of ethnographic methods and in oraccess to resources, all of which influence how com
.AWion made to the success of a nutrition education munity health activities and services are planned
dk^r Wagram in Indonesia. Loevinsohn [38] showed how delivered and utilized and how and to what extent
ithe;
i
‘ Ae use of food incentives improved PHC coverage in
local ‘participation’ is actualized.
; ^fe^O^agua. Nicher [39] described how a ‘participaOne example of a report which incorporates an
analysis of the relationships between agencies and
’
ory
research
’
strategy
fostered
community
particit all
institutions at different levels is Welsch s study of
IHKin a PHC program in India.
king
BMere health programs are analyzed within PHC in Papua New Guinea [41], He shows^how
UO0leader health systems, there does appear to be despite the rhetoric of 'self-reliance in PHC the
t the
fide agreement on the importance of a number o
administrative culture of health care supports a toptrsic
down flow of policy and information^^thro“8b°u 'h
Mrs-such
as
national
political
will,
government
alue;
bureaucratic levels of the system. Each higher level
ijjfepdrt to community health worker training an
»piies, administrative decentralization of decision- sees itself as superior to and more knowledgeable
-alue
Ong, and, of course, community participation-in than lower levels. Thus,
,1116?
v^ytermining program success [21]. At this leve , t e
WHO sees itself as the knowledgeable partner in its
wiu,... ^tionisnot, ideally, ‘what works?’ but rather, how
member countries m the developing world.
,atinv
a multiplicity of agencies be made to coordinate
I
■
Wss
' '.V ’V-
t 1
a
4
®I
s
•MOM
ij
14
i®
fhg,
s|
I
IS
E;.
h
rW'.
Ban
It
Bi
1
414
tew
L
I
RS
^<4
Linda Stone
the relationship
central
a 1pattern that replicates
.
r between
...
planners and village communities [41, p. 106].
In more general terms Van der Geest et al. [7] have
used a multi-level or ‘linkages’ perspective to discuss
how current problems with PHC are related to the
fact that it is perceived and implemented very differ
ently at different levels of social organization. They
cover the levels of international organizations, the
state, health workers, and the local population, show
ing how each level redefines PHC in accordance with
its own interests and political position.
A second implication of this new focus on power
and politics is that if offers a beginning in the
breakdown of a conceptual barrier between local
village peoples and outside developers. Previously,
even with the best of intentions and a true spirit of
equality inherent in the PHC movement, discussions
and reports on health programs implicitly divided off
local villagers as an alien category of persons, who,
if not outright ‘ignorant’ then al least in need of all
kinds of outside education, advice and guidance, and,
with respect to community participation, ‘stimu
lation’. All this was to be provided by another
amorphous category of well-meaning but patronizing
outsiders who had already defined local peoples’
‘rights and duties’ for them with regard to health. The
new perspective, by contrast, sees the world of PCH
as one filled with a myriad of diverse groups, each
admittedly constrained by self-interest and by politi
cal realities. This perspective, in short, encourages all
of us to look inwardly at ourselves, our own affilia
tions, our own institutions, and our own professional
subcultures, as potential obstacles to global health
development.
One of the first to promote this new perspective
was George Foster. After claiming a general agree
ment today that cultural knowledge of recipient
groups is essential in the planning and implemen
tation of health programs, Foster wrote:
Less widely appreciated is the fact that the structural and
dynamic characteristics of health agencies profoundly influ
ences the strategies, planning and mode of operations of
international health programs [1, p. 1039],
It
-.4
Foster encouraged the study of the cultures of these
health agencies to understand how bureaucratic
behavior and bureaucratic imperatives influence the
viability of health programs. His own work [1,42]
went a long way toward showing how rural health
policy and planning could be adversely affected by
built-in bureaucratic constraints, such as an agency’s
needs to justify budgets and validate itself, and
individuals’ needs to promote certain activities so
that they can demonstrate or justify their own pro
fessional skills.
Foster warned that social science research geared
toward the probing and exposing of these kinds of
bureaucratic and professional foibles would be un
popular and perceived as threatening to health
agencies. Undoubtedly for this reason we have seen
few such studies. Aside from Welsch’s study alreij
referred to, a study conducted by Justice [43] staiS
Srl
out as a clear demonstration of how PHC program
^W^W:-’'2S’eCting 1
in Nepal and other South and Southeast
\vfe'v °f
countries were ineffective because they were desigri^
to meet the needs of various health bureauc^cw^^K’;%rofessiom
“
rather than the needs of local villagers. For NfSjmjwM
Ish0"th
the officials who attended meetings in Geneva,
Geneva
i about deci
tending their country’s commitment to PHC,
PHC weri
.
not the persons responsible for implementingPhAOIBS
partlC
,t.„_
i
------"'-'Jj
.
'concludes
back home. For these latter officials
of demands in
|
...health
... primary health care appeared as an i__ J
P
be met in exchange for certain resources. The H.
question for them was how to meet these demands wtth
limited resources and without dislocating the existing
care system too severely [43, p. 1303).
... fl SlIX l
' ' 1 in<
Thus, for t
Another expression of the political perspectiSjnWtv
perspective!
how medic
J_ . _ P _
1.
1
a
' JCMKifl
the study of culture and community health1 comes
-in
coi
■St-"of even the
a series of articles on PHC by anthropologists,{pub|^p
staff
lished in the journal. Human Organization in 1986. In’lip
K
t prestige an
the introduction to this series [44], the authors noted|h
^^•Hydaims to s
that one of the reasons for this new focus on
center
political dimensions of health care was the relali^S
a new lcvcl
success of rural health programs in socialist countrfe^^^
: M and sought
Discussing the positive changes in the qualiiiffij||MM
. pheir activi
health in the populations of these countries,
|&-'tween two
wrote
'’
■■';'0^orkers ar
... we came to the conclusion that the changes were’notffi^gjg ME: the nurses
solely to measures taken in health promotion ... In
Bp'tbat the fa
instance, health care was placed in the context of bro^^.
clients to C
revolutionary changes in the political economy which
this
tated a more equitable reallocation of already
“health syste
natural resources. We began to analyze the effect on
■
of greater access of people to power and wealth(44.p.O
power strug
changes on
Along these lines, Donahue [45] showed
being tradi
the decentralization of decision-making durin^8H8|M
■It P°w seen a
Sandinista revolution in Nicaragua led to an aspeft^t*
fcr ako seen a
dency of meaningful kinds of popular participa^^^
in health over a previous professional dominaa^^S»? . ■ &TOst-War p
5660 less as
the health care system. Another kind of conraSHH| 4
gh tenmi
between politics and health care is seen in Stebw^
H'i and compl
[46] study of how local people in a region of
which all u
Mexico supported a new health clinic
^Ritatus and
served as a powerful symbol of political streng®^^
*n-interesi
their power struggle with another municipo.
'Jne may
case community ‘participation’ to maintain
aS an
was undertaken even though the clinic was p?®
it may
stocked, ill-managed and perceived by villagtf^^Bi
argue
bring few medical or health benefits.
Many observers have confirmed the importance^>4
^H^^Ptinunlly
national political will in bringing about
4’;-. ^iculate o
table health and successful PHC initiatives.
wh<
the extent to which this is necessarily tied to a
^pl^hnocentru
political ideology is not certain. Young’s [47] study
and Pe
PHC in Tanzania concluded that a socialist
.
formation is neither necessary nor sufficient
to succeed. And New [48] has shown how the
tonsfon
and other benefits of China’s PCH system bav^gr 5
•lM|l^^trary ai
been maintained under the country’s new econ?W' •;
policies.
> 1 -■
I **
■ J
-4 ■
-
4 ; It local ''1
Sfefe- ci a ri c
,. TCcogn i z
pooi
health
’s study air
stice [43] st,
PHC progr
^utheast
y were design^m
i bureaucrar^^™
srs. For Nepafw
in Geneva,
to PHC, wert 3
ementing PH^M
Jg-Nicher’s study [49] of PHC in South India
^tanka takes a close look at political realities
W^-the health care system from the point of
health center staff. This study details the
gj$i&ssional interests of various levels of staff, showthe promotion and guarding of these interthe Power struSgies between levels brings
alKtut decisions and actions antithetical to commu■“^^articipation and other ideals of PHC. He
ay of demand* to'w
:s. The pressiotf^u
mands with
ie existing hea^M
Ml programs which do not pay credence to the
nonal identity and social status of health staff may
id up in promoting conflict in the name of team-work
immunity participation (48. p. 347],
wi
udes that
7?|Sbr example, in South India, Nicher describes
Perspective
ealth comes
oologists,
fion in 1986.
authors not *
focus on j
as the ’ati
alist c
ri
he quality
ounces, they •
|
<es were not due
t
ion ... In eacwM
text of broadwfi^^^
my which faa'jjilready existing
effect on health'
. “"■’-’’SI
showed bow
ig during the
/
to an ascettparticipatt^:?^^
dominance
)f connecti^^^S
i in Stebbins*
c because it ' 1
al strem
ain
j was pr*'**^' *
' villag^*,.®T.»3MHtoMM
■
problems are further “defined in such a way that
some development program has to be accepted as a
legitimate solution” [50. p. 667]. A particular kind of
internationally managed ‘development’ is, in this
paradigm, uncritically accepted as a historical neces
sity.
The poor of developing countries are in turn
reconstructing their own realities as their world is
penetrated by the forces of international develop
ment. A recent study in Nepal by Pigg [52] discusses
how people of a rural Nepalese hill community are
now defining as ‘undeveloped’ what they used to
perceive as locally varied ways of life. Her work
shows how in particular local discussions and debates
about the roles of doctors as opposed to shamans is
a symbolic expression of these peoples’ concern to
formulateJ new identities for themselves and others in
their rapidly changing world.
dedical officers severely restricted the dispensing
the simplest curative drugs by nurse-midwife
g^d'Staff in order to protect their own power and
|pr£stige and maintain a ‘mystique’ around their own
DISCUSSION
Igaunis to special medical knowledge. In turn, health
lifter'field staff felt threatened by the introduction of
Over the years, international health professionals
level of health worker, the village health guides, have increasingly stressed the importance of under
^^Sought to keep strict administrative control over
standing the perspectives of the poor themselves. This
activities. In Sri Lanka, a power struggle be- is all the more the case whenever community partici
|t^n two levels of health workers, family health
pation is invoked. At the same time, these pro
and public health nurses, was expressed in fessionals have, in the very nature of things, worked
^giurses giving little credence to letters of referral
as outsiders who. as Robert Chambers wrote nearly
the family health workers were handing out to
10 years ago. “are people concerned with rural
^fcnts_to.encourage them to go to the health center.
development who are themselves neither rural nor
iP^this recent perspective, which emphasizes how
poor” [53, p. 2]. Throughout all the community
th systems and programs are structured and how health development efforts, through all the fads,
^struggles are played out, the image of the poor
slogans, debates and expressions of genuine concern,
—ps.once again. The poor rural person, far from one senses that outsiders are forever defining poor
BHgtradition-bound or constrained by culture, is peoples’ problems and solutions for them? Even
Wgseen as constrained by lack of power. He/she is community participation, designed to bring about the
fe’seen as rational and pragmatic, as in the early
opposite, is an external idea rooted in particular
■^ar period. Moreover, the poor rural person is
cultural values. The inevitable ethnocentrism and
|||^ess as an exotic ‘other’ in need of guidance and
paternalism which all this produces may be unavoid
Bteutenment, but more as an end point of a long able. On the other hand, one positive change I see in
£°mplicated hierarchy of health care within international health discussions, is a new awareness
un*ts and levels act to secure power and of the intellectual constraints and limitations of out
and promote their own social and economic siders. At least conceptually, if not in program plan
?<?S^^®terests-
.
icipo.
415
■
-
nportance.^',
t more
'es. Howeys , .
[4?]^
ciafist$g
entR^g
-‘cow^ ■
ning, new notes of self-criticism and realism are being
temPted to see this image of the rural heard.
as an improvement over that of previous eras
Meanwhile,
some international
organizations
have
niav
.u
•
................
luivmauuiiai
uiganizauons
nave
1 \USOry projecl,on- One recent,y shifted their own policies. These favor ‘selecM^rgue that international development is a whole ......................
live’ (vertical) approaches and tactics such as ‘social
Binary and relative world within which we all
marketing’. Community participation is still emphaKmually struggle to define our own realities and
. sized, but perhaps less is being demanded in the way
®g|ate our own identities. Escobar [50] suggests
of ‘self-reliance’ [7].
whole ‘development paradigm’ is inherently
This current mood of realism and political aware
rooted in patterns of political domina- ness raises new questions and challenges for commu
^apd perpetuation of a certain world economic
nity participation in health. Perhaps the time has
I^He points out how, within this paradigm,
come to see participation as a commo.a=sense_develrealities’ of Third World peasants must / opment strategy^but.not as a goal in Itself, nor as a
formed with labels, such as ‘small farmers’,
I powerful tool of democratic reform, since in these
||ries’ and ‘illiterate peasants’, so that they
latter cases the concept always seems to carry more
|gnizable to development institutions. Third
significance for outsiders than for the poor. But if the
P°or are defined as ‘problems’ and these concept is going to be kept at all, the real challenge
■
J
I mm
K'fi
k.
■
■
416
will be (and always was) how to remodel PHC to
fit the perceived needs and concerns of the poor
(themselves diverse). Finally, if power relationships,
conflicting self-interests, and entrenched political and
|os|l-
(
I III? ■
il
fe
v. .
!■:
I
r
Linda Stone
economic inequalities are the true stumbling blocks
to “Health for All by the Year 2000”, who can
legitimately ask whom to compromise power in the
interest of global health?
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'1
KK
Ki
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V'
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B
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‘*9
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■■
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t '
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■ iSOv
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*
>
36
A. L. MARTIN
INTFRNATIONAL-io’JRNAI OF HEALTH PLANNING AND MANAGEMENT, VOL. 2, 37-58 (1987)
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December (1965), 361.
Restuccia, J.D. (1982). The effect of concurrent feedback in reducing inappropriate
hospital utilization. Medical Care, 20 (1), 46-62.
Shortell, S.M., LaGerfo, J.P. (1981). Hospital medical staff organization and quality of
care: results for myocardial infarction and appendectomy. Medical Care 19 (10),
1041-1056.
Young, D.W., Saltman, R.B. (1983). Preventive medicine for hospital costs. Harvard
Business Review Jan.-Feb. 126-133.
Zaltman, Duncan (1977). Strategies for Planned Change. New York: John Wiley &
Sons.
The Role of Non-Governmental Organizations and
the Private Sector in the Provision of Health Care
in Developing Countries
Andrew Green
Nuffield Centre for Health Services Studies, The University of Leeds, 71-75 Clarendon
Road, Leeds, LS2 9PL, England
SUMMARY
A major component of total health care in many developing countries is that provided
by organizations outside the state sector. Analysis of the relationships between the state
and non-state sectors and explicit government policies towards the non-state sector have,
however, often been neglected. Within many developing countries, there is heterogeneity
rather than homogeneity within the non-state sector, making the task of developing
consistent and workable policies difficult. In order for such policies to be developed, a
clear understanding of the characteristics and roles of the various non-governmental and
private health care providers is needed. This, in turn, requires the development of
analytical tools and evaluative criteria. This article outlines and discusses issues requiring
consideration in the formulation of policies, and sets a preliminary agenda for research
action.
key words:
Non-governmental organizations; Private sector; Health planning; Health system
research; Health policy
INTRODUCTION
For many developing countries, health care provided by organizations outside
the state sector is a major constituent in the total sum of health care provision.
Indeed, in many countries, such non-state health care accounts for the majority
of all health care. Paradoxically, however, until recently there has been mark
edly little attention paid to the role of this sector by the governments of many
of these countries, by international agencies, or by academic researchers.
This situation is now changing, with greater recognition and interest in this
area by governments and some international agencies, particularly the Christian
Medical Commission, the World Health Organization (WHO) at its assembly
in 1986, and the World Bank. There are various reasons for this increased
awareness, but two stand out as being of particular importance. Firstly, the
emergence of the philosophy of primary health care, which, inter alia, stresses
the need for multi-sectoral and multi-agency collaboration. Secondly, the recent
and continuing global recession, and its effects on the public financing of social,
and in particular health, services, has prompted interest in alternative funding
arrangements. Linked to this second point has been increased interest in the
development of methodologies to determine the nature, sources and scale of
existing health care finance.
However, the burgeoning recognition of the size, and hence potential effects
(whether helpful or harmful) of the non-state sector, has not, in general, led
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39
A. GREEN
to concomitant policy action on the part of the sector itself, governments, nor
international development agencies. This paper attempts to set out the major
issues that require exploration and research, in order that such policies can be
more fully formulated.
The paper, firstly, examines the characteristics that distinguish and differen
tiate non-governmental organizations (NGOs) and the private sector, from each
other and from state-provided services. For analysis to be made of their relative
roles, it is important that their prime distinguishing characteristics be identified.
The next section then looks briefly at the existing evidence on the role and
importance of NGOs in the field of health care. What little literature there is,
is often characterized by either underplaying the extent of both NGOs and the
private sector, or by gross generalizations about their actual or potential role.
Such generalizations, it is argued, are both inaccurate and unhelpful, in a field
where heterogeneity, rather than homogeneity, is the order of the day. Various
criteria are then suggested as both descriptive and analytical tools, and which
highlight this heterogeneity.
The arguments surrounding the public/private mix for health care are then
addressed, noting that: (a) even the most ardent ‘marketeers’ have accepted
the need for some public sector provision, and that hence the debate focuses
on the optimal extent of this provision; (b) the theoretical debate has not yet
been, and indeed may never be, concluded; (c) even in the more industrial
countries of the West, where the debate has existed as a mainstream activity
in the fields of health planning and economics, there are wide differences of
opinion as to the optimum mix, and equally wide sources of contradictory
evidence.
The final section looks at the area of policy formulation and the optimal
strategy for any government in the mix of service provision and regulatory
controls. The article concludes by urging that urgent research attention should
be focused on tools and criteria that can be used to formulate appropriate
policies.
NGOs, THE PRIVATE SECTOR AND THE STATE
Analysis of the respective roles of, and comparative advantages between, the
state, NGOs and the private sector requires a prior definition of these three
terms. Presently, literature uses a variety of terms to describe health care
organizations, including: government, state, public sector, social security, volun
tary, non-governmental, charity, mission, private-non-profit, and private-forprofit.
For the purpose of this article, a working definition is chosen which accords
with common usage. This definition uses two criteria—whether an organization
is directly managed by and accountable to the state; and, w'hether its stated
aims are explicitly in pursuit of profit maximization. Under such criteria, NGOs
are defined as non-profit-making organization, outside direct state control, and
the private sector is defined as profit-maximizing non-state activites.
Though such a definition is adequate for present purposes, in practice the
demarcation is more ambiguous. Three examples illustrate this diversity. Firstly,
organizations such as district designated hospitals in Tanzania, managed by the
church, but heavily subsidized and controlled by the state, occupy an uneasy
position between being an NGO and being part of the state sector. Secondly,
the term ‘private’ is often used to denote the opposite to public rather than
profit-maximizing. Thus, for example, the Private Hospital Association of
Malawi is made up largely of church organizations. Thirdly, the term state is
deliberately chosen in many countries to include, in addition to ministry of
health (central government) activities, health services managed by local auth
orities, or other ministries and quasi-governmental activities, such as the large
social insurance organizations typical of Latin America. However, several of
these display organizational characteristics (for example, a degree of autonomy)
similar to NGOs.
The development of tools by which one can describe, categorize and analyse
the different health organizational forms, is of much more than academic
interest. The development of policy guidelines is dependent upon the ability to
describe and delineate such organizations, for which further research is
required. Such research would be able to draw upon the experience of health
sectors within developed countries and non-health sectors in the developing
world (such as education) where policies in this area may be further advanced.
THE IMPORTANCE OF NGOS AND THE PRIVATE SECTOR IN
HEALTH AND HOSPITAL CARE IN DEVELOPING COUNTRIES
Until recently the role in terms of both size and nature of the non-state sector
within the health field, was not given due recognition by governments or
international agencies. Government development plans were often character
ized by a failure to mention, let alone take account of, in anything more than
a cursory fashion, the existence and role of such organizations. Similarly,
international aid agencies concentrated their efforts on the government sector.
(To some degree this was due to a failure to differentiate sufficiently between
the dual role of government health agencies as responsible both for national
health policy, and for major service provision and funding.) Furthermore,
where recognition was given, there was often little distinction made between
NGOs and the private sector. The World Bank Health Sector Policy Paper of
1975, for example, makes no such distinction (World Bank, 1975).
This situation is, however, for many countries, now changing withi a more
explicit recognition of the extent and importance (wheher negative or |positive)
of the non-state sector. At least two explanations can be identified. Firstly, the
acceptance of the philosophy of primary health care has, to varying degrees,
forced upon governments and others involved in health care, a recognition of
the need to appraise critically the workings of all health care providers, through ■.
its stress on multi-agency collaboration, appropriate health'i care and equity,
decentralized •
Closely allied to this has been a push in many countries to a more
i.
planning,
management
system of health care, placing greater emphasis on a j ’
and coordinating role at the local (district) level.
40
A. GREEN
Secondly, the financial crisis, in part the result of a global recession, which
has been evident in many developing countries over the last decade, has forced
a closer look at means of expanding (or in some cases maintaining) health care
provision with minimal implications for government expenditure. This has led
to greater interest in the non-state sector as one possible way of achieving this
strategy. Financing surveys, whose importance in providing planning infor
mation is gradually being recognized, have been an important source of compre
hensive information on the overall size of the different sectors. For instance,
comparative information has been compiled (de Ferranti, 1985) on the level of
total private expenditure in 37 developing countries, showing a range, as a
percentage of total health expenditure, of between 12% for Lesotho to 87%
for Bangladesh and Korea.
The evidence that is readily available (Cumper, 1986; Abel-Smith, 1985)
would appear to show that: between countries there is a wide variation in the
size and composition of the non-state sector; and, that there are methodological
difficulties in making comparative estimates compounded by the lack of a single
survey/accounting system.
TYPES AND CHARACTERISTICS OF THE NGO/PRIVATE
SECTOR
Analysis of both NGOs and the private sector suffers from broad generaliz
ations. NGOs have been described variously as being autonomous, flexible,
innovative and cost-effective; or, alternatively, as failing to meet national health
needs, unplanned, duplicative or inefficient (WHO, 1985). Whilst any of these
descriptions may be justifiable when applied to particular NGOs, they are
inaccurate and unhelpful when applied to the sector as a whole. Similarly, the
debate on the role of the private sector has often polarized (Roemer et al, 1984).
For the development of policy, it is first essential that a clear understanding be
developed of both the types and the characteristics of individual NGOs in a
country.
Main NGO/Private sector types
Seven broad groupings of non-state organizations involved in the health field
can be identified:
Religious Organizations. Possibly the longest established organizations are
those which are church-related. They are often major providers of health
care alongside other social development services including, most commonly,
education. Whilst their connection with the church has always implied a religious
motive for this work, this has manifested itself in different ways with different
religious and denominations, some seeing health services as a vehicle for
proselytization, and others seeing them as an end in themselves.
P
SION OF HEALTH CARE IN DEVELOPING COUNTRIES
41
The motivations of any particular church-based health service have impli
cations for both its approach to health care and its desire to work with other
NGOs and with government. To some degree a gradual overall shift away
from a proselytizing motive can be discerned, resulting perhaps from the
reduced availability of external funding, and from a parallel localization of
church-related activities. However, wide variations still exist. Church-related
health services are often multi-dimensional, and involve hospital-based services
with outreach satellite clinics, of either a mobile or permanent nature. The
church has also often been associated with particular disease programmes of a
vertical nature — such as leprosy. Many church-related services have had exten
sive involvement in training staff, usually in the first instance for their own
purposes, but often for government and other sectors as well. Attitudes to
government vary from organizations that are committed to working within the
government structure and which mayi see their long-term future as part of
government, to those anxious to maintain their autonomy.
International (social welfare) NGOs. Various international NGOs, usually
based in developed countries, are involved in the provision of health care. The
relationship between the central office and the country-based office varies, with
some being seen as outreach branches carrying out central policy (e.g. Oxfam)
to those who have an affiliated relationship (e.g. Red Cross and Red Crescent
Societies). The scope of activities of such NGOs varies. Although originally an
explicit and well-defined target listed (e.g. Red Cross — disaster/emergency
relief; Save the Children — children’s welfare; International Planned Parent
hood Federation — family planning), this has, depending on the periphery-tocentre relationship, commonly broadened out. Thus the Red Cross, for exam
ple, is, in many countries, increasingly active in the primary health care field.
The degree of decentralization of such NGOs depends largely on the depen
dence of local branches on central funding. One specific subgroup of inter
national NGOs are the service clubs such as Lions and Rotary, which have
commonly shared international aims, but local organization. They differ from
other international NGOs in that they are primarily involved in fund-raising
activities rather than direct service provision.
Locally based (social welfare) NGOs. In contrast to the international NGOs
there are a variety of locally based NGOs operating within the social welfare
field. Two subgroups are identifiable — NGOs dealing with broad community
development issues, and often geographically focused, and NGOs which are
more issue specific.
Within the first group fall traditional social groupings and women’s groups.
The second group focuses on specific issues and may have as much a pressure
group role as a service delivery role. The impact of both such groups is
extremely variable. Their restricted funding base implies that the majority are
unlikely to be involved in the direct provision and management of health and,
in particular hospital, care; but, through their pressure group activities, they
may be highly influential in general policy formulation.
42
A. GREEN
Unions and trade and professional associations. A fourth group comprises
organizations whose primary motive is the protection and promotion of their
constituents, including trade unions and trade associations. Whilst their present
role within the field of health activities is limited, there is a potential, particularly
on the demand-side, for an expansion of their role. The present extent and
strength of such groups is still generally small, though within Latin America
the role of union activity in this field has been recognized for some time.
Professional health-related associations are, of course, important for specific
reasons on the supply-side.
Other non-profit making organizations. A fifth group of non-government
organizations comprises services provided outside the public sector, but with
access limited to certain groups or individuals on non-financial grounds. Occu
pational health services, for example, often have a substantive input to the
overall health sector, and may be regarded as non-profit making in themselves.
Non-profit making (but pre-paid) health care. This sector, comprising organiz
ations modelled on American group health care, such as Health Maintenance
Organizations (HMOs), is still relatively rare in many developing countries,
requiring a minimum concentrated population base of adequate income. How
ever, it is likely that this sector will grow. One example of this is Latin America,
where urban concentrations of skilled labour have led to a growth in this sector.
ISAPRES in Chile, for example, perform similar roles to HMOs in the USA;
in 1984 the 17 ISAPRES had a total of over 852 000 enrollees out of a total
population of approximately 11.2 million (Scarpaci, 1985).
Private sector The last group comprises the for-profit organizations, which
may be locally based, or part of a wider international corporate structure.
Though this sector as a whole is presently a major element in the total health
care system of many developing countries, the main emphasis lies in the area
of individual private medical and nursing practices, and the provision of drugs,
rather than in the organization of hospital care. Of considerable importance in
many developing countries, however, is the use of public facilities, in a private,
profit-seeking manner, by either state-employed physicians or private prac
titioners. Such use may or may not be officially condoned or used as a fringe
benefit to government medical employees.
Characterists
A number of characteristics can be examined which further demonstrate the
diversity in the nature of the non-state sector, and are important in analysing
the role of such institutions within the health sector. These major characteristics
are outlined, and their importance discussed, below.
Motivational. The influence of an organization’s objectives on its performance
is a field that is fraught with difficulty. Studies relating to hospitals within
PROVE
OF HEALTH CARE IN DEVELOPING COUNTRIES
43
industrialized countries have looked at a variety of variables within both the
for-profit and not-for-profit sectors, to explain performance; such variables
coming from both economic schools of thought (via the theory of the firm) and
from behavioural schools of though (McGuire, 1985). Despite the depth of
debate, no clear view on which are the key determining variables has emerged.
In part this is the result of the difficulty in analysing the role within organizations
of health professionals and, in particular, doctors. It has been argued (Majone,
1984), for example, that there is a convergence of interests between non-profitmaking organizations and professionals, and that as such NGOs are highly
suitable organizations for the delivery of health care. However, though in
specific instances this may be the case, it cannot be held, a priori, that all
NGOs are more suited, either in comparison to the private sector or to the
state sector. Furthermore, it is by no means clear that the interests of health
professionals converge with the health care needs of the community.
Proselytization was originally an important motive for many religious health
services, and such motives may have led to an unduly curative bias, as a means
of attracting patients. Whilst proselytization as the sole motive is now rare, the
religious culture of some church health services can on occasion be a source of
tension between them and other organizations, and in particular government
health services. An example of an often contentious area can be found in the
field of family planning (and most particularly abortions), where strong attitudi
nal differences may exist. A more general problem may be found in the area
of personnel management. Where staff are expected to identify themselves with
the organization’s religious motive, this may be positive resulting in higher
commitment; or, negative, when for example schemes to allow staff transfers
between government and NGOs are arranged or training is carried out for
government staff by NGOs. Motivation is often cited as a cause for perceived
quality differences between government, NGOs and the private sector; how
ever, even where such quality differences can be demonstrated, it is difficult
to single out motivation as the prime variable.
A second tension may exist between those NGOs that are issue specific, or
those that are primarily involved in fund-raising, where different views of
priorities may exist. This may be particularly difficult where the NGO has a
pressure group role, within a system where lobbying balances between uses of
resources are weak.
Between the NGOs themselves there may be sufficient differences in philos
ophy leading to an atmosphere of competition rather than collaboration. For
example, many religious NGOs are located in close proximity to each other as
a result of earlier competitive proselytization. Whilst there are some circum
stances where competition may be regarded as healthy, situations are still
common where there is unnecessary duplication of facilities, or where inefficient
and possibly dangerous dualistic supervisory or referral mechanisms exist within
an area served by two NGOs, or an NGO and government.
The interests of other than religious NGOs are again different. Organizations
involved in the provision of employment-related health care, are primarily
motivated to demonstrate that such services affect profits or productivity
through either decreasing employee absenteeism, increasing worker pro
ductivity, or enhancing the payment package in fields of skill shortage. The
PR
44
ION OF HEALTH CARE IN DEVELOPING COUNTRIES
A. GREEN
last of these may give rise to an unduly curative approach, with expensive,
high-technology health care as a conspicuous end in itself.
The effect of profit-maximization as an organizational objective, on the
type of health care provided, has been well documented in the literature on
industrialized countries and is unlikely to be very different in shape in develop
ing countries. Of crucial importance on the scale and type of health care is the
means of financing (and particularly fee-for-service and insurance) and the
degree and type of regulation. Also of great importance to the for-profit sector,
though its importance is not confined to this sector, is the form of payment to
the doctor (Glazer, 1970).
Types of health service. Within the non-state sector, there is a wide diversity,
as has already been shown, of types of activities within the health field including
fund-raising, lobbying, and service provision. Even within these activities, wide
variations are possible. Examination of just one of these activities
the
provision of hospital care, illustrates wide variations in (a) location: many
NGOs (though certainly not all, as is sometimes urgued) are rurally based;
whereas private hospitals are almost entirely based in the larger towns and
cities, as are industrial health services (though some mines/plantation/agrobusin’ess-related hospitals may be rural); (b) activity: differences exist as to the
type of hospital care — whether specialist or general — and the degree of
identification with primary health care through, for example, referral mechan
isms, preventive activities, or community development activities. Private hospi
tals, for example, are likely to cater for short-term, acute cases, as being the
most profitable; (c) form of provision of service: even between similar activities,
differences often exist as to the way in which services are provided, as a result
of the technology used, including staffing mix, equipment, form of buildings,
and plant, and the degree of innovation.
Internal organizational characteristics. The characteristics of the organiz
ational structure of non-state sector organizations differ tremendously. They
can be contrasted with the state sector which usually has, within any one
country, similar organizational structures between institutions of the same type,
such as hospitals. Differences are likely to emerge, as a result of a number of
factors including: (a) motivational differences. Firstly, NGOs that have a strong
proselytizing tradition may be heavily influenced by either the local or inter
national church. Secondly, within industrial health care the decision-making
process is likely to reflect the management style of the industry it services.
Lastly, the degree of divergence between the professionals and the profit
recipients in a for-profit institution will influence the relative strengths of the
medical profession vis-a-vis the adminstrative cadres; (b) size, both in terms of
the hospital itself, and (where applicable) in terms of its size in relation to its
parent organization; (c) accountability — the degree to which formal structures
of accountability have been set up and are adhered to; (d) strength of the
medical and nursing professions generally within the country, and their ability
to exploit this within the context of a specific administrative framework; (e)
45
staffing policies — the extent to which the particular organization is staffed and
run by expatriates, and the degree of participation in management by the
workforce.
External relationships. The relationships that NGOs/private health services
have with other agencies are extremely varied, and are documented in Figure
1. Examples of factors that influence the relationship are given in the body of
the matrix, and include: historical antecedents; motivational considerations;
considerations of trust, often as a result of information sharing; legal/bureaucratic barriers; existing service patterns throughout the country; and, lastly, the
degree of government or external financing.
FACTORS AFFECTING RELATIONSHIP WITH OTHER INSTITUTION IN
AREAS OF:
T
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'
RELATIONS
WITH:
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run by the
same parent
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,
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information
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policies and
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Location of facilities
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1 Such as the Voluntary Health Association of India; Private Hospital Association of Lesotho.
2 Varying as between subvention provision to formal designation as district hospitals (as in
Tanzania).
Figure 1
The combination of relationships possible between an NGO/private health service with
other agencies.
F
A. GREEN
46
SION OF HEALTH CARE IN DEVELOPING COUNI RIES
aid (bilateral or multilateral), international NGO aid has often been directed
at capital expenditures — thereby worsening the financing situation, through
incurring greater future recurrent commitments. Other factors are, secondly,
the impact of world inflation, particularly in the area of pharmaceuticals; and.
lastly, an increasing divergence in fee levels between comparable government
be no clear evidence as to which model is likely, a priori, to be most effective.
that are possible.
care — the religious/charity
During the 1970s a major form of NGO health
face financial difficulties. This can be traced, in
sector — began increasingly to I
' a reduction in overseas recurrent cost support.
general, to three factors. Firstly
...
in, and priority given by
In part this may be a result of a declining interest
with official government
many denominations to, mission work. In common
FORMS OF FUNDING SOURCE
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Major forms of funding of different health care providers.
agencies and NGOs.
An many cases the situation has become critical, particularly where govern
ment policies had been to restain or freeze their own user charges. In such
situations the NGOs that relied on user charges (which can often be as high
as 70% (Kolobe and Pekeohe, 1980)) as a source of finance fell back onto a
strategy of increasing them, often to a point where utilization rates began to
decline, as users either could not afford services or chose to travel to the nearest
government facility. Such a strategy often compounded the problem. In some
countries this situation led to demands for (increased) government subventions,
prompting the Ministry of Health to review policies towards NGOs. Alongside
such government policy reviews, the NGOs themselves, faced with a common
problem, recognized in a number of countries the need for a common policy
and formed coordinating mechanisms. To the extent that governments have
accepted a need to increase subventions, this has carried the potential (not
always exploited) for closer integration of such NGOs into the state sector.
The extent of overseas funding and hidden subsidies is often unknown, so that
withdrawal of overseas support creates unexpected difficulties. Examples of
this include donations in kind (for example, of drugs) and the deployment of
volunteer staff.
-•
Government-explicit subsidies may take a variety of forms, ranging from, a
straight annual grant (in some cases linked to factors such as the operating
size or budget); to payment for particular services (such as treatment for
communicable disease); or, reimbursement for particular items of expenditure
(such as salaries or drugs).
Elements of the non-state sector that relied on health insurance as a main
source of funding appear to have been less affected by the global economic
recession, which may have hit higher income groups and hence their clients
less severely. Within the NGO sector, there is, in some cases, the development
of ‘private’ facilities, charging commercial rates, which are provided alongside
their usual services, and are used to cross-subsidize such services.
One area that is of clear importance for the development of government
policy is the degree to which both NGOs and the private sector receive hidden
subsidies from government in the form of, amongst others, tax relief, training,
access to cheaper or even free medical supplies, and the use of government
facilities either directly or indirectly (Segall, 1983). Information of such hidden
subsidies is rarely carried in conventional accounting systems, and yet is essential
to obtain a comprehensive picture of the funding characteristics of the non
state sector.
Manpower training and usage. Manpower may include both externally
recruited expatriates and citizens trained either within the particular employing
organization or outside. There are a number of major issues to be addressed
48
49
A. GREEN
PROVISION OF HEALTH CARE IN DEVELOPING COUNTRIES
here, involving the relationship between government and the non-state sector,
as regards training and employment policies. These include: (a) Standardization
and coordination of training: individual NGOs may provide a variety of different
training programmes mainly devised for their own needs. This is most obvious
in auxiliary training programmes where national licensing and curriculum stan
dards are relatively undeveloped. Where such training is nationally recognized,
NGOs have often had a lead role in determining national curricula. The general
relevance of such curricula then depends of the degree to which the training
organization is effectively integrated with or collaborates with government. The
private sector is rarely involved in training, with resultant hidden subsidies for
this sector, (b) Staff transferability and deployment: as a result of either different
training levels of bureaucratic barriers (such as the non-recognition of experi
ence) transferability of staff between institutions within the non-state sector,
or between the non-state sector and government, may be difficult. Furthermore,
pay-scale differentials between the private sector and the state sector are often
a cause of staff movement between sectors, or of pressure within the state
sector to move towards unrealistic private sector levels of pay. Conversely, the
NGO sector may be unable to meet even state sector pay levels, leading
to recruitment difficulties (McGilvray, 1974). In a number of countries, the
government has responded either through coercive policies such as bonding, or
by incentive policies such as allowing state doctors to practise privately, in
some cases using government facilities, thereby effectively increasing their real
income. Further major differences between NGOs and government agencies
stem from their ability to attract volunteers and to employ part-time staff. The
motivational differences between government and NGOs, and the often wide
activity base of NGOs, appear to give them a substantial comparative advantage
over the use of volunteers (Rankin, 1985). Even where government agencies
have made deliberate efforts to involve communities in the planning of local
services, and as resources to provide the services, their success rate would
appear to have been low compared to NGOs. This seeming advantage can,
however, on occasion, become a sourse of tension, where volunteers are being
used as substitutes for paid staff, (c) Appropriate manpower mixes: utilization
of different types of staff would appear to vary between organizations, having
implications for their cost-effectiveness. This can either be relative (for example
ratio of doctors to nurses) or absolute (for example doctors per head). An
example of the latter is given by Gish (1971), who compares a 100-bedded
women's wing in a public hospital in Tehran, with a 30-bedded private hospital.
The former has four part-time and one full-time doctors, the latter has six parttime and four full-time doctors, (d) Localization policies: the ability of some
NGOs to recruit expatriates at subsidized rates may be a deterrent to localiz
ation policies. One example of where this may be difficult is the not uncommon
situation of expatriate spouses holding unpaid positions, thereby reducing local
employment opportunities, (e) Manpower planning: all the above have impli
cations for the ability of government to perform effectively manpower planning,
which is often further constrained by the lack of information on both the demand
for, and supply of manpower from the non-state sector, and in particular the
private sector.
Degree of innovation. One argument that is frequently put forward in favour
of NGOs, and to a lesser extent the private sector, relates to their apparent
innovativeness. Innovation may in this context occur either in the form of
technology adopted, or the form of organization. Within the private sector, the
former may manifest itself in a replication of the latest high-technology medical
care practised in the more industrialized countries. In addition, in some coun
tries, the private sector has introduced new forms of organization. (Scarpaci,
1985). Many NGOs pride themselves on the use of more appropriate technology
and on their degree of innovation in service delivery. The degree to which this
is generally true merits investigation, though certainly NGOs have been
involved in path-breaking work such as the Flying Doctor Service in East Africa
by AMREF. The ability and need to innovate is generated, it is suggested,
through an historically lower funding rate, motivational differences and a
flexibility of operation. Whilst many governments recognize the usefulness of
NGOs in this respect, and indeed may use them to circumvent their own
organizational constraints, such individualistic, unplanned and often unevalu
ated innovation can result in extremely heterogenious services whose prime
characteristic is not necessarily better health care, but different health care, with
implications for planning and coordination.
EVALUATING THE NON-STATE SECTOR
The preceding section outlined a number of characteristics that differentiate
NGOs and the private sector from government, and between themselves. As
a result of certain of these differing characteristics, arguments are employed
that purport to demonstrate the comparative advantage of one sector over
another, and hence the need for policies to encourage or discourage parts of
all of the sector. This section accepts as a premise, the provision by the state
of certain forms of (particularly public) health care. Such as assumption is
commonly accepted, with the debate focusing rather on how comprehensive
such state provision should be. Figure 3 outlines the arguments which are now
discussed in greater detail in the test below. The arguments, though often
interlinked, are grouped into five sets of issues:
—Does the existence of the non-state sector lead to additional net resources'!
—Are organizations within the non-state sector more or less efficient at
providing (certain types of) health care?
—Are there differences in quality between the state and non-state health
care?
—Does the existence of a variety of organizations within the non-state sector
alongside a state sector, have implications for the planning and coordination
of health services, and ultimately for the efficiency of the health sector as
a whole?
—What are the equity implications of the existence of difference sectors?
Resource mobilization.
One of the central issues surrounding the non-state sector is whether or not
the existence of this sector increases the total share of resources available for
t
49
A. GREEN
PROVISION OF HEALTH CARE IN DEVELOPING COUNTRIES
here, involving the relationship between government and the non-state sector,
as regards training and employment policies. These include: (a) Standardization
and coordination of training: individual NGOs may provide a variety of different
training programmes mainly devised for their own needs. This is most obvious
in auxiliary training programmes where national licensing and curriculum stan
dards are relatively undeveloped. Where such training is nationally recognized,
NGOs have often had a lead role in determining national curricula. The general
relevance of such curricula then depends of the degree to which the training
organization is effectively integrated with or collaborates with government. The
private sector is rarely involved in training, with resultant hidden subsidies for
this sector, (b) Staff transferability and deployment: as a result of either different
training levels of bureaucratic barriers (such as the non-recognition of experi
ence) transferability of staff between institutions within the non-state sector,
or between the non-state sector and government, may be difficult. Furthermore,
pay-scale differentials between the private sector and the state sector are often
a cause of staff movement between sectors, or of pressure within the state
sector to move towards unrealistic private sector levels of pay. Conversely, the
NGO sector may be unable to meet even state sector pay levels, leading
to recruitment difficulties (McGilvray, 1974). In a number of countries, the
government has responded either through coercive policies such as bonding, or
by incentive policies such as allowing state doctors to practise privately, in
some cases using government facilities, thereby effectively increasing their real
income. Further major differences between NGOs and government agencies
stem from their ability to attract volunteers and to employ part-time staff. The
motivational differences between government and NGOs, and the often wide
activity base of NGOs, appear to give them a substantial comparative advantage
over the use of volunteers (Rankin, 1985). Even where government agencies
have made deliberate efforts to involve communities in the planning of local
services, and as resources to provide the services, their success rate would
appear to have been low compared to NGOs. This seeming advantage can,
however, on occasion, become a sourse of tension, where volunteers are being
used as substitutes for paid staff, (c) Appropriate manpower mixes: utilization
of different types of staff would appear to vary between organizations, having
implications for their cost-effectiveness. This can either be relative (for example
ratio of doctors to nurses) or absolute (for example doctors per head). An
example of the latter is given by Gish (1971), who compares a 100-bedded
women's wing in a public hospital in Tehran, with a 30-bedded private hospital.
The former has four part-time and one full-time doctors, the latter has six parttime and four full-time doctors, (d) Localization policies: the ability of some
NGOs to recruit expatriates at subsidized rates may be a deterrent to localiz
ation policies. One example of where this may be difficult is the not uncommon
situation of expatriate spouses holding unpaid positions, thereby reducing local
employment opportunities, (e) Manpower planning: all the above have impli
cations for the ability of government to perform effectively manpower planning,
which is often further constrained by the lack of information on both the demand
for. and supply of manpower from the non-state sector, and in particular the
private sector.
Degree of innovation. One argument that is frequently put forward in favour
of NGOs, and to a lesser extent the private sector, relates to their apparent
innovativeness. Innovation may in this context occur either in the form of
technology adopted, or the form of organization. Within the private sector, the
former may manifest itself in a replication of the latest high-technology medical
care practised in the more industrialized countries. In addition, in some coun
tries, the private sector has introduced new forms of organization. (Scarpaci,
1985). Many NGOs pride themselves on the use of more appropriate technology
and on their degree of innovation in service delivery. The degree to which this
is generally true merits investigation, though certainly NGOs have been
involved in path-breaking work such as the Flying Doctor Service in East Africa
by AMREF. The ability and need to innovate is generated, it is suggested,
through an historically lower funding rate, motivational differences and a
flexibility of operation. Whilst many governments recognize the usefulness of
NGOs in this respect, and indeed may use them to circumvent their own
organizational constraints, such individualistic, unplanned and often unevalu
ated innovation can result in extremely heterogenious services whose prime
characteristic is not necessarily better health care, but different health care, with
implications for planning and coordination.
48
EVALUATING THE NON-STATE SECTOR
The preceding section outlined a number of characteristics that differentiate
NGOs and the private sector from government, and between themselves. As
a result of certain of these differing characteristics, arguments are employed
that purport to demonstrate the comparative advantage of one sector over
another, and hence the need for policies to encourage or discourage parts of
all of the sector. This section accepts as a premise, the provision by the state
of certain forms of (particularly public) health care. Such as assumption is
commonly accepted, with the debate focusing rather on how comprehensive
such state provision should be. Figure 3 outlines the arguments which are now
discussed in greater detail in the test below. The arguments, though often
interlinked, are grouped into five sets of issues:
—Does the existence of the non-state sector lead to additional net resources?
—Are organizations within the non-state sector more or less efficient at
providing (certain types of) health care?
—Are there differences in quality between the state and non-state health
care?
—Does the existence of a variety of organizations within the non-state sector
alongside a state sector, have implications for the planning and coordination
of health services, and ultimately for the efficiency of the health sector as
a whole?
—What are the equity implications of the existence of difference sectors?
Resource mobilization.
One of the central issues surrounding the non-state sector is whether or not
the existence of this sector increases the total share of resources available for
A. GREEN
50
Arguments for NG Os/private sector
Arguments against NGOs/private sector
Resource mobilization
| Use of user charges creates inequities.
Can tap additional sources of funds.
I The extent of additional real resources
Can release public sector resources
I is less than apparent, due to:
by syphoning off demand.
• (a) hidden subsidies;
I (b) less efficient use of resources.
Efficiency
i Less efficient due to inabilities to
More efficient in use of resources
| exploit economies of scale.
due to motivation/management
[ Duplicates service provision.
structure
Service quality
[ Creates unrealistic expectations in
Provides high quality of service.
l the public sector.
i Lack of regulatory mechanisms may
I reduce quality of service below
I acceptable minimum.
Planning/coordination
j Duplicates services.
Is autonomous, innovative, ‘loyal
! Is unplanned in national terms.
opposition’.
Equity
• Private sector located in urban areas.
NGOs locate services in rural areas.
i Access to health care dependent on
Existence of alternative provision
I financial status of patient.
provides freedom of choice.
I Less responsive to community needs.
More responsive to consumers
| Not democratically controlled.
through market mechanism.
Figure 3. Summary of the main arguments for/against the non-state sector.
health care, from either internal or external sources. External resources may
be available through tapping different aid channels such as international NGOs,
in which case it is particularly useful as a source of foreign exchange. Internal
resources may be seemingly generated by shifting the demand of certain groups
from the public sector to the private/NGO sector, thereby releasing public
sector resources for other purposes.
Counter arguments focus on two themes. Firstly, that the level of additional
real resources generated may, in net terms, be less than is at first sight
apparent—either because subsidies of various kinds are borne centrally, or
becuase it results in a less efficient use of overall resources. A second argument
is that expressed in terms of equity. It is argued that for demand for private
services to exist alongside the public sector, there must be a (perceived at least)
difference between either the coverage or quality of service provision of the
public sector and the private sector, which may be a result of either the hotel
aspects of the service, or of the treatment itself. To the degree to which fees
charged in the private sector are prohibitive for a large section of the population,
this is a continuing source of inequity.
PROVISION OF HEALTH CARE IN DEVELOPING COUNTRIES
51
non-state sector are based on neo-classical economic arguments that competition
will (under certain circumstances) achieve an optimal allocation of resources.
Though such proponents recognize that in the field of health care, such perfect
conditions do not pertain, they argue that effort should be directed to creating
such conditions or substitutes for such conditions, rather than providing alterna
tive publicly operated systems. However, it is worth noting that the basic
premise for competitive markets — profit maximization — not only does not
apply to the not-for-profit sector, including NGOs, but may also not apply to
the for-profit sector, where research has suggested a number of other maximands, rather than profit (McGuire, 1985).
Arguments as to the comparative advantage of the NGO sector, the state
sector, or the private sector are complex and, to a large degree, untested, with
perceptions being largely based on anecdotal evidence (Brown and Tenn, 1985).
Inefficient or unnecessary medical practice in terms of the treatment used, may
occur in private practice where consumer information may be limited (this may
be a particular problem in developing countries) as a result of profit motivation
and fee-for-service payment systems; flexible management may be the hallmark
of some NGOs/private organizations, free from government bureaucratic
encumberances; conversely, poor management may occur in other NGOs or
private health care, where specialist management training is unavailable or
where medical interests dominate. The potential for exploiting economies of
scale in areas such as drug purchasing, which are open to large public sector
purchasers, may not be available (though through group purchasing could be)
to individual non-state organizations acting alone.
In addition to the above questions, which clearly need empirical investigatin,
and which are primarily concerned with the technical efficiency of individual
organizations, are arguments that relate to the non-state sector and its effect
on the overall efficiency of the health sector. Some of these arguments relate
to the present uncoordinated nature of the health sector in many countries,
with the inefficient duplication of resources and activities. Other arguments are
concerned with allocative efficiency and the use to which resources are put.
Thus, scarce health resources may be used (albeit with technical efficiency) by
the private sector on services which are not regarded in community health
terms as of high priority. Such inefficiency is often compounded by its ability
to raise unrealistic expectations/public pressure for similar provision by the
state. Such issues are further explored below.
It is clear that research into general indicators of efficiency, and the relative
cost-effectiveness of various organizational modes, is a vital pre-requisite of
policy formulation. It is important to note, however, that because of the
multiplicity of factors that impinge on the efficiency of a particular organization,
much of this research will be country-specific; it is possible that only the
research methodology itself will be more widely applicable.
Quality of service.
Efficiency
A second set of arguments focuses on whether resources are likely to be
used more efficiently in the state or the non-state sector. Arguments for the
Clearly linked to the last point is the set of arguments that concern the
relative quality of services provided by the state and non-state sectors. There
are two main issues — the first related to the provision of ‘over-high quality’
52
A. GREEN
care, and the second to ensuring provision of minimum standards of care. One
perception of NGOs is their ability to provide a higher quality of health
care. Within developing countries this has rarely been tested: partly due to
methodological difficulties in finding institutions whose ownership or manage
ment can be compared; and, partly due to difficulties in measuring quality
itself, particularly in developing countries (Eldar, 1983). Such perceptions may
arise through observation of the lower occupancy rates prevailing in NGO and
private sector hospitals. However, the opportunity cost of this particular indi
cator of quality is likely to be a reduction in accessibility or coverage.
To the extent that service provision in NGOs, and more particularly the
private sector, is determined by clinicians, it is reasonable to hypothesize that
policies regarding resource allocation may be biased towards individualistic
clinical viewpoints, at the expense of the wider community health. Such
phenomena are well-reported and are the cause of tension in many health
organizations (Majone, 1984). At the other end of the spectrum is the inability
or unwillingness of the state, in many developing countries, to devote scarce
resources to the regulation and inspection of non-state services to ensure that
minimum standards are maintained.
Planning and coordination role in primary health care.
In terms of the planned provision of care, arguments for the non-state sector
range from the viewpoint that the market is the best planner, or that NGOs
are as a result of their community links, or that the private sector is as a result
of its responsiveness to demand, to a viewpoint that a regulatory form of
government planning and/or government funding of services is possible without
necessarily the involvement of the state in the actual provision of services.
Emerging interest in the decentralization of health care management is also
used as an argument for the non-state sector. Arguments against focus on
efficiency criteria, as discussed above, with, for example, the claim that the
absence of planning leads to: a duplication of services (Schulpen, 1975); and
the lack of referral mechanisms or standardization of medical practice; and, on
equity, to the belief that planning is a mechanism for determining needs-based
services, rather than demand-responsive services.
Private health care based on a medical model, it has been argued earlier, is
less likely to be concerned with wider issues of community health or primary
health care, and as such, where its existence is permitted at all, requires close
regulation. NGOs, on the other hand, have, in many instances, been at the
forefront of innovative primary health care activities, particularly those with
links into other sectors or activities, such as broader community development.
Governments may, in addition, welcome the existence of NGOs, not just as
potential innovative pilots, but as agencies providing specific services whose
importance the government recognizes but which are politically too sensitive
for it to provide; for example family planning services. In some countries NGOs
may also act as a ‘ginger group’ or as loyal opposition; they may also be used
by ministries of health to bypass their own government bureaucratic constraints,
through contracting-out service provision. Acceptance of the need for state
Provision of health care in developing countries
53
planned health care does not necessarily imply or require state provision of
health care. However, it does imply the need for knowledge of the particular
activities of non-state health care, their strengths and weaknesses, and the
ability, where necessary, to regulate them. Such information and regulatory
mechanisms are at present conspicuous by their absence in many developing
countries; research in this area would clearly be beneficial.
Equity/social justice.
Health care may be viewed as either an investment or a consumption good.
In the former case, its allocation is not related to issues of equity but rather to
those of productivity. Proponents of this view of health care argue that health
care should be targeted at certain groups; and that equity losses in the short
term are worth such overall development gains. Roemer, arguing for social
insurance, has made this point strongly (Roemer, et al, 1984); the same could
be argued for occupational health care and its subsidization by the state.
Proponents of the consumption good view of health care are concerned rather
that health care is available in relation to need and not on any other criteria.
As such it is difficult to reconcile the two views.
Arguments couched in terms of equity and social justice are of four types,
the first two concerned with access to services. Firstly, those concerned with
the location of facilities point, on the one hand, to the concentration of private
hospital care in urban areas, and on the other to the location of many NGO
facilities in rural areas. Secondly, where access is restricted through financing
mechanisms, namely reliance on user charges, or high insurance premiums/copayment charges, there are clear implications for equity in terms of utilization
of services in relation to need. Thirdly, there arc arguments which relate to
the degree of subsidization of private services by public monies. Lastly, there
is the libertarian view that argues for freedom of choice. How such arguments
are assessed and concluded will depend on a government's understanding of,
and commitment to, equity; and, hence, on the ideological standpoint of the
government.
For many countries, other than those with a clear socialist ideology, an
evaluation of the non-state sector as a whole is unlikely to lead to unambiguous
answers: value judgements will be required as to the trade-off between equity
and resource mobilization. The two research questions that need answering
are:
—Do organizations within the non-state sector release or tap additional
resources (either through efficiency or resource mobilization)?
—If so, do any equity losses outweigh any benefits gained from the additional
resources?
IMPLICATIONS FOR POLICY
Preceding sections have examined the size and characteristics of the non-state
sector, and argued that, in many countries, it is a significant force in the health
i
55
A. GREEN
PROVISION OF HEALTH CARE IN DEVELOPING COUNTRIES
care field. The last section concluded that, for many countries with a non
Socialist ideology, it is not possible to make generalized evaluative comments
about the non-state sector. Rather, country-specific and organization-specific
evaluations are needed, as a precursor to policy formation.
Perhpas because of the very real difficulties in making such assessments,
health care policy formulation for many countries appears to have avoided
looking too closely at this sector. Yet, as a significant component within the
health sector, it is clear that such a situation cannot continue. Indeed, increas
ingly. governments are being forced, often through their own financial crises,
or those of the NGO sector, to formulate policies in this field; however, this
is often in the absence of a workable policy-making framework that asks the
right questions and provides the methodology to find the answers.
This concluding section, therefore, suggests a range of policy options open
to governments in this area and identifies areas of research that are needed to
improve policy selection.
The state has two potential roles within the field of health care — as a
provider and as a regulator. Policy development within this area needs to
disentangle these two functions, if the full range of options available are to be
adequately assessed. Figure 4 shows the possible range of positions open, in
broad terms, to governments. Any country can be represented by a position on
the diagram which shows the particular mix of service provision and regulatory
controls prevailing.
The optimal strategy for any particular country at a certain time and under
particular circumstances may change, as external circumstances or political
assumptions and social values change. In addition, policies may be markedly
different towards the different organizations, or towards NGOs compared to
the private sector. It has been argued, for example (de Ferranti, 1985), that it
may be more sensible in the long term for governments to support private
insurance than employer-based health care for firms. Similarly, it would be
perfectly consistent for governments to contract-out and fund certain types of
service provision to certain NGOs, and yet withdraw all subsidies from the
private sector. What is required is a means of continuously assessing the options
available, and determining the best route of attaining the chosen position.
Figure 5 sets out a variety of such options.
For the development of coherent government policies towards the non-state
health sector, research is required that will assist governments: (a) in determin
ing their long-term goals in terms of a public/private mix, through identification
of the specific implications and effects of different systems; (b) to determine
and analyse their own present country position, and, in the absence of specific
policy interventions, its likely future course; (c) to identify and assess feasible
short- and medium-term options to attain their long-term goals.
Similarly, NGOs themselves need to determine their long-term role and
strategy. The Christian Medical Council of the World Council of Churches has,
in a number of countries, provided support and advice in such deliberations.
For many church-related NGOs, such reviews provide the impetus to rethink
the rationale and hence character of their work. Some, as a result of such
reviews, have concluded that their involvement should be terminated and the
health facility handed over to government; others have looked towards strateg
ies for working more closely with government whilst maintaining a separate
identity; some have taken the opportunity to increase local control of church
policy.
Industrial health services fall into a different category, in that their future is
likely to be as strong or as tenuous as the industry to which they are linked.
However, their wider role in the health care system does need a similar review.
In order to assist organizations to carry out such reviews, which should form
an important input into the formulation of government policy, research is
needed which assists NGOs to: identify their preferred long-term and medium
term role within the health sector (this may differ from their present role);
determine the true costs of current operations; identify areas of inefficient
operation (both within and between organizations); identify medium- and long
term strategies; and, identify means to improve efficiency. Furthermore,
research is required that results in evaluative techniques, and indicators of
output and efficiency, which can be easily used by NGOs.
54
CONCLUSION
HIGHLY REGULATED
I
Provision of services
through quangos, social
security
institutions,
NGOs
PUBLIC
________________
PROVISION
State (centrally planned
__ 1 _______ I J and
provided
I
I
I
I
I
I
Private
provision
under standard speci
fications
PRIVATE
PROVISION
+
Free market
I
I
LITTLE REGULATION
Figure 4. Mix of service provision and regulatory controls.
A number of themes have run through this article. Firstly, the heterogeneity
of organizations operating in the health sector (both between countries and
within them); secondly, the present and potential impact of the non-state sector;
thirdly, the present incomplete state of the art relating to the economics of the
public/private mix; fourthly, the different social objectives between countries
on which policy is made; and lastly, the lack, in many countries, of a clear
framework for policy formulation in this field. On that last point, however,
there would appear to be little justification for global blanket policies about
NGOs, in the absence of specific country analysis, and an understanding of
each particular NGO. There may be more justification for broad policies
towards the private-for-profit sector where more homogeneity is exhibited, and
where the negative effects are apparent.
ISION OF HEALTH CARE IN DEVELOPING COUNTRIES
57
A. GREEN
56
RESOURCE IMPLI
CATIONS
MEASURE
Nationalization — the
take-over and continual
operation, with or with
out compensation, of
facilities
DEGREE OF
REGULATION/
CONTROL
Major resource
implications
I
]
i
l
I
i
i
I
I
Legislative requirement
for industrial health care
l___________________
T
Increase or decrease in
| Resource implications
subsidy/subvention —
[ either positive or
either on a general basis, i negative
or specific to certain items ]
or functions
i
i
Designation of hospitals
as government agents
Provide seed money for
initiatives (through
subventions, grants or
fiscal incentives)
i Would allow complete
I integration into national
j system
+
I May require funding,
! through subventions or
I through agreed fees for
| service
1-----------------
| Provides an opportunity
' for closer coordination of
. _____ frxfol
services without total
I integration; can be used
I
I to encourage provision of
I certain services
I
[
Fiscal Policy
Revenue earner/loser
j Minimal funding
I requirements other
| than regulatory
• mechanism and
i inspectorate
l Allows integration into
} the government planning
I system, without total
I management
■ responsibilities
| Can be linked to specific
factors
|
l
I
|
I
May be difficult to
enforce; can be applied
on costs or quality
(including type of
technology adopted)
i______________________ ____
I
• Reciprocal participation
l on decision-making
I
j bodies; encouragement of
I
l
I central coordinating
I
j bodies, etc
I
l
- -------------------------------- —- ---------------------------------I Can be used to control
Foreign exchange controls I May have positive
| drugs, and importation of
economic
benefits
i
| equipment
I
Minimal
Encourage collaborative
j
------------
r
i
Manpower controls
(
i
—i---------------------------------------------
Minimal direct
implications
—
1
Central drug supply
controls
Legislative prohibition of
certain categories of
health care
Resource requirements
in short term
I
I
4-------------------------------------I
I
|
!
Minimal government;
may affect industrial
profits
i
|
I
j
May be used to
underwrite new,
innovatory forms of
organization
4-------------------------------- —
i Problems of
I
implementation
i
I_______________________
-4
•
l
I___________________________ —I
7
Direct regulatory action
l
]
I
Figure 5. (continued)
l
l____________________________ 1----------
“I
DEGREE OF
REGULATION/
CONTROL
RESOURCE IMPLI
CATIONS
MEASURE
| Through bonding,
I licensing, licensing etc
—I
I Central drug policies
)
Minimal
}
I
I
May require funding to) | May drive such activities
i as private care underprovide replacement
i ground
services
I
l
I____________________________“IiI____________________________
7I-"
Figure 5. Selected policy options open to government.
A
%
-
Three main types of institution are involved in policy formulation in this field
— the national governments in developing countries, NGOs and the private
sector institutions themselves, and aid agencies. Whilst each of these is likely
to have different policy objectives, they share much common ground in their
need for information and analytical tools on which to formulate their policy
actions, and it is in this area — the development not of policies themselves,
but rather of tools and criteria that can be used to formulate policies, that, it
is argued, urgent research attention should be focused. The following summa
rizes the main questions which need to be addressed in each country in order
for robust and relevant policies to be formulated.
Firstly, basic question that needs to be answered for each country concerns
the present size of the non-state health sector, both in aggregate terms (by
facility, resource and expenditure) and by type. Where financing or comprehen
sive sector reviews surveys have been carried out, this information may be
available; in other countries, research may be required to determine this basic
picture. Some further attention also needs to be given to develop definitions
that describe accurately the different types of organization.
Secondly, not only is country-specific information required as to the current
size of the non-state sector, but information is needed that describes past trends,
and projects into the future, in the absence of policy changes, the future size
of the sector. Thirdly, a number of possible characteristics on non-state sector
hospitals have been set out in this article, the precise configuration of which
will vary as a result of the country or organization context. Tools need to be
developed to allow the analysis of such characteristics.
Finally, this article has reviewed a series of issues that relate to the effects
that the non-state sector have on the availability and utilization of resources.
These issues have been identified as a series of questions, for the answer to
which evaluative tools need developing. The size and potential impact of the
non-state sector upon health care and upon health itself strongly suggest that
policy development and, hence, research in this area should be seen as a
priority.
*
58
A. GREEN
INTERNATIONAL JOU
OE HEALTH PLANNING AND MANAGEMENT, VOL. 2, 59-65 (1987)
ACKNOWLEDGEMENTS
This article is based on work completed in 1986 on behalf of the World Bank,
whose support is hereby acknowledged. The views expressed within the paper
do not, however, necessarily reflect World Bank policies, nor is the World
Bank responsible for its content.
The author would like to thank Carol Barker, Nuffield Centre for Health
Services Studies, University of Leeds, and Ann Mills, London School of
Hygiene and Tropical Medicine, for comments on an earlier draft.
REFERENCES
Ii
Abel-Smith, B. (1985). Global perspectives on health service financing. Social Science
and Medicine 21 (9). 957-963.
Brown G., Tenn, W. (1985). Management in church hospitals. International Hospital
Federation, Official Yearbook, IHF.
Cumper, G. (1986). Health Sector Financing: Estimating Health Expenditure in Develop
ing Countries. EPC Publication No. 9. London: London School of Hygiene and
Tropical Medicine.
de Ferranti, D. (1985). Paying for Health Services in Developing Countries: An Overview.
World Bank Staffing Working Paper No. 721. World Bank.
Dunlop, D. (1983). Health care financing: recent experience in Africa. Social Science
and Medicine 17 (24), 2017-2025.
Eldar, R. (1983). Quality assessment and assurance in hospitals of developing countries.
Public Administration and Development 5 (1), 13-24.
Gish. O. (1971). Doctor Migration and World Health. Occasional Papers in Social
Administration, No. 43. London: bell.
Glazer. W.A. (1970). Paying the Doctor: Systems of Renumeration and Their Effects.
Baltimore: John Hopkins.
Kolobe, Pekeohe. (1980). A survey of the financial status of the private health association
of Lesotho’s hospital. Private Health Association of Lesotho, estimate 70% of
recurrent expenditure by private hospitals is recovered from user charges. Quoted
in: Prescott, N., Warford, J., Economic appraisal in the health sector. In: Lee. K.,
& Mills, A., (Eds). (1983). The Economics of Health in Developing Countries.
Oxford: Oxford university Press.
McGilvray. J. (1974). An exercise in the development of health care priorities. Christian
Medical Commission.
McGuire, A. (1985). The theory of the hospital: a review of the models. Social Science
and Medicine 20 (11), 117-184.
Majone, G. (1984). Professionalism and non-profit organisations. Journal of Health
Politics, Policy and law 8 (4), 639-659.
Rankin, J.P. (1985). Volunteers in primary health care: problems and possibilities.
World Health Forum 6, 24-26.
Roemer, M I. et al. (1984). Private medical practice: obstacle to health for all. Round
Table Discussion. World Health Forum 5, 195-210.
Scarpaci, J.L. (1985). Restructuring health care financing in Chile. Social Science and
Medicine 21 (4), 415—431.
Schulpen, T.W.J. (1975). Integration of Church and Government Medical Services In
Tanzania: Effects at District Level. African Medical and Research Foundation, Nai
robi: AMREF.
Segall, M. (1983). Planning and politics of resource allocation for primary health
care: promotion of meaningful national policy. Social Science and Medicine 17 (24),
1947-1960.
WHO. (1985). Collaboration with non-governmental organisations in implementing the
global strategy for Health for All. Background document for the Technical Discussions
at the 38th World Health Assembly. Geneva: WHO.
World Bank. (1975). Health Sector Policy Paper. Washington: World Bank.
SHORT COMMUNICATION
SPECIALLY DISADVANTAGED GROUPS: A '
CHALLENGE FOR HEALTH SERVICES
Per-Gunnar Svensson
Scientist, Health Research, Regional Office for Europe, World Health Organization. 8.
Scherfigsvej, DK-2100 Copenhagen. Denmark
1985 saw the publication, by the World Health Organization, Regional Office
for Europe, of a text that is intended to set out the fundamental requirements
for people to be healthy, to define the improvements in health that can be
achieved by the year 2000 for the peoples of the European Region of WHO.
and to propose action to secure those improvements (WHO, 1985a). The
strategy in that book also calls for the formulation of specific regional targets
to support its implementation. This short communication spells out the main
elements in that overall commitment by the European Member States, and
focuses directly on the health needs of those most disadvantaged.
As the WHO text states clearly, if health for all is to be reached in Europe
by the year 20(X) (HFA 2000). two basic issues must be tackled: first, to reduce
health inequalities among countries and among groups within countries; and,
second, to strengthen health as much as to reduce disease and its consequences.
Thus, health for all in Europe has four dimensions as regards health outcomes,
involving action to:
— ensure equity in health, by reducing the present gap in health status between
countries and between different population groups within countries;
— add life to years, by ensuring the full development and use of people’s
integral or residual physical and mental capacity to derive full benefit from
and to cope with their life situation in a healthy way;
— add health to life, by increasing the number of years people live free from
major diseases and disabilities;
add years to life, by reducing the number of premature deaths, and thereby
increasing life expectancy at birth.
Here, the HFA strategy will be judged in years to come to the extent that it
achieves these four aims, the key being the manner in which individual countries
come to grips with the basic issues identified.
A number of the targets in the strategy deal with the concern (WHO, 1985a)
to reduce inequity in health, and with the disadvantaged. Indeed, the very first
target of the European HFA strategy reads:
0749-6753/87/010059-07-$05.00
© 1987 by John Wiley & Sons, Ltd.
’
HEALTH
A
PRECIOUS
ASSET
Accelerating fol low-up to the
World Summit for Social Development
Proposals by the
World Health Organization
i
HEALTH: A PRECIOUS ASSET
Contents
HEALTH: A PRECIOUS ASSET
5 Foreword by Gro Harlem Brundtland, Director General, World Health Organization
7 Introduction
Five years after the Copenhagen Summit
9 The health revolution that left out a billion people
10 Major health problems of the poor
• HIV/AIDS
• Malaria
• Tuberculosis
• Malnutrition
• Maternal mortality
• Water-borne diseases
• Respiratory infections
• Childhood immunization
13 Health services in crisis
• Inequities between countries
• Inequities within countries
• Anti-poor delivery of services
• Decline of the government health sector
World Health Organization's Proposals for Action
15 Making health a force for poverty reduction
16 Strengthening global policy for social development
17 Integrating health dimensions into social and economic policy
• Health in macroeconomic policy
• Trade in health goods and services
• Health and the promotion of full employment
19 Developing health systems which target health problems affecting poor and vulnerable populations
• Substantial reductions in the major diseases affecting the poor
• Equitable health financing systems
• Promotion of responsible health stewardship
22 References
4
HEALTH: A PRECIOUS ASSET
Foreword
The world has committed to halving the number of people living in extreme
poverty by 2015, and a set of concrete targets has been set.
Many of themfocus on health — on child and maternal health and
access to primary and reproductive health care. To me it is clear that we must
strengthen ourfocus on the pathway that leadsfrom health to
poverty reduction and sustainable development.
Until recently, many developmentprofessionals have argued that
the health sector, itsef, is only a minorplayer in efforts to improve the overall
health of populations. And the overwhelming majority offinance officials and
economists have believed that health is relatively unimportant as a development
goal or as an instrumentforpoverty reduction. 'Health was seen as a
consumption rather than an investment cost.
But this is changng. We are standing on the threshold of a major
shift in thinking. Health is increasingly being seen as a crucially important
asset of poorpeople. From this perspectiveprotecting and improving health are
central to the entire process of poverty eradication and human development.
It is the purpose of this report to share WHOi views on health in development.
I believe that the Special Session of the UN GeneralAssembly
in Geneva in June 2000 offers a timely opportunityfor
international endorsement of a more robust,
multidimensional approach to human development
and its social components, particularly health.
Gro Harlem Brundtland
Director General
World Health Organization
5
HEALTH: A PRECIOUS ASSET
Health as an asset
" The wealth ofpoor people is their capabilities and
their "assets". Of these, health is the most precious
and important. Health allows poor people the oppor
tunity to participate in the labour market or in the
production ofgoods. It is a key to productivity. Having
a fit, strong body is an asset to anyone: a sick, weak
and disabled body is a liability, both to the persons
affected and to those who must support them. When
breadwinners die or experience episodes of ill-health
or long-term disability the results can be disastrous
for the entire household. The family faces not only a
loss of income and care but also needs to find the
money to cover medical care costs as well. Health
calamities are a common cause of impoverishment.
If health is an asset and ill-health a liability for poor
people, protecting and promoting health are centra! to
the entire process ofpoverty eradication and human
development. As such they should be goals of devel
opment policy shared by all sectors - economic, envi
ronmental and social. "
6
HEALTH: A PRECIOUS ASSET
Introduction
‘ We commit ourselves to the goal of eradicating extremepoverty in the world, through decdive national actions and international cooperation, as an
ethical, social, political and economic imperative of humankind. ”
Copenhagen Declaration, World Summit for Social Development, 1995
ive years after the commitments were
made at the World Summit for Social
Development
(WSSD)
in
Copenhagen, progress in achieving the targets
has failed to match expectations. Whereas the
Summit aimed for substantial reductions in the
number of people living in extreme poverty,
the number has actually grown. Nor has much
progress been made in the objective of achiev
ing universal health care. In some countries
access has deteriorated, particularly for the
poorest populations.
Nevertheless, the international consensus
on what constitutes the essential elements of
human development has progressed. Belief
in economic liberalization has given way to a
global social concern. There is a greater un
derstanding that effective human development
policy must allow a better integration of eco
nomic, social and environmental concerns.
The centrality of health has been
recognized. Health is seen as both a critical
input to development and as an outcome of
development, as well as a fundamental human
right with a value in and of itself. Herein lies
the opportunity which must be seized in
“Copenhagen Plus Five”, the five-year follow
up meeting. It takes place in Geneva, 26-30
June 2000, as the Special Session of the United
Nations General Assembly on the Implemen
tation of the Outcome of the World Summit
for Social Development and Further Initiatives.
Health as an asset
The wealth of poor people is their capabilities
and their “assets”. Of these, health is the most
precious and important. Health allows poor
people the opportunity to participate in the
labour market or the production of goods. It
is a key to productivity. Having a fit, strong
body is an asset to anyone: a sick, weak and
disabled body is a liability, both to the persons
affected and to those who must support them.
When breadwinners die or experience episodes
of ill-health or long-term disability, the results
can be disastrous for the entire household. The
family faces not only a loss of income and
care but also needs to find the money to cover
medical care costs as well. Health calamities
are a common cause of impoverishment.
If health is an asset and ill-health a liability
for poor people, protecting and promoting
health are central to the entire process of pov
erty' eradication and human development. As
such they should be goals of development
"teS• It
'HlS
Health improvements are disproportionately beneficial to the poor because
they are wholly dependent on their labour power.
policy shared by all sectors — economic, envi
ronmental and social.
A multisectoral vision
The Copenhagen Declaration and Programme
of Action accorded responsibility for health
to basic health services. This narrow percep
tion of health undervalues the contribution
of improved health status to development. At
the same time, it does not recognize the
potential of many sectors to foster the health
of poor people in the interests of furthering
human wellbeing. Any positive contribution
to human and social capital is the result of the
improved health status of populations, and not
merely the output of health service industry.
Better health contributes to sustainable liveli
hoods and human development.
Universal access to health services is
important. But if health is to fulfil its potential
in human development, the services required
need to have the capacity to improve health
status and to reduce the inequities in health.
Health inequities are in themselves contribu
tors to ill health.
The World Health Organization believes
that the Special Session of the UN General
Assembly in Geneva in June 2000 offers an
extremely timely opportunity to build on the
commitments of the Copenhagen Summit by
obtaining an endorsement for a more robust,
multidimensional approach to human
7
" When breadwinners die or
experience episodes ofill-health
or long-term disability, the
results can be disastrous for the
entire household."
HEALTH: A PRECIOUS ASSET
Health in Human Development
Determinants of development
Determinants of health of the poor
Health sector
Major disease
burden of the poor
Social
development
e.g. more effective
learning
Health system:
financing, provision,
stewardship
Protection and
improvement of health
status:
Dimensions of health in development
Longer life expectancy
Reduced morbidity/mortality
Improved nutritional status
Lower fertility rates
>•
Human
development
e.g. well-being
increased
Reducing risk factors
A Economic
development
e. g. more days
worked per year
Influencing social,
economic and
environmental policies
Source: WHO/HSD
development with strengthened social com
ponents, particularly relating to health.
Further information
Poverty eradication as part of the overall development goal
In societies with clear policies on equality and democracy, and where the overall
goal of equity is the improvement of the health status of the entire population,
the chances of health development for the poorest people is higher. Experi
ences from countries with a historical commitment to health as a social goal,
and to equality as a political goal, confirm this. Costa Rica, Sri Lanka and the
state of Kerala in India have achieved considerable improvements in the health
status of their populations by a series of political, social and economic interven
tions in society as a whole, actively involving communities in the process. In
Costa Rica, where health is considered an "investment in the nation, a neces
sity for social vitality and economic progress," progressive health policies have
increased the income of the poorest 10% of the population by more than 65%.
Source: "Poverty and health: Who lives, who dies, who cares?" Macroecon
omics, Health and Development Series, No. 28 by Margareta Skbld, Depart
ment of Health in Sustainable Development (HSD), WHO/ICO/MESD.28
8
This report is necessarily brief and selective.
It responds to the request of the preparatory
committee for the Special Session of the UN
General Assembly for information on progress
in achieving universal access to primary health
services.
The report begins with a summarized
global update on the main diseases and condi
tions which disproportionately affect the poor.
It also describes current problems in health
services. The second section sets out a number
of proposals for action, within the Copenhagen
framework, which the World Health Organi
zation believes can make health a significant
force for poverty reduction.
The information in this document will be
supplemented by the World Health Report
2000.
HEALTH: A PRECIOUS ASSET
Five years after the Copenhagen Summit
THE HEALTH REVOLUTION THAT LEFT OUT A BILLION
PEOPLE
he 20th century has seen a global
transformation in human health
unmatched in human history. Over
the past three decades, overall improvements
in health and human development can be illus
trated as follows:
• Infant mortality rates have fallen from 104
per 1000 live births in 1970-75 to 59 in 1996.
On average, life expectancy has risen by four
months each year since 1970.
• Per capita income growth in developing coun
tries has averaged about 1.3 percent a year,
bringing relief from poverty for millions of
people.
• Governments report rapid progress in
primary school enrolment. Adult literacy has
risen, from 46 to 70 percent.1
We can soon expect a world without polio
myelitis, with no new cases of leprosy, and with
no more deaths from guinea worm.
But over one billion people — one in six of
the world’s population — will enter the 21st cen
tury without having benefited from the health
and human development revolution. The lives
of these people are difficult and short, and
scarred by a ruthless disease called “extreme
poverty”. Extreme poverty is categorized as a
disease under code Z59.5 in WHO’s
International Classification of Diseases.
Growing disparities
Unacceptable and growing disparities in the
health of rich and poor countries, rich and poor
people, and between men and women, are
important characteristics of human kind at the
start of this new millennium. It is only if the
health problems of the poor can be reduced
that human assets can be liberated for social
development.
It is hard to give a detailed, up-to-theminute account of trends in the health of poor
and vulnerable populations since 1995. We
must frankly acknowledge that the poor qual
ity or, in some instances the absence, of data
is a significant obstacle to tracking the health
status of the poor.
However, it is now generally recognized
that the many dimensions of poverty including
lack of basic education, inadequate housing,
social exclusion, lack of employment or
opportunities, environmental degradation, and
low income all pose a threat to health. On every
health indicator studied by the World Health
Organization, the poor fare worse than the
better off in any given society. Specifically,
compared to fellow citizens, those living in
absolute poverty are:
• Five times more likely to die before reach
ing the age of 5 years
• Two and a half times more likely to die
between the ages of 15 and 59 years.
Potentially deadly infections, such as HIV/
AIDS, malaria, tuberculosis and diarrhoeal
diseases, disproportionately affect poor people
producing devastating effects on households
and national economies. As a result, the World
Health Organization accords high priority to
controlling these diseases - a task made espec
ially difficult by the evolution of drug-resis
tant microbes. Major current health problems
such as malnutrition and maternal mortality
also have a greater prevalence among the poor.
"One in six of the world's
population will enter the 21st
century without having
benefited from the health and
human development
revolution."
Health status of the poor versus the non-poor in selected countries, around 1990
Country
Aggregate
Chile
China
Ecuador
India
Kenya
Malaysia
Percentage of
population
in absolute
poverty
15
22
8
53
50
6
____________ Probability of dying per 1000
between birth
between ages 15
and 59, females_____
and age 5, females
Non-poor Poor:non-poor
Non-poor Poor:non-poor
ratio
ratio
38
7
28
45
40
41
10
4.8
8.3
6.6
4.9
4.3
3.8
15.0
92
34
35
107
84
131
99
4.3
12.3
11.0
4.4
3.7
3.8
5.1
Prevalence of
tuberculosis
Non-poor
Poor:non-poor
ratio
23
2
13
25
28
20
13
2.6
8.0
3.8
1.8
2.5
2.6
3.2
Poverty is defined as income per capita of less than or equal to $1 per day, expressed in dollars adjusted for purchasing power.
Source: World Health Report 1999, Making a difference.
9
HEALTH: A PRECIOUS ASSET
MAJOR HEALTH PROBLEMS OF THE POOR
HIV/AIDS2
"Developing countries have
95% ofcases... Yet, developing
countries only receive about
12% ofglobal spending on
HIV/AIDS care. “
The prevalence of HIV/AIDS is associated
with poverty:
• More than 95% of all HIV-infected people
now live in the developing world, which has
likewise experienced 95% of all deaths to
date from AIDS, largely among young adults
who would normally be in their peak pro
ductive and reproductive years.
• The economic effect of HIV/AIDS on
households is devastating. From household
surveys in Africa and Asia we know that
families living with HIV/AIDS have an
income reduction of 40-60%. The inevitable
response is the spending of savings, borrow
ing, and reductions in consumption.3
• HIV/AIDS illustrates the effect of multi
dimensional poverty on health. The socio
economic factors contributing to the spread
of HIV/AIDS include: illiteracy related to
income poverty; gender inequality; increased
mobility of populations within and between
countries; and, rapid industrialization involv
ing the movement of workers from villages
to cities, with consequent breakdown of
traditional values.4
• HIV/AIDS also illustrates the global equity
gap. Successful public health measures have
stabilized the epidemic in most developed
countries, but the same is true only of some
developing countries. Developing countries
have 95% of cases, and many poor countries
are experiencing exponential growth of
HIV/AIDS cases. Yet, developing countries
only receive about 12% of global spending
on HIV/AIDS care.5
Malaria6
Malaria hits hard on the poor and the vulner
able:
• Over one million people die of malaria each
year of which almost 90% occur in subSaharan Africa.
• Malaria is directly responsible for one in five
childhood deaths in Africa. Indirectly, it con
tributes to illness and deaths from respira
tory infections, diarrhoeal disease and mal
nutrition.
• For reasons which are not fully understood,
women are more susceptible to malaria
during pregnancy. This is particularly so
during the first pregnancy. Fetal growth, and
the survival of the new-bom, may be seri
ously compromised.
Malaria flourishes in situations of social
and environmental crisis, such as mass migra
tion, military conflict and social unrest, where
health systems are weak and communities dis
advantaged.
The severity and urgency of the problem
has led to the formation of global partner
ships to control malaria. Roll Back Malaria,
a World Health Organization initiative, is a
coalition involving the United Nations Devel
opment Programme (UNDP), UNICEF,
WHO and the World Bank. Roll Back Malaria
assists health systems to deliver the cost effec
tive interventions that exist to control malaria.
The initiative harnesses the support of the
private and public sector in developing new
malaria drugs and vaccines.
Tuberculosis8
Tuberculosis and poverty are closely linked.
Both the probability of becoming infected, and
the probability of developing clinical disease
are associated with factors which are associ
ated with poverty. These factors include mal
nutrition, overcrowding, poor air circulation
and inadequate sanitation. Given the often
crowded conditions in which poor populations
live, they are more likely to contract tubercu
losis. At the same time, those who contract
the disease are more likely to become poor
given the economic consequences of the
disease. Ninety-five per cent of cases and
deaths occur in developing countries.
Tuberculosis is a growing problem in many
regions of the world. It is on the rise in devel
oping and transition economies due to a com
bination of economic decline, insufficient
application of control measures, and the HIV/
AIDS epidemic. People whose immune
defences are weakened by HIV infection
become an easy prey for other microbes,
including the bacillus that causes tuberculosis.
The resulting infections (along with some
cancers) are responsible for the recurring ill
nesses which in their late stages are called
“AIDS”, and which ultimately lead to death.9
• Between 1993 and 1996 there was a 13%
increase in estimated tuberculosis cases
world-wide, one third of which can be
attributed to HIV.10
Global distribution of death by main causes
Communicable diseases, such as tuberculosis and respiratory infections as well as
maternal, perinatal and neonatal causes account for about 20 million, or 40% of global
deaths. Ninety-nine per cent of these deaths occur in developing countries.
Source: "Bridging the gaps", World Health Report 1995.
10
HEALTH: A PRECIOUS ASSET
• Around 30% of all AIDS deaths result
directly from tuberculosis.11
• WHO estimates that by the end of the
century, HIV infection will cause an addi
tional 1.5 million cases of tuberculosis
annually.12
Concerted efforts to end social apathy
towards TB; to expand the global coalition of
partners involved in TB control; and, to advo
cate for TB to be placed high on the interna
tional agenda are currently being mounted
through the STOP TB Initiative based at the
World Health Organization. The initiative is
creating a social and political movement against
TB by promoting the use of the cost effective
Directly Observed Treatment Short-course
(DOTS).
Malnutrition13
Nearly 30% of humanity is currently suffering
from one or more of the multiple forms of
malnutrition. Protein-energy malnutrition and
iron deficiency anaemia are major sources of
concern, iodine deficiency is the greatest single
preventable cause of brain-damage and mental
retardation (affecting 740 million people or
13% of the world’s population) and Vitamin A
deficiency (VAD) remains the single greatest
cause of preventable childhood blindness.
Overall, malnutrition accounts for 15.9% of
the global burden of disease.14
Each year some 49% of the 10 million
deaths taking place among children under five
in the developing world are associated with
malnutrition. Currently, 26.7% of the world’s
children under five years are malnourished
when measured in terms of weight for age.
Recent achievements:
• Remarkable progress has been made in con
trolling iodine deficiency disorders (IDD)
in the last decade. More than two-thirds of
households living in IDD-affected countries
now consume iodized salt, and 20 countries
have reached the goal of universal salt
iodization (USI) defined as more than 90%
of households consuming iodized salt.
• There has been progress since 1990 in com
bating VAD. In 1997, it was estimated that
in about 30 countries, 50% of children were
either given vitamin A supplements or had
access to fortified food.
However, progress in reducing protein
energy malnutrition (PEM) among infants and
young children is exceedingly slow, and little
progress has been made in reducing the preva
lence of anaemia over the past two decades.
Maternal mortality
The death of a mother is a catastrophe in any
family. In many developing countries, it
deprives a household of a vital income as well
as love and affection. When a mother dies in a
poor families, the loss is such that it may also
spell death for her children.
Every year 585 000 poor women die from
the complications of pregnancy and childbirth.
In developing countries, maternal mortality and
morbidity is by far the greatest cause of pre
mature death and disability amongst women
aged 15 to 44 years. Women in Northern
Europe have a one in 4000 risk of dying from
pregnancy-related causes. For women in
Africa, the ratio is one in 16. There could hardly
be a more striking disparity between North
and South than this.
The target of the International Conference
on Population and Development (ICPD) in
1994 was to reduce 1990 levels of maternal
mortality' by half by the year 2000 — a target
which will not be met - and by a further half
by the year 2015.lr’ New targets were agreed
in the five-year review of the ICPD in 1999.
They are that at least 40% of all births should
be assisted by skilled attendants where the
maternal mortality rate is very high, and 80%
globally by 2005; these figures should rise to
50% and 85% respectively by 2010; and to
60% and 90% by 2015.16 '
In October 1999, WHO, the United
Nations Population Fund (UNFPA), UNICEF
and the World Bank combined forces in a joint
commitment to fight maternal mortality more
effectively.
"Currently, 26.7% of the
world's children under flveyears
ofage are malnourished."
Water-borne diseases17
Diarrhoeal diseases, largely preventable
through access to adequate clean water and
sanitation, claim nearly two million lives a year
and account for 1.5 billion bouts of illness each
year in the under-five age group. Diarrhoeal
diseases impose a heavy burden on develop
ing countries. The World Health Organization
estimates that diarrhoeal diseases accounted
for 73 million disability adjusted life years
(DALYs)18 lostin!998.19
Out of the total global population of six
billion:
• More than 1 billion people are highly vul
nerable to diarrhoeal diseases because they
do not have ready access to an adequate and
safe water supply.
• Approximately 3 billion people are
vulnerable because of they lack access to
any form of improved excreta disposal
services.
Respiratory infections
In 1998, acute respiratory infections (ARIs)
were responsible for approximately 3.5 million
deaths among people of all ages world-wide.
Almost 2 million of these deaths were in
children under the age of five years. Pneumo
nia kills more children than any other infec
tious disease, and 99% of these deaths occur
in developing countries.
The World Health Organization estimates
that acute respiratory infections accounted for
83 million DALYs lost in 1998.20 An over11
Trained childbirth assistance drastically
reduces the risk involved in
becoming a mother.
HEALTH: A PRECIOUS ASSET
whelming proportion of this burden of disease
is attributable to environmental factors.
Children the world over die of respiratory
infections associated with poverty and poor
housing.
Mothers are also vulnerable to respiratory
infections. Hundreds of millions of adult
women in developing countries are exposed
to extremely high levels of airborne particles
when cooking with biomass fuels. Studies in
India and Nepal have shown that chronic
obstructive lung disease and cor pulmonale are
common, and develop at an early age, in
women exposed to high levels of indoor
smoke.21
Four out of five children are fully
immunized against six major
killer diseases.
12
Childhood immunization
Globally, immunization coverage has contin
ued to increase slowly. Yet, one in five children
is not fully immunized against the six major
killer diseases: diphtheria, whooping cough,
tetanus, polio, measles and tuberculosis.22
On 31 January 2000, the new Global
Alliance for Vaccines and Immunization
(GAVI) was formally announced at the World
Economic Forum in Davos, Switzerland. It
represents a commitment by the World Health
Organization, UNICEF, the World Bank,
industry, philanthropic foundations and public
sector agencies to work in parmership towards
the protection of all children against major
vaccine-preventable diseases.
HEALTH: A PRECIOUS ASSET
HEALTH SERVICES IN CRISIS
In the 25 years since the Alma-Ata Declara
tion was signed, the rapid and sustained
progress towards “Health for All” that was
hoped for has not been realized. Figures which
give reliable, comparable and recent estimates
on health care coverage and access to care are
not always available. However, the picture
which does emerge is profoundly disturbing.
In too many countries health systems are illequipped to cope with present demands - let
alone those they will face in future. Certainly
the call for universal access to basic health
services made five years ago at Copenhagen
has not been heeded.
The inequities in health are striking, both
between countries and within them.
Inequities between countries
The differences between developed and
developing countries in terms of access to ser
vices can be illustrated as follows:
• In developed countries there may be one
nurse for every 130 people and one phar
macist for every 2000 to 3000 people. A
course of antibiotics to cure pneumonia can
be bought for the equivalent of 2 to 3 hours’
wages. A one-year treatment for HIV infec
tion costs the equivalent of 4 to 6 months’
salary. And the majority of drug costs are
reimbursed.
• In developing countries there may be only
one nurse for every 5000 people and one
pharmacist for 1 million people. A full course
of antibiotics for pneumonia may cost
one month’s wages. In many poorer
countries, a one year HIV treatment costs
the equivalent of 30 years’ income. And the
majority of households must buy medicines
with money from their own pockets.
Total government expenditure on health
services is too low in poor countries. This is
true despite the fact that social services may
comprise 20% of government spending. A
serious, aggravating factor has been the low
level of international aid during the past
decade. On current trends, the absolute levels
of resource transfers required to help the poor
est countries attain the international develop
ment goals will not be achieved.
Inequities within countries
Within countries, the distribution and
delivery of health care is often anti-poor. In
most countries of the world the distribution
of services remains highly skewed in favour
of the better-off.
Recent studies have underlined patterns of
resource allocation, both human and financial,
that are de facto anti-poor. For example, the
majority of health personnel is found in urban
areas, while the great majority of the poor live
in rural areas. Financial resources favour hos-
pital-based curative care whereas the poor need
accessible and affordable primary health care.
Allocations also favour personal medical care
when the poor benefit most from broad public
health measures such as clean water and sani
tation.
Anti-poor delivery of services
The delivery of health care itself is often
profoundly anti-poor. There is rarely, if ever,
a focus on the risk factors that are the root
causes of the ill health of the poor. And
services are rarely designed with the poor in
mind. For the poor, time is truly money and
opportunity lost. This is reflected in how far
they have to go to obtain a service, how long
it takes them to travel there, how much the
transport costs, whether only one service (or
several services) is available in any given
session, and how much waiting time there will
be. Any of these factors may be financial
barriers to the services - in addition to official
and non-official hospital, laboratory and medi
cation charges.
Women face particular constraints of time
and mobility, and with regard to the decisions
they can make about their own health and that
of their children. For them, these barriers in
access to care represent a clear obstacle to
health.25
Another obstacle is the way poor people
are received in hospitals. A number of studies
have brought to light the lack of dignity and
respect shown by health personnel. One study
in a primary health care centre serving a
primarily poor population in a developing
country highlighted that an average of only
54 seconds was given to each patient.24 No
time for dialogue, no time for explanation,
barely time for any human contact.
In times of sickness, those without assets
do not even attempt to seek treatment. Those
who do have some assets may sell them to
raise money for care, or may use them as
security to borrow from moneylenders at high
rates of interest. Herein lies the route from
sickness, or injury, to poverty and destitution.
With assets disappearing, especially if it is the
breadwinner who has fallen ill, the loss of the
precious income-earning asset makes the
situation particularly desperate.
Voices of the poor
" We watch our children die because we
cannot pay the high hospital bills." Ghana 1995
Source: " Voices of the Poor, Can any
one hear us?" Oxford University Press
for World Bank, 2000.
13
" Within countries, the
distribution and delivery of
health care is often anti-poor"
HEALTH: A PRECIOUS ASSET
Decline of the government
health sector
"Spontaneous, unmanaged
growth in any country's health
system cannot be relied upon
to ensure that the greatest
health needs are met."
Unfettered market intervention in health
care is anti-poor. A recent review of health
services in one country concluded: “Due to
the prevailing situation in the government
sector, there has been an unprecedented
growth of the private sector, in both primary
and secondary health care all over the country.
Given the current ethical standards of the
medical profession and totally free market tech
nology-driven operational principles, the pri
vate sector generally does not provide quality
health care at reasonable cost. Before this
sector becomes a public menace, it is neces
14
sary to introduce participatory regulatory
norms.”25
A clear historical lesson emerges from
health systems development in the 20th century:
spontaneous, unmanaged growth in any
country’s health system cannot be relied upon
to ensure that the greatest health needs are
met. In any country, the greatest burden of
ill-health and the biggest risk of avoidable
morbidity' or mortality are borne by the poor.
Public intervention is necessary to achieve
universal access. While the equity' arguments
for universal public finance are widely
accepted, the fact that this approach also
achieves greater efficiency is less well known.26
HEALTH: A PRECIOUS ASSET
WHO's Proposals for Action
MAKING HEALTH A FORCE FOR POVERTY REDUCTION
he ultimate objective of develop
ment is improvement in the human
condition — of which enjoyment of
good health is an essential part. However, while
improving health status is an essential objec
tive of the development process, the capacity
to develop is itself dependent on good health.
If health interventions are to ensure a
maximum contribution to development, they
should be planned and implemented within
an integrated development framework. Today,
the health components of poverty reduction
programmes remain largely absent or marginal.
On the one hand, health authorities limit their
responsibility to the production of publicly
funded health services. On the other, the
architects of poverty reduction policies neglect
the human and social capital contributions of
health to sustainable livelihoods.
Universal access to basic health services
is important, and achieving that goal in a way
which will make a significant input to poverty'
reduction will require a massive international
effort. However, the fact remains that leaving
health to the health sector alone will not work.
The major determinants of health, including
poverty' itself, are beyond the control of health
services.
Copenhagen Plus Five can set future
development policy on a new and more effec
tive track by recognising the value of good
health status as one of the most important
assets of the poor. On that basis, the
Copenhagen Plus Five meeting should recom
mend that the protection and improvement
of the health status of poor and vulnerable
populations be adopted as a core international
development strategy. It should be shared by
all actors in the development process - social,
economic and environmental.
Strategy areas for follow-up
As its particular contribution to this new strat
egy, the World Health Organization proposes
the following three areas of action as integral
components of the follow-up to Copenhagen
Plus Five.
■
■
-
H
Health is an asset for playing, learning and working.
• Strengthening global policy for social
development
• Integrating health dimensions into
social and economic policy
• Developing health systems which can
meet the needs of poor and vulnerable
populations
Partnerships
These initiatives will require action at global,
regional and country levels in close collabora
tion with a range of partners, including the
World Bank and IMF. In addition, it is sug
gested that some activities should take place
under the auspices of the UN Economic and
Social Commissions. This would be in view
of the need both to ensure holistic and inte
grated approaches to poverty reduction, and
to take account of significant differences in
health issues between regions. The Economic
Commission for Africa (ECA) and the Eco
nomic and Social Commission for Asia and
the Pacific (ESCAP) would be particularly
important parmers since their responsibilities
span the regions with the greatest concentra-
Health and development
Conventional wisdom holds that income growth results in improved health, but that is
only part of the health-income story. The remainder concerns the role of health as an
instrument of self-sustaining economic growth and human progress. Poor health is
more than just a consequence of low income; it is also one of its fundamental causes.
To be sure, health and demography are not the only influences on economic growth,
but they certainly appear to be among the most potent.
Source: The health and wealth of nations, David Bloom and David Canning, Science
Vol. 287, 18 February 2000.
15
" The Copenhagen Plus Five
meeting should recommend
that the protection and
improvement of the health
status ofpoor and vulnerable
populations be adopted as a
core international development
strategy."
HEALTH: A PRECIOUS ASSET
tion of the extreme poor. Both EGA and
ESCAP could also serve as fora to bring to-
gether representatives of national social and
economic ministries and sectors.
STRENGTHENING GLOBAL POLICY FOR SOCIAL
DEVELOPMENT
"Reducing the striking health
inequities... requires determined
international action to turn
globalization to the full
advantage ofpoor and
marginalized populations."
The international concern for accelerated
social development that was initiated at the
Copenhagen summit is continuing to grow. It
has given rise to still-early-steps towards
defining the principles of future global policy
for social development. Much work still
remains to be done to bridge the gap between
growing social concerns and current global
practice, particularly in global trade and inter
national relations.
Reducing the striking health inequities
between and within countries requires deter
mined international action. The benefits of glo
balization need to be turned to the full advan
tage of poor and marginalized populations.
The concepts, content and strategies for a
global social development policy require
further development. Thinking needs to move
beyond traditional concepts of provision of
basic social services towards defining an
explicit pathway to the creation of social
wellbeing, social capabilities, livelihoods and
human development.
The World Health Organization proposes
to engage in the UN-wide initiative to help
take forward the process of global policy
development. WHO’s particular contributions
will include:
• building country capacities to assess the
impact and design responses to eco
nomic, technological, cultural and
political aspects of globalization on
helth equity and the health status of poor
and vulnerable populations
• building a global knowledge base on
social development with regard to health
and good practices in protecting and
improving health status of poor and vul
nerable populations
• strengthening governance for social
development through development and
advocacy of health protection norms and
standards for the guidance of the inter
national and national business sectors.
Global governance for health
There is an urgent need for a public health involvement in key discussions about the
future structure of the global political economy and the development and implementa
tion of much needed governance to manage the rapidly growing spectrum of global
activities. These discussions include: the promotion of a fairer trading system; debt
relief; a global code of best practice of social policy; new practices in international coop
eration to secure the provision of adequate public services for all, and contributing towards
a more reliable supply of and access to global public goods (such as global health). WHO
is currently working with the UN, the Bretton Woods institutions, the World Trade Orga
nization (WTO) and leading non-governmental and academic institutions worldwide to
place better health on these agendas and to promote the production, supply of and
access to health as a global public good. We need to analyse and monitor how new
international agreements can support public health. Making trade work to improve health
is a major part of our agenda in our ongoing technical discussions with WTO.
Source: "Making globalization work better for health'' by Tomris Turmen in " Responses
to globalization: Rethinking health and equity", Development Vol. 42 No. 4 December
1999.
16
HEALTH: A PRECIOUS ASSET
INTEGRATING HEALTH DIMENSIONS INTO SOCIAL
AND ECONOMIC POLICY
Macroeconomic policy has a major impact on
countries’ abilities to protect and improve the
health status of their citizens, particularly the
poor and vulnerable. Human migration, rapid
urbanization and increased road traffic are both
the results of economic policy and, through
their effects on the environment and on human
health, also the cause of massive drains on
public expenditure. For example, road traffic
accidents are predicted to become the second
major global cause of injury and ill health by
the year 2020.
Recent econometric studies and the
experiences of the East Asian countries have
brought out the important role of good health
status in stimulating economic as well as social
development. Good health is also known to
be crucial to effective learning and, for
example, improving the effectiveness of
microcredit programmes.
Maximizing the positive opportunities of
globalization whilst minimizing the negative
impacts poses particular challenges. Policy
makers need to ask themselves questions such
as what opportunities exist for identifying new
sources of revenue for health services, or for
regulating the trade of goods and services in
the interests of health equity? New tools such
as health impact assessment analysis need to
be developed to help countries to achieve the
maximum contributions of good health to eco
nomic, social, environmental and development
policies.
Health in macroeconomic
policy
Considerable international support now exists
for the inclusion of greater investment in social
determinants of development within macroeconomic policy. The well documented expe
riences of the East Asian economies have con
tributed to this new awareness. The nature of
investments will vary according to need. In subSaharan Africa and South Asia both health and
education are important priorities.
With regard to health, countries require
considerable guidance on the specific mix of
investments across a range of sectors to ensure
optimum health impact on poverty reduction.
The World Health Organization has estab
lished an international Commission on Mac
roeconomics and Health to advise WHO and
the international development community on
how health relates to macroeconomic and
development issues. The Commission’s main
areas of analysis will include: the economics
of investment in protecting and improving
health status; public policies to stimulate
development of drugs and vaccines for the
poor; health in the international economy; and,
health in international development assistance.
The World Health Organization proposes
to provide the evidence for elaborating tech
nical options and costs as the basis for more
informed macroeconomic decision-making to
improve the health of the poor by 2015 by
governments, the World Bank, the Interna
tional Monetary Fund (IMF), and Regional
Development Banks.
Trade in health goods and
services
Increasing trade in drugs, biotechnology and
health services, including private health insur
ance, have important implications for health
equity. The international agreement on the
trade-related aspects of intellectual property
rights (TRIPS) could result in the development
of new drugs and vaccines for treating the
diseases of the poor. But it could also worsen
access by poor people through price rises.
Trade in health services includes foreign
direct investment, the movement of consum
ers and providers across borders to receive and
supply health care, and the emerging areas of
e-commerce and telemedicine. In principle,
increased trade in health services could bring
needed technology and management exper-
The East Asian experience
In East Asia, the working-age population grew several times faster than the dependent
population between 1965 and 1990. The whole process seems to have been triggered
by declining child and infant mortality, itself prompted by the development of antibiotics
and anti-microbials (such as penicillin, sulfa drugs, streptomycin, bacitracin, chloroquine
and tetracycline, all of which were discovered and introduced in the 1920s, 1930s and
1940s), the use of DDT (which became available in 1943), and classic public health
improvements related to safe water and sanitation. Health improvements can therefore
be seen to be one of the major pillars upon which East Asia's phenomenal economic
achievements were based, with the demographic dividend accounting for perhaps onethird of its "economic miracle".
Source: The health and wealth of nations. David Bloom and David Canning, Science Vol.
287, 18 February 2000.
17
"Considerable international
support now exists for the
inclusion ofgreater investment
in social determinants of
development"
HEALTH: A PRECIOUS ASSET
Health and the promotion of
full employment
I
Without health, people cannot contribute to development. Policies such as free
health care contribute to the health status of the poor by reducing a major cause of poverty.
" Improving and protecting the
health status ofpoor and
vulnerable people... (is) one
means ofimproving their
employability and access to
livelihoods''
tise and, for some countries, increased export
earnings. But it could also deepen current
inequities in access to services and promote
the migration of skilled health professionals
from already underserviced areas to private
sector jobs in wealthy, urban communities.
The new openness to trade in health goods
and services presents a need to ensure that
trade agreements improve access to good
quality services particularly for poor and
vulnerable populations.
The World Health Organization proposes
to build upon its collaboration with the World
Trade Organization (WTO) and other agen
cies to help strengthen the capacities of less
developed countries to analyse the conse
quences of agreements on trade in health
services for health equity and for meeting the
health needs of the poor. WHO also intends
to help develop policies and collective negoti
ating strategies to ensure the promotion and
protection of public health.
Copenhagen Plus Five will focus particular
attention on promoting full employment,
including self employment and employment
in the informal sector. The health dimensions
of this policy are significant. People need to
be fit in order to work, and to continue to work
effectively, their health needs to be protected..
If the person is the sole breadwinner, the health
of their dependants also needs to be considered.
First, millions of people are unable to
access livelihoods or compete for employment
due to chronic ill health, undernutrition and
disability. Second, for those who are employed,
particularly in the informal sector, lack of
occupational health and safety protection can
lead to death, permanent disability and desti
tution. The International Labour Organization
(ILO) estimates that some 250 million work
ers suffer accidents at work and over 300 000
are Idlled every year. The annual death toll rises
to more than 1 million when deaths due to
occupational disease are taken into account.
The World Health ()rganization proposes
to work with ILO and other agencies to
promote health protection measures in future
international and national policies for full and
productive employment. These measures will'
include:
• Improving and protecting the health
status of poor and vulnerable people,
including the disabled, as one means of
improving their employability and
access to livelihoods
• Promoting safe and healthy settings for
work, particularly for women in infor
mal employment
• Promoting social insurance and solidar
ity mechanisms, formal and informal, to
protect households from the burden of
health care costs arising from occupa
tional causes, including in the informal
sector
• Promoting the employ ability of women
by creating community-based health
and social services for sick and depen
dent family members.
Surviving in the informal sector
The majority of the poor work in the informal sector with no social security or social
protection from any source. Innovative micro-insurance schemes are needed to pro
tect poor workers. Over 90% of the labour force in India is estimated to be in the
informal sector, and the share is believed to be extremely high in many other countries
as well. Most informal sector workers are causal workers with no direct access to
government provided social security. The Self-Employed Women's Association (SEWA)
has developed the largest and most comprehensive contributory social security scheme
in India at the present time. It presently insures over 32 000 female workers and may
offer a promising model for bringing urgently needed health, life and asset insurance to
the informal sector.
Source: "Voices of the poor, Can anyone hear us?" OUP for World Bank, 2000.
18
HEALTH: A PRECIOUS ASSET
DEVELOPING HEALTH SYSTEMS WHICH TARGET
HEALTH PROBLEMS AFFECTING POOR AND
VULNERABLE POPULATIONS
“Pro-poor” health systems are needed which
effectively target resources on the most criti
cal health problems affecting the poor and
which are financed and organized to address
the determinants of health among the poor
and vulnerable populations.
Many countries have fallen short of pro
viding basic health services which are univer
sally accessible. The majority of resources go
to expensive curative care. Basic health services
are not provided for free or low-cost to the
poorest people. Public health programmes
often ignore the health needs of household
breadwinners. And national health systems gen
erally fail to effectively manage private sector
providers from whom the poor receive much
of their care.
To halve the number of people in extreme
poverty by 2015, health systems must be more
effective in achieving greater equality of health
outcomes and greater equity in health financ
ing between rich and poor. Thus, renewed
efforts must be made to build sustainable
health systems for the poor that:
• aggressively prevent illness and protect
health,
• protect the poor and near-poor from
impoverishing health costs,
• direct more resources to improving and
maintaining the health of household bread
winners, and
• marshal the efforts of private providers
towards improved health of the poor.
The World Health Report 2000 will
address in greater depth what policy makers
and programme managers can do to create
more equitable and effective health systems
based on evidence about alternative ways to
deliver, finance and “steward”, or “responsi
bly manage”, the health care system.
Based on what is known already about
what works to improve the health of the poor,
the World Health Organization urges the
international community to join forces to
develop sustainable, pro-poor health systems
by focusing on the following three areas:
Four things must happen if these health
interventions are to have a greater impact in
improving the health of the poor.
• First, prevention and treatment resources
must be redirected to focus on cost-effec
tive interventions for the diseases and con
ditions that disproportionately affect the
poor. These “pro-poor” interventions
include the Expanded Programme on
Immunization, the Integrated Management
of Childhood Illness, the Adult Lung Health
Initiative, the Integrated Management of
Pregnancy and Childbirth, and targeted
interventions for HIV/AIDS and malaria many of which have been jointly developed
and implemented by the World Health
Organization in collaboration with
UNICEF.
• Second, health systems must better target
the poor and vulnerable by directing funds,
staff and supplies to facilities located in areas
near where disadvantaged people work, live
and learn. The benefits can also be enhanced
by designing systems to protect the poor
from out-of-pocket costs (see page 20) and
by linking the delivery of these services with
other poverty reduction programmes, such
as microcredit and employment training.
• Third, more resources must be mobilized
for the purchase of cost-effective medicines
and supplies, such as mosquito nets, antiTB and anti-malaria drugs, treatments for
"Protect the poor and near-poor
from impoverishing health
costs"
Substantial reductions in the
major diseases affecting the poor
A large proportion of the excess burden of
disease among the poor can be attributed to a
limited number of health problems - particu
larly communicable diseases such as HIV/
AIDS, malaria, measles, and TB - as well as
diarrhoeal diseases, respiratory infections, and
complications from pregnancy and childbirth.
For nearly all of these diseases or conditions,
a set of cost-effective interventions exist.
■■
IM
I
19
Countries need equitable,
pre-payment health financing which
subsidizes the poor.
HEALTH: A PRECIOUS ASSET
" WHO endorses several key
principles ofhealth system
financing."
First, countries must seek to increase the
level of pre-payment for health care via gen
eral taxation or mandated social health insur
ance contributions. This approach allows costs
to be spread in accordance with ability to pay
and helps to reduce dependence on out-ofpocket financing. Direct payments systems
restrict health care access to those who can
afford it and tend to exclude the poor from
health services.
Second, efforts should be made to subsi
dize the poor by expanding the pool of con
tributors widely so that the rich are not able to
sexually transmitted diseases, vaccines and
oral rehydration therapy. These can be con
sidered “global public goods” to the extent
that they are directed to low-income coun
tries contributing most to the spread of com
municable disease.
• Fourth, significant investment should be
made in the development of new and im
proved tools for the control of health prob
lems which disproportionately affect the
poor. On the one hand, there is a serious
lack of efficient tools due to “market fail
ure” issues; on the other, some of the drugs
now in use are rapidly losing their efficacy
due to increasing drug resistance.
“opt-out”.
Third, progressive taxes or contributory
rates are recommended. While multiple pools
may be organized for particular groups of con
tributors, subsidies across the pools should be
used to ensure fair financing.
Many low-income countries have institu
tional constraints — high levels of informal
work and weak revenue collection systems that make it difficult to develop pre-payment
systems (based on taxes or social insurance).
In the short-term, community-based pre
payment schemes can be promoted by the
World Health Organization, the International
Labour Organization and other UN agencies.
But, in the long-term, health officials must
work closely with other sectors in developing
the financial infrastructure to promote greater
social solidarity in health financing.
Equitable health financing
systems
Achieving greater fairness in health financing
is not just a laudable goal of the health system.
It is also key to protecting the income of the
poor and insulating them from economic
shocks. One of the major factors leading to
poverty is illness, which prevents people from
working and earning income, and in some cases
leads to high health spending that depletes
household savings or assets.
To increase financial risk protection of the
poor, the World Health Organization endorses
several key principles of health system financ
ing to increase financial risk protection of the
poor.
Source of funds
Private
More private
than public
More public
than private
Public
Form of payment
Out-of-pocket
insurance
Private
insurance
Social
General
revenues
Locus of cost burden
Individual
Increasingly pooled risk
Whole
population
Coverage
Poorest
excluded
Increasingly equitable
Universal
Current example
Most low
income
countries
USA
Middle income
and some
OECD countries
Other OECD
countries
Health system financing
This figure shows how risk pooling in health, and the share of public spending in total,
increase as countries move away from out-of-pocket payment methods. Various institu
tional alternatives exist for achieving universal coverage. Recent comparative research,
measuring equity in both the financing burden and the use of services by different
income groups in countries, shows that the least organized and most inequitable way of
paying for health care is on an out-of-pocket basis; people pay for their medical care
when they need and use it. The financing burden falls disproportionately on the poorest
(who face higher health care costs than the better-off), and the financial barrier means
that use of services is lower among the lower income groups, in spite of their need
being typically higher.
Source: "Making a difference", World Health Report 1999.
20
HEALTH: A PRECIOUS ASSET
Promotion of responsible health
stewardship
Health systems of the 20‘1’ century have grown
to encompass multiple actors, agencies, and
institutions. As a result, they have become more
fragmented and narrow, self-interested goals
are often pursued at the expense of overall
health objectives.
The new context has made it critical for
states to ensure that the key functions of the
health system - raising and pooling funds, pur
chasing health services, and providing care —
work in harmony to achieve overall health
system goals. This role can be called steward
ship - the responsible management of the
functions and interactions among a health
system’s multiple actors and interests to achieve
societal goals.
Responsible health stewardship implies two
key attributes:
The first is oversight of all components
of the health system. Rather than a focus on
publicly-provided services, Ministries of
Health need to make efforts to engage the
resources of the private sector. The provisions
of the private sector are especially important
for the poor given the high reliance on the
private market for health care in many lowincome countries. A combination of
approaches can be employed to harness the
resources of the private sector including
financial incentives, use of purchasing power
via contracts with private providers, consumer
information and government regulations. Gov
ernment oversight and intervention in sub
sectors of the private market for example
insurance, pharmaceuticals, and human
resource production, are necessary to ensure
that these industries are contributing to the
overall goals of the health system.
To carry out these stewardship responsi
bilities implies a fundamental shift in the focus
of Ministries of Health. It means a shift from
directly providing health services to broad
oversight, advocacy, strategic purchasing,
setting rules for financing and delivering health
care by multiple actors, and assessing overall
system performance. This shift - from rowing
to steering - must be accelerated through train
ing and technical cooperation to build the skills
needed to carry out these functions.
Ministries of Health must be better at con
sensus-building, negotiation and mediation
among all relevant actors — within and outside
government - in order to create stronger part
nerships and coalitions across diverse interests
and sectors. They must be able to hold all actors
accountable for country performance on
agreed-upon national and international health
goals. This requires stronger systems for moni
toring which provide not only average trends
in health status, health care use, and health care
spending, but also socio-economic trends in
these indicators.
The second attribute of responsible health
stewardship is a duty to engage in crosssectoral advocacy to influence policy on the
wider determinants of health of the poor.
When the policies and practices of other
sectors of the economy present both risks and
opportunities for improving health, it is not
enough for Ministries of Health to concern
themselves only with the delivery of publiclyprovided health services. Thus, for example,
the Ministry of Health should become a strong
advocate for better nutrition by participating
in policy discussions regarding access to land,
crop subsidies and other agricultural issues.
Likewise, health ministries should support
efforts to raise the level of female education
and advocate for more equal distribution of
incomes. Compelling evidence exists that both
are positively related to better health outcomes.
The World Health Organization believes
that this vision of strengthened health stew
ardship must be realized for health to fulfil its
potential contribution to poverty reduction and
human development It is particularly needed
in those countries where health governance is
weak.
Fulfilling this vision of strengthened health
stewardship will require strong international
political, financial and technical support,
especially in sub-Saharan Africa and South
Asia.
"Responsible health stewardship
implies... oversight ofall
components of the health
system."
Health Mnistries should support effort to raise the level of female education
“ Io
21
HEALTH: A PRECIOUS ASSET
References
World Bank. Poverty Net.
Source for data in this section: UNAIDS. “AIDS epidemic update: December 1998”. UNAIDS/
WHO, Geneva, 1998.
3 UNAIDS. A review of household and community responses to the HIV/AIDS epidemic in
the rural areas of Sub-Saharan Africa. UNAIDS, Geneva, 1999.
4 UNAIDS. “Handbook for Legislators on HIV/AIDS, Law and Human Rights.” UNAIDS/
IPU, Geneva, Switzerland, 1999.
5 idem
6 Source for data in this section: World Health Organization. “World Health Report 1999.”
WHO, Geneva, 1999.
7 Steketee et al, 1994. Malaria prevention in pregnancy. CDC Atlanta
8 Source for data in this section: Dye et al. “Global burden of tuberculosis: Estimated inci
dence, prevalence and mortality by country in 1997.” JAMA. 1999; 282:677-686.
9 UNAIDS/IPU. “Handbook for Legislators on HIV/AIDS, Law and Human Rights. UNAIDS/
IPU, Geneva, 1999.
10 World Health Organization. “Tuberculosis.” WHO Fact Sheet No. 104. WHO, Geneva, 1998
11 UNAIDS/IPU. “Handbook for Legislators on HIV/AIDS, Law and Human Rights. UNAIDS/
IPU, Geneva, 1999.
12 Ahiburg, Dennis A. ‘The Economic Impacts of Tuberculosis.” A report prepared for WHO,
October 1999.
13 Source for data in this section: World Health Organization. “Nutrition for Health and Devel
opment. Progress and Prospects on the Eve of the 21st Century”. WHO, 1999.
14 Murray C. and Lopez A. ‘The Global Burden of Disease.” Harvard UniversityPress, 1996.
15 UNFPA. “State of the World’s Population 1999.” UNFPA, New York, 1999.
16 idem
17 Source for data in this section: World Health Organization, EOS/WSH.
18 DALYs express years of life lost to premature death and years lived with a disability, adjusted
for the severity of the disability.
19 World Health Organization. “Removing Obstacles to Healthy Development.” WHO/CDS/
99.1
20 World Health Organization. “Removing Obstacles to Healthy Development.” WHO/CDS/
99.1
21 Health and Environment in Sustainable Development. WHO, 1997:159
22 World Health Organization. “Removing Obstacles to Healthy Development” WHO/CDS/
99.1
23 Vlassof, C et al. “Towards the Healthy Women Counselling Guide.” UNDP/World Bank/
WHO, 1995.
24 UNICEF 1992 as quoted in Barkat, Abul, “Crisis in Governance of Public Health System in
Bangladesh: A Challenge of Humane Governance.” Paper prepared for presentation at the
Special Symposium on Poverty and Health in South Asia - Crisis and Challenge - Bangalore,
India, 16 November 1999.
25 Report of The Independent Commission on Health in India. Voluntary Health Association
of India, 1999.
26 World Health Organization. “World Health Report 1999.” WHO, Geneva, 1999.
1
2
22
Department of Health in Sustainable Development, World Health Organization, 1211 Geneva 27, Switzerland.
Tel: +41 22 791 2558. Fax: +41 22 791 4158. E-mail: martinj@who.ch Website: http://www.who.org
WHO/HSD/HID/OO.1
Co
HEALTH
B
PRECIOUS
ASSET
Accelerating follow-up to the
World Summit for Social Development
Proposals by the
World Health Organization
'
This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document
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No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or
other - without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of authors.
Printed in May 2000 by WHO
Printed in Switzerland
G 59
Caring Touch Makes the Difference
It is now widely recognized that the demographic trends of the past decades in
many developing countries, and particularly those in Asia, are leading to
unprecedented increases not only in the absolute numbers of older persons but
also in the relative share of the population that belong to the elderly age groups.
At the same time, rapid social and economic changes are underway that are
widely assumed to have profound implications for the circumstances under
which the future elderly will live. These changes include declines in the number
of children couples have, greater longevity, increased involvement of women (the
predominant providers of care) in economic activities outside the home,
physical separation of parents and adult children associated with urbanization
and agc-selcctivc rural-to-urban migration.
In Asian countries, the family is the traditional social institution for the care of
the elderly who live and work with their children. Even when the children are
all adults, elderly parents often continue to make valuable contributions in the
form of services, such as child care, house-keeping, cooking and house
minding, many of which are facilitated by co-residence.
Ref: Social and Economic Support Systems for the Elderly in Asia: An Introduction By John Knodcl and
Nibhon Debavalya
Problems faced by elderly women are likely to be especially acute and may
require special policies to deal with them.
People need care because of disability, disease, long illness, mental incapacity,
or ageing. The care may be in the form of:
«
eating, drinking, or preparing food or drinks
taking clothes on or off
taking a bath or shower
getting to the toilet
helping controlling urine or bowels
shopping
washing or drying clothes and linen, or
9
cleaning, housework, and garden tasks
standing or walking
getting onto or off of chairs, toilets, or the bed
bending or picking things up from the tloor or lifting or carrying things
likely to fall or slip
physical or mental conditions, illnesses, or disabilities cannot live
without help from others
help of others if they cannot leave their home without the
Strain of caring for the elderly can be killing: Study finds the greater risk of
dying for caregivers under stress - Elderly people under stress because of caring
for their ailing spouses were 63 percent more likely to die during the period of a
four-year study than their non-caregiving counterparts
|.
linder extreme circumstances, it may be right to relieve a vulnerable older
person from caregiving by finding an alternative caregiver or institutionalizing
the ailing spouse.
There are only four kinds of people in this world: Those who have been
caregivers. Those who currently are caregivers. Those who will be caregivers.
Those who will need caregivers."
Training Caregivers
Taught by registered nurses and occupational therapists, classes run three
hours twice a week for about eight weeks. Classes cover such topics as agerelated emotional and mental health changes, vital signs, body mechanics,
environmental safety, injury prevention, personal care, nutrition, first aid, home
management, dementia, caregiver stress and interviewing and job-hunting.
Students wear clouded eyeglasses so they can identify with visually impaired
clients. It's more important that caregivers have compassion and that they
understand the clients they're caring for as opposed to making a bed 100
percent," she says.
"Our hands-on activities range from how to read a mercury thermometer
correctly to how to give a bed bath. In one class the students learn how to
change bed linens around a person still in the bed by practicing with linens on
the classroom tables".
Students are taken to hospital's rehabilitation unit where they learn firsthand
how to move clients from a wheelchair to an armchair, bed, car or commode—
and how to prevent their own injury when lifting and moving clients. And they
can observe the many types of special walkers, canes, bathtub grab bars and
other equipment available to ease the lives of both the elderly and their care- givers.
During class faculty describes age-related changes to the brain, bone
degeneration and skin changes, how to properly note vital signs like heart and
respiration rates and details the many hazards present in each home, like
slippery throw rugs, troublesome stairs, gas stoves and various electrical
appliances.
Students discuss nutrition and learn a brand of first aid different from the
standard Red Cross offering. They practice dealing with cuts and nosebleeds,
distinguishing heart pain from gastric pain, noting real heart attack signs,
understanding various allergic reactions and learning what to do if they suspect
broken bones or head injuries.
The class learns how to properly clean dentures, administer bed baths and
shampoos, help clients in and out of showers and tubs and work with bedpans
and urinals.
Cy
Guest speakers teach home management, including correct housekeeping,
kitchen cleanliness and proper chemical and food storage. Another discusses
dementia, memory change, Alzheimer's disease and care-giver stress.
Lesson One: Nursing assistant Quiz Lesson Two: Basic nursing care Quiz
Lesson Three: Basic Nutrition Quiz Lesson Four: Basic communication and
interpersonal skills Quiz Lesson Five: Prevention of infection Quiz Lesson Six:
Simple body mechanics Quiz Lesson Seven: Introduction to basic terminology
Quiz Lesson Eight: Basic Human Anatomy Quiz Syllabus is subject to change.
(•’ 3
HEALTH AND BEHAVIOUR
Dr.S.Shanmiiganandan,
Professor and Head i/c
Department of Geography,
School of Earth and Atmospheric Sciences
Madurai Kamaraj University
Madurai-625021
Health is a state of complete physical, mental, and social well being, and not
merely the absence of disease and infirmity. (World Health Organization
(WHO) 1947) Started health professionals and general public thinking about
health as a state of well-being. Health status is measured Still measure our
nation’s health status by 1) Morbidity (disease rates) and 2) Mortality (death
rates). The Linguistics of health care can be understood with reference to
disease insurance and sick days; part of a disease/sick care system and not a
health care system. One major indicator of health is infant mortality and % of
deaths within the first year of life per 1,000 live births The years of potential
life lost can be determined from the deaths alone are not an adequate
measure of the health status of the country and begun to calculate the Years
of Potential Life Lost (YPLL). It considers the age at which deaths occur and
also the cost to society in terms of the loss of human potential and
productivity. Also refers to unintentional and intentional injuries - especially for
young people carry a high cost of YPLL.
The goals of the Health care system is mainly intended to prevent the disease
and this includes 1) Primary prevention (involves activities that prevent a
disease from ever occurring e.g. cutting down on saturated fats reduction in
some cancers 2) Secondary prevention refers to detecting conditions early so
that the duration and severity of the disease can be shortened e g. women
who have regular Pap smears or mammograms for early detectiert-of cervical
cancer or breast cancer 3) Tertiary prevention activities used to rehabilitate
someone from a particular disease e.g. cardiac rehab program. The goal is to
help the individual to achieve the highest level of functioning
possible following the disease or health problem.
Health is determined by four main elements viz., Environment, Heredity,
Health-care services and Behaviour. Most disease and injury risk factors fit
undi^ one of these elements.
A
The Environmental factor begins with the fetal environment and is the fetus
exposed to drugs or chemicals - does a fetus receive adequate nutrition and
expand outward to include our physical surroundings - air, water, social
interactions, level of education, type of job we have,
The Heredity factor describes one area of health risk over which we have little control
e.g. Down’s syndrome, Sickle cell anemia but also includes such things as heredity of
heart disease, high blood pressure
Behaviour factor is one of the major determinants of health and is often referred to as
lifestyle factor such as foods you choose to consume, abuse of drugs and alcohol,
exercise habits and stress management etc.,
The estimated role of each determinant confirms according to Centers for Disease
Control and Prevention (CDC, Atlanta, USA) using an environmental model of health,
it is estimated that 43% of the leading causes of death in the U.S.A are related to
LJFESTYLE FACTORS (Behaviour). Hence current disease prevention programs aim
at these known behavioural and environmental risk factors.
The Wellness concept emphasizes a process involving a Zest For Living and a self
designed style of living that allows you to live your life to the fullest The wellness is
determined by three criteria viz., 1) direction and program - not a static state - a
movement toward ever-higher potentials of functioning 2) the total individual (Physical,
Mental (Intellectural), emotional (feeling), social, and spiritual dimensions and 3)
functioning (able to function during daily living and during times of challenge)
A panel of health professionals who reviewed wellness models and components
defines contemporary model of wellness. This includes the belief - while individual’s
initiative and is an important dimension of wellness and it is not the key to wellness. It
is equally important to the sense of community, sense of community being aware of
your role and responsibility within your own community relating to thoughtfully about
the environment, having a wellness mentor; building reinforcements into your wellness
lifestyle
The present lecture thus attempts to focus the interrelationships of Health and
Behaviour with reference to selected diseases and analyses the intrinsic relationships
between the selected diseases associated with life style (behaviour) and health. The
contemporary world is facing many of the diseases mostly associated with the risk
factors concurrently determined by human behaviour and hence the study emphasized
its importance a total behavioural change in the community to prevent most of our
diseases to aim for a sustainable health.
A
Behavioural medicine or mind/body medicine (a subspecialty of behavioural medicine)
is a newly developed area that responds to the psychosocial component of disease. In
this field, mental and emotional factors, the ways in which we think and behave, are
recognized for the significant role they play in our health. Such factors have a
fundamental impact on our ability to withstand and recover from illness and injury.
Mind/body medicine recognizes the strong interconnection of mind and body, believing
it is only through a deeper understanding of this relationship that we can truly
understand health and disease. The power that made the body can heal the body; in
this way, it shares a strong similarity with chiropractic philosophy.
Thus the present study throws light in analyzing conceptual links on the
following in relation to Health, behaviour and disease:
Health-related behaviour - death and illness attributable to alcohol
Health-related behaviour - death and illness attributable to smoking
Cigarette smoking contributes to many causes of death and illness, including
cancers of the lung, larynx, mouth and cervix, coronary heart disease, stroke,
chronic lung disease, sudden infant death syndrome and low birth-weight
(English et al. 1995 cited in CHO Report, 2000).
Attributable burden of behavioural risk factors:
A variety of factors determine the prevalence, onset and course of mental and
behavioural disorders. These include social and economic factors, demographic
factors such as sex and age, serious threats such as conflicts and disasters, the
presence of major physical diseases, and the family environment, which are
briefly described here to illustrate their impact on mental disorders.
Poverty and associated conditions of unemployment, low educational level,
deprivation and homelessness are not only widespread in poor countries, but
also affect a sizeable minority of rich countries. Data from cross-national surveys
in Brazil, Chile, India and Zimbabwe show that common mental disorders are
about twice as frequent among the poor as among the rich (Patel et al. 1999). In
the United States, children from the poorest families were found to be at
increased risk of disorders in the ratio of 2:1 for behavioural disorders and 3:1 for
co morbid conditions (Costello et al. 1996). A review of 15 studies found the
median ratio for overall prevalence of mental disorders between the lowest and
the highest socioeconomic categories was 2.1:1 for one year and 1.4:1 for
lifetime prevalence (Kohn et al. 1998). Similar results have been reported from
recent studies carried out in North America, Latin America and Europe (WHO
International Consortium of Psychiatric Epidemiology 2000). Figure shows that
depression is more common among the poor than the rich.
A
There is also evidence that the course of disorders is determined by the
socioeconomic status of the individual (Kessler et al. 1994; Saraceno & Barbui
1997). This may be a result of service-related variables, including barriers to
accessing care. Poor countries have few resources for mental health care and
these resources are often unavailable to the poorer segments of society. Even in
rich countries, poverty and associated factors such as lack of insurance
coverage, lower levels of education, unemployment, and racial, ethnic and
language minority status create insurmountable barriers to care. The treatment
gap for most mental disorders is large, but for the poor population it is massive.
In addition, poor people often raise mental health concerns when seeking
treatment for physical problems.
The relationship between mental and behavioural disorders, including those
related to alcohol use, and the economic development of communities and
countries has not been explored in a systematic way. It appears, however, that
the vicious cycle of poverty and mental disorders at the family level may well be
operative at the community and country levels.
A
figure 2.6 Prevalence of depression In low versus high income groups, selected countries
I
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:
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raio at pwvttewe
wtowmcwne groups «
lo feet '
high iBcsnw ptoups, Aixwe this ane people witi alow iacwnehsve a Kgheppewterce ofdepression.
' Awas.M «t ti. {1dsoftfers te
MKCbern Frtiojw.Xcm
IW (SMppI 397); S6-64.
S ft at CMWJ.n* 1 2-itkhs^ prewtewe and favors tor Mger sfepressitfe epWe an
sample of
’Wittd»en alU <?! at
Frewiercr dJ imentrf dhoidws and iwycfeasodal irtrpairrwnts *1 witflwants and ytw*?
ftychsiogitXi Mrtfav*!, 2k 139- 426.
*8iJI W et 01. (hew^enoc of psyettserk tfsowiets k> the genertf. peputovar. wjfc of the Methcrtm^s MeotaJ Mcsllfa Survey
andincKkRre Sw^
KesUer RC et st (1994).
and1 l-nwitb prevalence xrf DSW-W- Kpiychiank tfwidefs is the United States, itescks tayv. ttec
NakcnaC tnrwrbidty‘Survey.
‘kbAs N'K fcraafUKWi K ( m/?.Depression arul awxwfiy aneng wpmep in an tt/ban
ri Zfrwbabwe. PsyclKth^c^^aMat^
27:59-71.
When questioned about their health, poor people mention a broad range of
injuries and illnesses: broken limbs, burns, poisoning from chemicals and
pollution, diabetes, pneumonia, bronchitis, tuberculosis, HIV/AIDS, asthma,
diarrhoea, typhoid, malaria, parasitic diseases from contaminated water, skin
infections, and other debilitating diseases. Mental health problems are often
raised jointly with physical concerns, and hardships associated with drug and
alcohol abuse are also frequently discussed. Stress, anxiety, depression, lack of
seif-esteem and suicide are among the effects of poverty and ill-health commonly
identified by discussion groups. A recurring theme is the stress of not being able
to provide for one's family. People associate many forms of sickness with stress,
anguish and being ill at ease, but often pick out three for special mention:
HIV/AIDS, alcoholism and drugs.
A
HIV/AIDS has a marked impact: in Zambia a youth group made a causal link
between poverty and prostitution, AIDS and, finally, death. Group discussions in
Argentina, Ghana, Jamaica, Thailand, Viet Nam, and several other countries also
mention HIV/AIDS and related diseases as problems that affect their livelihoods
and strain the extended family.
People regard drug use and alcoholism as causes of violence, insecurity and
theft, and see money spent on alcohol or other drugs, male drunkenness, and
domestic violence as syndromes of poverty. Many discussion groups from all
regions report problems of physical abuse of women when husbands come home
drunk, and several groups find that beer-drinking leads to promiscuity and
disease. Alcoholism is especially prevalent among men. In both urban and rural
Africa, poor people mention it more frequently than drugs
Drug abuse is mentioned frequently in urban areas, especially in Latin America,
Thailand and Viet Nam. It is also raised in parts of Bulgaria, Kyrgyzstan, the
Russian Federation and Uzbekistan. People addicted to drugs are miserable,
and so are their families.
A
Age is an important determinant of mental disorders. Mental disorders during
childhood and adolescence have been briefly described above. A high
prevalence of disorders is also seen in old age. Besides Alzheimer's disease,
discussed above, elderly people also suffer from a number of other mental and
behavioural disorders. Overall, the prevalence of some disorders tends to rise
with age. Predominant among these is depression. Depressive disorder is
common among elderly people: studies show that 820% being cared for in the
community and 37% being cared for at the primary level are suffering from
depression. A recent study on a community sample of people over 65 years of
age found depression among 11.2% of this population (Newman et al. 1998).
Another recent study, however, found the point prevalence of depressive
disorders to be 4.4% for women and 2.7% for men, although the corresponding
figures for lifetime prevalence were 20.4% and 9.6%. Depression is more
common among older people with physically disabling disorders (Katona &
Livingston 2000). The presence of depression further increases the disability
among this population. Depressive disorders among elderly people go
undetected even more often than among younger adults because they are often
mistakenly considered a part of the.conflicts, including wars and civil strife, and
disasters affect a large number of people and result in mental problems. It is
estimated that globally about 50 million people are refugees or are internally
displaced. In addition, millions are affected by natural disasters including
earthquakes, floods, typhoons, hurricanes and studies on victims of natural
disasters have also shown a high rate of mental disorders. A recent study from
China found a high rate of psychological symptoms and a poor quality of life
among earthquake survivors. The study also showed that post-disaster support
was effective in the improvement of well being (Wang et al. 2000). Similar largescale calamities (IFRC 2000). Such situations take a heavy toll on the mental
health of the people involved, most of who live in developing countries, where
capacity to take care of these problems is extremely limited. Between a third and
half of all the affected persons suffer from mental distress. The most frequent
diagnosis made rs post-traumatic stress disorder (PTSD), often along with
depressive or anxiety disorders. In addition, most individuals report psychological
symptoms that do not amount to disorders. PTSD arises after a stressful event of
an exceptionally threatening or catastrophic nature and is characterized by
intrusive memories, avoidance of circumstances associated with the stressor,
sleep disturbances, irritability an d anger, Jack of concentration and excessive
vigilance. The point prevalence of PTSD in the general population, according to
GBD 2000, is 0.37%. The specific diagnosis of PTSD has been questioned as
being culture-specific and also as being made too often. Indeed, PTSD has been
called a diagnostic category that has been invented based on sociopolitical
needs (Summerfield 2001). Even if the suitability of this specific diagnosis is
uncertain, the overall significance of mental morbidity among individuals exposed
to severe trauma is generally accepted.
The presence of major physical diseases affects the mental health of individuals
as well as of entire families. Most of the seriously disabling or life-threatening
diseases, including cancers in both men and women, have this impact. The case
of HIV/AIDS is described here as an illustration of this effect.
HIV is spreading very rapidly in many parts of the world. At the end of 2000, a
total of 36.1 million people were living with HIV/AIDS and 21.8 million had
already died (UNAIDS 2000). Of the 5.3 million new infections in 2000,- 1 in 10
occurred in children and almost half among women. In 16 countries of subSaharan Africa more than 10% of the population of reproductive age is now
infected with HIV. The HIV/AIDS epidemics has lowered economic growth and is
reducing life expectancy by up to 50% in the hardest hit countries. In many
countries HIV/AIDS is now considered a threat to national security. With neither
cure nor vaccine, prevention of transmission remains the principal response, with
care and support for those infected with HIV offering a critical entry point.
The mental health consequences of this epidemic are substantial. A proportion of
individuals suffer psychological consequences (disorders as well as problems) as
a result of their infection. The effects of intense stigma and discrimination against
people with HIV/AIDS also play a major role in psychological stress. Disorders
range from anxiety or depressive disorders to adjustment disorder (Maj et al.
1994a). Cognitive deficits are also detected if looked for specifically (Maj et al.
1994b; Starace et al. 1998). In addition, family members also suffer the
consequences of stigma and, later, of the premature deaths of their infected
family members. The psychological effects on members of families broken and
on children orphaned by AIDS have not been studied in any detail, but are likely
to be substantial.
These complex situations, where a physical condition leads to psychosocial
consequences at individual, family and community levels, require comprehensive
assessment in order to determine their full impact on mental health. There is a
need for further research in this area. The lack of physical activity is a major
cause of death, disease, and disability. Preliminary data from a WHO study on
risk factors suggest that inactivity or sedentary life style is one of the 10 leading
global
causes
of
death
and
disability.
Low- and middle-income countries suffer the greatest impact from these and
other communicable diseases-77% of total number of deaths caused by noncommunicable diseases occurs in developing countries. These diseases are on
the
r'se
CARDIOVASCULAR risks
cases added^TyTar AmXTdeafhs from X868 °f CanCe'’’ W‘th 500'000 new
most common malignancies are cancer o thT?'!tOtalaround 300,000. The
tobacco use and pan chewing-about 35 percent of S
(mostly relating to
Cardiovascular diseases are a major health nrnhi
ses^’ cervix> and breast.
from them in almost equal numbers (14 mill,on vX^So^n
^XvUSXsS
2020
- have the targes,
account for one th^rdof al'otath™ Sadlymany ofmeseT?58' By ‘he year 2020’ '*wl"
.Hear, disease in India occurs ,0 ,o 15 ytZmX ■ “ "
mcXm: n"ot'young SsS^omT'1'
—
An
diSeaSe
.millions hooked to a rotler-coaster lifestyle, the futurefooksZ™ gnmS.
n™^a^'aX^™S w^'pXXn^^A"1.6 hishoal ever reported
m urban and 2-3% in rural adults.
P
nce of diabetes varies between 6-8%
earlier than inVVes?'3^10 3t 9 relatlvely youn9 age of 45 years which is about 10 years
t in
—
years, more in urban than in rural areas'o',er ,he lasl 50
in rural subjects.
nsion is 25-30% in urban and 10-15%
xsy^v'srs
ph^
diabetes and obesity. I, also increasedUsk of X^nTb
3r diSeaSe’ '«« "
pressure,
„pid
« “Ion and breast cancer, high blood
ar,d
anxiety.
''re-empha^i^ng^heLportlnceofa balanre^veaet6 °f MddiCa' Sciences stresses on,
Physical activity and cessation of smokino would he S"301
Increasin9 the levels of
factors and Coronary Artery Disease nra i
UCia In con*ainir|g the rise of risk
industrialization"
D'SeaSe Prevale™e induced by urbanization and
diseases simultXoJslXtMhl gXing^burden on s^X?6 dt 'mPaCt °f infectious
?Z„n°'?'COmmunicable diseases. Physical activitv in 3dXX^?®!lth?ystems caused
free life style is an efficient, cost effective and
t0 healthy diet and a smoke
health in low and middle-income countries.
stainable way for promoting public
Physical activity can be done almost
anywhere and requires no equipment,
Walking, perhaps the most practiced and
most highly recommended physical
activity is absolutely free.
At least thirty minutes of moderate physical activity every day are recommended
to improve and maintain your health.'-Even if you are very busy-you can still work
in thirty minutes of activity in your daily routine.
Patterns of physical activity acquired during childhood and adolescence are more
likely to be maintained throughout the life span, thus providing a basis for an
active and healthy life.
Physical activity can improve quality of life in many ways for people of all ages.
Benefits of physical activity can be enjoyed even if regular practice starts late in
life.
Acquired Immune Deficiency Syndrome
The incidence of AIDS cases in India is steadily rising amidst concerns that the
nation faces the prospect of an AIDS epidemic. By June 1991, out of a total of
more than 900,000 screened, some 5,130 people tested positive for the human
immunodeficiency virus (HIV). However, the total number infected with HIV in
1992 was estimated by a New Delhi-based official of the World Health
Organization (WHO) at 500,000, and more pessimistic estimates by the World
Bank in 1995 suggested a figure of 2 million, the highest in Asia. Confirmed
cases of AIDS numbered only 102 by 1991 but had jumped to 885 by 1994, the
second highest reported number in Asia after Thailand. Suspected AIDS cases,
according to WHO and the Indian government, may be in the area of 80,000 in
1995.
The main factors cited in the spread of the virus are heterosexual transmission,
primarily by urban prostitutes and migrant workers, such as long-distance truck
drivers; the use of unsterilized needles and syringes by physicians and
intravenous drug users; and transfusions of blood from infected donors. Based
on the HIV infection rate in 1991, and India's position as the second most
populated country in the world, it was projected that by 1995 India would have
more HIV and AIDS cases than any other country in the world. This prediction
appeared true. By mid-1995 India had been labeled by the media as "ground
zero" in the global AIDS epidemic and new predictions for 2000 were that India
would have 1 million AIDS cases and 5 million HIV-positive.
In 1987 the newly formed National AIDS Control Program began limited
screening of the blood supply and monitoring of high-risk groups. A national
education program aimed at AIDS prevention and control began in 1990. The
first AIDS prevention television campaign began in 1991. By the mid-1990s,
AIDS awareness signs on public streets, condoms for sale near brothels, and
media announcements were more in evidence. There was very negative publicity
as well. Posters with the names and photographs of known HIV-positive persons
have been seen in New Delhi, and there have been reports of HIV patients
chained in medical facilities and deprived of treatment.
A
Fear and ignorance have continued to compound the difficulty of controlling the
spread of the virus, and discrimination against AIDS sufferers has surfaced. For
example, in 1990 the All-lndia Institute of Medical Sciences, New Delhi's leading
medical facility, reportedly turned away two people infected with HIV because its
staff were too scared to treat them.
A new program to control the spread of AIDS was launched in 1991 by the Indian
Council of Medical Research. The council looked to ancient scriptures and
religious books for traditional messages that preach moderation in sex and
describe prostitution as a sin. The council considered that the great extent to
which Indian, life-styles are shaped by religion rather than by science would
cause many people to be confused by foreign-modeled educational campaigns
relying on television and printed booklets.
The severity of the growing AIDS crisis in India is clear, according to statistics
compiled during the mid-1990s. In Bombay, a city of 12.6 million inhabitants in
1991, the HIV infection rate among the estimated 80,000 prostitutes jumped from
1 percent in 1987 to 30 percent in 1991 to 53 percent in 1993. Migrant workers
engaging in promiscuous and unprotected sexual relations in the big city carry
the infection to other sexual partners on the road and then to their homes and
families.
...
India's blood supply, despite official blood screening efforts, continues to become
infected. In 1991 donated blood was screened for HIV in only four major cities:
New Delhi, Calcutta, Madras, and Bombay. One of the leading factors in the
contamination of the blood supply is that 30 percent of the blood required comes
from private, profit-making banks whose practices are difficult to regulate.
Furthermore,’ professional donors are an integral part of the Indian blood supply
network, providing about 30 percent of the annual requirement nationally. These
donors are generally poor and tend to engage in high-risk sex and use
intravenous drugs more than the general population. Professional donors also
tend to donate frequently at different centers and, in many cases, under different
names Reuse of improperly sterilized needles in health care and blood-collection
facilities also is a factor. India's minister of health and family welfare reported in
1992 that only 138 out of 608 blood banks were equipped for HIV screening. A
1992 study conducted by the Indian Health Organization revealed that 86 percent
of commercial blood donors surveyed were HIV-positive.
Conclusion:
The study thus emphasized its significance in bringing out the significance of the
behavioural factors and its role in determining the human health in a larger
perspective. Since the human behaviour is a complex one and also based on the
individual’s behaviour, it is really a very difficult task to bring out the behavioural
change among the individuals and community in large.
PradUhann Manntn
SwasOaya Sunimlkslhiai
Y®Janna
Five components of a
major new pro-poor
programme prepared by
the Ministiy of Health:
1. Six new hospitals on
the pattern of ARMS,
New Delhi
2.
Upgrading one
medical college in
each State to the level
of ARMS
3. ‘Sanjivani’ Task Force
for emergency medical
services
4. Janani Suraksha
Yojana for safe
delivery. The mother
will get Rs. 500 for a
male child and Rs.
1,000 for female
5.
Universal Health
Insurance Scheme for
the poor
IHIIEALTIHIs CLIEA1R GOALS, DETERMINED APPROACH
o
A NationalHealth Policy has been approved,with stronger governmental commitment to primary health care and
greater encouragement for private sector participation in secondary and tertiary health care. Health sector
expenditure increased to 6 per cent of GDP.
o
The new National AIDS Policy has achieved final form. Its aimisto achieve zero level of infectivity by 2007.
o
National Population Policy (NPP) 2000 has been unveiled. A National Commission on Population has been set
up to monitor implementation of the policy. Also, a Community Incentive Scheme has been introduced to
encourage involvement of village communities in the national effort to stabilise population.
o
The Government has approved the setting up of the National Population Stabilisation Fund - Rashtriya
Jansankhya Kosh - as an autonomous body with a seed capital of Rs. 100 crore. The Fund willmobilise
resourcesfromthe privatesectorand charitableorganisationsforundertaking activities and programmes aimed at
achieving a stable population.
o
A Bill proposing death penalty for persons producing and distributing spurious drugs has been introduced in the
Lok Sabha during winter session.
o
The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and
Commerce, Production, Supply and Distribution) Act, 2003 has been enacted by Parliament in April2003.
o
Incidence of malaria has reduced from 2.28 million cases in 1999 to 2.03 million in 2001. Focused attention to
malaria-prone areas led to more than 50 per centdeclinein malaria cases in 2001 as compared to 1997 in 32
predominantly tribal districts in seven States.
o
Population coverage under the Revised NationalTB Control Programme has increased from less than 20 million
in 1999 to 800 million at present. Nearly 60 million persons were covered under RNTCP in the second and third
quarters of 2003. Entire population of the country to be covered by 2005.
Q
-r
)
o
Umveirsall IHIeaittlhi
Hnnsimrainice
foir the Foot
For a large majority of our poor
citizens, easy access to good
health services is just not there.
In order to correct this, public
insurance
sector
general
companies wi 11 offer a
universal
community-based
health insurance scheme. A
premium of Rs. 1 per day for an
individual, Rs. 1.50 for a family
of five, and Rs. 2 for a family of
seven, will entitle eligibility to
get reimbursement of medical
expenses up to Rs. 30,000
towards hospitalisation, a cover
for death due to accident for Rs.
25,000, and compensation due
to loss of earning at the rate of
Rs. 50 per day up to a
maximum of 15 days. To make
the scheme affordable to BPL
families, the Government will
contribute Rs. 100 per year
towards their annual premium.
o
o
o
o
Leprosy prevalence rate in the country has been brought down from 5.3 per 10,000 population in March 1999
to 3.36 per 10,000 population in September 2002. Leprosy has now been eliminated from 14 states.
Prevalence of blindness, which was 1.49 per cent during 1996=99 has been reduced to 1.1 per cent in 1999=
2002. The number of cataract operations performed, especially for the poor, has increased from about 9
million during 1996=99 to about 11 million during 1999=2002.
The Safe Motherhood Programme was launched by the Prime Minister in April 1998. The slogan of the
■ ’, powerfully
“ “ expressed1 one of the most crying
campaign, 'Pregnancy is Precious, Let Us Make It Safe
imperatives of the social sector. The campaign sought to recognise the role of traditional&is and train them in
new, hygienic and safe methods of delivery.
Sixty districts have been provided equipment to upgrade neonatal care facilities.
Efforts for eradication of polio have been stepped up and the number of polio cases has come down to 194
between January-November 2003 as against 1500 during 2002. Six rounds of pulse polio vaccination will be
taken up this year and will be continued till the eradication of polio by 2005.
Q
National Blood Policy has been approved.
o
Guidelines for bio-medical research framed.
o
Central Government Health Scheme (CGHS) rules simplified to provide creditfacilitiesto patients at
recognised private hospitals in case of emergency.
o
A premier postgraduate Medical institute at Shillong (NEIGRIMS) costing Rs. 422.60 crore approved.
o
Code of ethics forallopathic doctors - regulations of professional conduct, ethics and etiquette - approved.
Healffln for AHI
o
Allocation to health sector
increased to six per cent of
GDP
o
Pilot project for testing the feasibility of introducing Hepatitis-B vaccine immunisation programme in
slums launched.
o
The Government has given a big boost to Ayurveda, other Indian Systems of Medicine and
Homeopathy by more than quadrupling the budget of this Department in five years.
o
Increased number of sub
centres in remote areas and
villages
o
The Essential Drug Lists for Ayurveda, Unani and Homeopathy medicines issued for the first time.
Also, a Traditional Knowledge Digital Library documenting 35,000 Ayurvedic formulations has been
launched.
o
Decreased prevalence
leprosy and malaria
of
o
A National Medicinal Plants Board has been established to give a specialthrustto Indian systems of
medicine and realise India's huge potential in the production of standardised herbal products for
domestic use and for exports.
o
Incidence of polio reduced, to
be eradicated by 2005
o
For the first time a comprehensive programme to provide free Anti-Retro Viral Drugs to certain
categories of HIV/AIDS patients like children under the age of 15 years and mothers with HIV/AIDS
who approach public hospitals has been formulated. It will come in effect from 1st April 2004. About
one lakh patients are expected to be covered at a cost of about Rs. 130 crores.
o
RNTCP to cover
country by 2005
o
Free Anti-Retro Viral Drugs
to AIDS infected patients by
April 2004
o
An Integrated National Vector Borne Diseases Control Programme incorporating the components of
Dengue/DHF, Malaria, Filaria, Kala-azar and Japanese Encephalitis has been cleared by the Cabinet
and will come into operation from April2004.
o
Boost to traditional systems of
medicines
o
New international norms for pesticide residues for bottled water were notified to take effect from 1 st
January 2004.
o
Death penalty to producers of
spurious drugs envisaged
o
Joint Parliamentary Committee has been constituted to look into the controversy related to pesticide
residues in cola drinks.
o
An additional 8,669 sub centres will be set up under Primary Health Centres in underserved states to
provide better health services at grassroots level.
entire
ConA H - ).
1
RATIONAL HEALTH CARE
Health Is a personal and social state of balance and well-being In which a woman feels strong,
active, creative, wise and worthwhile; where her body's vital power of functioning and healing is
intact; where her diverse capacities and rhythms are valued; where she may decide and choose,
express herself and move about freely.
Health as defined above Is thus a state which a person has or wishes to reach.
Rational health care, would be care that seeks to promote the above state of health, either
through preventing diseases by leading a healthy lifestyle, or healing illness by choosing the best
possible of the options available. It must be noted here that access and affordability are major
deterrents to care for a vast majority of women in our country.
s
Health care services are organised systems that provide information or skills or methods to
enable people to move towards a state of health.
i
In today’s world, It becomes very difficult to make choices which are the best for ones own health
for a number of different reasons. To start with the number of choices possible appear to be many
but in reality many of them are beyond the average woman's control.
Let us start with the presumption that most people including women do not wish to suffer from ill
health. Here ill-health may be taken to mean ‘dis-ease’ or any condition that disturbs the balance
of well being and causes suffering. In order to enjoy a state of positive health (see defn in the
box) she and her family must have certain basic necessities or the means to generate these
needs of food, shelter and clothing. Following this, she should be respected in the family and
society as a useful contributing member with individual, creative talents; her lifestyle can only
then foster positive health. As can be seen from this background, there are very few women in
our country today who enjoy these conditions that favour a healthy life. To the huge numbers of
women who struggle to survive with the minimum number of calories every day after feeding their
families; illness is an inevitable part of life. To those lucky to escape this battle, there is another
set of bridges to cross, a patriarchal society that puts such little value on its women, denying her
needs, potential and limiting her freedom.
In such a situation, women probably need more than ever to be aware of the possibilities of
therapy when she or other members of her family fall ill.
Health care is broadly provided by two groups of people
♦ The organised sector :
This group of people form part of the medical system that provides curative care to people all
over our country. This will include the government health care delivery system, the primary health
centres and their subcentres, the taluk hospitals and the district hospitals. In addition to this, there
are private practitioners who practice different systems of medicine such as allopathy, ayurveda
or homeopathy.
♦ The unorganised sector:
This group which is available to most people is family or extended family. Traditionally this sector
was very strong and women formed the backbone of this group as either grandmother, mother or
daughter. However as more families turn nuclear, this is less common today, especially in the
cities.
It is important to understand the different levels of the health system and the way it is meant to
function so that women can access the most appropriate level of care. Most women in India use a
combination of traditional remedies and modem ‘allopathic ‘ medicine to treat a number of simple
ailments. However, in some areas there may be very reliable traditional healers and practitioners
of ayurveda, siddha and homeopathy. It is a worthwhile exercise to explore all the possible
caregivers known locally with the women’s groups you are involved in. In many cases, the cure
for simple ailments is available at home, but for some problems, a woman may need to seek
medical advice. It is also well known that patients often use a number of healers to treat the same
2
illnesses especially if they do not meet success in treatment. Unfortunately, as most heaters
trained in different systems are unaware of each others strengths and weaknesses, and are often
in competition with each other, patients do not fully disclose past or even co- existing treatments
taken. Thus, the issue of rational health care becomes even more complicated. Add to this
scenario the unfortunate but often real dimension of the greed of the medical professionals, who
wish to extract maximum gains from the consultation and the real predicament of the poor woman
who is ‘dis-eased’ is evident
What is quality health care?
There are a number of attributes that could be looked for in good health care. Some of these are
seen through the eyes of the patient, others through the eyes of the care- giver, and yet others
through the eyes of people who make decisions about our health system like the officials in our
governments. It is important that all these groups of people understand what is quality care in
order that quality can improve. The groups of women participants can try to contnbute to
improving the care available in their communities by asking the following questions and seeking
answers. In brief, these are
.
1. Is the care efficacious? Can the treatment bring about an improvement in health and well
being, given the best possible chance?
2. Is the care efficient? Does the treatment bring about an improvement in health and well
being under the day- to day realities many of our women live in?
3. Is the care effective or in other words cost- efficient? Given a choice of two equally
effective treatments, is this the less expensive of the two?
4. Is the health care optimal use of resources? This means in the long run does it still make
sense to use this treatmenV care or do the costs outweigh the benefits?
5. Is the care acceptable? This important criterion includes:
(a) Is the care accessible in terms of time, distance and money?
(b) Does the care- giver have a good, mutually respectful relationship with the patient?
(c) Is the setting in which the care is given, convenient, comfortable and pleasing? Is account
taken of the fact that she will require privacy for some aspects of the care?
(d) Are the patient’s preferences as to the costs and effects of treatment heard and taken into
account?
. x
6. Is the care equitable? In other words, can most other people in society access the health
care or treatment choice that is available to you?
You will notice that the first two of these questions will be best answered by the doctor/ healer
who is giving the treatment. The second two questions are best answered by people who are
managing the health care system- whether at local level the panchayat or elders, or at national
level the government administration. The fifth question with all its various aspects is obviously
best answered by the patients themselves, and the sixth question is one to which all members of
society are answerable. You will also notice that most patients use these criteria all the time to
assess the quality of a health service and the services that fulfill these criteria are those that are
flourishing.
Life- styles that promote health
Our ancient science of Ayurveda, says that the purpose of life is four-fold, to achieve dharma
(virtue), artha (wealth), kama (enjoyment) and moksha (salvation). In order to attain success in
this four-fold purpose of life, it is essential to maintain life not only in a disease-free state but also
in a positive state of body, mind and spirit. With this emphasis on the promotion of positive health,
it prescribes a regime of Swastha Vrutta (healthy conduct) and Sad Vrutta (ethical conduct). The
following advice by Charaka sums up the whole concept beautifully.
3
Nityam Hitaharavihara Sevee, Samishyakari Vishayetwasakthah
Datha, Samah, Satyaparah, Kshmawan, Aptopasevee Bhavet Arogah
“She alone can remain healthy, who takes regulated diet and exercise, who deliberates all her
actions, who controls her sensual pleasures, who is generous, just, truthful and forgiving, and
who can get along with her kinsfolk."
Unfortunately, conditions in today’s world often do not allow for even the first of these
requirements, namely diet or nutrition. It is vital for good health to have a daily diet that is
complete in calories (meaning that it provides enough energy to do the day’s work) as well as
balanced in proteins, fats, vitamins and minerals. In many places, women who are in poorer
families do not have enough to eat (See hand out on a balanced diet) and certainly, a majority of
women suffer from anemia. This is an illness where there is not enough iron in the body and as
women have greater needs due to pregnancy and menstruation, they often lack the necessary
stores. As the discrimination in the diet starts from early childhood, the young girl- child is already
at a disadvantage, and this deficiency grows worse as each pregnancy takes it’s toll with the
symptoms of listlessness and chronic fatigue appearing very soon. At present, 85% of women
during pregnancy are known to be anaemic; and one-fifth of mothers who die during childbirth die
due to anemia- related causes. It is a simple matter to eat plenty of green leafy vegetables, and
certainly avail of the iron tablets that are given free during the antenatal check-up at the
subcentres by the nurses. You must urge the women leaders to insist that this simple tablet is
available at the primary health centre, it is one of the most cost-effective methods to improve
women’s health.
The other very important part of the diet is water, clean drinking water which has also become a
luxury in so many poor households. Poor environmental sanitation and unsafe drinking water
together account for almost 60-80% of infections that occur in our country. One of the basic steps
to improve rural sanitation is by the proper and safe disposal of human excreta. Otherwise, this
pollutes the soil, ponds, canals, rivers and wells. This results in more people falling ill from
diseases like typhoid, dysentry, jaundice, cholera and diarrhoea. It is worthwhile discussing in
your women’s groups both the problems of vteiter and sanitation (see the handout on low-cost
sanitary latrines) and exchanging notes on water management within the home.
As women are often the prime care givers within the family, it is important that she is aware of the
basic rules of diet, and the good health promotive practices, such as exercise and avoidance of
addictive habits such as tobacco and alcohol. In addition she should be aware of threats to her
own body and peace of mind and try to avoid allowing these to surface in her life. An important
message of Ayurveda is that health, instead of being ‘provided ‘ or ‘delivered’ has to be practiced
by Swasth Vrutta and Sad Vrutta. As individuals, all of us have the power and responsibility to
keep our body and mind healthy by observing a number of simple rules of conduct and behaviour
in relation to food, exercise, sleep, personal cleanliness and by rules of ethical and moral
conduct.
/i
Fact sheet 1- Rational therapy and essential drugs
Rational drug therapy means the practice of scientifically sound medidne that is relevant
concerned and takes into account the socioeconomic context of the patient. It recognises that in
some diseases, drugs do not have a .role, in others and alternative therapies are required,
. Irrational prescriptions raise .the cost of medical care; they waste available resources, delay
treatment and/or worsen the conditions of ill- health. They also change the way we spend our
hard-earned money in our families, as our health culture changes to a philosophy of “a pill for
every ill". Finally, they widen the existing gaps between rich and poor, as debt incurred from illhealth makes health -care even more inaccessible to the poorest among us.
- What is an irrational prescription? One that contains:
• Banned or bannable drugs
• Multiple drugs for the same effect
• Irrational and unnecessary combinations
• Drugs that are costly because of fancy wrapping
• Underdosage or over-dosage
• Wrong indications
• Injections instead of oral preparations
Who .could the irrational prescilbpr pe?
• A doctor
• A specialist
• A nurse
• A health worker
• A compounder or a pharmadst
• An unregistered medical practitioner
• A folk healer
• •-A practitionerin indigenotrs systems of medicine
• A family elder/contact
nr
--TTre patient herself
“
What can you as ^ patient do in order not to fall into this trap?
When telling the doctor your problem always mention previous treatments, show the
prescriptions if possible."This will prevent you from wasting time arid money on a repeat
treatment. It may also help the doctor to correctly diagnose your condition.
You must have the courage to ask the following questions
Do I really need all the drugs in this prescription? Many doctors in particular, are known to
respond “ Are you the doctor or am I?” Don’t be cowed down by this response, you can explain
that you have exactly 20/100 or whatever rupees in hand so could he/she please check how
much the prescription will cost and reduce it to the essential drugs.
What isdhB ^ffectdf the"body? If the response is “ Are you going to become a
doctor?" you can laughingly respond, “No, but I am going to take the medicines." However, insist
on an answer. Here you may expect to hear about side- effects that some drugs may have.
After receiving the prescription, when you go to the drug store to buy the drugs,
Ask specifically that the merirdnes are not ‘expired"- that means they are old and may riot be
effective.
------------------
1
You may also ask here for the least expensive drug from a reputed company. Every drug is
prepared by a number of different companies and there is at times a significant difference in
prices.
Most drugs are cheapest in the tablet form as compared to a suspension or ‘liquid’ form. Avoid
injectables as far as possible. A needle that is not dean may give you an additional disease like
AIDS’ Remember that an injection is needed only if the medication cannot be absorbed through
the stomach, or if the condition is so serious that the drug levels must be kept at a high level with
six hourly or eight hourly injedions (for a patient admitted in hospital).
These guidelines are mainly with regard to the western system or allopathic system of medidne.
With traditional remedies made from locally available herbs/ ingredients these problems do not
arise, so maybe you should reconsider going to the doctor in the first place!
Are there any other ways in which this problem can be treated?
This question may inspire the doctor to think about alternative solutions to your problem, and
occasionally he or she may refer you to someone they trust who they feel may be able to help
you. Always remember, if in doubt, you are entitled to a second opinion, although routinely
‘doctor-shopping’ or going from doctor to doctor without faith or intent to take the therapy
completely is bound to fail.
Is it a complete cure or will the problem recur?
This is a very important question to be asked, especially since the doctor’s idea of ‘cure’ and
yours expectations may be different. Ask specifically if the drugs need to be taken for a longer
time, or until a repeat check-up is advised. If it appears to be a long term treatment that you will
find difficult to follow because it is not affordable, be open and you could explore the possibilities
of less expensive alternatives together.
Why did I fall ill and how can I prevent doing it in the future?
Rational health care means paying equal attention to cure and prevention. Although the cure is
preventing the disease from progressing, it is important to prevent a recurrence or relapse, which
might be both more difficult and expensive to treat. It is important to note that in different systems
of medicine the causes of diseases are very differently understood, however in all the systems,
the doctors or practitioners will be able to give you guideline to follow in answer to this question.
You may find that your doctor or nurse finds it difficult or expresses irritation at having to
answer your questions. They are not in the practice of giving information, are often busy,
and may not take the time to answer your questions. Be respectful and patient with them
but firm. They should be able to make you understand.
PATIENT’S RIGHTS
♦
♦
♦
♦
♦
♦
♦
All patients have a right to health care. This is regardless of how much money she has, what
her status in society is, what community she comes from, or what health problem she has.
:
The patient has a right to considerate and respectful care at all times and under all
circumstances, with recognition of her personal dignity. Care should be taken that she feels
as comfortable as possible.
The patient has a right to privacy and confidentiality at all times. This includes during the
history taking and examination, and with reference to her medical records.
The patient has a right to safety at all times.
The patient has a right to know the complete information concerning her diagnosis, treatment
and possibilities for cure. This information must be communicated in terms she can
reasonably understand. If possible, the means to prevent the same illness from recurring
must be clearly explained.
The patient has a right to ‘ informed consent’ that means no procedure can be done on her
without her voluntary and understanding consent after understanding the risks involved.
The patient has a right to a second opinion, as also to refuse care.
The patent has a right to ask for an explanation of all medical costs incurred by her.
OBJECTIVES OF THIS MODULE
1.
2.
3.
4.
5.
Trainers understand a concept of women’s health, which is holistic, and encompasses
aspects of her body, mind and spirit.
Trainers are well informed on what constitutes good care (considering all aspects) and can
look for these elements in the care available. As care includes the issues of life-styles, this
would also include water, sanitation and nutrition as part of the subject matter.
Trainers are familiar with the different groups of health care providers available to
communities and particularly women in these communities. They can share this information
and then help women to choose from these options available, the best choice to prevent
illness and/or treat the illness early, in the most rational way.
Trainers know about patient’s rights and can impart this to the women’s groups also
discussing possible ways in which these can be demanded or negotiated.
Trainers know about essential drugs (in the allopathic system of medicine) and can make
maximum use of a consultation and a prescription for drugs.
Duration of session
Content of session
30 min
Discussion on ‘dis -ease’
and health____________
The importance of
prevention- nutrition and
life-styles____________
Health care providers
60 min
30 min
30 min
60 min
60 min
Quality care- what does it
mean to you?_________
Patients rights and how
to ensure them________
Essential drugs and a
prescription scrutiny
Methods that can be
used______________
Question and answers
Sharing experiences
Discussion and
sharing
Materials required
Resource persons
from different groups
and self introductions
Brainstorming with the
group_____________
Role- plays
Role- plays
Exercise with three
prescriptions
List of the essential
drugs
Three prepared
prescriptions
Note to the trainer: If you feel that the majority of your participants give you a feedback of non
utilisation of the allopathic providers, do not waste time on the last topic. Use that hour instead to
strengthen traditional practices that move towards the positive state of health.
SOURCES;
Essential drug list (As prepared by CHC along Who recommendations)
Seven pillars of the Quality of care (1987) A.Donabedian
Ayurveda and modem medicine (1986) Dr. R.D. Lele
Chapter 1
^ow^ONi'n Participation
i
.
In
NlS.H/pK>
Community participation in
health care: a brief history
The growth of primary health care
I
Interest in community participation in health care is not new;
there was community support for healers in past centuries and it is
still a feature of traditional cultures today. It was recognized in the
nineteenth century as a fundamental factor in the public health
movements that swept Europe—particularly the United Kingdom—
and North America during that period. Today, many international
organizations and agencies, including UNICEF and WHO, empha
size the importance of community involvement in health care as a
basis for improving health throughout the world.
The stress now laid on community participation has resulted
from two trends that emerged after the Second World War. I he first
was increasing disillusionment with the ability of the Western
medical system to improve the health of the majority of the world s
people. That system, which had developed in the industrial coun
tries, stressed curative, hospital-based treatment and one-to-one
doctor/patient relationships, and was transferred to their colonies by
those same countries. With the advent of decolonization, the in
adequacies of the system were dramatically exposed. New nations
had neither a suitable infrastructure to sustain it nor the money to
support its high costs. Moreover, since it was based mainly in the
urban areas and available principally to those with the money to pay
for its services, it denied care to the majority of the people, who lived
in rural areas where they had little access to any type of health care.
To deal with the health crisis that began to develop as a
consequence, it was proposed that a logical step would be to shift the
emphasis away from this type of medical service and new technol
ogies towards preventive, decentralized, community care based on
epidemiological priorities. Health service delivery was seen in terms
of social policy rather than' technological development. Planners
believed that providing people with knowledge, through health
P3
T
COMMUNI I Y HAH I IUIHA I IUN IN HtALin vAKt
Jp
i
education, would greatly
i
’ i’ mprov- health. However, the policy
Squally degenerated into the
erally handed downfrom expertTo lav^Tf11
knowledge, gen•
'
improvements
m
healthA
reSUking ?
limited i
care
delivery
were
adooted
LhJh
’
Y
,aPProaches to
health
handed down from “the ton-’ arTd h i i?
re)ected health policies
ly with the provision of knowledge h
concerned merethat it was necessary to involveSin the
t0
aPParen,: t0 many
those who most needed them
Planmng of health services
ences that exist
regional groups, and people with Hiff
s°CIetles, ethnic and
make it essential that the consumer—riier 'feStyIes and values>
the nature of the health service available toT ThTiF lnflUenCeS
able improvement in health status is m h° '
any nOticemust be involved in decisions concerning heaKiX
recognidoXt pubbc health^ ”
P£riOd Was the
curing disease but formed ' n mt^Tof^
development policies. In line wii-lAk P
a country s general
economist Myrdal health was inr
■ e arguments °f the Swedish
ment in man” (Mvrdal & Kine raVy^A recognized as an “investwere no longer the preserve of the7
res_uIt’.health services
an integral part ofall economic dev 1°^
p.rofession but became
bates about “basic needs” “snc' 7 Opme7,t Planning- Thus the dePauon” began uXX healffl
’ 3nd
UNICEF,
hll.1S;by WHO and
following:
grain all «h deve'iZen
primary health care are the
P
"e
awareness through
T
T*O z-*4- z-v
* __
’
(3)
If he;
care is to be improved it is essential that the com
munity should define its needs and suggest ways of meeting
them.
(4)
Decentralization is necessary if community needs are to be met
and problems solved.
(5)
Community resources, financial and human, can make an im
portant contribution to health and development activities.
Community participation is seen as the key to primary health
care, which is concerned not with advanced medical technology but
rather with applying tried and tested health care procedures to the
health problems of the poor and underprivileged, most of whom live
in rural areas of the developing countries. It is believed that only if
those who most need health care participate in its delivery will there
be any impact on the diseases afflicting them, and that only commu
nity involvement can ensure that culturally acceptable care is avail
able to those who are at present underserved.
WHO and UNICEF have not.confined thdfrseleves to mere
advocacy of primary health care based on community participation
but have also pursued activities designed to promote its practical
application. In developing a strategy for “health for all by the year
2000”, WHO has focused on examining the role of members of the
community in the delivery of health services. For example, it has
promoted exchange of experience among countries in which com
munity health workers have been utilized and has supported re
search to assess the extent to which community participation in
health services has led to an improvement in health status. It has also
sought to integrate community participation into several specialized
health care activities. Those concerned with the control of
communicable diseases have examined methods of involving mem
bers of the community in their efforts and have incorporated com
munity participation components in their training modules.
UNICEF has adopted a more integrated approach, in which
community participation is developed through a number of commu
nity development activities (discussed in the next section) in addi
tion to health services, including food production, nutrition, water
and sanitation, education, and income generation. UNICEF’s ex
perience of this approach to community participation has contrib
uted much to an understanding of how people in the community can
be motivated and involved in improving their own health. It has also
helped give a broader meaning to “health” in primary health care,
expanding the definition beyond health service activities alone.
2
3
I
COMMUNITY PARTICIPATION IN MCH/FAMILY
JNING PROGRAMMES
COMMUNITY PARTICIPATION IN HEALTH CARE
Primary health care and community
development
In approaching the integration of health into development
planning by promoting primary health care, the history of community participation in development programmes in general is relevant
he interest in community participation in development prodevT68 m T ,rhlrd World is not new> nor did it begin with
?jn7r1ed Nern
hea‘th 0316 “"“P1' In the ^OS, the
United Nations was instrumental in promoting what has been called
the community development movement, which advocated that
people in the community should play a major role in their own
development programmes. Used originally in various parts of Africa
as a mass education activity for the rural poor,
poor, it
eraduallv gained
vainAd
it gradually
CambXPTCe thr°^h°ut the world- : was
defined at
1948
was defined
at the
the 1948
f-anibridge Summer Conference on Af
'
» . . .
African
Administration,
called
to, discuss
the social policies
of colonial
.
- --------------—«1 administrations; in part, the
ennition read Community development .... embraces all forms
0 btttermenl. It includes the whole range of activities in the district
nno/l'd hen T UI}dertaken bV government or unofficial bodies”
(quoted m Srokensha & Hodge, 1969). The definition was later
expanded by the United Nations Department of Social and Econormc Affairs to stress the processes in which communities and
go ernment joined together to improve the economic, social and
and Fc COndltl^s.of the community (UN Department of
of Social
Social
and Economic Affairs, 1971).
Community development, it has been suggested, can be seen a-=
a method, as a movement, as a programme and as a concept
( anders, 197C9. as a method, it is very similar, but on a community
scale to the techniques used by social workers with individual
clients, such as gaming the trust of the client, using that trust to find
out the client s view of the problem (felt needs) and its causes (real
needs), encoui aging the client to discover what he or she can do to
help improve the situation, and supporting any efforts to find and
use the resources necessary for such improvement (self-help). When
piogrammes are implemented, this method develops the following
characteristics (Mezirow, 1963):
6
—
concern for ensuring the integrated development of the whole
of community life, involving the integration or coordination of
technical specialities;
—
planning based on the “felt needs” of the people;
—
emphasis on self-help;
4
;
I
:
—
concentration on singling out, enouraging and training local
leaders;
—
provision of technical assistance in the form of personnel,
equipment, materials and/or money.
Foster (1982) has compared the conceptual similarities be
tween community development and primary health care. He notes
that both concepts:
—
emphasize multipurpose activities;
—
presuppose that the provision of basic services and material
gains are essential to development;
—
recognize to a greater (community development) or lesser (pri
mary health care) degree that the processes by which the goals
are achieved (local initiatives, self-confidence, self-reliance and
cooperation) are more important than the goals themselves
(achievement of concrete objectives).
In addition, both concepts stress the need for planners to base their
plans on a community’s felt needs and to utilize community re
sources, including its people, to carry out programme tasks.
Foster also discusses a number of false assumptions that plag
ued the community development movement and that, in his view,
had to be corrected if primary health care was to be successfully
developed. They include the following:
(1)
“Communities are homogeneous.” In fact, communities are
mostly not homogeneous, nor do they usually see reasons for
always cooperating “for the common good”. Experience shows
that individual concerns often override community goals, par
ticularly in areas of poverty. Only when people rise above the
level of extreme poverty and lack of resources does cooperation
become feasible.
(2)
“Knowledge will automatically create desired changes in
behaviour.” In reafity, communities do not change their types
of behaviour because new practices are taught by community
development workers. Time and experience have proved not
only that new knowledge does not automatically induce change
but also that traditional practices often have some value.
Behavioural change — for better or worse — takes a long time.
(3)
“Community leaders act in the best interests of their people.”
The actions of community leaders do not always benefit the
entire community. People singled out by community workers
■
COMMUNITY PARTICIPATION
IN MCH/
ILY planning programmes
COMMON.. < PARTICIPATION IN HEALTH CARE
selves and £ famil^Thus^a °PP°rtunity t0 enrich them-
Poor has often benefited Qnly thMe XZTalSXS off
I
community devellpS^TL^oftenn^
Same gOa’S f°r
i
went workers want to mobilize InLl
he CaSe- Governcapital for other nationalXammeT 00^ "
t0 free
want to inculcate confidence and
J- COmmunity workers
of the community. This conflict of
12006
the mernbers
inhibited community development proXmes
sometimes
i
Planners.”‘in faTthe mTnaglment "001
COnflicts for
may pose several problems for olann^C°™nity Programmes
to show results may conflict with rhe ”
example, the need
the community sufficient time to her
t0 aI1°W members of
with new orientations- profession l °me actlve in Programmes
nity’s needs on the basis of ffieir own r
the COm™to provide for those needs, whereas thecom®
the'r Capacity
give priority to other needs which 7 COmmunity may wish to
be more important- the wkh of n
°7 eXperience ^ows to
may conflict with their own camerZal' “
the peOp,e”
wish to promote their own secror’s ■ f
’ nd personnel may
ate with other ministries.
nterests rather than cooperThese problems have
actually been encountered in many pro
of ignored when planners in
ealth and development programmes
definition of community participation
were searching for a
that could be used as a basis
for implementation.
borhTT^ tended t0 be forgotten
Community participation and MCH/FP activities
few case study reports have dealt spedS
TVhe Past decade’
community participation to MCH/FP n r Wlth the relationship of
tended to explore the roH for members o the
repOrtS
range of health activities, of which MCH/FP h™™7 ” 3 Wh°le
usually considered a pan por ,h,
CH/FP, Pro8r«mmes are
however, i. ,ee„. „sefK XieXedTj’ °f "'f P“M™.
derive di™. .„d
6
I
>
and on the potential and limitations of their involvement in improv
ing health conditions and health care.
The factors that either constrain or favour the involvement of
women in community health activities were treated at length in a
recent WHO book Women as providers of health care (Pizurki et al.,
1987). The book points out the following factors, inter alia, as
reasons for involving women in health activities, particularly those
designed to improve the health care they themselves receive.
First, women have a traditional and natural role in providing
health care. They are the principal providers of health care both
within the family and in communities. Moreover, as role-models for
children and younger people, they can do much to encourage health
sustaining attitudes and behaviour. Women also provide the greater
part of care delivered by formal health systems, within which they
work as doctors, nurses, modern and traditional midwives, and
paramedical and voluntary workers.
Second, the opportunities provided for communicating with
other women during the course of normal domestic tasks—water
collecting, shopping, etc.—ensure that much valuable information
is passed on. Communication and mutual support within this infor
mal “network” often supplements the work of formal health pro
viders.
Third, women frequently have stronger community roots, es
pecially in developing societies where men may migrate to urban
areas in search of better-paid work. In volunteering to become
village or community health workers, or becoming active in other
areas of community life, they provide a continuity that is essential in
rural development and health programmes.
Many of the traditional activities of women, such as the collec
tion of water, the provision and preparation of food, the rearing of
children, reflect aspects of the intersectoral approach to improving
health. Where they strive for basic levels of sanitation, clean water
supplies, improved food safety, etc., women can have a positive
influence on health status; the promotion of health will then come to
be seen as a community activity rather than solely a task for the
health services.
Finally, the women’s organizations that already exist in many
communities provide a ready-made structure for the participation of
women in health-promoting activities. Such organizations include
child-care groups, community centres and, to an extent, schools,
where the majority of teachers are usually women; they are experi
enced in mobilizing resources for the common good and are there
fore able to put their experience to good use in promoting the
improvement of health.
F
COMMUNITY PARTICIPATION IN MCH/FAM.
■ PLANNING PROGRAMMES
Chapter 2
i.
>
1
■nd
<bem
e'T1
T',™1
■»« releg.re
there is likelv to be entrenchedXno^t' ” 3 male‘dominated society
the status or role of wXen
t0 anyradicaI ^ange in
authority.
1S seen as SIV'ng them greater
often
■»» ™>l =ee.S
health, which leaves theml.rX t XX,P°nSlblll?eS and prone to ill
■he home.
S
for
•:
I
hke.y
te in
” “hJ" ”'k »•“ “
benefit rather than lonp-tprm od
bring immediate economic
grammes mav well be seen as the^resn86’
th °fr sanitation prorather than the community
reSP°nSlb,llty of tb« government
nity development generally and Xhealth6"1 °f W°men in commumust be taken into account in an ?
activities specifically and
MCH/FP programmes.
alyslng community participation in
li
I;
I
Reviewing the history of interest in community participation in
health programmes provides a basis for determining what factors
influence community participation in MCH/FP programmes. As a
first step it is important to attempt to define the term community
participation”.
Some interpretations
A variety of different interpretations have been placed on the
term “community participation”, each of which can give rise to a
different form of practice. The following are quoted as examples by
Oakley (1989):
Participation means ... in its broadest sense, to sensitize people
and thus to increase the receptivity and ability of rural people
to respond to development programmes, as well as to encourage
local initiatives.
With regard to development ... participation includes
people’s involvement in decision-making processes, implement
ing programmes ... their sharing in the benefits of development
programmes, and their involvement in efforts to evaluate such
programmes.
I
I-J
!■
What does “community
participation” mean?
societies, combined with the frequent lack of ™ra‘and developing
ities, as a result of which rhoir m
i
^ucational opportuntheir traditional role a^ Leah1 pro vid
materia,1 COntributio^ to
planners. Government policv
d
are. rarely understood by
or support to w”or womergive little cred‘t
result that womTn are rarX
0rgan'zatI0ns this area, with the
■j
__
Participation involves ... organized efforts to increase control
over resources and regulative institutions in given social situa
tions, on the part of groups and movements of those hitherto
excluded from such control.
*
These interpretations‘do not answer the question of whether
community participation is a means or an end, or give any idea
of what is meant in practice by such terms as a_comrnunity s
A e•
8
‘
’ -
“ — -
/
I!
COMMUNITY PARTICIPATION IN MCH/'
'Lv planning programmes
WHAT DO.
devetol=™"> Programme,-
•nd
their needs. Thus, discussion between the community and
planners and agencies would enable more appropriate services
to be provided. In addition, people would be more likely to use
services that they had helped to develop.
measured. .
result of any serious proposal that ma Ci S rJ?at lnevitabiy arise as a
changes in resource anocations^^
t0 Shifts in Power"or j
(3)
A functional meaning
ar,onUUp
Participationfthe Rural^Parric^^
"derStanding
derstanding of
of immunity
[
Project 3t
at Cornell
University
has looked into the concept In fauon
~
,nUJlenqUT.tauna^SlSofth'swork,it
;
be defined by asking
I
C3n
thken,tOparticiPadoninMcH/^TnoTarnIf thC Same aPProach is
that help or hinder its achievenfe
mes’ some ofthe factors
following three questions seem Zr
be dete™ined. The
as a basis for judging the value of dTZ'' Th7
nOt asked
rather to try to define MCH/FP program
T-8’ their plJrPose >s
community participation This is nT
objecnves in terms of
are all too often defined in terms f 1 311 eaSy task Slnce objectives
not clear who in the communky shouWund “t 'T'5’ S° that ic is
what purpose.
y
undertake what actions for
I
•
Why participation?
Put forward many cogent arguments forlorn
dlC3i Commiss'on
fodow^^
The most important can LeTummSS Is
effective in imp^vmrSfo intarS^’031 technoJoS-v is ^ss
People can do for themselves In devel Ommunltles than what
hygiene and food consumorinn □ sanitation, environmental
health will be achieved than by incre^
lmProvernent in
vices alone.
y lncreasmg investment in ser-
I
Health care services
who need .he ^XTSXXd'lTj
opn»nr .nd app,lcatio„. the
10
Communities possess untapped resources that could be used to
make health care more accessible and acceptable, particularly
to the poor and underprivileged. It is for the community to
decide on the best ways of mobilizing those resources, which
include materials, money and personnel, to satisfy community
priorities, particularly by providing better care for more
people.
(4) People have both the right and the duty to be involved in
decisions about activities that affect their daily lives. Such
involvement provides a basis for increasing self-confidence and
self-reliance, which are sorely lacking among the poor and
underprivileged. It gives practical force to the idea of health as
a human right and an element in social justice issues. In
addition, if it enables even the very poorest sections of the
community to take part in improving the health services avail
able to them, it will thereby create a precedent for their partici
pation in yet wider community activities.
Who participates?
governmentaingrXsCsurhtOsCliheeCht'On “"Imateriais fr°m non-
(2)
COMMUNITY PARTICIPATION” MEAN?
” P^J «r
I
Since primary health care is concerned with using scarce re
sources in a way that will bring the greatest possible health benefits
to the greatest possible number of people, its success will obviously
depend on persuading as many members of the community as
possible to participate in planning and providing it. Determination
of the numbers doing so will help to measure the extent of partici
pation. As already mentioned, however, communities are composed
of various economic and social groups, and the participation of
particular groups may be essential for the attainment of particular
programme objectives. In such cases, the extent to which the sup
port of these specific groups has been enlisted in practice will be the
measure of success of community participation in the programmes
concerned.
How do people participate?
Five different levels can be distinguished in a community’s
participation in programmes with an important health services com
ponent:
11
COMMUNITY PARTICIPATION IN MCH/FAMIL
anning programmes
WHAT DOES ‘x,^MMUNITY PARTICIPATION” MEAN?
Examples of this kind of participation abound in the commu
nity-based contraceptive distribution schemes that were devel
oped in several countries in Africa and Asia in the early 1970s.
Members of the community were recruited to sell contra
ceptive devices and give some family planning information;
they were usually provided with some economic incentives for
their work. In the early stages they were basically employees
and had virtually no say in decisions about the launching or
Pi
|.
xsssthan
provided.
development of programmes.
Y PaSS1Vely aCCept the health services that are
il
People participate in implementing health programmes. In addi
tion to participating in benefits and activities, members of the
community may choose the site of a clinic, run drug-purchasing
schemes, organize infant welfare and nutrition clinics, etc. At this
level, those involved have some managerial responsibilities, since
they make decisions about how these activities are to be run.
However, the activities to be undertaken and the programme objec
tives to which they contribute are decided by planners to whom the
members of the community have to refer for advice, supervision and
approval. It is therefore the planners rather than the community
who are the focal points for these activities.
1
i
sigSllS
Examples of this type of participation are found in the many
programmes that set up village health committees, choose
community health workers and/or institute community health
insurance schemes in response to suggestions by those who
administer the community health programmes. A study under
taken by the American Public Health Association (1977) on the
delivery of low-cost health services in 150 projects showed
that, in the early*stage of project development, most commu
nity’participation that involved community choice occurred at
above^mLlTrslT^rc^
0^0'”'”' activities. In
programme
In addition
addition t0 the
this level.
i
-
12
People participate in monitoring and evaluating programmes. In
addition to the above, members of the community help planners to
judge whether the programme objectives have been met—and if not,
why not. At this level they are involved in deciding how to measure
programmes
WHAT DOES “COMMUNITY PARTICIPATION" MEAN?
position to modify programme obj0
activities- They are in a
objectives themselves a u^ whilh ^still'th0' “
planners. This level of participation is
prer°gatlve of the
there is least experience. This is parrlvehhaPS tHe °ne of which
grammes, only lip service is paid IS
mP
? because, in many propartly because programme objective^ nart^11]8
evaluation and :
mumty participation, are often not ’h!“!Cularly as regards com- I
cannot be measured
Nearly stated and therefore >
about, and taking responsibility for, programme policy and manage
ment. It is the ideal towards which many programmes strive.
WHO received a request for a small amount of money to fund
supplies for a project in Peru that involved a community health
programme and had developed the organization necessary for
implementation and management and begun to undertake
activities. There are few reports of such programmes. In the
1977 study by the American Public Health Association, of 150
projects surveyed only 8% claimed to have attained this level
of participation. (The study did not seek to verify this figure.)
I
have been involved in moniS^ a d^5
such as conducting surveys
evaluated, discussing the findinnt
<
Comrnunify
^'^'on activhies
9 What should be
ti°n, and deciding the future not ° monitor'ng and evaluastudy by the Amedcan Public
P-^a-me. A
he Pilot project undertaken bv the R» SS°clatlon (1983) cites
Ministry of Health in ColomWa as an
DePartment of the
ough system for communitTtvoivement 3 V6ry Pt
project, the community health comXt
evaluationthat
surveys, then analyse"them io^X J,
KCarry out immunity
The evaluation is done by the comm L
'°Ca' hea'th team'
trained to use a simple form with ouesn
members’ "ho are
households in their villages
® J ons to wh,ch heads of
the structure, activities and impart of J'S.desi9ned to cover
well as the participatory process Self.
h SerVices as
ticipating in the wavs described
n to
In aaaitI0
addition
t~ parPeople from the community (usually lea^
,preceding
P,receding sections,
sections,
n a5hers’ etc-) actually decide what bJhh
key members such
should be undertaken and ask health
'PrO8rammcs the.v fhink
government to provide the expert knowlld ’ agenC'eS and/or the
enable the activities to be pursued
res0larces to
decide upon and manage a health nt Members °f the community
and provides the necelsar^r«^
This is the level at which community Dar °r
Ve their obi«tives.
H
14
15
!
(
FACTORS AND .
Chapter 3
aTURES OF PROGRAMMES
— the degree to which communication takes place between the
centre and the periphery at both local and national levels.
Factors and features of
programmes: a framework
for analysis
In developing a programme, planners and agencies can have
little impact on these factors. Through advocacy they may succeed
to some extent in changing government attitudes or removing speci
fic bureaucratic obstacles, but they will certainly have little influence
on cultural and historical factors. Case studies show that, for the
most part, planners have accepted these factors and recognized their
importance in developing and defining programme objectives. How
ever, since few details have been given in the literature and because
these factors are specific to each programme, they will not be
discussed in detail here.
Types of programme
On the basis of the five levels of participation described in the
tPvnes ofTrw/pp “ attempt can be made t0 categorize the various
types of MCH/FP programme and define the factors that determine
whether and in what ways they can attain their community participation objectives.
Mcwpp Programmes chosen
have health services, mainly
CH/FP services, as an important component and are all designed
to achieve, inter alia, the following goals:
Table 1.
!
improving the health status of large and mainly impoverished
groups of people;
Factors in programme formation
Descriptive factors
Action factors
Cultural
Economic, social and political
Historical
Government policy
Decentralization
Local level organization
Core/periphery communication
Assessment of needs
Community organization
Programme management
Resource mobilization
Leadership development
Attention to the needs of the poor
de\ eloping long-term, self-sustaining programmes through
community contribution in management, money and human
resources.
Action factors
Descriptive factors
The second set of factors that influence the success of a pro
gramme may be called “action factors”. They can be acted upon by
programme planners in order to achieve the objectives set. A review
of the programmes covered by the case studies suggests that action
factors are of special importance in determining to what extent
short-term and long-term objectives in respect of health services and
community participation in them are being achieved in the pro
gramme under review. These action factors reflect:
7 he effectiveness of community participation in helping plan
ners and agencies achieve their goals in MCH/FP programmes
depends on two distinct groups of factors (see Table i). The first
may be called “descriptive factors”. Many of these were highlighted
in a WHO/UNICEF study (1977); they describe the local and
national context m which a programme develops, and may be
cultural, economic, social and political, or historical, or they mav
reflect:
J
J
the degree to which national policy responds to local aspirations
and needs;
the degree to which the civil service has been decentralized;
—
the degree of organization at local level;
16
I
■
—
how community needs are assessed
—
how community organizations are developed
—
how programmes are managed
—
how financial and human resources are mobilized
—
how leadership is developed
COMMUNITY PARTICIPATION IN MCH/FAMILv "LANNING PROGRAMMES
FACTORS
-
> FEATURES OF PROGRAMMES
how the problems of the poor, especially the very poor, are dealt
witn.
and dThe following ParagraPhs deal in more detail with these factors
hmd
S S°me °f tHe conditions under which they may favour or
hinder effective community participation in MCH/FP programmes.
Assessment of needs
tiring alread^ St,ated’ one waV of bringing about community par
ticipation is to find out what members of the community see as their
major problems and then work with them to define some possible
solutions. As members of the health or other professions, planners
Jh^eo11611' °Wn ^dgements about both problems and solutions in
the commumty, but may be bewildered to find that asking the
ommumty to do the same produces a number of different ideas In
ch cases, which are common, planners can react in various ways
hey can adhere to their own judgements in the belief that they will
provide the most efficient and effective solution. They can attempt
to explain their professional views to the community in an effort M
get its agreement They can try to reconcile the different opinions bv
discussion, building up community awareness and self-reliance
This di lemma is particularly acute for health planners who are often
respectoStho
dHiSeaSe-related Problems and take action in
respect of health or medical services: when they ask questions about
probTemT7
S thCy 3re aCtUally concerned about health
th If Panners and agencies regard the improvement of health
through the improvement of health services as their major objective
heakhDroblemsCCeSStOnly
Community sets the solution of
health problems as its own priority. This creates broad possibilities
wharPiann“s t0 promote community participation by discussing
what should be done and then undertaking it. There are also furthef
advantages to the community identifying health improvement as a
prionty. One is that health sector planners are then able to use their
professional skills to undertake specific tasks and to educate commu
nity members about the health topics in which they have expressed
nterest^ Planners can also define other development activities in
terms that they understand, using people from other sectors as
resources rather than as managers. Moreover, political questions can
be set aside, allowing planners to define health in purely technical
coverage C°nCentrate On providing an efficient service with wide
In Costa Rica, in response to an ever-increasing demand for
hospital services, a programme for community care was devel
oped in the early 1970s. Described as a programme for a
“hospital without walls”, it focused on integrating the services
of the Ministry of Health, the Social Security Fund, local hospi
tal boards and other community organizations, and medical
and social service professionals with a view to improving
health in the rural areas of the country. It established regional
structures for community involvement that included health
committees and community health workers. The committees
have built, equipped and supervised over 44 community health
posts, established nutrition centres and water-supply systems,
organized school gardens and food distribution and implemen
ted various other health-related projects. They provide muchneeded and highly appreciated support for the Ministry of
Health's plans for the rapid improvement of rural health ser
vices, a need defined both by the government and by the rural
population.
There are many programmes in which planners have already
decided that health care, particularly services, is a community need.
By devising a programme without consulting the community, they
have denied a role to members of the community in deciding what is
best for the community. They have thus, intentionally or un
intentionally, limited community participation to receiving benefits
or possibly being involved in programme activities. As a result,
planners have lessened the opportunity to involve the community in
decision-making because they have already defined the problem and
also, by implication, the range of possible solutions.
A hospital programme in Hong Kong began an innovative
attempt to improve health and health care among the large,
mainly refugee, population in one of the growing “new towns"
by setting a goal of “having the community take responsibility
for its own health care". However, the planners decided that
the health problems of this diverse community could be best
met by providing improved services. They therefore devel
oped, without consulting the community, three community clin
ics and a health insurance scheme under which mothers and
children, workers, and old people could avail themselves of
basic curative, preventive and health education services on
18
19
COMMUNITY PARTICIPATION IN MCH/FAMILY PLAN
5 PROGRAMMES
payment of a small fee. The result was that the members of the
community, who had not participated in developing the pro
gramme, saw it as a hospital project without a role for them
selves in forming policy or activities. They participated in the
programme only by accepting the services it provided, not by
contributing resources or ideas to it.
In other yprogrammes, the planners and agencies have advocated not only improved health service delivery but also integrated
development on the grounds that wider community participation,
which is necessary to bring about health improvements, depends not
only on health services but also on programmes for agriculture,
education, housing, and income generation. Planners who hold this
view believe that successful assessment of needs depends on a
community not identifying health as a priority; though they may
well use health as a focal point for their activities, they will rely on
personnel from other sectors to deal with more pressing community
needs. A team of people from various professions working with a
community in this way will afford any programme the greatest
chance of success-.
In Indonesia, a rural doctor persuaded members of a commu
nity to participate in a health insurance scheme and to provide
community health workers for front-line health care. However,
the people did not participate in any decisions about the
programme. When the doctor began to discuss the
community’s problems with the people, it became apparent
that health care was not considered to be a priority need. He
therefore encouraged community leaders to develop their own
programmes, using the established health insurance and com
munity health worker activities as a basis for housing, sanita
tion and income-generation schemes. He also asked people
from community development and government agriculture and
rural development organizations to assist the community in
developing programmes. This wider approach to health prob
lems became a model for the entire province and provided a
basis for intersectoral cooperation.
For those who want to use participation as a means of incul
cating a spirit of initiative and self-reliance in the poor as the first
20
FACTORS AN
-ATURES OF PROGRAMMES
step towards achieving wider community development objectives,
the problem is one not merely of finding out what the poor want but
of gaining their confidence, so that they will discuss problems with
people from outside their communities. Case studies in which this
has been a clearly stated aim have shown that planners and agencies
have been able to use maternal and child health services (curative
and preventive) as a means of gaining the confidence of the poor.
Maternal and child health services have thus provided a basis for
gradually determining community needs. In this way, outsiders
have also been able to work in areas designated by governments as
politically unstable, since the provision of health services is regarded
as an apolitical activity.
When an attempt by a group of university students in India to
improve the very poor socioeconomic conditions of tribespeople in their vicinity by beginning a dairy scheme had failed,
they decided instead to provide simple curative medicine,
concentrating on the prevalent diseases of tuberculosis and
malaria and on maternal and child health. Simple education
about these problems led to the establishment of a village
health committee and the training of village health workers. In
this way the tribespeople were given the confidence not only to
undertake wider development schemes but also to demon
strate resistance to a group of people who had exploited them
economically for years. The support of the students enabled
these very poor tribespeople to discover, and do something
about, some of the underlying causes of their poverty.
Community organization
If members of the community are to participate by taking an
active part in programmes, and not merely receiving health benefits,
there is a need for community organizations that will initiate,
support and maintain the activities concerned. The importance of
such organizations was well demonstrated by the 1977 APHA study.
Of 150 projects studied, two-thirds were based on established or
newly created community organizations, which were quoted as
being responsible for the successes achieved. Conversely, lack of
success in those projects considered as failures was blamed on the
absence of organizations to support their activities (APHA, 1977).
COMMUNITY PARTICIPATION IN MCK/FAMILY PLANNING PROGRAMMES
k•
§
Ideally, any organization through which a community partici
pates in MCH/FP programmes or in health programmes in general
should be created by members of the community to deal with a
health problem they themselves have identified as being of prime
importance. When such an organization exists, it provides planners
and agencies with a structure that has already attracted community
support and can become the basis for active collaboration. An
example of a programme of this type in Costa Rica has already been
mentioned. However, programmes that have developed in this way
are very rare. Planners and agencies therefore need to search for
other approaches if they are to meet their programme objectives.
Where no health-related organization exists, use can be made
of established organizations in other fields to promote health activi
ties. In many communities such organizations have been set up to
meet other development needs and thus have the structure and
experience to handle community involvement in a range of
activities.
The Mothers’ Clubs of the Republic of Korea are often cited as
examples of MCH/FP activities being successfully introduced
into existing programmes. Women's organizations had long
existed in Korean villages as a counterpart to all-male organiza
tions. In the 1960s some were transformed into mothers’
groups of the National Reconstruction Movement at which
many topics of national importance, including health care and
family planning practices, were discussed. These discussions
proved to be so successful that the Korean Family Planning
Association, with the help of USAID, later decided to revive the
mothers' clubs. Although they were initially concerned with
family planning activities, the clubs expanded in later years to
include other community development projects. In the 1970s,
established clubs sent members to help set up family planning
education in the most remote parts of the country. They have
also undertaken work in the urban slums.
J
I
I
Another possibility, and one that is particularly common in
programmes designed to improve health services, is to create an
organization from scratch, often in the form of a community health
committee. A number of case studies have recorded experiences in
developing this type of organization. An initial step that has proved
22
FACTORS AND FEATURES OF PROGRAMMES
effective in some programmes has been to call a community assem
bly and ask it to authorize the establishment of a health committee.
Other programmes have formed health committees on the basis of
strong community leaders and the authority of existing community
administrative groups. From case studies it seems that health com
mittees established under the auspices of outside planners and
agencies need careful supervision, help in identifying tasks, and, in
many cases, funds. In addition it is necessary to find ways of
ensuring that the community at large is involved in committee
decisions. Otherwise there is a danger of the committee’s work being
dominated by staff, strong community leaders and/or community
elites, thus limiting the part played by larger groups and the support
they will give.
In Cameroon, an American university and a central African
organization decided to establish village health committees
with a view to giving villagers experience in finding their own
solutions to health problems and to applying that experience to
the solution of wider development problems. After a slow initial
process, involving surveys, discussions with the community
and reciprocal education between the outside agency workers
and the community leaders, village health committees were
established. Specific health problems, such as disease control
and making maternal and child health services more access
ible, were put on the agenda. These committees were carefully
planned and supported, both the outside agency and the Minis
try spending time and effort to ensure success. Although the
Ministry decided to extend this approach to the whole country,
only one out of the four pilot villages succeeded in achieving
the original goal of extrapolating experience in health pro
motion to broader development activities. In other villages,
lack of interest, cultural and historical divisions, and traditional
beliefs about disease made it difficult to attain even the health
objectives.
Other problems of which planners must be aware may also
arise. In some programmes, for instance, particularly those aimed at
improving health services, planners have organized health
committees only to find that later, when other community devel
opment problems had also to be covered, the committees were too
inflexible to cope with the new tasks that faced them.
23
COMMUNITY PARTICIPATION IN MCH/FAMILY PLANT
PROGRAMMES
rJn H°9ramrne ln Tunisia’ local family health workers were
trained to promote maternal and child health care and family
planning by persuading women in isolated rural areas to use
selfTeln"9 heat‘h servlces and' in the lon9 ’erm, encouraging
self-help projects among the female population. In the training
stress was laid on ways of improving the utilization of the
s.T'TJTh
An evaluation of the Project found that little
success had been achieved in the development of self-help
heJhh68' TheSe h3d been swamPed by efforts to improve the
health services—the programme's main objective—and more
planning, support and resources would have been required to
achieve any noticeable improvement.
for whole range of development activities. Since health workers
from outside have an opportunity to gain the confidence of the
community, promote its activities and build up awareness of its
potential through their work in the health services health
committees can serve as organizational starting points for efforts to
solve wider community problems. Planners and agencies have there
fore come to regard health activities as a means of encouraging the
thev^ hav3^le,eCOnf°miC’ S°Cial and p011tical Problems. In so doing,
hey hate had to face up to the conflicts that arise as a result of
XSnrtanCe
m P°Wer t0 Change in existing community
structures which they consider to be against their interests. In such
circumstances, every aspect of power and control may be brought
into question. This type of situation is well illustrated in the pro
gramme in India described in the section on assessment of needs.
Programme management
°ne °f T16 ,n}a’or obiectives of many programmes is that the
community should manage the programme, i.e. play a decisive role
m its planning implementation and evaluation. Achievement of this
objective would represent the highest degree of participation. Unrhfnb113 mkln thlS rdspect there has been far too much wishful
thinking. There is evidence to suggest that, despite statements to the
contrary m many programmes, management is in the hands of
professionals who are from outside the community and/or have
FACTORS A.
■EATURES OF PROGRAMMES
come from outside agencies. The 1977 APHA study found that most
projects limited community management to consultation by the
planners and agencies. Members of the community could, for in
stance, express opinions on the opening hours of clinics, what drugs
should be purchased and sold, and how money should be allocated
to projects. In fewer than 20% of the projects studied were commu
nity members allowed policy and administrative control. Of these
projects, 16% allowed the community to decide where the health
centre should be sited; a far lower percentage allowed the commu
nity to participate in decisions on other matters (APHA, I97?)It is mostly in programmes established by the community
itself, and in which it has set its own priorities, that a community has
a say in decisions. In such cases, very few of which have been
recorded, professionals and planners from outside are sometimes
asked for some support, usually financial.
It is far more common for planners and professionals to domi
nate programme developments. One reason for this is that pro
grammes in which improving MCH/FP services is a major objective
tend to stress the more technical aspects of the work to be done. For
example, the 1983 APHA study found that, although community
workers are theoretically responsible to the community, they in fact
see themselves as accountable to the health staff, who are responsible
for supervision and evaluation. Failure to define community health
workers’ tasks clearly and the lack of trained supervisors also hinder
the development of community management in this area (APHA,
1983).
In a community in Thailand in which a health committee had
been established to choose and support community health
workers, the committee lapsed into inactivity after selecting
them because its specific functions and responsibilities had
not been made clear (APHA, 1983). Although it is also desirable
that members of the community should play a bigger part in
evaluation, the APHA study again found that only about 25% of
the programmes studied gave the community some role (un
defined) in programme evaluation. In a further 40% the
community’s role was limited to answering questions in sur
veys. In 35%, the community was assigned no role at all in
evaluation.
All the above evidence suggests that giving members of a
community an important role in taking decisions about programmes
U C C r.
24
25
COMMUNITY PARTICIPATION IN MCH/FAMILY PLANNI.
I
FACTORS
ROGRAMMES
is a much more complicated matter than the literature would indi
cate. While most programmes pay lip service to the idea of devel
oping the management potential of the community, planners and
agencies find that it is in fact very difficult to do so. Involving
members of the community in decision-making processes appears to
need a clear statement of the tasks involved and strong support from
professionals, planners and agencies. It needs a concerted effort by
professionals to share information about new technologies and new
approaches to programme planning and implementation. Lay
people need time to gain confidence and experience in an unfamiliar
field. In some programmes, members of the community have gained
experience in managing activities such as water supply and sani
tation before going on to manage health activities. In other pro
grammes, which have started with health services and tried to
promote community management, members of the community have
relinquished the more technical aspects of the programme to the
professionals and moved into management of broader community
projects such as water supply, nutrition and income-generating
schemes.
however, planners have encountered the same barriers of commu
nity expectations and professional dominance as those found in
programmes aimed solely at improving the health services. Here
again, the gap between vision and reality forces planners to recog
nize that achieving their declared goals will be a long-term process.
In a national community health programme launched by a non
governmental organization in the Philippines, the planners
believed that education of the community—explaining the
reasons for its poverty—would spur it to take action to change
the exisiting situation. In the early stages of the programme
emphasis was therefore laid on community organization rather
than on the provision of services. The community, however,
had looked upon the programme as a health programme and,
when they were not provided with the services they had ex
pected, lost interest in the organizational and educational
activities. As a result, it proved necessary to develop the health
aspect of the programme and use it to gain the confidence of
the community, building up awareness of the need for change
and of the community's ability to bring that change about.
I
In Kenya, a rural community in an arid area defined water
supply as its most urgent need and provided the resources,
planning and infrastructure to develop a strong water project.
After its primary goal had been achieved, it used this experi
ence and the organizational framework that had been created
to provide access to health services. In Indonesia, a commu
nity initiated a community health programme with a health
insurance scheme and community health workers, but after
some time the programme became less concerned with ser
vice delivery and concentrated on other more essential com
munity development activities.
'\
A few cases have been described in which planners have at
tempted to use health services as a basis for persuading members of
the community, particularly the poor, to assume responsibility
for wider community concerns. In these instances, planners have
usually aimed at enabling the poor to become self-reliant and to
show initiative, and have regarded health services, because of their
apolitical nature and the rapidity with which they produce results, as
a means of achieving that aim. In the early stages of such schemes,
9A
FEATURES OF PROGRAMMES
Resource mobilization
One of the reasons already given for community participation
in MCH/FP programmes is to provide more resources for activities
that are needed continuously. Community participation will also
enable communities to become self-reliant and reduce their depen
dence on outside planners and agencies for money and advice.
Nearly all programmes with community participation as an objec
tive accept this as one of the reasons for their work. The literature on
the potential contribution of communities is too extensive to men
tion in detail here, but some general observations will show how
community contributions influence effective community partici
pation in MCH/FP programmes.
The resources generally provided by communities have tended
to fall into three categories:
—
labour for building and maintaining facilities
—
people to serve as community health workers
—
funds to pay for minor forms of treatment and medicaments.
COMMUNITY PARTICIPATION IN MCH/FAMILY PLANNIN(
□GRAMMES
These contributions are often cited as evidence that community
participation is taking place. Review of a wide range of case studies
however, suggests that participation tends to be limited to partici
pation in benefits and activities. The decisions taken by the commu
nity are limited to choosing people to serve as community health
workers and determining how to raise money for the activities that
planners have decided upon.
I his situation arises particularly in programmes concerned
principally with health services, when planners tend to assess the
budget implications of programmes and then ask members of the
community to contribute to the planned activities. A 1982 APHA
study on community financing covered over too programmes and
concluded that the decisions to train community health workers, to
finance the procurement of medicaments, and to provide labour for
building health facilities were generally dependent on national
budgetary constraints rather than on the community’s willingness
and ability to pay. Community financing would be more viable if
planners began by studying demand (APHA, 1982).
In programmes in which the improvement of health has been
singled out as a priority, or which comprise a wider range of
development activities, there appears to be more scope for the
community to decide how to mobilize resources. In both cases
however, it is the better-off members of the community who tend to
be involved both in decisions and in contributions (either as an act of
charity or for reasons of self-advancement). In such cases, partici
pation is confined to a limited group of people, usually acting against
the interests of the poor. Sometimes, although resource mobilization
is a result of community rather than outside decision, it is actually a
minority in the community that makes the decision. There is also
evidence to suggest that wide participation of the poorer segments of
the community does not guarantee a more equitable distribution of
the benefits. Unless planners make special efforts to direct benefits
to the poor, their greater participation may serve only to supplement
the comforts of those who are already better off (Carino et al., 1982).
In this respect the experience of programmes that have selfreliance as one of their objectives is also of interest. A review of case
studies suggests that self-reliance is very difficult to achieve. Experi
ence has shown that, when a health programme based on community
participation is launched, outside assistance is initially needed to
help mobilize resources, ensure discussion and communication,
provide technical and management back-up where necessary and
make up temporary budget deficits (APHA, 1982). In programmes
destined to help the very poor, the situation is more complex in that
such people rarely have any resources to contribute. To date there is
28
FACTORS Al
MATURES OF PROGRAMMES
little evidence to suggest that mobilizing community resources will
make a health programme self-reliant. This is a field in which
research might be very useful.
Leadership development
Planners who choose programme objectives that include com
munity participation most often select a completely new way of
dealing with health problems. Acceptance or rejection of this new
approach, which emphasizes that people who need health care
should play a part in ensuring that it is provided, depends on who
introduces it. In most communities, leadership patterns are histori
cally and culturally determined. If these patterns are not recognized
or are deliberately or unwittingly ignored, experience suggests that
programmes have little chance of being accepted or utilized at any
level in the community.
Programmes that have had some success in achieving their
stated objective of providing health services on the basis of commu
nity participation have mostly had the support of local leaders. This
leadership may be either structural or personal. If it is provided by
community organizations created to support community develop
ment programmes, there is a fairly good chance that a new pro
gramme, accepted by this leadership, can be institutionalized and
maintained. Programmes to which community officials are commit
ted enjoy influential support and have ready access to resources.
Personal leadership has also played an important role in the
development of many programmes. Programmes that have received
the most publicity and have been put forward as models are often
those in which personal leadership, usually by a charismatic leader,
has been most influential. Such programmes are often based on the
vision of one person rather than on concerns shared by all members
of the community. Unfortunately there is a risk that, once that
leader is no longer there, too few of the visionary objectives will have
been institutionalized to enable the programme to continue.
The idea of primary health care arose, in part, as a result of
action by nongovernmental organizations in which committed and
highly respected people developed an alternative health care system
in rural areas where there was great deprivation and need. Their
experiences have been recorded in the WHO publication Health by
the people (Newell, 1975), as well as in various publications of the
Christian Medical Commission and other bodies. They showed
that, in very difficult conditions, new approaches based on a high
degree of community involvement in both benefits and activities
COMMUNITY PARTICIPATION IN MCH/FAMILY PLANNIt
ROGRAMMES
improved health status and health conditions. However, there is still
nothing to prove that equally impressive results could be achieved
elsewhere on a larger scale without the guidance of the planners.
The structure of community leadership and the types of people
who provide it will also determine, to some extent, whether partici
pation will be narrow and represent only community elites or
whether it will continually broaden so that all socioeconomic groups
become involved. There is evidence that programmes in which it is
wished to ensure community participation succeed more often when
they do not rely solely on leadership that supports the views of the
elite. This is particularly true in maternal and child health pro
grammes, since the elite in most communities is male and does not
represent women’s interests or needs. In addition, a more represen
tative leadership will not be paternalistic or dictatorial, but will tend
to be democratic and more flexible in responding to the various
needs and demands of the community.
In a pilot programme run by the Department of Community
Medicine of a university in the Islamic Republic of Iran, the
traditional village structures of authoritarian leadership and
male domination militated against broad and sustained com
munity participation. The programme failed for a number of
reasons, among which was the lack of effective utilization of
community health workers from the vicinity. In the end, the
majority of primary level workers were brought in from outside
the pilot areas in an attempt by the planners to remove them
from the control of the village authorities (elites) and to reduce
their involvement in political and family disputes.
V
The nature of community leadership must in some respects be
classified as a “descriptive” factor, which planners and agencies
cannot change without assuming an openly political role. On the
other hand, they can encourage leaders to take certain actions that
will promote achievement of programme objectives and also support
leaders who wish to encourage wide community involvement in
health promotion. Experience shows that leadership plays a vital
role in every programme but that its features will depend on the
conditions present in each specific case and on the correlations
between them.
FACTORS
Concentrating on the needs of the poor
All the programmes described in the case studies under review
include some form of community participation on the grounds that
past health care systems have not been accessible or acceptable to the
poor. When planners and agencies see improved health services or
wider community development as their objectives, the poor become
the “target” group. The literature suggests, however, that it is
difficult to get the poor to participate in MCH/FP programmes, or
indeed in any type of service programme, beyond the level of
receiving benefits. This appears to be true whether a programme is
concerned mainly with improving health services or with wider
community development. There are several possible reasons for
this.
First, the social and economic structures in most communities
give the poor virtually no access to resources. This is partly because
those who have the knowledge and skill to gain access to resources
also gain control of them and, in most cases, have little inclination to
share them with others. The poor, lacking the knowledge and skill to
gain such access, remain poor.
Second, the poor have neither the time nor the energy to
change this situation. They live from hand to mouth and have to
concentrate their efforts on surviving rather than on obtaining
benefits. They have virtually nothing to contribute to programmes
which in the longer term might provide them with a better standard
of living.
Third, their lack of the necessary knowledge and skill confirms
them in their feeling that they cannot improve their lot. As a result,
they tend neither to respond to new programmes nor to attempt to gain
access to services and activities to improve their lives. This barrier
seems to be the most difficult to overcome.
For these reasons programmes have encountered difficulties in
persuading the poor to participate. Concentrating on the needs of
the poor raises two problems, of which the first is political. Planners
and agencies must be seen as attempting to solve a problem in an
even-handed manner. MCH/FP programmes are designed to meet
community needs. Discrimination in favour of the poor may well
lead the better-off to protest that they too need help in solving their
problems.
A cognate problem arises when agencies and planners support
groups outside the existing power structure, thus running a serious
risk of alienating, the existing elites. If common ground is not found
and compromise achieved, confrontation may develop. There have
been instances in which lives have been lost because of the polar
ization brought about by a programme.
(
30
FEATURES OF PROGRAMMES
31
COMMUNITY PARTICIPATION IN MCH/FAMILY PLANN.
PROGRAMMES
T
Chapter 4
In one Asian country, a community health
programme origiWi,h h0(spi,al services expanded its activities
o inc ude the training of female community health workers (a
novelty in this traditionally male-dominated society) and wider
community development activities. Gradually, as the probers^of^hp^an t0 9'Ve the P°0''er and more “PPressed mem
bers of the community additional income and more political
^vcrage, the groups previously holding the reins of power—
mainly land-owners—began to feel threatened. One evening
fa7ed tothretniOStHaCtlVerJand respec,ed male health workers
Conclusion: what the
analysis revealed and
failed to reveal
2 o°me' He W3S later found decapitated at the
side of the road. Subsequent investigations by the programme
PersoPuel indicated that he had been killed by persons hired by
the local landlords. Unfortunately, there was insufficient evidence
to bring any of the suspects to trial.
Summary
rhp rTh |ekOrld probIem 1S economic. Studies on how to improve
the Ines of the very poor have concluded that, if their needs are^o be
met, planners and agencies must devote a large amount of time
money and effort to the task (Coombs, 1980; Carino et al , 1982) If
hT T 1 k6 resc>urces ln question are unavailable for programmes
that might br
more immediate benefits to a
Sarnes
p ople As a result, in many programmes with the declared objective
of participation by the poor in health services or community deveh
,Pmei?t: aetu31 participation is limited to receiving benefits AlP'an"ersra1nd ^encies realize the importance of trying to
meet the needs of the poor and often list it as one of their major aims
beeXTg^neT68'5
comPlicated than had
32
On the basis of the data reviewed in the preceding chapters of
this book, a framework has been suggested for analysing the types of
MCH/FP programmes that include community participation. Two
sets of factors, “descriptive” and “action”, are described, which
determine the progress made by a programme and assess its future
prospects in relation to the degree of community participation.
Limitations
The analysis does not make it possible to draw generally
applicable conclusions as to what factors, under what conditions,
produce the kind of participation planners and agencies have listed
among their programme objectives. There are several reasons for
this.
As already stated, very few of the case studies deal in detail with
“descriptive” factors. Although they are recognized as important,
very little is said about why they are important in a specific context
and how, specifically, they affect participation. It is therefore diffi
cult to understand their effect on policy and programme implemen
tation.
Second, although a wide range of case studies from a large
number of organizations was reviewed, there is no guarantee that
they are representative of all MCH/FP programmes in which com
munity participation plays a major part. In fact, there is a possible
bias, in that the cases presented are those that have outside funding,
while those that have utilized their own resources are not represen
ted in the documents forming the basis of this study. The data base is
thus not reliable.
Third, as already mentioned, the case studies vary in length
and in quality. By far the most numerous are those that are basically
33
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COMMUNITY PARTICIPATION IN MCH/FAMILY PLANNIN
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programme descriptions and fail to inquire into the manner in which
community participation develops. They do not offer any clearcut
definitions of community participation and pass over important
topics such as differences of opinion between planners and members
of the community, the degree to which community support has been
enlisted, and the power structure in the community. In addition,
programmes are often described in terms designed to promote
funding and/or acceptance by international bodies, important issues
being either omitted or glossed over. For instance, in the case of
programmes designed to encourage more initiative and self-reliance
among underprivileged groups, stress may be laid instead on the
provision of improved health services, an objective more likely to
attract support from government or outside agencies. Few of the
documented studies succeed in advancing understanding of the
subject.
In addition, relatively few of the documents analyse problems
and failures. Most are positive statements about the value of com
munity participation and the possibility of developing it. Those
obstacles that are mentioned are either those that planners managed
to overcome or those that can be attributed to “descriptive” factors
such as culture or history. Thus it is often not possible to find
answers to questions about the process of community decision
making, the cost-effectiveness of the community approach, or the
possibility of replication elsewhere.
Finally, there has been little field research. Since communities
are composed of people, it is essential to ascertain their views of the
value of community participation as an approach to health care. Few
of the studies reviewed have investigated with any thoroughness the
views of members of the community. Moreover, few have asked the
questions essential to understanding how effective community par
ticipation can be achieved. Thus, the analysis may well have omitted
important factors that field research would have revealed.
Potentials
The analysis does make it possible to suggest some ways in
which planners and agencies might obtain the kind of community
participation in MCH/FP programmes that would promote their
programme objectives. For instance, they might be better able to
clarify their objectives by asking why there should be participation,
who should participate, and how they should participate. This
would provide a practical basis for action instead of the platitudes
commonly encountered.
34
CONCLUS'
ROGRAMMES
When broad community participation is one of the stated
objectives of a programme, members of the community must be
offered a wide range of options and activities. In a comprehensive
analysis of nine Asian community-based projects, most of which
were concerned with some aspect of health, Coombs rightly states:
“A programme that subscribes to the values and ethics of a
community-based service has to subordinate its immediate and
narrow objectives—be it the acceptance of contraceptives
and/or the treatment of parasites, or vaccination against pre
ventable diseases—to the ultimate needs and interests of the
community people. These needs and interests of the commu
nity as perceived by the community can be the only basis for an
authentic community-based service programme” (Coombs,
1980).
In a review of 35 projects, the American Public Health
Association struck the same note:
“Project experience shows a correlation between high partici
pation and an integrated approach open to community pri
orities and not strictly related to health care” (APHA, 1983).
Those who regard community participation as a means of
making MCH/FP programmes more cost-effective must study ex
perience gained in various programmes. This suggests that, in the
short term, particularly in programmes that focus on the needs of
the poor and contain a health service component, financial require
ments are considerable. In addition, community participation tends
to be limited to receiving benefits and being involved in activities.
Participation in decision-making and resource mobilization appears
to need a long time to develop.
Planners and agencies should study their own experience and
the experience of others to find answers to a number of questions.
Among the more important are the following:
(1)
What effect has the programme had on the health status of the
population and how has community participation affected
health status?
(2)
What effect has community participation, as defined by the
programme, had on service utilization in the view of both
planners and members of the community and why?
35
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COMMUNITY PARTICIPATION IN MCH/FAMILY PLANNING PROGRAMMES
I,
' t.
I
i...
4
b
(3)
What broader improvements in health has community partici
pation brought about and how have those improvements been
manifested?
(4)
How have programme planners and agencies defined and dealt
with the inevitable problems of political control when broad
participation has challenged the power of the existing elites?
Answers to these questions will lead to a better understanding of
the dynamics of community participation and of some of the conditions
under which it does or does not help meet programme objectives.
As has been seen, the concept and implementation of commu
nity participation are very complex. Although the literature, in
relation both to health programmes and to other development pro
grammes, continues to grow, little is yet understood about the
dynamics and impact of community participation. If its possibilities
are to be realized, more thorough and critical analysis of experience
in programmes is needed.
Goaa H - 1 .
WH0/CSI/2001/DP2
I
Understanding Civil Society:
Issues for WHO
CIVIL SOCIETY INIII ATI VE
External Relations and Governing Bodies
f I
World Health Organization
Discussion Paper No. 2
CSI/2001/DP2
Understanding Civil Society:
Issues for WHO
February 2002
Civil Society Initiative
External Relations and Governing Bodies
WORLD HEALTH ORGANIZATION
CSI/2001/DP2
TABLE OF CONTENTS
Introduction.............................................................................
Exploring the definitions.........................................................
The fuzzy boundaries between State, market and civil society
Differences within civil society...............................................
Making an informed choice.....................................................
Constitution and composition..................................................
Functions and capacities.........................................................
Scale and outreach...................................................................
Conclusion...............................................................................
Reading list..............................................................................
2
3
4
4
5
6
6
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8
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CSI/2001/DP2
Introduction
We live in a world of shrinking borders and burgeoning needs, where people faced by
rapid social, economic and political change are seeking new ways of controlling their
lives and the future of their communities. Armed with more access to information
than ever before, and backed by new technologies, people are banding together to find
new means of articulating their needs and to ensure that government and business
policies protect and promote their interests.
Along with governments, the United Nations (UN) system, which believes that
development must rest on people’s needs, has not been immune to this unleashing of
people power. The UN as an institution has a history of opening its doors to
organizations and institutions that represent the diverse interests of people. In recent
years, the UN family has made a special effort to broaden its collaboration and
consultation with such organizations.
The World Health Organization’s (WHO) Constitution encourages interaction,
consultation and co-operation with nongovernmental organizations (NGOs) while a
number of World Health Assembly, Executive Board and Regional Committee
resolutions have strengthened this collaboration.
In recent years, there has been an unprecedented growth in the activity and influence
of civil society actors in the area of public health. They have engaged with WHO to
implement WHO programmes at country level, made outreach to remote areas and
populations possible, advocated WHO issues to a broad audience, addressed sensitive
issues that WHO cannot for political reasons and worked in alliance with WHO to
raise funds more effectively.
The increasing role of civil society in public health and the mutual benefits involved
in expanding partnerships have placed new demands upon WHO. The Civil Society
Initiative (CSI) was established in June 2001 in order to ensure that the changing roles
and expectations of civil society are more adequately reflected within WHO. The
mandate of this new initiative is to initiate a policy discussion on the role of civil
society in public health and to guide WHO policy on ways to strengthen relationships
with civil society organizations (CSOs)
This paper is part of a series produced by CSI to help promote a wider understanding
of civil society and the various ways in which it is involved in health. It introduces
some basic concepts and issues to assist WHO in its development of policies and
interactions with civil society. It has been edited by CSI based on a background
contribution written by Dr Rene Loewenson, TARSC, Zimbabwe.
3
CSI/2001/DP2
Exploring the definitions
Civil society has its roots in the word ‘civics’, which comes from the Latin word
‘civis’, meaning citizen. Both the Romans and Greeks had equivalent terms meaning
‘political society’1 where citizens active in the political life of the state helped shape
its institutions and policies.
Today, there is no universally accepted definition of civil society or organizations formed
to represent civil society. Even within Member States and the family of the UN, the
definition and classification of civil society actors seems to vary. Many use the term
NGOs synonymously with CSOs.
The common understanding is that civil society embraces the general public at large,
representing the social domain that is not part of the State or the market. Lacking the
coercive or regulatory power of the State and the economic power of market actors,
civil society provides the social power of its networks of people. Its ideas,
information, services and expertise are used to advance the interests of people by
seeking to influence the State and the market. It is a sphere where people combine for
their collective interests to engage in activities with public consequence.
The increasingly accepted understanding of the term CSOs is that of non-state, notfor-profit, voluntary organizations formed by people within the social sphere of civil
society. These organizations draw from community, neighbourhood, work, social and
other connections. CSOs have become an increasingly common channel through
which people seek to exercise citizenship and contribute to social and economic
change They cover a variety of organizational interests and forms, ranging from
formal organizations registered with authorities to informal social movements coming
together around a common cause.
The term NGO is also commonly used to describe non-state, not-for-profit, voluntary
organizations. However, NGOs usually have a formal structure and are, in most cases,
registered with national authorities. WHO and other UN agencies use the term NGO in
their formal and official language and policies. The term CSOs is used in this paper to
indicate a wide range of civil society actors including NGOs.
The fuzzy boundaries between State, market and civil society
In theory, the State can be strictly separated from non-state actors. Non-state actors
refer to both the market and civil society. While the market refers to the private forprofit sector, civil society actors are known by their not-for-profit operations.
In practice, however, this categorization between state and non-state, profit and notfor-profit is far from being clear cut. The boundaries between the market, civil society
1 In Latin ‘ societas civilis’ and in Greek ‘politke koinona’
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CSI/2001/DP2
5
and the State are not always clear, nor are the interests of those in civil society always
divorced from the State or market. The interests that motivate people to form
associations may reinforce State or market interests or they may challenge them.
There are some not-for-profit organizations that by virtue of their area of operation,
governance mechanism, or funding may be closer to or involved in the market. These
include, for example, chambers of commerce or trade unions. Other organizations may
be more linked to the State. Many CSOs are dependent on public or government funds,
including aid from international sources. This has given rise to categories such as
Government Organised NGOs (GONGOs) or Business Organised NGOs (BONGOs) and
Business Interest NGOs (BINGOs).
As far as WHO’s public health mandate is concerned, the importance of
differentiating between non-state actors with commercial or market interests and those
without such interests is considered important. Some market interests may be in direct
conflict with health outcomes, such as the marketing of hazardous products like
tobacco or alcohol, while other markets may need to be regulated to protect
consumers or ensure equitable distribution of health care resources. Given the
possibility of real or perceived conflicts of interest between market motives and
public health goals, it is important that market links or interests be transparent to
WHO, particularly in the organization’s normative and policy role.
Differences within civil society
The world of civil society is not uniform. The role of CSOs in promoting “public”
interests may not always be clear. The interests that motivate people to form
associations may be public, but they may also be personal. Associations may be
formed to support kinship or narrow group interests that have little to do with wider
public concerns. Civil society interests provide an important channel for
understanding and reaching out to particular social groups but need not be oriented
towards wider public good. CSOs may reflect social, political and economic
inequalities based on factors such as wealth, geography, religion, and gender.
The wide range of interests, combined with the possible existence of market or State
links in civil society organizations, implies that even within civil society there may be
competition and conflict over different values and interests. Such debate and conflict,
if they are open and transparent, are essential for the development and implementation
of socially acceptable and equitable policies. Such contention can be constructive,
especially when it is used to open channels of communication and negotiation around
areas of real conflict, find mutually acceptable ways of resolving conflict and build
social harmony.
Far from shying away from or fearing such conflict, international agencies such as
WHO have a constructive role to play in encouraging this open public debate,
encouraging the expression of all points of view and bringing in new actors and
perspectives in the search for constructive policy solutions.
WHO’s primary interest is in working with CSOs that share its values and offer the
greatest opportunities and synergies for improving health outcomes. Achieving this
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CSI/2001/DP2
calls for ‘due diligence’ in understanding the nature and interests of the organizations
within civil society. Given the number, scale and diversity of such organisations this
is a challenging but essential task for WHO if it is to ensure the relevance and
integrity of its work. The values, agendas and interests of CSOs and communities that
‘talk through’ them may be clear and easily assessed against WHO and UN values
and goals. Hence, for example, organizations that are involved in promoting interests
directly in conflict with health such as arms, tobacco, or alcohol or in conflict with
UN values - such as promoting racism - may not form the best partners for WHO.
Making an informed choice
The opportunities of partnerships carry with them the challenge of informed choice—
who to engage with and how, who to listen to, whose capacity to build and who to
involve in joint actions. WHO needs to be able to sort through and evaluate the wide
range of CSOs in operation.
Since there is no single classification system, those wishing to work with CSOs may
start by identifying some basic premises on the role the CSO is expected to fulfil. For
instance:
•
Will the organization contribute to WHO’s role as a global health institution
responsible for developing and advocating norms, goals and policies in public
health?
•
Will the organization contribute to WHO’s role as a technical agency contributing
to the knowledge base for the development of health policies, systems and
programmes?
•
Will the organization contribute to WHO’s role as institutional support at country
level for the development of national health systems?
Once clarity on the broad role of the organization has been achieved, judgements on
the suitability of CSO need to be made. Three features—constitutional, functional and
scale—could form the basis of the information needed to form these judgements.
Constitution and composition
For any representative, normative or policy work it is important to know how the
CSO is constituted, who it represents, who funds it and to whom it is accountable.
Some of the key constitutional features that locate the representativeness and interests
of CSOs in policy and normative issues are:
•
whether the CSO is accountable to a membership and if so
what is the membership , its relevance and interests in any health issue.
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CSI/2001/DP2
Membership-based CSOs are governed in a manner that makes them accountable to a
common interest membership, whether organised on grounds of professional,
religious, welfare, social or other special interests. In contrast, non-membership CSOs
are governed by a trust, board of directors or other shareholder mechanism. They
include direct service providers, research institutes, technical, training and funding
agencies.
•
the composition, scale and organization of the groups represented; and whether
the CSO has a constitutional mandate for the policy issues under debate.
Knowing how the CSO is composed, and who it represents, will provide WHO a
starting point for evaluating the reach, activities, and potential influence of a CSO.
The composition of CSOs can cover a wide range. One can have community-based
organizations with direct membership from community members (such as home
based care groups); organizations with members drawn from representatives at
national level (such as national patient rights organizations); formally organised
networks formed by a number of civil society organizations (such as country AIDS
networks); and informally organised social movements coming together around a
common cause.
•
the various funding sources of a CSO; and composition of its governing board
members, including transparency of individual board members’ related interests.
Knowledge regarding the funding sources, the executive or governing body
membership and the affiliations of this membership is also very important for WHO.
Without access to this information WHO will not be able to assess potential or real
conflict of interest risks when entering into relationships with NGOs and CSOs.
Transparency in providing this information is critical for WHO.
Functions and capacities
For all areas of WHO’s operation whether it be policy, technical, or health systemrelated, it is important to know the primary functions, capacities and resources of the
CSO.
CSO functions of relevance to WHO include:
• Action, research and training in service provision, outreach, technical and
research inputs in specific areas;
• Advocacy, lobbying and information sharing through existing networks and,
building wider alliances for health goals and sharing information;
• Policy dialogue and development, policy strategy research and analysis
• Monitoring and ‘watchdog’ roles and protection of consumer interests.
• Fundraising, resource mobilisation and financial contributions;
The capacities that a CSO brings to its work with WHO include its technical, human,
financial and institutional resources. It is also important to build an understanding of
the processes and methods used by CSOs to strengthen joint actions on health. This
includes processes used to obtain and share information, build networks of support,
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CSI/2001/DP2
obtain mandates, generate alliances, provide services and advocate and negotiate
interests.
Scale and outreach
Given the global nature of WHO and its regional and country offices, it is important
to know the scale of operation—local, national, regional, international— and
north/south location of the CSO and its branch offices. Depending on the issue and
strategy under discussion, WHO may wish to work with organizations having a
specific reach and range.
Knowing where an organization is located is also important for equity issues. There is
concern that many international CSOs have their headquarters based in northern,
high-income Member States and that this may lead to an under-representation of
developing country interests. Thus it is important for WHO to receive information on
the composition and location of the governing body and branch offices of
international CSOs
Conclusion
There has been an explosion of civil society actors in recent years. Competing
interests and rapid change have created a more complex environment but have also
contributed positively to improving human health and development.
Harnessing the energy of these diverse voices to improve public health is both a
challenge and an opportunity for an international agency such as WHO.
This paper has outlined some features of civil society relevant to WHO’s work and
that can be used to help WHO staff to begin assessing which CSOs they want to work
with. The manner in which WHO draws civil society into its health policy
development will be vital to the relevance of its future public health policies. A better
understanding of civil society puts the organization in a clearer and more strategic
position to build more inclusive alliances for global and local public health goals.
8
CSI/2001/DP2
»
Reading list
African Development Bank (1999) Co-operation with civil society organizations: Draft policy and
guidelines, Mimeo, September 1999
Annheir H, Glasius M, Kaldor M (2001) Global civil society 2001, Oxford University Press, Oxford
Chuengsatiansup K (2001) Civil society and health: Broadening the alliance for Health Development
Paper prepared for the Ministry of Public Health, Thailand
DFID (1999) Strengthening DFID support for civil society, DFID strategy paper, Mimeo, UK
Meltzer J (2000) The Micropolitics of Civil Society and Citizen Participation, Report for IDRC Canada
Non Government Liaison Service NGLS (1997a) Working with civil society: Issues and challenges,
NGLS Mimeo, Geneva
Non Government Liaison Service NGLS (1997b) Working with civil society: Issues and challenges,
Report of a meeting, Geneva 23-24 April 1997
Non Government Liaison Service NGLS (1998) Interagency consultation on operational collaboration
with NGOs, Geneva 20-21 November 1997
United Nations Consultative Committee on programme and operational questions Item 2d
‘Collaboration with civil society’ New York, 22-26 September 1997
United Nations (UN) (2001) Reference document on civil society participation UN June 2001
http://www.un.org/ga/president/55/speech/civilsocietyl.htm
UNESCO (1995) Directives concerning UNESCOS relations with NGOs, 1995 Resolution 28 C/13.42
UNDP (1999) Governance for Human Development: UNDP and civil society, New York, December 1999
UNDP (2000) UNDP and civil society - issues for a new policy of engagement, Mimeo, New York
UNFPA (1998) UNFPA, Civil society and the programme of action ICPD, A working paper prepared for the
United Nations Population Fund, 27 July 1998
World Bank (2000) Consultations with CSOs: general guidelines for World Bank staff, World Bank,
Washington, June 2000
World Health Organization (1987) resolution WHA40.25, Principles governing relations between the
World Health Organization and Non governmental Organizations (NGOs
World Health Organization (1997) A new global health policy for the twenty first century: An NGO
perspective, WHO, Geneva. (Meeting Report)
WHO (1998) EB 101(16) Review of overall policy on collaboration with NGOs.
World Health Organization (1999) Corporate strategy, WHO, Geneva.
World Health Organization (2000) The World Health Report 2000: Health systems - Improving
performance, Geneva.
WHO (2000b) EB 107.7 Partnerships with Nongovernment Organizations, WHO, Geneva.
9
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Civil Socis^y Initiate®
World Health Organization
Annotated bibliography
of selected research on civil society and health
Civil society actors have become visible, active and influential
within health and health systems. Understanding their role, the
factors influencing them and the health outcomes they produce is
important for anyone aiming to improve public health.
The Civil Society Initiative has produced an annotated bibliography
of research on civil society and health with the assistance of
Training and Research Support Centre (TARSC), Zimbabwe.
The research is divided into three theme areas:
❖ Civil society-state interactions within national health systems
❖ Civil society contributions to pro-poor, health equity policies
❖ Civil society influence on global health policy
The bibliography can be found at:
http://www.tarsc.orq/WHOCSI/index.php
At this web site you can:
❖ View and download a general overview paper on the major
findings and research issues from the three theme areas.
❖ View and download highlights of research findings and
issues arising from the literature within each of the three
theme areas.
❖ View and search a database of the annotated bibliography
of research covering all three theme areas.
NGO FORUM FOR HEALTH
- Partnering to make health a reality Promoting equity and justice in health care
The NGO Forum for Health is pleased to invite you to its annual symposium,
conducted in association with the HIV/AIDS Department of the WHO:
Making the difference:
3/5 initiative and the Civil Society’s response
Wednesday, May 19, 2004, 14:30 - 17:30
room XVI
Agenda:
Presentation of the 3/5 initiative
Jim Yong Kim, Director, Department of HIV/AIDS
Facets of experience of the civil society in relation to the 3/5 Initiative
• Advocacy
o The role of regional networks in mobilizing support for care and treatment. The
PHM dialogue and action with the 3 by 5 initiative: Thelma Narayan &
Mwajuma Masaiganah Peoples Health Movement
o Global networks - advocating local action- the experience of mobilizing
resources for treatment globally: Albert Peterson, Ecumenical Advocacy
Alliance
o Building on Good Practice NGOs: Julia Cabassi, NGO Code of Practice
Project
• HIV Treatment Access and Primary Health Care
o Forging a Common Advocacy Agenda: Subha Raghavan, Solidarity and
Action Against the HIV Infection in India
•
Access to drugs- the civil society contribution and challenges.
o The role of Civil Society in the procurement and supply of drugs: Eva
Ombakka, Ecumenical Pharmaceutical Network
o Access of Antirectoviral to rural areas of the Bagamoyo district Tanzania: Dr.
Abdalla Omar Dihenga, Bagamoyo Medical Hospital
•
Infrastructure & Health Systems in the implementation of 3/5 programme
o Strengthening Health care for 3by5 delivery: Alan Leather, Public Services
International
o Improving prevention and improving care in the era of ARV care: Nance
Upham, The International Health Care and HIV Working Group, and PHM
•
Resource mobilisation that assist the implementation of 3/5
o The role of the Global Fund: Christoph Benn, Global Fund to fight AIDS, T.B,
Malaria
o The role of Civil society: Milton Amayoun, World Vision
www.ngo-forum-health.ch
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WH0/CSI/2001/DP1
Cc> m vi - |.
Strategic alliances:
The role of Civil Society
in health
CIVIL SOCIETY INITIATIVE
External Relations and Governing Bodies
a
World Health Organization
Discussion Paper No. 1
CSI/2001/DP1
Strategic alliances:
The role of civil society in health
December 2001
Civil Society Initiative
External Relations and Governing Bodies
WORLD HEALTH ORGANIZATION
CSI/2001/DP1
Table of contents
Introduction.......................................................................
Terminology......................................................................
The expanding role of civil society organizations.............
Civil society organizations in development processes......
The role of civil society organizations in the health sector
State and civil society interactions: benefits and risks......
Conclusions.......................................................................
Reading list........................................................................
2
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.3
.4
.4
.5
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CSI/2001/DP1
Introduction
“We are dealing with the prime public health concerns of our time. We are focusing
on conditions with a major impact on the poor and disadvantaged [...] and we are
working alongside a broad range ofpartners, maximizing what we can achieve
together ’’
Dr Gro Harlem Brundtland, WHO Director-General
Civil society and non-state organisations have been contributing to public health for
centuries. In more recent years, however, they have grown in scale and influence and
are having profound impacts on health.
People, as part of the civil society, form the core of health systems. They use health
services, contribute finances, are care givers and have a role in developing health
policies and in shaping health systems. In all these respects, there is growing pressure
for public accountability and increased response to inputs from civil society. The
manner in which the state responds to these changes, and the extent to which civil
society actors are recognized and included in health policies and programmes, are
some of the critical factors determining the course of public health today.
This paper is part of a series produced by the WHO Civil Society Initiative (CSI) to
help promote a wider understanding of civil society. It provides a brief overview of
civil society trends in development and health, along with a brief discussion of the
risks and benefits arising out of future strategic alliances between the state and civil
society to improve health. It has been edited by CSI based on a background
contribution written by Dr Rene Loewenson, TARSC, Zimbabwe.
Terminology
In the absence of common understanding or definition, civil society is usually
understood as the social arena that exists between the state and the individual or
household. Civil society lacks the coercive or regulatory power of the state and the
economic power of the market but provides the social power or influence of ordinary
people.
Within this social domain, individuals and groups organize themselves into civil
society organizations (CSOs) to pursue their collective interests and engage in
activities of public importance. CSOs draw from community, neighbourhood, work,
social and other connections and provide institutional vehicles, beyond the ties of
immediate family, to collectively relate to the state or market.
CSOs are broadly understood to be non-state, not-for-profit, voluntary organizations.
In reality, however, there may be state or market links to CSOs that blur the borders
between the non-state and not-for-profit aspects of these organizations. States or the
private for-profit sector may play a key role in the establishment of some CSOs or
provide significant funding, calling into question their independence from the state
and private sectors. The interests that motivate people to associate may be public but
they may also be personal. Associations may form to support kinships or narrow
3
CSI/2001/DP1
group interests that have little to do with wider public concerns. Non-governmental
organizations (NGOs) are considered part of civil society and the term is often used
interchangeably with the term CSOs, particularly the health sector. The term CSOs is
used in this paper to indicate a wide range of civil society actors including NGOs.
The expanding role of civil society organizations
In recent years, CSOs have become more prominent, more visible and more diverse
all over the world. One of the factors influencing the growth of CSOs has been the
increased challenge to imbalances of power between state and its structures on the one
hand and civil society on the other. This has been driven by many forces such as
reactions to centralized authority in state structures; dissatisfaction with state
performance on public services; and dissatisfaction with policy positions taken by the
state in international arenas.
Civil society activity has also increased as a response to the perceived weakening of
the nation states’ authority under globalisation and increasing strength of transnational
corporations. CSO networks have been formed within and across countries to promote
a wider and more ‘transnational’ support of public interests on global policy issues
such as human rights, environment, debt, development and health. Meetings of the
World Trade Organization, Jubilee 2000 on debt relief, civil society lobbies on drug
access and pricing, and the many civic lobbies around World Bank /IMF programmes,
for instance, have come to dominate global headlines.
Increased public concern over the right to participate in policies and processes that
affect people’s lives and the growing demand for improved public accountability and
responsiveness to citizen inputs at the local, national and global levels has made the
work of CSOs more prominent. Their visibility has also been enhanced as CSOs
become increasingly widely connected and organised into national and global
networks, supported by expanded access to information. Electronic communication
through email and the Internet has opened opportunities for communication and
association within and across national boundaries.
Civil society organizations in development processes
The growing role of civil society in development processes is not simply a response to
political lobbies or to an increased scale of Organization. It also emerges from a shift
in the understanding of development processes. When people and human dimensions
are defined as the core of development, then social exclusion itself becomes a facet of
under-development and social networking a development asset. Under these terms,
the fulfilment of human development will require concerted efforts of the State
together with citizens and their Organization.
As there has been a shift towards a more rights based approach to development, more
prominence has been given to civil society roles in raising, advancing and claiming
the entitlements of different social groups. This gives CSOs a vital role as
participants, legitimizers, and watchdogs of policy as well as collaborators in national
development.
4
CSI/2001/DP1
The complexity of development needs, declining resources, declining aid and various
structural adjustment policies and global political changes at large, have also
contributed to declining service provision by the state. This gap has been increasingly
filled by CSOs adding to their importance as development agents within countries.
Analysts have noted that these capabilities have had a positive impact on development
outcomes and on government accountability and performance.
The increased channelling of bilateral and private financing, in this context, to
international CSOs has reinforced the prominence of CSOs and drawn the attention to
their potential role in new modalities and strategic alliances for health in development
cooperation.
These trends at local, national and global level reflect the changing relationship
between the state and the civil society. There are growing demands on governments
for democracy, accountability, participation and compliance with human rights.
Demands on the state to alleviate economic and social inequalities, provide public
services to poor populations, and conform to a liberalised global market has led to a
range of state relations with civil society—co-operation, confrontation and, in some
cases, repression.
The growing presence and importance of CSOs at global and national levels has also
motivated both national governments and global institutions to establish more formal
mechanisms for listening to and responding to claims made from within civil society.
Mechanisms forjudging how representative CSOs are and evaluating the mandate of
the civil society actors have also taken on added value.
The role of civil society organizations in the health sector
Civil society has a long history of involvement in public health. Early public health
actions to clean up American cities in the 1800s, for example, were led by well known
public figures supported by women’s’ groups. However, the recognition of civil
society’s contribution to health has varied over time. One of the most significant
developments in the recent past has been the 1978 Alma Ata declaration, which is
considered a landmark for recognising people’s participation in health systems as
central to Primary Health Care and for recognising the role that organised social
action plays in securing health gains.
Health reforms in the 1990s, however, de-emphasised the welfare state and
community participation and gave greater profile to the market. Social values were
given less attention than the technical, economic and management factors in health
systems. The state’s role was ‘downsized’, either by deliberate policy measures such
as Structural Adjustment Programmes, by reduced public spending or by the declining
quality of public services. In low-income countries, coverage of the lowest income
social groups fell, leaving many people cut off from effective services and dependant
on self-help. These trends motivated many CSOs to new actions including health
service delivery and renewed advocacy for basic health rights and access to health
resources.
5
CSI/2001/DP1
As the attainment of health goals has become more evidently influenced by political,
legal, investment, trade, employment, and social factors, civil society involvement in
health has also widened to include organizations whose main mandate lies outside the
health sector. Hence, for example, youth organizations not specifically set up to deal
with health issues have been an important contributor to adolescent reproductive
health promotion, or groups dealing with economic and trade issues like trade unions
have played an important role in essential drug lobbies.
The following sections outline some of the contributions that CSOs have made to
various aspects of health:
Health systems
CSOs contributes to a range of health system functions, summarised in Table 1 below.
TABLE 1: HEALTH SYSTEMS AND CIVIL SOCIETY ROLES
Health system function
Health services
Health promotion and
information exchange
Policy setting
Resource mobilisation
and allocation
Monitoring quality of
care and responsiveness
Examples of roles of CSOs
Service provision;
Facilitating community interactions with services;
Distributing health resources such as condoms, bed nets, or
cement for toilets; and
Building health worker moral and support._________________
Obtaining and disseminating health information;
Building informed public choice on health;
Implementing and using health research;
Helping to shift social attitudes; and
Mobilising and organizing for health.______________________
Representing public and community interests in policy;
Promoting equity and pro-poor policies;
Negotiating public health standards and approaches;
Building policy consensus, disseminating policy positions; and
Enhancing public support for policies.____________________
Financing health services;
Raising community preferences in resource allocation;
Mobilising and organising community co-financing of services;
Promoting pro-poor and equity concerns in resource allocation;
and
Building public accountability and transparency in raising,
allocating and managing resources._______________________
Monitoring responsiveness and quality of health services;
Giving voice to marginalised groups, promoting equity;
Representing patient rights in quality of care issues; and
Channelling and negotiating patient complaints and claims.
6
CSI/2001/DP1
Health service delivery
CSOs play a major role in the delivery of health services. Religious organizations
have had a long history of service provision while other organisations have become
more involved in recent years. In Asia and Latin America, CSOs have been involved
in mobilising effective demand for services, building awareness of community needs
and experimenting in innovative approaches to service delivery that were later
replicated by the state sector. In Africa, among other tasks, CSOs have assisted in
working with the state to integrate evidence led health planning and community
preferences.
These CSO health services may or may not be contracted by the state. In many cases,
CSOs provide cover to groups otherwise disadvantaged in health service access or
assist governments in major treatment campaigns and disease control programmes, in
drug distribution, in reaching vulnerable communities, and in fostering innovative
approaches to disease control.
CSOs contribute to enhanced health care by providing services in response to
community needs and adapted to local conditions; they lobby for equity and pro-poor
health policies, often acting as an intermediary between communities and
government; reach remote areas poorly served by government facilities; and provide
services that may be less expensive and more efficient. CSOs also provide technical
skills on a range of issues from planning to delivery to services. They innovate and
disseminate good practices to other NGOs or the state sector. CSOs contribute to
public understanding and enhance public information. This can build more effective
interaction between services and clients and enhancing community control over health
interventions.
There is, however, significant variability in the quality and scope of non-state
services. Some CSOs may not be responsive to the population they serve and may in
fact be more accountable to the international agencies that fund them. Many national
CSOs struggle with issues of how to access their own national public resources; their
capacities to manage and sustain programmes; negative attitudes and non participation
of health workers; poverty and other social problems; and how to build strong and
active links with their own members.
Analysts have pointed out that CSOs have a long-term and sustained comparative
advantage when they can access resources not available to government, or where they
can meet a need not currently met such as in improving coverage.
Advocacy, policy and standard-setting
In addition to service provision, CSO make other important inputs to health such as
transforming public understanding and attitudes about health; promoting healthy
public choices; building more effective interactions between health services and
clients; and enhancing community control over and commitment to health
interventions.
The recent recognition of health as an outcome of economic, social and political
inputs and actions call for participation from a wide diversity of state and non-state
7
CSI/2001/DP1
actors. Many developments oriented CSOs are active in political areas such as
monitoring of the impact of global agreements on public health, fuelling demand for
more effective public health safeguards. CSOs have participated in global policy areas
such as trade agreements and health, prices of and access to drugs, international
conventions and treaties on health related subjects such as landmines, environment,
breast milk substitutes and tobacco and in debates around policies and public health
standards.
Many global CSOs promote and use the increasing profile given to human rights
instruments and actions in health. They monitor health and human rights issues such
as patients rights, women’s and children's health rights, reproductive health rights and
occupational health risks. Increased CSO activity reflects public discontent over
socially unacceptable inequalities in health or access to health care or over falling
coverage of public health services, both in terms of increased advocacy for health or
in terms of private not for profit service efforts to fill gaps in health care coverage.
CSOs have also become more visible and important as primary health care policies
have placed emphasis on participation of communities.
These developments within health systems at local, national and global level signal
that CSOs are an important channel for public involvement in health systems. They
bring human resources, technical expertise and new knowledge to health and provide
a powerful additional pressure for the recognition of public interests within the health
sector.
State and civil society interactions: benefits and risks
These trends have led to a call for greater ‘stewardship’ from governments in health, that
is for governments to better facilitate the range of stakeholders, relations and inputs
needed for health gains, and to balance links with the private for profit sector with
stronger links with the public interest organizations in civil society
Clearly the interaction between civil society and state is not without both benefits and
risks for both state and non-state agents. Some of these are summarised below
Benefits for the state
Interaction with CSOs can bring to the state:
•
Support for national / global values, for state regulation of commercial interests
adverse to health, for public policy goals and enhancing public information and
legitimacy of state work.
•
Introduction of new perspectives, technical expertise, capacities and human
resources, networks and informed leadership on health.
•
Increased service provision and implementation of public programmes,
particularly among marginal communities and in remote areas, and increased
financial contributions to health programmes.
8
CSI/2001/DP1
Benefits for civil society
Interaction with the state confers on CSOs:
•
Increased possibilities of influencing health policy by incorporation of CSO issues
in policy processes including counterbalancing of commercial interests and
consensus building on health priorities.
•
Provision of legal authority for public participation and enhanced legitimacy of
CSO work. Enhanced linkages and transparency of interaction with the state and
technical inputs to CSO work from the state.
•
Enhanced prospects for civic education, participation and building of social
capital thus strengthening CSO capacities. Improved options for access to health
services. Expanded opportunities for greater involvement in health programmes.
Risks for the state
Interaction with CSOs carry certain risks including:
•
CSO representativeness cannot be assumed, pseudo NCOS may be a hidden
channel for corporate interests and potential conflicts of interests between the state
and CSO interests. For the state, it is important to assess the representativeness,
authenticity, interests and capacities of the CSOs it works with.
•
Crosscutting and multiple roles among CSOs leading to great diversity in views
and numbers can be difficult to manage. CSOs clearly do not speak with one
voice, and there are asymmetries in the capabilities and numbers between the
North and South.
•
CSOs have varying levels of accountability to the communities they speak for.
These features may weaken the legitimacy of CSO positions within national and
international platforms.
•
CSO’s political roles and polemic approaches on issues such as human rights,
consumer protection, or ethical issues may generate tension with governments.
•
Risk of government staff leaving to join CSOs, leaving the state weaker in
technical expertise and capacity.
Risks for civil society
Interaction with the state carries with it risks for CSOs, including:
•
State links may distort CSO voices and representation by giving privilege to a few
interlocutors. If this bias is towards CSOs representing more affluent or Northern
Hemisphere interests, then perspectives and access of more marginal, Southern
Hemisphere groups can be weakened.
9
CSI/2001/DP1
v1
•
Dependence on the state for access or resources may compromise the autonomy,
accountability or self-determination of CSOs and make CSOs reluctant to criticise
the state. Work on government programme or funding priorities could distort CSO
priorities.
•
Risk of CSO staff leaving to join government units, leaving CSOs weaker in
technical expertise and capacity.
Conclusions
There is great potential for improving public health through systematic collaboration
between governments and civil society. This document is a first attempt to summarize
and provide an overview of the role of CSOs in health. The conclusions at this stage
can therefore only be of a very general nature.
What is sure is that there is a need to collect more systematic evidence on the role of
CSOs in health, to improve our knowledge and to give visibility to good practice and
to the contribution of CSOs in health. As described in this paper, the interfaces are
complex and there are many aspects, risks and benefits to be taken into account.
The public health sector must understand CSOs and CSOs must better adapt to the
needs of the health sector and better organize themselves as a group. States need to
work with civil society to organise the social dimensions of health actions, to build
wider constituencies for health rights and goals, and to strengthen public
accountability and responsiveness within health systems. As regards CSOs, they
clearly do not speak with one voice and their perspectives differ between different
interest groups. There are also asymmetries in capabilities and numbers between the
North and the South, and CSO have varying levels of accountability to the
communities they speak for. All these features may weaken the legitimacy of CSO
positions within national and international platforms, and therefore need to be
addressed in order to maximize the benefits of the collaboration.
The overall impression and conclusion however, is, that the benefits of collaboration
for both the State and CSOs outweigh the risks of possible tensions in CSO-state
interactions. Strategic alliances offer opportunities for enhancing the legitimacy of
health policies and programmes, improving public outreach, advocacy of health goals,
information exchange and increasing resource inputs to health programmes.
10
CSI/2001/DP1
•4
Reading list
Dr Gro Harlem Brundtland, "Towards a strategic agenda for the WHO secretariat". Statement to the
105th session of the Executive Board, January 2000
African Development Bank (1999) Co-operation with civil society organisations: Draft policy and
guidelines, Mimeo, September 1999
Anello E (2001) Assessing conflict of Interest, Briefing paper prepared for WHO, Mimeo, Geneva 11
June 2001
Brown DL, Ashman D (1996) Participation, social capital and Intersectoral problem solving: African
and Asian cases, Institute for development research Vol 12 No 2 USA
Chuengsatiansup K (2001) Civil society and health: Broadening the alliance for Health Development
Paper prepared for the Ministry of Public Health, Thailand, Mimeo, Thailand
CID A (2001) Civil Society and development co-operation: An issues paper, March 15/2001 (draft),
Canada
Community Working Group on Health (1997) HEALTH IN ZIMBABWE: Community perceptions and
views Research report Zimbabwe, November 1997, Supported by OXFAM and TARSC
CSI (2001) EGB Consultations with Executive Directors on the Civil Society Initiative,
Summary Report of Interviews, Mimeo, WHO
EQUINET Steering Committee (1998) Equity in Health in Southern Africa: Overview and issues
from an annotated bibliography, EQUINET Policy Series No 2, Benaby Printers, Harare
Gilson L, Kilima P, Tanner M (1994) Local government decentralisation and the health sector in
Tanzania Public Administration and Development 14(451-477)
INFACT (1999) Mobilising NGOs and the media behind the International Framework Convention on
Tobacco Control: Experiences from the code on Marketing of breastmilk substitutes and conventions
on landmines and the environment, WHO/NCD/TFI/99.3, Geneva
Kahssay HM (ed) (1991) Community Involvement in District Health Systems, WHO SHS/DHS/91.4,
Geneva
Kahssay HM and Baum F (1996) The role of civil society in District Health Systems ,
WHO/ARA/96.3, Geneva
Loewenson R (1999) Public Participation in Health: Making People Matter IDS/TARSC Working
paper no 84, Sussex March 1999
Loewenson R (2000) Putting your money where your mouth is: Participation in mobilising and
allocating health resources Paper presented to the TARSC/Equinet regional meeting on Public
Participation in Health, Harare, May 2000
Loewenson R (2000b) Report of the TARSC/Equinet regional meeting on Public Participation in
Health, in co-operation with IDRC (Canada) and WHO (AFRO/HSSD) Equinet policy series no 5
Benaby printers Harare
11
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McFarlane C et al (1998) Financial and operational factors influence the provision of municipal solid
waste services in large cities, WHO EUR/ENHA, Denmark
Meltzer J (2000) The Micropolitics of Civil Society and Citizen Participation, Report for IDRC
(Canada), Canada
Minet (1997) The relationships between the UN system and civil society, Discussion paper prepared for OC,
New York 2-6 October 1997
Non Government Liaison Service NGLS UN (1997) Working with civil society: Issues and
challenges, NGLS Mimeo, Geneva
Reid G, Kasale H (2000) Tanzania Essential Health Interventions Project Paper presented to the
TARSC/Equinet regional meeting on Public Participation in Health, Harare, May 2000
Robinson M, White G (1997) The role of civil society in the provision of social services: the non
market, voluntary sector, Mimeo, IDS (Sussex), UK
Schneider H (1999) Participatory Governance: The missing link for poverty reduction, OECD policy
brief no 17, OECD 1999
SID/WHO/ISS (2000) Report on the International Seminar on ‘Global Public-Private partnerships for
health and equity’ Nov 23-24 2000, SID/WHO/ISS, Italy
UNDP (1999) Governance for Human Development: UNDP and civil society, New York, December 1999
UNDP (2000) UNDP and civil society - issues for a new policy of engagement, Mimeo, New York
World Bank (1996) Social Capital, Office Memorandum, Washington
World Health Organisation (1997) A new global health policy for the twenty first century: An NGO
perspective, WHO, Geneva
World Health Organisation, Govt Ireland (1997) Poverty and Ill health in developing countries:
Learning from NGOs, Meeting Report, Kildare, Ireland June 1996
World Health Organisation, Govt Ireland (1997) Poverty and Ill health in developing countries:
Learning from NGOs, Meeting Report, Kildare, Ireland June 1996
WHO/DAP (1998) Collaboration between NGOs, ministries of Health and WHO in drug distribution
and supply WHO Geneva
WHO Essential Drugs Management (EDM) (1999) Briefing update on non government and
pharmaceuticals roundtable 26.1.99, Geneva
World Health Organisation (1999) Corporate strategy, WHO, Geneva
12
4
4X
SOCIAL DEVELOPMENT INITIATIVES IN PAKISTAN
BY
THE AGA KHAN UNIVERSITY
DEPT. OF COMMUNITY HEALTH SCIENCES
D
o
3
I
Govt, largest health care provider however, utilization is as low as 20 %
Over crowded tertiary hospital and underutilized PHC facilities
Most of the TBAs are untrained
Practice in health sector is clinically driven
Around 4000 medical graduates and 600 specialists are produced annually
Over all doctor to population ratio is 1:2200 and may be as high as 1:700 in
urban areas.
Only 55 % of the population has any access to health services
Govt. largest health care provider however, utilization is as low as 20%
Over crowded tertiary hospital and underutilized PHC facilities
Most of the TBAs are untrained
Practice in health sector is clinically driven
Around 4000 medical graduates and 600 specialists are produced annually
Over all doctor to population ratio is 1:2200 and may be as high as 1:700 in
urban areas.
Only 55 % of the population has any access to health services
i.
£
%
i.
The Aga Khan University
Karachi, Pakistan
■
■£?
-
The Aga Khan
University
;? a.
ig
>
Olli
®
-....
-
■
-
► First private International University in
Pakistan, Chartered in 1983
► Committed to Excellence in Education and
Health Services
► Prioritizing higher education and research
relevant to Pakistan and developing countries
Pivotal position in social development activities
of Aga Khan Development Network
► Empowerment of Women
J
v' £
^4
I Unto
^ssws
Present
Faculties
1
s
Emwy
I
Ki^kt-W.^
Faculty of Health Sciences
l
Institute of Educational
Development
I
Medical Collage School of Nursing Professional Development Centre
Teaching Hospital
COMMUNITY HEALTH SCIENCES (CHS) DEPARTMENT
EDUCATION
To educate health personnel for leadership in dealing with health and development
problems, particularly those of the more deprived and dis-advantaged community
in Pakistan and developing countries
RESEARCH
To strengthen the development of Health Systems in Pakistan through RESEARCH
with emphasis on the development and implementation of health system prototypes
in collaboration with local and national authorities.
SERVICES
To promote development of equitable and sustainable health care system, that
embraces the basic needs of underprivileged and under-served segments of the
population in partnership i.e. communities, government and non-government
organizations.
Research areas include:
>PHC prototype models
> Community empowerment
> Gender and reproductive health
> Health systems research
>Epidemiological research
> Health Management Information System
SERVICE
RESEARCH
EDUCATION
SERVICES
PRINCIPLES
• PARTNERSHIP
• CAPACITY BUILDING
• PARTICIPATORY APPROACH
• EQUITY
• SUSTAINABILITY
AKU
I
CHS
Education
>
Research
>
Services
>
Public
Health Practice
Family
Medicine
3
Epidemiology
& Bio-Statistics
Health
Systems
▼
Reproductive
Health
CHS
Research Projects
Public Health Practice
Health Systems
▼
Violence
Diabetes
STD / HIV
Urban
Health
Project
Family
Health
Project
Thatta
Health
System
Research
Project
Rural
Community
Development
Project
School
Nutrition
Project
Thatta Health System Research Project (1985):
Operation Research Project of AKU in collaboration with Dept, of Health.
Aim was to strengthen the district health system towards improving the
health of the population.
Lessons learnt:
District and Village Level:
THSRP provided opportunity to both AKU and Govt, for better understanding of
health system issues and on the basis of studies done, two projects came into
existence.
PHC level: Improved utilization of health facilities.
Family Health Project:
Started in 1991, with the collaboration of Health Department.
Aims:
• Improve the health of the population in the project area
• Increase the effectiveness of health care network
• Develop the institutional capacity
Initiatives:
• Established in each district a permanent cader of staff, at district
health development centers.
• To acquire the skills, knowledge and attitude that will enable them
to implement programs that will benefit the health of the Province.
Lessons learnt:
Access to better services can be improved by :
• Training and supporting the TBAs and field staff
• Increasing female para-medical staff
• Creating linkages with community health workers
• Strengthening referral system, improving drug supplies and diagnostic facilities
• Utilization is being improved by encouraging community participation
and health education
School Nutrition Program:
Started in 1991 with the collaboration of Sindh Education Dept.
Aim is to explore alternative strategies to develop an effective School Nutrition
Program in rural Sindh and increase parental and community awareness of the
importance of child nutrition and education.
Initiatives:
• Explore possibilities of community involvement at school-village level in
improving education and nutrition.
• Improve the nutrition status of primary school children.
• Explore the possibilities of implementing school nutrition program through NGOs.
The initial study by AKU showed prevalence of malnutrition to be high in rural
children and parents are aware of the need for better health and education for
children. They are ready to collaborate for the welfare of their children.
The Urban Health Project (UHP):
An integrated model of health and development initiatives in poor urban squatter
settlements of Karachi.
Phase 1 (1985-94)
Primary Health Care (PHC) centers in five squatter settlements of Karachi
Each PHC module served a pop. of 10,000, and the Program covered approximately
50,000 people.
The PHC Program concentrated on improving the health status of mothers and
children under 5, and was later extended to families.
Lesson Learnt in Phase 1
IMR fell from 126 to 64; the under five mortality rate from 177 to 83.
Supervision and training need to be strengthened
No comparison or control population.
Interventions of a more global and developmental nature like safe water supply,
sanitation and income generation were also considered in order to have continuous
improvement in health.
Moreover the sustainability of these interventions without adequate community
involvement was also found to be questionable.
Phase II (1994-1999)
Based on Pre-defined criteria, six intervention field sites were selected amongst the
500 squatter settlements of Karachi.
Steps wise Evolution of the Project
• Formation of community groups and prioritization of health issues
• Capacity building of CMTs and communities
• Provision of basic health and development services
• Improvement in the quality of existing health services
• Networking with government institutions and NGOs
• Training for medical/ paramedical personnel
• The annual cost per person thus figures out to be Rs 49 (less than I U.S $)
Achievements:
• An excellent, continuing learning experience for faculty, CBOs, NGOs and
community
• Empowering poor squatter communities in mobilizing resources
• Catalyst for disadvantaged communities to organize and seek partnerships with
government and non-government agencies
• A PHC system focusing on prioritized aspects of maternal and child health
• Capacity building activities have helped volunteers, health providers and CHMTs
to assume increasing responsibilities
Conclusion:
• Like all universities with a social commitment, through these activities AKU is responding
to the critical health and social development need of Pakistan and other developing
countries
• These activities demonstrate the value of community participation in improving the health
of vulnerable groups
• The process of empowerment in communities (with the university serving as a catalvst,
technical resource and an intermediary between communities, government, and NGOs) is
a stepping stone towards sustainable primary health care and social development.
i
Bangalore Hospice Trust
c
-
These tender hands rock you to sleep
i been discharged from hospitals. Alternately, the girl
eirl said absolutely nothing while the nurse
contacted by the famUies of administered painkillers. When she did speak,
HATH is the ultimate reality of life but they are also <
she said, “I think I’ve caused my family enough
very few are prepared to meet it. It's patients themselves.
Once they reach the family, the first thing trouble. It’s time I died.”
worse when it is untimely and caused
“When someone so young says something
they do is give the patient relief from pain if
by a terminal disease that relentlessly possible.
possible. The
The nurse
then trains
family members
members like
like that,
that, you
you know how important it is to
nurse then
trains family
corrodes your being and is not satisfied until it on how to take care of the patient’s physical provide help and counselling to the terminally
takes away your life, and nearly the lives of
needs. “There are little things like how to lift the ilVremarks Rao.
,
.
those left behind.
The
idea
of
starting
a
hospice
came
to Rao
patient without causing him/her pain, how to
What do you do when a loved one is going to
change sheets when the patient is lying on the when he was invited by the State Government
die? When the doctors can do no more? When
to be on the governing
he/she is discharged from the hospital to make bed, which the layman
------council of the Kidwai
nothing
way for someone else whose life can be saved? knows
Memorial Institute of
When you know practically nothing about how about,” explains Rao.
Oncology and saw the
He recounts some
to take care of the patient at home? When you
insecurity that dying
cases which stand out
can’t think of things like wills and last rites?
patients went through
It was the realisation of problems like this as instances where
when
they had to be
which convinced Kishore S Rao, founding the home care system
discharged
from the
member of the Bangalore chapter of the Indian helped families cope
hospital.
Cancer Society, to start the Bangalore Hospice with the loss of a dear
Starting a trust was
one.
Trust.
not
too difficult. The
—
A five-year-old girl
s
The main aim of the trust is to provide pallia
' Rotary Club of Bangative care and support to people so that they can had been discharged
from the hospital. The Caring at the most crucial time
I°re’ Indiranagar, came
die in peace, with dignity and free from pain.
father had spent all his
forward to help since
This is the sixth hospice in the country but the
money and even sold his tiny meatshop, which they wanted to be involved in a continuing
first and only one which provides a home care was their only means of income, on die girl’s project, and so did the Indian Cancer Society.
service.
BHT is setting up a 50-bed hospice for termi“I believe that the time when the patient is treatment. The mother would not move from
_________
o
n;tally ill _patients in Whitefield where they have
her
bedside,
neglecting
the
needs
of
the
rest
of
discharged from the hospital is the most
..........
..............
..............
...... o
--- --La
the family. xxx
In such
a case,
there..wasn
’t much
got
five acres of land from the ~
Government on
crucial,” says Rao. “The psychological trauma for theniise todo?But the’situation caUed for a long lease. Karunashraya, as the centre will be
alone is often unbearable: thoughts of your end
counsellor to help the family come to terms known, will provide free care for
f all patients,
being near is when you need counselling the with the fact that their little girl was going to go irrespective of caste, sex or economic condimost.”
away forever.
tions.
The trust has two teams of two members
Another little girl wasjound by. the team in a
“In the past also, more than half our patients
each:- a trained nurse and a family counsellor, - slum in Frazer Town, sitting
Frazer Town, sitting in her
her little
little * have been from the lower-middle class and
on call round the clock. It works in co-ordina
poorer sections of society,” reveals Rao. To
tion with oncologists all over the city who hutment with the tumour on her knee swollen date, BHT has taken care of over 200 patients.
and
causing
a
lot
of
pain.
For
the
first
few
days,
inform them of the terminal patients who have
Suma Ramachandran
I
The home care system will continue even after
Karunashraya starts functioning in a year's.
time.
In fact it started because Rao did not want
the trust to keep- asking for funds for
X^^sho^frwoXe8 he^I
knew it was going to take time to collect the
kind of money we would need to build the
centre and in the meantime, we could lose
credibility. So we started the home-care
system.”
BHT’s teams work with certain guidelines.
The treating doctor’s advice and instructions
’ j are taken. There is no interference in the
alone
type of treatment the patient wishes. (Many
want to try last-ditch efforts with other medical
systems.) And BHT’s teams never take sides in
terms of religion. They help the family with.
information, if it is asked for, in terms of lawyers
to make wills, where to get medical equipment
for the patient and what the costs might be.
The going has not been easy. Death is after all
a depressing situation and according to Rao,
the strain has begun to tell on the counsellors.
BHT is on the lookout for interested, strong
hearted persons who would be willing to spena
time with their patients.
3
Contributions to BHT, a public charitable
trust, are exemptfrom income tax under Section
80G (50 per cent deduction) and Section 35AC
(i qo per cent deduction) of the Income Tax Act.
For further information, contact Bangalore
Hospice Trust, do The Indian Cancer Society,
Neiu Thippasandra Main Road, HAJL 3rd Stage,
Bangalore 560 075. Phone: 5254127. Internet http:ZuJUJW.pcu/eb.com/karuna
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