HEALTH CARE DELIVERY
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- HEALTH CARE DELIVERY
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Cd nH5A- 10
RF_COM_H_5_A_SUDHA_PART _2
POSITION PAPER ON NATIONAL
HEALTH POLICY
Am la Rama Rao
Voluntary Health Association of India
© 1987
Voluntary Health Association of India
40, Institutional Area, South of I.I.T., New Delhi-110 016
Printed by
Joginder Sain & Bros. (Printing Division)
A 30 1, Naraina Ind. Area, Phase I, New Delhi-110028.
POSITION PAPER ON NATIONAL
HEALTH POLICY
The National Health Policy as planned may remain only a policy document unless
all of us make a commitment to it, and try to implement it at all levels. Each of us
must carefully analyse the health problems, keeping in mind the country’s capacity
to deal with them. The goals and priorities will be fixed accordingly. Strategies to
achieve them need to be based on social justice and equity, intrasectoral linkage and
self-reliance as far as possible.
The ill-conceived and inadequate health services currently provided to the vast
majority of the population has created a feeling of social injustice and given many
voluntary organisations the impetus to act as natural leaders of theircommunities.
They have the responsibility to lead movements for the change. For this they need to
identify the strategies to develop their full leadership potential. They should look
beyond the traditional system of health care and develop a deeper understanding of
the philosophy of primary health care and a commitment to achieve health for all
by 2000 A.D.
1.
PROVISION OF HEALTH SERVICES TO ALL
For those who live in remote areas and belong to the lower income groups, health
care can be provided only through a system which creates a broad base of
functionaries and provides health care to the maximum number of people. The
training of new community health workers at the village level has only duplicated
the existing system and has not proved very helpful in the long run. Wherever the
traditional health functionaries have been involved, the infrastructure has become
stronger. The health care system may continue to be lopsided, unless efforts are
made to improve the training and supervision of CHW’s and Dais.
2.
REFERRAL SYSTEM AND PRIMARY HEALTH CARE :
A STRATEGY
The bottlenecks that exist between the village and a health sub-centre are again a
matter of concern. The health assistant is no better equipped with the skills and will
to deal with certain health problems than a CFIW. So unless there is a way to reach
Primary Health Centres very little can be done at these levels.
3
Another important point is that the referral system does not allow for any planned
way to go from one to another. There is no geographical or political boundary
which one cannot cross. Unless the screening is done at all levels, the political and
the social linkage is established between a specialist hospital to a Primary Health
Centre of the block, from there to the village sub-centre and back from village to the
specialist hospital; the congestion, duplication and the parallel system will
continue to exist. The suggested change of effective links between primary health
centres and medical colleges and hospitals in order to harness and provide
specialised skills is no doubt progressive thinking for re-orientation of medical
education and better health service, but its implementation has been held up due to
many administrative difficulties. As a result, neither are the Block Administrators
taking responsibility for the better functioning of these Primary Health Centres nor
have the medical college hospitals established a proper linkage with them. Very few
specialists from these hospitals like to go out to the Primary Health Centres. In fact
the person who goes there is only a junior or senior resident working in those
specialised units. Most of the time they treat these trips as holiday excursions. There
is no continuity of ties nor any feedback from such hospitals to the Primary Health
Centre doctor.
3.
INFORMATION SUPPORT
To estalish a proper information support, there must be a well-defined referral
system. General practitioners, indigenous practitioners and all others who are
involved in any way with the health care system should become a part of the
information support. The Epidemiological Cell in each State may not be essential
but it should have a computerised system for collecting and processing information
from different units. Without information, support evaluation and monitoring of
any programme is not possible.
4.
RE-ORIENTATION OF HEALTH PERSONNEL
To equip health personnel with appropriate and scientific techniques we must
provide a system of continuous education. Inservice training programmes are
essential to develop the skill to do the job better. Certain managerial skills which are
never imparted to medical professionals in their undergraduate courses must
become a part of the orientation training programmes. All courses could be so
planned that NGO/Govt. officials attend the courses together and can interact with
each other.
The voluntary organisations have a greater sense of dedication and commitment to
social causes and are more open to change. This gives them an enormous advantage
in the field. They provide care at all levels in all kinds of settings to the poorer
section. They frequently act as links between the individuals, community and the
rest of the health care system.
4
5.
INTERSECTORAL coordination
That various sectors have influence on health is well understood, but intra or
intersectoral coordination remains most of the time only in the minds of people or
as words on paper. Actual coordination at various levels is possible only if the
planning of the two sectors are done at one place, and from bottom to top. The
possibility of removing the bottlenecks is maximised if two sectors, well connected
like water and sanitation, nutrition and education, are planned together. Again,
regarding the educational status of woman and her acceptance of family planning,
both must be worked out together, and receive the same importance. The
administrative blocks also need attention. There is a need to define the job
responsibility of various people at different levels, as well as a policy of delegation
of authority at each level. If decision making is confined to the planners’ level, the
implementing functionaries find it very difficult to carry out their day-to-day
duties.
6.
ALTERNATIVE SYSTEMS OF MEDICINE
There is a need for integrating the training programmes of different personnel in
different systems. The policy has recommended the use of indigenous systems of
medicine like Ayurveda, Unani, Sidha and Homeopathy. It also emphasises
introducing Yoga and Naturopathy into the overall Health Care Programme. But
when it comes to putting this into practice, none of the Primary Health Centres or
the dispensaries is equipped to give advice on any of the traditional systems of
medicine.
Traditional systems of medicine have always had a place in our culture. They are
both less expensive than modern medicine and more easily accessible to the
majority of our population. To allow them to stagnate will only increase existing
inequalities in the health care system. Therefore, ways of integrating the modern
with traditional system of medicine must be thought of.
7.
REGIONAL IMBALANCES OF THE HEALTH CARE SYSTEM
It is of vital importance to correct the regional imbalances that exist in health care
systems today. The policy cannot be successfully implemented unless sustained
political, social and administrative support is obtained from everyone concerned.
Here the local communities play a very important role and it is our duty to make
them aware of the facilities they are entitled to, so that they demand the care they
need. The concept of preventive and promotive services is still lacking all through.
8.
MEDICAL EDUCATION
We need not go into the details of formal medical education as we all know that it is
not tailored to meet the requirements of the type of medical practitioners who work
5
in Primary Health Centres. If more clear and effective strategies could be specified,
the wasted resources could be harnessed. The re-orientation of medical education
has been talked about for the last several years but very little has been done to make
education community-oriented and problem-based. Most of a medical graduate’s
lime is spent in hospitals. The type of knowledge and skills that he/she acquires are
the ones from the hospital itself, when almost 80% of the ailments are preventable
and can be cured by simple remedies. But these cases never reach the hospital for
their attention.
The National Health Policy is aimed at taking services to the doorstep of the people
ensuring fuller participation of the community and improvement in the quality of
their life. It is intended to restructure the health care services on the preventive,
promotive and rehabilitative aspect rather than on cure only. Therefore to provide
trained personnel with the right attitude and outlook is more important for proper
functioning of the services talked of in the policy document.
9.
MEDICAL RESEARCH
It is the opinion of various experts that today there is a lot of money being wasted on
basic research which could be well shared by the developed world. The technical
know-how can be easily obtained from them.
Special research on health care system, problem based medical education and need
based para-medical education at various levels, require a lot more attention than is
being given in this country. In my opinion “behaviour problem” of the recipients
of health services should form the priority for the research grant in India. There is
also a need for a constant feedback on the new findings and advances in medical
research and their application to health services. The dissemination of this
information to the proper levels both upward and downward are equally
important. Unless we keep informing our workers at the grassroots level of what is
happening at the central level, the implementation of the programmes become
difficult.
10. THE TARGETS
The National Health Policy paper gives the targets to be achieved according to the
time frame. These targets are not comprehensive nor have they been worked out on
any realistic terms. The exercise only tells what future achievements can be expected
provided the base is known. No doubt it is better to work on some frame, to measure
the milestone and progress being made but the baseline information is of crucial
importance.
The target sets are based on certain information that was available at one point of
time: perhaps as far as 1975 or 1976. Unless the relevant data is available from
different states it is of no use setting up targets to reduce the incidence. A few studies
6
carried out by big institutions like the AH India Institute of Medical Sciencesor PGI
Chandigarh tell us very little about the overall health status of our country. Lack of
vigilance in reporting and collecting of information will hinder us from reaching
our targets.
11. ROLEOFNGO’s
The role of voluntary agencies has been very well spelt out by the Alma Ata
Declaration. It includes:
1.
Identification of the needs and problems of the people.
2.
Development and innovative programmes for Primary Health Care, in the
context of comprehensive human development.
3.
Promotion of full participation by individuals and communities in the
planning, implementation and control of these programmes.
4.
Training of health workers, supervisors, administrators, planners and various
agricultural and development workers, along with training schemes, build on
the skills of traditional healers and midwives.
5.
Creation of new and effective methods of health education.
6.
Recognition of the essential role of women in health promotion and in the full
range of community development concerns.
7.
Contribution to the search for greater social justice.
8.
Development of locally appropriate health technologies and use of resources.
Most of the voluntary organisations are working for both health and development.
The standards of health cannot be improved unless there is an improvement in the
general quality of life. The NGO’s are more willing to go to the most difficult areas
where nothing exists as far as the health system is concerned. Still they find it
difficult to be recognised and get little or no help from the government system. It is
time we all realised that to achieve health for all by 2000 AD, the involvement of the
voluntary sector is essential.
THE DILEMMA—NATIONAL HEALTH PROGRAMME
Most of the time the doctor faces a very big dilemma in his day-to-day functioning.
He is unable to find what to do and how to get started with diverse programmes like
TB Leprosy, Prevention of Blindness, Malaria control, Family Planning,
Immunization, School Health, Nutrition and MCH, as well as to keep evaluating
the programmes from time to time. Only if the planning process, information
system, resources, supervision, coordination and training is adequate can the
7
doctor use his energy as a team leader to build up the team, organise the community,
keep proper records, monitor the programmes and do a follow up review, as well as
initiate certain changes in the programme when the need arises.
The bring about any change is a very complex task. The people who are striving to
reach the goal of health for all must have a clear understanding of the National
Health Policy, the critical issue required for its implementation and the broad
principles involved in it.
In these three days let us together work out an action plan for our own areas keeping
all the elements of the National Health Policy in mind and evolve our own
strategies to reach the goal of health for all by 2000 AD.
*
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8
PROBLEMS
PRIMARY HEALTH CARE
Based or. the analyses of. human resource development for primary health
care offered in previous chapters, we may now attempt to summarize the major
problems found in six study—eoantries and the desk review. Net every
problem, of course, is found in every country, but if a problem or issue has
been identified in two or snore countries it has been considered worth
reporting. These observations will ba presented in three groupings; health
human resources development, primary health care deliver)', and underlying
issues. It should, be clear that all problems are inter-related.
~6-ri—^avelopgient of Human Resources for Health
To avoid repetition and to sharpen this presentation, the problems of
human resource development for health will be presented mainly under
generalised concepts, rather than separately for aacli-personnel category
-(1) -inadequate Wtunbers and Ratios of Convent!oriel Personnel. Most
developin^cewitrie'r-have^nadequate supplies of-physiciaits,- professional.
nurses, sanitarians, dentists, pRaTmaeists, some types of technicians and
other conventional categories of personnel to meet their health needs. While
various adjustmentssuch as training many assistant nurses or community
health workers (see below) - are necessary, a minimal supply of fully-trained
physicians, sanitarians, and others J.s..still essential far the effective
'ope^aiiaii of a health.care system prcvlid±ng-psfcnsry~
*
’eattSr6are.
In sojae- —
countries, where the supply of doctors is adequate, relative shortages of
nurses and other personnel result in the inefficient use cf medical rima.
(2) Inappropriate Training of Conventional Personnel. The education and
training of physicians, nurses and other conventional personnel in developing
-countries- are-based largely on teaching models drawn .from industrialized
countries. The emphasis—is- errlaboratery’ sc ienceu,—elinicnl specialization—
and high technology. It is weak on the basic requirements of
~pritrarry
*
health
care such as prevention - personal and environmental - and the psycho-social
aspects of family health problems, so important in PHC. Some use may. be made
of field training in a community setting, but seldom enough and often nona.
Seme medical schools are greatly overcrowded, reducing the quality of
teaching, and teachers are technologically, rather than socially, oriented;
this applies to the education cf nurses and sanitarians as much as to
physicians- Little if any use is made of social scientists in the
educational programmes.
(3)
Lack of Health Human Resource Planning. . For health personnel trained in
universities there is seldom communication with health authorities or
national planning bodies on the needs. Even for personnel categories trained
in a Ministry of Health, there may be poor communication between the branches
responsible for training and those using the personnel. The lack of planning
applies to both the numbers turned out and the content, of their education.
Nurses or assistant nurses trained in hospitals, .for example, may be quite
unprepared for functions 'they are later expected to perform in community
health centres.
■
l4) Lack of Coaaunity Health Workers. In rospuns-. to many health human
resource problems, new types of multi-purpose community health workers (CHW)
have been produced, with varying levels of training. Some highly developed
countries have also done this to meet health needs in rural areas, where
doctors were lacking. In most developing countries, however, the numbers of
these CHWs trained have to date been below the needs. There have been
difficulties in finding suitable teachers, in developing appropriate teaching
materials, and in recruiting qualified students. Moreover, the educational content in
■ -- h.-been'highly technical and clinical,
rather than social and preventive. As a result, the later performance :cf
CK'Js may be largely confined to treating the sick rather than promoting
community health and welfare.
(5)
LPauecuate
and Supervision. Zill of -the countries reviewed :in
this study, and most developing countries generally, provide primary ^health
care through teams of personnel working in organised frameworks. The
effective functioning of such systems, however, requires an understanding of
the meaning ana practice of teamwork. It also requires that team leaders are
capable of leadership and effective (not dictatorial) supervision. Such
qualifications seera to be rare in the countries studied.
Basic education in medicine, nursing, pharmacy, etc. seldom has the time
or resources to teach the requirements for teamwork and supervision. As a
result this ordinarily becomes a task for in-service training and continuing
education. Even such education, 'however, appears to be lacking or
unsuccessful in the countries studied. Teamwork requires sensitivity to
personal relationships and supervision requires organizational knowledge and
skills; such matters are not easily taught in a classroom but are. learned
best in a field practice setting.
(6) Lack of Continuing Education. Effective teamwork and leadership are not
the only subjects for which continuing education can be useful. For good
nerformance of all health care functions, clinical as well as social,
education should be a lifetime precess. Systematic arrangements for periodic
continuing education are important but seldom found tn developing countries.
Its lack may also help to explain the poor morale among many health workers.
(7) Lack of Job Descr<r1'4ons. Prob'1 err tn teamwork and general work
performance are often due to lack of any clear explicit statement of the
tasks expected from each member of the health team. Absence of job
descriptions leads to confusion and uncertainty in the relationships among
personnel in a health facility. It also contributes to inappropriate
training. Both the teacher and the student require a clear understanding of
future job functions. Such job descriptions should be prepared by health
authorities responsible for programmes, and they should be updated
periodically with experience.
(8) Absence of Relations with Traditional Healers. In most of -the
developing countries studied, traditional practitioners and traditional birth
attendants (TBAs) play a large part in the primary health care of the
people. Yet - with some exceptions for TEAs and in one country for general
..-u_■ ths policy in the countric.
gnore these personnel
and hope that provision of modern health services will lead eventually to
the r disappearance. The soundest policy toward traditional healers may be
subject to debate, but Ministries of Health- that simply ignore their
existence are missing an opportunity to exert influence on the nature of
health services used by millions of people.
!;•?} Lo.? Motivation of Perf»nneJt. Permeating many of the health manpower
problems reviewed above are the att<rvdes and motivation of health
personnel. These ertrionr.es maybe initially acquired during'basic training.,
but they are shaped by r.-any subsequent experiences.. All too c.ftan one
encounters health professionals, particularly physicians, who rush to
complete their tasks in e health centre in order to maximize 'the 'time they
have for private practice. Others undertake post-graduate studies Abroad end
do not return to their home country; this "brain drain" means a serious doss
of health mirpower javastment by many developing countries.
The issue of personnel motivation is, of course, complicated, and it is
caused by many economic, social and psychological factors that are not-easily
influenced. Ho simple course of training can -impart a socially responsible
motivation in any doctor,- pharmacist or nurse. But many .policies may -have an
influence on motivation, as will be explored in the-next Chapter.
5 -Problems in the Functioning of Primary7. Health Care
It is recognised chat it is somewhat artificial to separate'the
considerations of health human resource development in 'the last section from
’the overall primary care system; however, this section will attempt to
address the problems in the functioning of programmes on a somewhat ’broader
basis. '
,
(1) Poor Working and Living Conditions. The greatest need 'for primary
health care programmes in developing countries is in rural areas, and life
there offers few of the amenities to which staff trained in urban centres -are
accustomed. While most countries are devising strategies to make -rural
health worx. and rural life more attractive to such personnel, work in many
rural health centres remains difficult.; the physical -structure is-often
deteriorated, and may lack properly functioning beat., water and elects'! city.
When personal housing is ^.owlded for staff, it may be modest and in poor
condition; schools for dependents of personnel -from urban areas are usually
below the standards to which they are accustomed. A particular need in most
countries is housing for young unmarried female staff such as nurse-midwives
whose posting to areas other than the home village may be culturally
unacceptable without appropriate housing. These are., of course, problems
inherent in rurallty, but they must be recognized as requiring various
compensatory measures.
.
(^7 Inadequate Salaries and incentives. Among -the greatest -obstacles to
organizing adequate PHC programmes is the low level of salaries paid'to all
levels of staff. The typically low public service .-salaries are undoubtedly
■responsible for short periods of public employment and high turnover.
Physician salaries are a particular problem, insofar as - unlike most other
personnel ~ doctors have an alternative option to engage in private
practice. There may sometimes be financial awards for meritorious service,
but they are not very large.
Regeneration for com unity health workers p.esents special problems.
Ordinarily, countries do not want to ,aj CuWs official salaries. They are
sometimes regarded as "volunteers", and way receive only compensation for
their work expenses. In reality, these small amounts may be the only
monetary income of the CliW, and therefore are significant for their stability
in the PHC work. Governments differ or. this policy question and
international agencies tend to be reluctant to finance such personnel
expenditures, but experience has shown that reliance on "volunteerism" is
unrealistic for sustained health activities (as against one-time compaigns in
village clean-up, immunization, etc.).
(3) Weak Health System Management. The above problems concern the
management of a health care system, but there are other more fundamental
difficulties. In all the study countries, responsibilities in the Ministries
of Health (and other ministries) are highly centralized. Even when MOH
officials function at a provincial or district level, they have usually been
appointed by central authorities and often must get approval from the top for
almost anything involving the expenditure of money. This policy causes
delays, inefficiencies and irritations. Proper management also requires a
flow of information on the operation of health programmes - information on
patients seen, services provided, problems encountered, etc. Seldom do such
information systems function efficiently. Sometimes there are printed forms
to be used, but they are not filled out. In some higher-level offices
receiving such forms, they pile up and are not analysed.
Official personnel policies, another aspect of management, may be
counter-productive. In one of the study-countries, any physician doing
clinical work is paid aiore than a physician whose main duties are
administrative. Thus a Provincial Health Officer receives a lower salary
than a fresh young medical graduate treating patients. The problems of
inadequate training in teamwork and svp''r”ision are further obstacles to good
management, discussed above. Another impediment to supervision is simply the
frequent inadequacy of communication (if telephones do not work) and
transportation (if vehicles are not available). The isolated health worker
is often left with little or no supervision or consultation.
(4) Problems with Equipment and Supplies. Operational equipment and
adequate supplies can be crucial in a PHC programme, and yet they are often
lacking in health facilities. The supply of drugs and vaccines is
particularly important, but - depending ofxen. on imports from abroad - they
may simply be unavailable.
Even when available in a central depot, the
logistical process of getting them out to rural units may break down, causing
serious delays. Recurrent costs of drugs are a chronic problem. Vehicles
may be available, but without fuel. Refrigerators, important for storing
vaccines, may not work for lack of spare parts; personnel with the necessary
skills may not be available to.maintain equipment in working order.
(5) Meagre Community Participation. One of the weakest aspects of the PHC
■programmes in the six Btudy-countri.ee relates to the involvement of the
■community. While a village or municipality may contribute laud or money for
establishing a health'centre and even labour for Its construction, local
people rarely are involved in deciding priorities for health unit operation.
In some countries local Health Councils are established-to represent
community people in programme administration, but - sometimes after initial
enthusiasm - they seldom meet and do not function. Co-operative work by
local people is essential in improvement of water supplies and sanitation,
but this usually require# mobilization and guidance by sanitarians, which is
often lacking. Campaigns against snails or other disease vectors can bo .
carried out by community groups, with proper technical leadership and
inter-sectoral co-operation, but this has not been observed in the country
studies.
*
(6) Weak Intersectoral Co-operation. While it :1s widely recognized that
health depends on far more than health services, implementation of this
concept has proven difficult. At the local, provincial and central levels,
health personnel are often overburdened with their own work. Opportunities
to improve environmental sanitation through association with agricultural and
public works personnel are not exploited. Seldom does the PHC nurse have the
authority to gain access to children in the schools. Even within a Ministry
of Health, theoretically committed to primary health care, integration at the
local level, local operation of specialized vertical programmes in such
fields as malaria control or family planning often continues.
(7) W-ak Preventive Orientation. While curative health services are an
essential responsibility of health personnel, much too often preventive and
health promotive activities are overlooked both in training personnel and in
the functioning of the health post. Overworked staff, under pressure from
the. community to provide curative services, may have little time or energy to
devote to prevention activities, aven where their training has included it.
Moreover, prevention is an overall orientation rather than a discrete set of
activities which is needed at all levels, from CHWs to doctors.
(8) Low Utilization of-Services. As a result of the many problems
summarized above, both in health manpower development and in the functioning
of PHC programmes, it is not surprising that many community people seem to
have relatively low regard for the PHC services of health centres or other
local health units. Analysis of utilization rates in countries studied shows
them to be very low, by comparison with other programmes in the same country
(such as health insurance schemes), with health care utilization rates in
other countries, with the capacities of the health facility staffs, or with
obvious evidence of health needs.
In spite of (or perhaps because of) the low rates of utilization of PHC
services, the data .suggest that hospital out-patient departments are heavily
osed and overcrowded. Clients with ailments which could be handled at the
health post,- by-pass it and go to a hospital where they are aware that they
vill see a Specialist rather than a general medical practitioner, non-medical
community health worker (or perhaps neither of these types of personnel) at
/...
ths health post. in florae countries there 1« evidence: that physicians arc
offering private medical services, even in rural areas, -for which individuals
and families aro paying personally- Alternatively, patients consult a
traditional healer or a private physician.
(9) ’Hsease. and. Sfcsr-a, .The ultimate cost of all the inefficiencies and
other problems reviewed is peraist^nt rfiqMBH ami death, excessive birth
rates and unnecessary waste in the use of re»ourc.ec. Children and adults do
not receive preventive and/or treatment services that could avert disease or
cure it; instead they get seriously nici-. and may die, Wo see the evidence
of this in the high infant mortality rates and the relatively low life
expectancies of all six of the etudy-countriee
*
Waste is easy te demonstrate. The low utilization of PHC resourepa
means that those resources are not; fully utilized. In countries with serious
shortages of1 personae-1 - according to widely accepted standards - one secs
doctors, nurses, and others sitting around and waiting for patients who do
not come. The money paid for thair salaries is wasted and, more important,
the capability of these personnel to serve people 18 squandered.
6.3 Underlying Issues
All of the problems in health manpower development and primary health
care functions may, in a deeper sense, bo regarded as symptoms of certain
underlying issues.
Exploration of Cheats basic social issues in depth 18
impossible here, but they may be identified briefly.
(1) ^adequate health Funds in the Narinrw) Budget:. Where total figures
were available in The’”?tudy countries? uW
undu
*
allocated to the Ministry of
Health have been only a vary small percentage of the national government
budget. They usually amount to lees than 5 percent: for both recurrent and
capital costs, and in at least two of the six, study-eountrlcfl this figure has
been declining in recent yearn. This reflects, of course, low government
priorities^
(2) 'Low Regard tor Vrl«u>fy Haalth Care. Comptuheneivn health services
include a wide taus
*
wau».uCul uctivlCluC for the diagnosis, treatment,
and rehabilitation of dioeased persons, as well as for prevention and health
promotion. The complex technologies found in hospitals have a dramatic
quality not seen In the day
to"day
**
kobVo of health maintenance.
Primary
health care, therefore, tends to be appreciated by many people -st much less
than ite true value. These attitudes are unfortunately reflected in the
budgetary allotments of Mlnle-triee of Health.
There are, of course, health expenditure8 by mlni'stri-ee other than the
Ministry of health, but the MOH in the major source of public support for PHC
furnished to the general population. Yet, analysis of MOM axpenditurec
nearly always ehjws the lion's share of funds - usually over 50 percent - to
go to the aupport of hospitals and reflect an urban emphasis rather than a
rural one. Primary health-care tends to occupy a very Important place in the
declared priorities of health author!tie©, but not in the way that the
available funds are actually allocated and spent,
(3/
lits-iXth Care Ha rim. 'Private household expenditures for
health ^orvi^'’bav?i‘^M<T)ftett‘qttanFl£led In many developing countries, but
wht''e they hav-t been, they have usually been found to be large •• larger
indeed than
J.J government health' expenditure, In one of the study
countries uhera thia 'tuestlon has been Investigated, private health
expenditure® wcra found to < -eou.nl for florae 60 percent of the total.
A
large share of t-heae personal expenditure £«<■•? for primary health care.
including private plpums, traditional healers and self'-''prescribed
drugs.
Thuac exjw.ckUurey reeulf. not only in uerioua inequities, but also
in e.'fioub inefficiencies. They mean inequities because the services go to
those with moot money to spend, talhor than to those Lu greatest'need., They
»ean Inefficiencies, because the lack of planning and organisation in the
private Eif’dieul market Ly inevitably wasteful, Private incentives even mean
th«i‘: i'itisnee agy be given services that are unjustified and unnecessary
be.-“atH-isr Lhuy yield a fee to the provider.
(4; External Support for Health. In the next Chapter we will examine in
more detaiTThe proce'se oFoxterhal support for health. One fundamental
question involved is the level of resources which developed oountrleo are
prepared io make available to developing countries; on a global level thle
Is Xe&o thaa 0.5 percent and health expsmdltuten are only a very small
percentage of this. Even if the Inefficiencies noted previously did not
exist, the impact of external health support on the developing countries
would he small. Inefficiencies and lack of co-ordination unfortunately make
the ispnae even smaller,
.«sv -su v~vii CfflamititQnt. Probably most fundamental of all the Issues Chat
ua L’fcticneh protdeme in HRD/PHC la the political will 'of each nation J or the
advancomont of its people’® health. Since WHO was founded in 1948 and
especially since the Alma Ata Conference of 1978, declarations about health
a® a "boi- human right" and about the goal of "health for all" have been
made fey health leaders In every country, But there Is a vast differencebetween denifesutioas and actions taken to lapleiaeiit them. The gap between
the80 two Is deieemlnod by rise degree of political eoMSitaent to health in a
cauuiry. This, in turn, la lBfli?&!.ieed by countless different forces in eaeh
national society.
6 •4 Ball •*
The evaluation of projects in primary health care, se- In fifty other
eroso-aectoralj siulti'f'dinclplinai'y fieltl, is Inherently difficult. As
regards the problaras outlined In thle study, each problem hae its
explanation!!, «'.nd pointing a finger of blarae at any one international ar
national organisation does not usually serve to right the situation. By its
nature, national development in health and every other sector ie a
complicated proce&Ci, bound to involve delays. Perhaps the raeet important
lecR-on 1b that, with very limited rssourceti, goals rauet not be too ambit Iowa,
and tlrae-echt-sdulcfl should anticipate the probability of delays, Otherwise
both. national and internal Ionol staff can beeorae frustrated
and demoralised.
<
Tha ultimate evaluation o£ a health project must depend on its impacts
er? the- health of the people. Is there evidence that the
project hevs made theta healthier? Xs there a reduntlon
morbidity or an improvement in the capability of people to work and function
in society? Is there evidence of improved nutritional statue in children?
Are there lower rates of parasitic Infestatioft? These are, of course, very
difficult to measure » even eg atrnlgl.itforward an- lades aa the infant
mortality rate in e defined geogrebie area, Even If an objective improvement
An cose such measure can '?g demonstrated, it can seldom be concluded that- the
change has been du® solely to the project under study, and not also tn other
related social and environmental cireymstsnoee. Moreover, the slightest real
change in the health status of a papulation usually takes years to
demonstrate<
Evaluation of activities in the field of human rneouree development is
particularly difficult,. One may assess what students have learned in a
course, through esaainations. But the crucial question is what effect does
the course have on the graduates• subsequent performance, Determining this,
An relation to other influences on perfot’amnee, is not so easy.
In the- face of such difficulties in evaluating health impacts or
outcomes, most health and social scientists must be satisfied with mere
modest criteria for assessment. Xs there improved "coverage" of a
population, for example, with personnel providing primary health ears? Are
they accessible more equitably than in the past? San 16 be shown that a
project has resulted in a higher rate of utilisation of certain services by
the people? Such measurements of the "process" o£ health care are easier to
make, and. yen again there are difficulties, "Baseline data" on eonditiehs
before tha project must be available, and often they are not, Alsu, one must
grill face the question of whether any changes identified can be attributed .
te the project, Perhaps the mere passage of t-lme in a country brings changes
in the health behaviour of people, with or without any bpecifie intervention
tint an international project may provide, There are comparative research
designs that can overecme these difficulties, but it la costly‘to carry them
out and they must be carefully planned in advance.
It is small wonder, therefore, that many attempts at- evaluation of
health projects, international and national, continue, to be too descriptive
and impressionistic. One observes events and talks with the personnel
involved. Are they satisfied wltn what hag been happening? is there
evidence that people (patients) ate pleased with the cervine? What problems
“ physical, behavioural, social - have bacn encountered? Have plans been
frustrated and, if co, how much has been due to defects In the planning or to
events beyond anyone’s control? After a reasonable time has passed, to what
extent do the realities of a programme correspond to the Original plan?
Despite all the difficulties, evaluation of health projects must be
attempted, Primary health care is especially difficult to evaluate, becauss
it encompasses so many activities. In generals if the object of study can ta
narrowed down, successful evaluation is more likely, Th® performance of
specified immunisations, the ehiidblrths oceurrlng under hygienic conditions,
the households accessible to safe water, the proportion of school children
with signs of malnutrition, the percentage of women of child-bearing age
accepting family planning methods, the rate af malaria parasites detectable
in blond smears “ such measurements are much more feasible than "primary
health • ire" as a whole. Yet each of these specific criteria requires the
collect >n of information nd its recording. The findings must also be
interpr :ed against a background of knowledge about the total health care
system ind, indeed, the overall environment) in which an activity is being
evaluate I. In the long run, such efforts have always been necessary for the
advancei '.nt of health sciences and health services.
RECOMMENDATIONS FOR STRENGTHENING HOMAN
RESOURCE DEVELOPMENT FOR PRIMARY HEALTH
CARE THROUGH EXTERNAL SUPPORT.
Solution of the pro'.'lems or reduction of the difficulties reviewed in
the last chapter obviously must depend on national actions and actions
suitable to the conditions in each country. Externally-financed technical
co-operation is obviously not appropriate for all problems. International
agencies may help by supporting such actions or sometimes by suggesting
strategies that have been effective in other countries. It must be
emphasised that internationally-funded projects or activities are effective
only insofar as they support national objectives.
In this chapter some recommendations are made on human resource
development for health anti the functioning of primary care systems. While
they are presented in a roughly logical sequence, the rank order of the
proposals, however, should not be interpreted as implying any recommended
priorities. Decisions on first-level or second-level priorities will
obviously vary in different countries, and at different times in the same
country. Priority ratings for the development of primary health care
necessarily depend on considerations of resources, deficiencies, historical
experiences and political factors in each national health system.
7.1
Development of Human rtesource for Health
Actions needed to improve health human resource development should
correspond rp_ the.
IJ qns, here rough7 y pa ra11 el
the problems identified in Chapter VI. However the most appropriate
international strategy will vary with the. category of health personnel and
the country involved.
(1) Increasing the Supply of Health Personnel.. In countries with a low
supply of doctors, the training of "community health workers" deserves higher
priority than the formation or expansion of medical schools. Still a certain
minimum number of doctors are needed for rhe proper operation of a national
health care system. Qualified women should be admitted to medical schools on
the same basis as men. International agencies can provide consultants,
fellowships, equipment, teaching materials, etc. to help establish or enlarge
medical schools.
The training .of nurses, midwives, pharmacists, sanitarians and other
basic types of health personnel can usually be undertaken within the normal
resources of hospitals but it is important to develop hospital-based training
schools which make use of community settings for teaching students about the
social and preventive aspects of PHC. ‘The training of sanitarians in
adequate numbers is especially urgent, but it is made difficult by the lack
of qualified teachers. Because this work usually pays very low salaries, the
most competent sanitarians often leave government for private employment or
change to other occupations. External support can provide incentives
(including salary supplementation) to teachers, effective teaching materials
and housing for students. The schools may be multi-disciplinary
institutions, where laboratory technicians, pharmacy assistants and others
are taught - with common instruction in basic biology and chemistry.
(2) Improving the Social Content and Methods of Health Training. The
possible role of International agencies for improvement of the social and
community content of health training is substantial. In all six
study-countries, no deficiency in PHC personnel training is more general than
the weak place of community field experience or social science instruction in
the preparation of students. Education on the purely technical aspects of
medicine, nursing, midwifery and sanitation may be very well provided, but
the social, behavioural and environmental aspects of primary health care are
almost ignored or, more often, taught only superficially and Ineffectively.
In. medical education, there are several ways by which the policies might
be improved. Departments of Community Medicine (sometimes "preventive and
social medicine") are typically small and weak. They require enlargement and
further training of their faculties. Secondly, every medical student should
have a social exposure to community health work in. a rural as well as an
urban area - experience at least equivalent in depth and breadth to that
received in hospitals on surgery or other clinical subjects. Thirdly, all
clinical faculty should be required to teach the social aspects of their
subjects - e.g. teaching paediatricians the social aspects of child health,
the social aspects of communicable disease, etc. (If faculty members in these
clinical departments are incapable of teaching such subjects, they should
either learn them or.invite others to teach them.)
Teaching methods in most professional health schools have not caught up
with modem pedagogical knowledge. Formal lectures are delivered on
classical subjects, without regard to their impact on students' learning or
understanding. Much education can be made more effective by teaching
teachers how to teach, and helping teachers design courses that enable
students to solve problems in the real world. (WHO offers a major advisory
programme or. this matter.)
Equivalent changes should be promoted in schools of nursing, sanitation,
etc. In fact, the establishment of field training areas could well serve the
training needs of all the PHC health disciplines. In several countries, such
field training areas have been established, but they are inadequately staffed
or used only by certain schools. The field training areas, in different
parts of a country, should be subject to change, but should have the same
importance as that now held by hospitals. As part of the field training,
students could participate in household surveys on various health problems,
which would contribute not only to their education, but also to research on
medical/social/envlronmental problems.
(3) Encouragement of Health Human Resource Planning. Technical co-operation
can serve as theTatalyst to bring together Ministries of Health, Ministries
of Education and universities to adjust training programmes to the needs of
the health services. It can also give advice on how to quantify existing
health human resources (often quite different from the names on official
"registers") and to make reasonable estimates of future needs. Joint
councils of health and educational authorities can be very useful for health
human resource planning which should, of course, be carried out as part of
the planning of overall health systems.
(4) Effective Training of Community Health Workers. The training of new
types of multi-purpose auxiliary health workers has helped to make PHC
accessible to rural populations in many countries, but aspects of the concept
remain to be clarified. Objective assessment of the situation by national
and international experts can lead to sound policies for an effective
schedule of training, training of trainers, proper teaching methods, scope of
functions, relationships with other health personnel, proper supervision,
continuing education, etc. Both women and men should become trained for this
work, preferably themselves coming from rural communities; however, even
these CHWs may lack community orientation in’their work, and need additional
training. Finally, very brief training of village "health communicators” or
"health promoters" is needed to acquaint people with the availability of PHC
units and advise on simple elements of hygiene.
(5) In-service and Continuing Education. The systematic provision of
continuing education, according to a practical periodic schedule, is needed
by all health personnel. This requires careful planning and administration,
physical facilities where teaching can be done and participants housed, as
well as proper teachers and teaching materials. The "field training areas"
recommended above to enrich the community content of basic health personnel
education, can serve also as the sites for continuing education. In-service
training, often needed at the beginning of employment in a health post, is a
good way for new health workers to learn about teamwork. Acquiring teamwork
skills and attitudes can be facilitated by regular meetings of health centre
staffs to discuss cases and general problems.
(6) Effective Relations with Traditional Healers. Wile some traditional
healers are highly entrepreneurial and concerned with personal gain, others probably more frequently among traditional birth attendants - welcome new
knowledge about methods of treating and preventing disease. The formal
health system, including external technical co-operation, can learn to
collaborate with and teach traditional healers, so that they provide
beneficial PHC services. Regular but short courses can be given to
traditional healers for this purpose, a practice that has been most often
done with TBAs.
7•2
Functioning of Primary Health Care
After health personnel are trained, conditions need to be created
whereby their work can be well done and effective. Physical settings have an
influence on the feelings and attitudes of both patients and health workers
and attention should be given to the work setting and the social environment
around it.
(1) Improved Working Conditions. To some extent, attractive working
conditions are a matter of physical structure and its maintenance. The
health pest, examining room, laboratory, waiting areas, equipment, pharmacy
and its essential drug supply, water and sanitation arrangements should all
be as orderly and well maintained as possible. The same applies to personal
housing provided for staff members. Technical co-operation can help on such
matters, even though physical measures alone are never enough.
(2) Better Salaries end Incentives. Salary levels in most countries have
certain uniformities among different ministries, so that changing them in the
Ministry of Health or any other single Ministry is usually difficult.
It
should be possible, however, within the boundaries of a MOH, to re-arrange
the levels payable to different kinds of health personnel.
If primary
health care is to be truly accorded high priority, this should be reflected
in higher salaries paid to its providers.
Increments for continuing service
and seniority should also ' • designed to encourage continuity,
Several countries among those studied have mandated periods of public
service (usually rural) for all or most new medical graduates.
In one
country, students with higher scholastic records escape this obligation and
may directly enter specialty training - an unfortunate policy since it makes
those serving in rural posts feel ’punished" and "second class’*.
Mandatory
rural service is a way of the student’s paying back society for a
socially-financed professional education, and it should be required equally
of all graduates. In factd greater rewards and incentives should be built
into these programmes, so that young doctors work at optimum levels. A
system of periodic reporting and review should be feasible. It is also
important to support the young graduate with proper supervision and to
provide her or him with opportunities for consultation.
Incentives through rewards for meritorious service are also feasible for
all health personnel. Financial increments can be combined with honour,
recognition and opportunities for further training. If such rewards go to
perhaps 10 per cent of health workers per year, the costs need not be very
high. Financial support for such policies might even be explored by
internettonal agencies, as has been done -by philanthropic foundations in the
past, in order to test the value of an idea.
Regarding community health workers, although the prevailing policy in.
many countries is to pay them no salaries, this policy should be more
flexible. When CHWs carry crucial responsibilities for PHC, both national
and international agencies should not hesitate to pay them amounts beyond the
compensation for their working expenses. Such expenditure would he only
minor in the overall health sector budget and would go a long way toward
alleviating the sense of disillusionment and high drop-out rate among CHWs.
Other strategies for elevating salaries are being tried. Small charges
to patients for drugs can go into a "revolving fund" for purchase of further
drugs, and paying small salary increments. Where community participation is
mobilized, this can include the organization of a health co-operative, to
which ell local families contribute siiiall periodic sums for supplementing
staff salaries and improvements in the health facility. Where the financial
benefit increases the diligence and devotion, of health, unit staff, the payoff
to the community in better service is apparent.
(3) Efficient'Health System Management. One of the most concrete and
definite ways that PHC programmes can be improved is by strengthening the
managerial process in national health care systems.
Strengthening is needed
at all levels, but especially at provincial and local levels.
Providing supervision is essential, and this ability does not belong
intuitively to every person in a supervisory capacity. For professional
personnel, supervision, administration and planning — the essentials of
teamwork — can be trained at graduate level such as a School of Public
Health, as discussed more fully below.
Proper management includes mechanisms for producing, transmitting,'
organising, and using information. Information systems are essential to
programme evaluation as well as day-to-day management. Without a reliable
flow of information on mcrbldity/mortality, use of human resources, and
provision of services to people, evaluation essential for programme planning
is very difficult to carry out. Other management essentials include
logistics for assuring drugs and other supplies, maintenance of equipment and
vehicles, and records on personnel schedules and on all financial matters.
At the community level management has an important role to play in achieving
effective integration of health programmes . As noted earlier, certain
vertical activities (e.g. family planning) may persist in a country for
historical reasons, but every effort should be made to integrate these with
overall FHC programmes as soon and as efficiently as possible.
To do all these managerial tasks efficiently requires special training.
A medical head of a health centre team should not be expected to carry all
these responsibilities, in addition to community health and clinical duties.
The training of “Health Care Managers" ie a realistic solution, for which
external support could be highly valuable. An appropriate locale for such
training would be a .School of Public Health.
(4) Active Community Involvement. Rarely is there a community in a
developing country Chat spontaneously develops the initiative to launch a
programme for primary care. A dramatic event, such as an epidemic, may
stimulate action, but ordinarily action must be promoted by the health
workers themselves. Chapter VI notes the typically limited performance of
sanitarians, doctors, and nurses in this regard, and little should be
expected unless modifications are made in their training.
In public health affairs, the personnel with training specifically
oriented, to community organisation are “Health Educators". Their skills with
posters and talks and audio-visual presentations are generally known, but
much more important is their ability - when properly trained - to communicate
with the natural leadership and understand the prevailing attitudes of local
people, so as to mobilise community action. This concept of health education
might be better described as “community health organization". All FHC
programmes should have trained Health Educators of this type, not at every
local facility, but at a district or provincial level from which every local
area can be reached.
The work of the Health Educator should be of two types: first, to
orient all health personnel in the PRC programme (especially field workers
and their supervisors) on the concepts and methods of health education, and
second, to work directly with community leaders and local people in the
attempt to demonstrate the value of community participation. The training of
Health Educators, like Health Care Managers, should be at a School of Public
Health.
(5) Strong Inter-sectoral -Co-operation. Organizing health benefits
achievable through: schools, agriculturel^and other sectors is a task mainly
for PHC team leadership. This would include leadership at local health
centres, as well as leadership at district and provincial levels. Obviously
inter-ministerial health...councils at the national level can be most helpful
of all, but they are often more difficult tc achieve and, if. established, to
keep active. Proper trailing and continuing edu .ation of PRC leaders is
required for this objective.
,
7.3
Schools of Public Health or Health Development Inst i tutes
References have been made above to the need for a School of Public
Health available to each country for training PHC leaders, Health Care
Managers, Health Educators, and others. In recent years, some countries have
designated such schools as "Health Development Institutes". The terms
"School of Public Health" and "Health Development Institute" are treated as
synonymous in this section. In three of the six countries studied, some such
school or institute existed, but for various historical reasons it was not
playing its potential and appropriate role.
Almost every country has a school of medicine, or several of these, not
only to train physicians but also to provide leadership role for medical
science and service in the country. However schools of medicine, it must be
recognized, are inevitably oriented to the treatment of disease in the
individual patient. Their educationaX_j>rogranimes~are built on basic sciences
of anatomy, pathology, biochemistry, physiology, et?T~and-jthes.r-CTrrricula
culminate in internal medicine, surgery, paediatrics, obstetrics,, gynecology,
ophthalmology, vseuro-psychiatry, etc. Aside from the classroom, their places
of learning are the laboratory and the hospital v.xrd.
The goals and methods of public health and of primary care, as now
understood, are- vexy different. Their orientation is.
patients but tc communities andi>»r..>
rateir task’s'ar.e mainly
”—
preventive^ jand-curative only in an organizational sense. The basic sciences
of public health are not anatomy, etc. but sociology, economics, political
science, statistics, nutritional science, sanitary engineering, management,
ecology, etc. The culmination of their curricula is in disciplines relevant
to the population: epidemiology, community health, education, public health
planning, health care management, applied nutrition, environmental
management, health information systems, and sc on. Their major places of
learning are in communities, rural and urban. In such settings, and in the
study of such disciplines, requirements for good primary health care
programmes - like teamwork, supervision, motivation, etc. - should be learned
naturally without necessarily labelling them as such.
Health Development Institutes must be multi-disciplinary not only in the
subjects they teach, but also in the students they admit and the personnel
they turn cut. The need for training Health Educators and Health Care
Managers in such schools has been discussed earlier. In addition, teachers
and leaders in nursing, midwifery, environmental sanitation, nutrition,
health information (statistics), communicable disease control (epidemiology)
and other fields should be trained. Perhaps most important, general Medical
Officers of Health should study in the School or Institute for at least one
year. With such education, one may expect that national, provincial and
district leaders in public health and primary care will acquire not only the
necessary technical knowledge, but also the motivation and inspiration to
provide effective leadership to all other personnel.
Like a school of medicine, every country should have access to a
national or regional Health Development Institute, not only to train urgently
needed categories of personnel, but also to provide general status and
inspiration to the whole field of advancing the health qf populations.
The
average doctor and nurse should, of course, also have some appreciation of
public health (or "community medicine", as it may be called, or perhaps
"preventive and social medicine"), but departments teaching this field are
invariably ef very minor importance in medical schools -- inevitably dominated
by the laboratory sciences and clinical disciplines. Public health is
usually regarded by both faculty and students, as a diversion from the central
purpose of medical education -the diagnosis and treatment of the individual
patient. Countless attempts to strengthen departments of public health in
medical schools have been unsuccessful. Other attempts to inject a "social
point of view" in each of the clinical disciplines have had moderate success
in a handful — perhaps in one per cent — of the world’s medical schools.
The strategy, therefore, should be to develop firmly grounded Health
Development Institutes accessible -to or in all countries. They should be
university-based, but as medical and nursing schools are linked to hospitals,
these Institutes should be linked to Ministries of Wealth or major provincial
Departments of Health. Academic degrees might be awarded for certain
programmes of study, but not necessarily for all. The Institutes should not
only train personnel, but should do research on the problems of the health
care system, and provide consultation and leadership. Development of the
faculty and resources for such institutions in developing countries would
take time, but such development would be an extremely useful objective for
external international support.
7•4
Co-ordination of External Technical Co-operation for Health
Co-ordination of international technical co-operation, both multilateral
and bilateral, has been discussed in Chapter V. It was clear that
co-ordination is necessary, not so much to prevent overlap in particular
■geographic areas, as to provide technical co-operation that corresponds to
the priorities of the recipient country rather than to those of the external
agencies. Almost any developing country welcomes financial support for any
reasonable purpose; the needs are so great in every sector. But the most
effective support is naturally that which co~incldes with the overall
planning strategy and priorities of the country. To achieve this,
co-ordination should be improved on three levels.
(1) Within national governments, general planning units or similar
bodies with overall responsibilities should co-ordinate technical
co-operation activities for health from all sources. Likewise, Ministries of
Health should contain, a unit responsible for monitoring, co-ordinating and
hopefully, peace. The second and less obvious, is that the health sector is,
in fact, one of the most amenable of the many sectors of society requiring
change for achieving speedier national development; unlike land ownership,
housing, industrial production or foreign policy, it does not touch the deep
roots of the basic power structure in a nation.. Although some changes in
health care may be subject to debate, they are net controversial in the sense
of significant changes in other sectors. This is why so many developed
countries have benefitted fro® major reforms in their health care systems,
without social upheavals. Important reforms-and improvements in health care
systems, including PHC, car, be made with relative ease politically, for a
relatively small price econosaically, and with large payoffs. The benefit
cost ratio of improved health services is high, especially in. developing
countries where the main diseases are so readily preventable. The benefits
can be high both economically and politically,-because every family is
concerned with disease and health every year or even every day.
Tackling the "underlying issues" that explain the problems of HRD/PHC,
as summarised in Chapter VI, need not, therefore, be so weighty a task as
might at first appear. The social forces that can lead to political
commitment for health include all sorts of population groupings - farmer's
associations, labour unions, women’s leagues, religious groups - for whose
members health usually has deep personal meaning. If the political
commitment to work toward “health for all" can be achieved, the other
strategies should be implementable without great difficulty. It is quite
feasible to mobilize the large expenditures, already being made in the
private sector, for the public sector of health. It has to a significant
extent already bean done in the many countries ~ developed and developing ~
with social security programmes fez health service. If this can be done, an
increase in the health sector's share of total governmental expenditures and
in the PHC share of health expenditures, should be implementable in
relatively short order.
Thus attainment of "health for all" in a country can demonstrate
concretely and dramatically the benefits of planning,'community efforts, and
social change, for everyone to see. The primary health care orientation of
an effective health care system brings benefits even closer to the field of
observation of every family. Such achievements in health can encourage
equivalent actions for .social refora in the many other sectors contributing
to national development.
PK&LS35 affiKTJe’JCATiCS
TSE y&IHAKY HEAI.Ta CASE CCKCEPT
».-ir
x
*
y
Health Care is not a new ptenossencn. Since tine
..: .r/eBOTiai a patieat. has bad a possibility to be cared for
by a doctor ox otter health person in case of illness or
infirmity- 'Ttere Bas been a referral system - the doctor has
referred the patieist to secondary ox tertiary health care
*eve_ xi need be. Tte service has largely been centered on
the
physician.
Another
typical feature tes been the
concentration, core or less, entirely, on curative care.
still another feature has been the great concentration of
this curative care to urban centres, Even this is not a new
phenomenon. It was mere natural to place the hospitals in
areas with higher population density.
'
However,
with
increasing number of hospital beds and
increased nuzbex of physicians and other health workers all. concentrated in urban areas - the inequalities became
most disturbing in developing countries with poor resources
and where 80 per-cent or: more of the population are living
in rural areas.
During the early 1970s the International community became
increasingly concerned about unequal and slow development.
It should also be stressed that in quite a few developing
countries the pattern of maldistribution of health services
had been inherited fro® the previous colonial powers.
One of the moat important nestings ever held in the field of
health services was in 1978 in Alma Ata in the Soviet Union.
On
September 12, 1978 the international conference on
Primary
Health Care meeting in Alma Ata made a most .
important declaration expressing the need for urgent action
by all governsients, all health and development workers and
the world coasrunity, to protect and promote health for ell
people of the world. The Conference strongly reaffirmed that
health is a state of complete physical, mental and social
well-being
and not merely the abscence of disease or infirmity.
Health
is
a
fundamental
human right.The
attainment of the highest possible level of health worldwide .
is a most important social goal, the, realization of which
requires the action of social and economic sectors in
addition co health.
The
conference
underlined
PHOBLKH IDENTIFICATION
that
the
existing
gross
The PHC concept
■•
J
|
in
-tbe
.health.
©eveloped
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to participate tBdxvidsally and
zxj!3«ssti«'eiry
2~ tJ-.c
*
plar^ai^g asd i^lezssxitssticra of thelx
wealth ■z^—.,, tut xlsss 'thzt gcrosesnssients have re'S^criSiblIlty
for tVo &E.sltM si their people. ‘"fee nahs ssasisg. target erf
exz-^TJsasitr. iz x^rr^-stictsii crg<ini.t£;'Xi^.s atsd tiJe ^ol-a world
©BassussiTy :ih£>aX-4 fee sit? z,xto•inses.t b-f all, people cf th©
t>v ti
e
*
year 2S£2 -zf a level of health that will perszi;;
ths®. to live .s. socially i<aci ecoaxMaicaily pztractive life. It
.was stressed xhirt ?sc is th— &ey to attaining this target as
& .part ta ^esreJagatfMSt ixx £hz spirit ©f social pasties.
Erioary Sse&Ite care f^s been identified as essential healti.
xc
*
c
-vss-e-K ©a pfmetical, scientifically s-oissd and socially
accsprab :e
and te-csaaolc-gy whicij i.% Hade sniversallAacocssible to issfiividsials arsci fasailiss in trae coxazuzkity
tCiroa^a t&edz? fax 3 participation «T$d at. t&i! cost t&at the
ctirs^c/ty t-cvf ther coo«xry ca© afford to
is the
rpirit cf sself—reldaace aad self-aetersBiwz>t2€?n. Ifce
cSccld fsrn iir_ integral part both of & ©s?xntzy,s? hr?21-th
systo, of '«bicn it i.\ the central fEnctiasi ai?d saiiw focus,
*2s£d of tchr- irvaxsjll so. rial asd ecozsooic aSevelopsest cf tzse
c_—snaity
It .s£»343id b. the .first level of eent^ct of
iraxivi-iiiais.
tsze xo^lly -ztii 'ccsascEity -«dtA t&e jaati^nzl
ifcsaZth -^i-.
ixr.isrd~sr- health -razrc as clcse as possible io
wfiieze
pac >2-s live zni -a^-k as^ ccos.fcit«tes the first
el«^K’.s:ts s:. «. caatla&ing xsalth car
*
process.
?^“.1*.? ec2aa’
^a* '
ccsuit^oz^E asza
ef..,.tfef
aeaxcsx
experience.
■It
sfcasald
“3l '!
•otther stresses that primary.
reflect and evolve rr©s tfcfr eearriiafcsocio-ec itisrsi aa^ political chsc.z'acfcerisiicss
based on the results of social,
seryicea research e*rx3
piablic health
address tfce stain health problem i®
v ns sm» ££ATICSi
The J?hC concept
psc-'uidi&g protective., preventive, curative and rebab!Sixetive
sex^-sces accordingly. .
St should include t&d following eight elesassats;
£ -&JiCatXC4B
2, oca! disease control
£ Mp
*z-&?43
Pr-onrajracae- of Ifania^iza-tiOTi
CK aad f&ally plaaaiag
Z ssesjtiai dx^gs
15 utrztio-ji
feed supplies
7 reatwent 3<ris prevent! co
S afe iseter ssapply
sajiatatloB
It. should -ijivelve iz; a edition to th
*=
be.31th sectcr all
re!:
sectors i-iss ■deaaad •
co-ordinated efforts erf all
thc.sa
sectc-rs
ioclxading
agrzcixltesre,
ed-jesistisso,
■LUBZ UHiicati-Ctn -and so forkiy..
2± should require tse self-reliaiiOE: and p-arti.cipstix.'i in the
olsiiaiKSk orgar.i xatisn srd ©fiszati<i»n ^<5 control of 25ST and
‘.ssakiffig xuiiezb use of Iccalj. si2?ti©Ea2 cr
cyai.ia2>le
resources.
It iX&oKld bs sustaizjed by an irit-e-grated ‘ iraKZtiosal and
asstsally
supportive
referral
.xystes
ejid
lead to a
•progrfissive iasproveseat of ciwzpreBeasive health care f ?r
all, -giving ariority t<3> ■these xfcost aw read.
Tidally, it should rely hoth at ths.' local a.;jxi ct t&s
referral
level
’health ■ wrkers iacludiag pgsysiciGins,
nxirs E-s. .»■
midwives ,
assci 5 lares ssd casassHSity usizaaers zr
applicrhle -ZiS i.ell z.s traditiooal px£.etitfcs.exi- cs needed.
^’Gjtr-ib37 tarai.ned socially as
?
*
tecSM’icall^’
voz3; zss c
iisaltb
t.w rerpcEd to the expressed health r;-z2ns □£
the c«so.Tvaity.
fne iecxlaxazisxa irrtbsr stresses that all ^vernsent?? ahaswi..-":
foKtat itst**
national policies, strategies esd plans cf action
to .’iasssch aa^ &. ^ze-ixi prwzizy i>ealih care ais part of ®
ccjip atesisive xiatimal health £^yst-e3!? sad lx. eo-osdinatioss
with ether sector s- To thir =ro it %>es
*ld
its n&ces^x^
exercise
a
j.^1. tical
will to ceil lire the coo&fcry
s
*
rest re&ss
ax^
■? s
cae®
available
exterrial
resnsreez'.
ffatlc-aally.
It 2"s about five years since the £ass>oss 2*S£ declaration -was
sade. It is a short period -whew it cosjes to plaxming and
ispi'crcentatioa’i
of
a
reoriestatiosi of siati.ora.1 health
systems.
PKC concept has besn interpreted in sasy
P20ELSX ID£fcfT3FlCATI0S
The F&c except
differeht ways depending on the prerequisites in difiei^nr
countries- ,-It has to do with the national resources, .it
• o go u’.th the population density, it has to do with the
value syfetem and th*?, way people ur<? used to refer and turn
to the hc---i.tr- sy*tefc.
PF IMARY HEALTH CARE IN SOMALIA
following the Alma Ata declaration of 1973, ‘the Somali
Ministry of Health prepared a health development strategy,
based on the PHC approach as outlined in the National Health
Plan 11980-85?. The Ministry has established a PHC Central
Policy Committee, a Printer? lice 5. th Care Co-ordinating Unit
thin the Ministry as well as a PHC National Office,
T’:ft PHC activities in Somalia were started in 1981- Ths
_ 'tenuit onal,
bilatexa
and.
no-vgovarnmental agencies
s .,s i s13 r •. the progr aom i
■... different regions isre listed
i. 1:- 1/5 tie 1H
ABLE j.. PHC di. i-1 v; , \’t> ,’ n Somalia
i.’njcei. WHO (1982)
•Jc- unity Aid Abrc.od (19321
carj.i&s, Cc'-'-Ubiny (1.982.)
7 •••••. A L ilSuJC?
15SA1D f 198
*8
J
Italy 11984)
jwcdisn Church Ste'txef «1964?
CHAPTER 5
Population and Family Planning
. Sex and self preservation are two major biological urges of
the mankind. Sex results in procreation. Children provide
emotional satisfaction to parents. In patriarchial societies,
the girls move to another family after marriage. In
. traditional societies and in joirit.Jamilies, boys stay with
their parents and look after them when they are o|d. In most
developing coutries, the son piovides social security to
. parents. Most families try to have at least two sons. If one
child unfortunately dies, the other child could look after
. them in their old age. To get two living sons, the family
generally needs to bear z.n average of 4 children; In families
with experience of farly childhood deaths, more children are
bom to compensatef -r ■ me deaths. There has beers a steady
improvement in the he 1th status of people. Illnesses and
■ scourages of yester-years are disappearing. Smallpox-has
been eradicated from the world. There are fewer deaths due
to malaria, Kala azar, tuberculosis and other communicable
diseases. More people survive longer, but death rates among
infants and young children have not declined as
dramatically and substantially as in adults. Two out of 5
children die' before they are 5 years old. Parents lose
confidence and are afraid that their surviving children might
die due to lack of good medical care.
We live in a finite world. The growing number of people •
need houses to live in for which there will always Ire limited
space and increasing demand. It will be a stupendous task to
provide adequate housing to all people in the years to come.
Besides housing, there must be other community facilities
such as roads, shopping centers, schools, playgrounds, safe
128 Management of Primary Health Care
potable water supply and means of disposal of waste water of
cities.
Factories installed to pros ide the increasig needs of the
people encroach on the fajt diminishing landmass available
lot agriculture and food production. Already many poorer
countries of the world cannot produce all the food for
providing minimum nutritional needs of the people and
have to imjxrrt food at huge cost
Less ami less money becomes available for other
developmental act A ities. needed for raising ’.he standard of
living o; p: ople. Some scientists feel that with new improved
seeds, biotechnology and better use of fertilisers, food yield
could be increased many fold. With the current advances in
science and tec hnology, the world might be able to tide over
the food crisis lot a few more decades esen it the population
continues io increase at the present rate. But this cannot
continue till infinity.
There is increasing demand tot limited available goods.
The industrial growth may satisfy the needs of people
for several decades. The cost of energy for industrial use and
transput a tat ion has increased several fold; the prices of
commodities are rising beyond a reasonable level. Most
people already find the inflation raising its ugly head, all
■over the world, a crushing burden fos survival.
Educational facilities ate not increasingai the same rate as
the population. 'It is- a greater snuggle for young people to
get appropriate educational experiences. More and more
young people are entering the .job market without full
educational preparation. They arc chasing fewer and fewer
jobs. Unemployment is a major social problem in all
countries of the world, largely responsible for the social
tension among urban underemployed frustrated youth who
take to life of crime and find it easy to take refuge in large
overcrowded cities.
f he social strife due to rising population and diminishing
opportunities is manifesting as conflicts between the rich
and poo;, different ethnic groups and among religious
denominational gtoups.
The dreauftir prospect of spiralling population and its
impact on social, cultural and economic ethos are awesome
for riw wo; id leaders, the rulers and the government officers,
Population and Family Planning
129
who conduct the affairs of the country. Bui these are of little
concern or at least are not well understood by an average man
in the village. His little world is’ often limited to his
immediate family. He is only obssessed with his own
survival for today and possibly for tomorrow. It is of little
concern 10 him, what will happen to the world in future, if
he continues to beget too may children. He will be anxious
only if a catasirophy falls on his family, his wife'and
children. The common man will be motivated to limit his
family size, only if lie comprehends the direct benefits of
1 iiiily planning to his little private world.
In the villages many girls are maried young. If they bear
children before they are twenty years old, it affects their
health badly. A 15 to 16 years old girl herself needs more food
for her growth. If she gets a baby, she becomes more pale and
undernourished. She is too small and fragile to bear the
strain of piegnancy. In the child-bearing ages, many mother
deaths are attributed to child bearing. More of these occur in
mothers who are below the age of 20 or above the age of 35
years. Women should know that it is safer for them to hear
children between the ages of 20 and 30, when they are healthy
and strong. If the baby is born before the mother is 20 years
old, there is a greater chance that the baby may die before
delivery. It may be born before full termor may be so small in
size that it may find it difficult to suck at breast or cope with
the outside environment. It may di^.soon after birth. Some
such small babies may survive the first few weeks of life, but
they remain small for years and do not do as well in later life
as compared with the babies of normal birth weight. They
may not be mentally as alert and many do poorly at school.
There is a greater risk both to the mother and child if the
mother’s age is over 35 years. More older mothers die of
repeated child births. They become severely pale, weak and
ill during pregnancy.
it has been seen that a large propoi t.ion of babies of older
inotheis have birth-defects and mental retardation due to
causes such as Down syndrome (which was erionebuslv
called a Mongol child, because of a superficial resemblance
to features of Mongo! races). Another problem; of having
babies at late age is that when children reach a marriageable
age anti require to be sealed in life, parents hare heroine too
old to arrange lor these anti piovide lor theii needs.
Mother should be told not to hare pregnancy too soon
after the birth oi the fits! child. It is risky for her to sufferthe
pangs of set ottd pregnancy, More she has it-covered from
the weakness caused by the first. There is a higher risk of
maternal deaths and mote serious tomplicalion of
pregnancy.
Since the mother is not able to breast feet! the earlier baby
due to the onset of next pregnancy, health of the first child
may .. fer. Th:' tnothei .niay be too tired to look after the first
baby, who ma suffer from infectious illnesses and is mote
vulnerable to uie just because t lie second pi egnancy o< tuned
too soon. .'lo iter may not hare time to recoup her own
health. She may become pale and malnourished. Therefore,
her new baby may be born small anti stiller from all the
consequences < f low birth weight described earlies.
Having too many children is not good foi the mother and
the family. Every new pregnancy exposes the life of mother
irs.new risks. Looking aftei too many children is exhausting
for her. She becomes timland irritable. Herangeris reflected
on the husband. They quarrel frequently ant! family life is
disturbed. .-Vs the earning of the family is limited, each
member gets less food and clothes as his Or her share.
Overworked mother ranno: provide even the basic
necessities of life to children. The older child has to be often
removed from the school to help the mother look after the
younger children.
1
Although it is noth general title, mental functions and
school achievement oiiihe first two or three born children aie
bener than these born subsequently.
Inspite of alt ilie arguments advanced that family
planning is good tor the mot tier. the child and tin- family,
the health wo; ..er miik not always he able to convince the
mother. She may shyly point out that decisions for the
number of children reMs with her husband and the mother-
family size. Many have joined, police and army. They cany
the message of family planning to their home. Most people
accept the need. Some women are too shy and feel awakward
if they are seen going to a family planning clinic. This
obstacle has been overcome by integrating family planning
with maternal and child-health clinics and by more frequent
home visits by the family-planning staff.
After the family has agreed to limit the family size, what
isthe best course to follow? Young couples should have a
child and then delay the birth of second child by 2 years by
using emporary methods such as condom or pills. Pills are
relam *ly safe for young mothers. Intrauterine device is a
good emporary method of birth control. Very rarely a
pregnancy may occur inspite of it and some women may
have train and bleeding from vagina with the use of
intrauterine contraceptive device (IUCD). Risk is small but
not acceptable to some mothers. However most mothers find
it quite convenient. Some mothers prefer to use hormonal
contraceptive pills. IThese need to be taken regularly
according to a prescribed schedule. Supplies should be made
available by the family planning clinics regularly. Rarely
these may cause unacceptable complications.
It is possible to slop all bii ths by a minor operation on lhe
father or. lhe mother. The operation on the father
(vasectomy) is safe. Il takes it few minutes. Post operative
period is short. Operation has absolutely no effect on the
health or vitality of the father. Unfortunately fewer father go
in for it. Tube which carries male sperms to the penis is
blocked. if necessaty, in some cases, it may be possible to
rejoin the .Blocked and cut ends of the tubes later, if lhe
couple wants-to bear more children due to death of their
earlier offspring. Most family planning operations are
performed on the women. The fallopian tubes which bring
female eggs from the ovary io lhe uterus are blocked and cut
either by an abdominal operation or by a special apparatus
tint) n.ivv ft? ix- icj iviiu U wkii mt'
desirable not to do permanent methods ol birth control in
tn-tcin.
i nnc
latter.
Fortunately the conditions ate changing. People are
Ix-comiiig more responsive to the need for family planning.
In the villages, mon
*
people are aware ol the need to limit the
innv ’ivpH
nri/'Jnrc
??
very young couples, before t hey are 30 years old or before they
had at least 2 children wi th the younger child beingat least 5
years old and in good health, of .good weight with no history
of any significant congenital or acquired illnesses.
SYNOPSIS OF SOCIO-ECONOMIC AND PUBLIC
.HEALTH CONSEQUENCES OF OVER POPULATION
Table 5.1
'
SOCIO ECONOMIC CONSEQUENCES
I. Increased demand for housing, encroachment on
available land mass needed tor agriculture, high cost of
construction, spiralling rents.
2. Increased demand for community serviccs-such as roads,
shopping centers, schools, play grounds, safe por?t ie
water supply and means for disposal of garbage and
sewage.
3. increasing demand for frxxland diminishing land mass
for agriculture. High cost of food: need to import;
political implications.
4. Educational facilities are not able to keep pace with the
needs osf spiralling popuEanon. Higher cost and
dif&alties in srr'ttrixtg adniissipst in educational
hist tuitions.
5.
Shrwtrig-. of pace oi ecwsomtc development because of
need tc divert resources. for social services.
&. Tncrersing. unemployment c-f burgeoning labour fo»w.
7. fnflatfen: Skivr rise ir« prcidtai-ion of gt.wxls attd rapid
rise rn,demand from snczeasiirg popt’&.f.ion-causesnaffelirat.
& focwashig. social terrssons fere to dttnmishhig job
ojjpai’rninilifs,,. uneraptoyment. high cost a£ living.
■ ecura/rair thsp-itrifies.
Sr.. Rising crime rare due co rise,in popular fou c?{ frustrated
unentployed youth.
take refuge isr large overcrowed:
crtfet-
Ifis Eletenfltrarin^qsaliry cst life due- rs> «tv:.-rrs>wdfr?g,. poor
*
sanscaiMK
and mcseasinsf poHsttiaEs.
*
TaMea
HEALTH CONSEQLESCES OF LARGE FAROES
Ffe tk<r il&ffte
*
L Higher ieeKfente- «rf af.scrsskt antf tstcdnsatttsfore few- to
repeated pregmitcies ia rfsr rasrt&er
2. 3&dK3& illnessesduring: pmgnasacy'Gassy rstfafeely poor
prpgaufeis.
3.
Increase in maternal mortality rate due to inadequately'
supervised perinatal careor complications of pregnancy .
and delivery.
4.
Higher incidence of handicaps in th" mothers as a
sequel of complications of pregnancy.
For the Baby
I.
Higher perinatal mortality if the mother is too y mng at
the time of delivery or is multiparous.
2. Higher incidence of preterm deliveries or birth of smailfor-date infants if the mother L below. 20 years old,
interval between successive pregnancies is small or in
multiparous mothers.
3. Growth and development of the fetus and infant arc
compromised.. There is-higher incidence csf intrauterine
growth retardation.
4 4. Higher incidence ot. minimal brain damage ar l.'5jnimg
disabilities.
.
■
s. Hsgh£Tittcidcncetrfctirerrnnr«rnai.disQnIiss,jf.niccf8seris
over 35 years- old at the time of conception,
>
6. Higher tnciderscir of iwaltMimtiart in chtfcfeen if fee
interval bemeen successive pregnancies is smaiL
FAMILY PLAM&ITNG- METHODSNATURAL METHODS'
Coitus. Inwr.rtipatSs This is- tincertaiK methsd, hi. sotsse •
penons tire oanSdcnu t’tf feel"' ability rc iniiEmip; coitns
before eyacidafemi.
SffifeFcjfcwfe tewotBtB vrirh regufes.msn^Lt;^ cyck-. «kuk
shoufd.be avoided beiwemSrh.to Kth.daysr? the rse fist-ruai
c^rfe. The safe or irtfectife peried: of iisetKUTitaS'eych' may he ■
dtssisiMrked liy refwetsce to.; the diate: -•sF tike neats sstensXTSUti
periwig SInring. esw&Mus^ the b®d-x tec^esa«ae
rfee
ru-orrtsrtg, rises over eSse-p»ewK>M&&ui$"MsstI>eraiMreiA lerwicaB.
Etucu.% increases, and' breasts may teoEBEr sXfg&dy atswfcs.
This.- is rsc£ a rei'aathfe tsiechtid' tirf: CBHWrasspsiriMac.
■
MECHAKEEAE. 3®ETH.0m
Cbfjdnmv Th© hu&basadl uses-, a tsofe&ss oint&eazawss £fe
nhahKtAmfeisc.mjascratsi?.ir_ lii tisedaewnerte itskef&K-feffihiii.
h may tear and spermatozoa may mote to the vagina
resulting in pregnancy.
Spemtacidal Jelsy or Diaphragm. The wife is advised to
use a spermit idal jelly or diaphragm dnt sag coitus tocnsure
ptoteciiosi front pregnancy.
Intrantcrine Devices IUD, .Several varieties such as Lippv’s
loop or copper T are being used. These are inserted into the
uteri;' hy a trained person preferably a physician. Lippe's
loop t.. vaiiab'e in -i sizes viz., 21,25, 27.5 and 30 mm. After
rhioug’.- gynecological examination of the women in
iiiitoiui-\y pos'. ion :o rule out pelvic infection and after
determining th ' position of uterus tire loop in a speculum is
inserted it) the . igina. Anterior lip of she cervix is held with a
single loathed .-gxrulum forceps with (uh aseptic precautions.
As the IUD introduced reaches the external os, the loop is
pushed by the plunger into the uleiine easily from the
irinod-icrr. The polyeihyirne filament attached to the loop
hangs out of the cervix into the vagina. While it is not
necessary to dilate the cervix, before insertion, in ease of
parous women, it may be necessary to do so in nulliparuus
women. If it is inserted within 5-5 days after delivery or
| abortion, there is a high
expulsion
*
rate. 2HD should not be
inserted in cases with pelvic inflammation, erosion or
ulceration of cervix, dysfunctional bleeding front •merits and
in ’Ire presence of uterine tumors. In case of cervical erosion,
patient should be referred to the hospital for excluding
malignancy by PAP staining.
Co: .plication of IUD include irregular and excessive
menstrua! bleeding, pelvic inflammation,
pains and
perforation of tl'ius. IUD may be expelled without the
knowledge of me user woman. Bleeding generally stops
within a month or two of insertion and is generally not
severe. If bleeds.ig persists for more than 3 months, the device
should be removed. Pelvic pain is commoner in nulliparous
than in parous women, if pain is severe- it may become
necessary to remove the IUD. Perforation of uterus is rare, it
is generally asymptomatic and is often diagnosed only on
radiography, when IUD is not seen on pelvic examination
and there is no evidence of its expulsion.
Ora! ''Contraception (Pilt). This is an effective method of
contraception. The pili is 'a mixture of estrogen and
progesterone, It is taken every day for 21 days from d. 5 (or for
28 days in some cases). Pills may cause nausea, vomiting.
headache, breakthrough bleeding, tenderness ol breasts,
vaginal discharge and increase in weight. These symptoms
disappear after 3-4 menstrual cycles. Jn some cases, serious
side effects such as venous thrombosis, pulmonary
embolisation a,nd cerebrovascular accidents have been
reported.
The pili should be avoided in patients w ith prior history
of suth episodes, hypertension, diabetes, heart disease,
jaundice, liver disease, malignancy and discing lactation.
Post-parttsin SterHisatiom Optimum time for post-partum
sterili ation .is brtwein 48 mid 72 hours after delivety. After
local anesthesia. a 5 , m incision is made near the fundus of
the uterus. Two fingers are put into the peritoneal cavity
and fallopian tubes me hooked out after clear identification
of lubes by looking at the fimbrial end. A loop of tube is
picked with the forceps. Base of the loop is tied with plain
catgut suture, passing through mesosalpinx avoiding the
blood vessels. The loop of die fallopian tube so isolated is
resected. 1 he process is repeated an the other side.
Cgtyi H
HEALTH
CARE
PROGRAMME
FOR
"
TRIBALS
Almas All
Concept paper prepared for the Workshop on role of Voluntary
Organisation in the field of Health Care Delivery to be held
at New Delhi - January, h- - 5, 1988.
***********
Ctwy 5/\ — I S'
HEALTH CARE PR3GRAMME-F0R TRIBALS
Almas All
India is a signatory to the Alma Ata Declaration of
1978 and it is committed to attaining the goal of "Health for
All (HFA) by the year 2000 A.D. through the Primary Health
Care Approach".
The concept of Health for All is not so
simple as we look at it but it is a continuous process which
means that we have to pay equal attention, to all strata of
society (regardless of location, position or ability to payP
and justifiably much greater attention to the underprivileged
and weaker sections like the Scheduled Tribes, majority of whom
live below the poverty line. Moreover, the Government has
expressed special concern for development of the Tribals, and
one of the long term objectives of Tribal Development is
improvement of the quality of life of the Tribal people. Thus,
human resource development becomes the most important aspect
for the conversion of the natural resource endowment into a ready
economic asset.
The overall health status of the tribal community is
the outcome of several interacting factors e.g. (a) effects of
environment in which the tribals inhabit, (b) behavioural
pattern and life styles of the tribals, (c) health care
delivery service (in tribals areas / constraints in accepting
modern health care), (d) heriditary and genetic determinants.
All these sub-systems make up the totality of the health
status of the tribals.
There is general agreement that the health status of
the tribal people in our country is very poor. Different stu
dies have tried to establish this with the help of morbidity and
mortality statistics. Though the exact estimates on vital indices
in tribal population of our country are not available/known, it
appears that the IMR and Ml-IR among these group of people is also
comparatively greater than the non-tribal population. The wide
spread}: poverty, illiteracy, malnutrition, hostile environment,
-2-
absence of sanitary living conditions, ignorance of the
causes of diseases, lack of health services or inability to
seek and use them have been traced out in several studies
as possible contributing factors for the deplorable health
conditions prevailing among the tribal groups.
Extention of existing health system is oeing made
during this plan period with the earnest hope that this will
improve the deplorable health conditions of the tribal
communities. The National Health Programme provides for greater
inputs in terms of man, material and facilities. For tribal
areas one primary Health Centre is open for every 30,000,
population. Similarly for every 3,000 population two multi
purpose health workers (one female and one male) are provided.
For the non-tribal areas these norms are 50,000 for Primary
Health Centre and 5,000 for two MPiVs. Inspite of these steps
and expansion of health facilities in tribal areas, the
situation is not improving much. The utilization of health
services is reported to be very poor. There is no significant
change in sc far as important indices of health like IMR,
MMR and incidence of communicable diseases are concerned.
It has become undoubtedly clear that the optimal level of
health among the tribal communities can not be achieved only
through simple linear expansion of the existing system of
|
health services.
Health problems and Health status of all Tribal groups
is not of the same type
and therefore any formula approach for
health care delivery is not only unsuitable but unthinkable.
Different tribal groups are characterised by their individual
socio-cultural, socii-biological and socio-economic attribute
and in a strict sense they are distinct biological isolates.
The health of these tribal population is as such a function
of the interaction between socio-cultural, and socio-bilogical
practices, the genetic attributes and the environmental conditions.
In order to understand the highly complex etiology of the health
statu: c
.
tjilals and to develop appropriate health care
strategies amidst variable conditions, it would be worthwhile
to have a proper understanding abouta tribal demographic; and
the regions of tribal concentration in the wider context of tribal
development.
- 3 Tribal Demography of Indja:
The tribal communities belong to different ethnolingual
groups, profess diverse faith and are at varied levels of socio
economic development. Spread along the entire spectrum-ranging
from hunters and gatherers of forest produce to the urbanised
skilled or industrial wage earners - the tribal communities
constitute very important segment of the Indian population.
The term (Tribe
*
is nowhere defined in the Constitution
and in fact, there is no satisfactory definition anywhere. No
standard term has been accepted to denominate the people who are
classified as of tribal origin. According to Article 3^2 of the
Constitution, the Scheduled Tribes are the tribes or tribal
communities which may be notified by the President. The Census
enumerates only such tribal communities as are scheduled under
the relevant constitutional order in force at the time of the
Census.
According to the 1981 Census, in India the Scheduled
Tribe population is 51,628, 638 comprising 26,038,535 nakes ahd
25,590,103 females constituting 7-76 per cent of the total
population. This figure of Scheduled Tribes excludes Assam
where the 1981 Census enumeration did not take place.
The
statement at Annexure-I shows the distribution of Scheduled
Tribe population in different States/UTs and their percentage
with respect to (a) total tribal population of India and
(b) total population of their respective States/UTs. It may be
noticed therefroln that the population of Scheduled Tribes varied
a good deal from one state to another. Their largest population
is found in Madhya Pradesh (11,987,031). The second largest
number of the tribals is enumerated in Orissa (5,915,067)
mined lately followed by Bihar (5,810,867) and Maharashtra
(5,772,038). But their largest proportion to total population
among all the states is found in Mizoram (93
55
*
per cent) followed
by Nagaland (83.99 per cent) and Meghalaya (80.58 per cent).
Among Union Territories, Lakshadweep (93.82) per cent) ranks
first. The tribals in the 1981 census were enumerated throughout
the country except in three States viz. Haryana, Jammu and
Kashmir and Punjab and three Union Territories viz. Chandigarh,
'Ll'
Delhi and Pondicherry, where no Scheduled Tribes have been
notified by the President of India.
Regions of Tribal Concentration:
The spatial distribution of the tribal communities,
is, however characterised by a striking tendency to cluster in
a few Pockets of diverse degree of isolation. Ecologically,
the tribal homelands are far from homogeneous and as such
display a diversity of a high order.
The areas of tribal concentration have been generally
described as the forest and hilly areas of the country. No
systematic classification of the tribal areas had been attempted
until the beginning of the Fifth Plan period when a new stra
tegy for tribal development was evolved and the areas of tribal
concentration were systematically identified and demarcated on 4
some objective criteria.
A clear picture of the areas of
tribal concentration in the national scene has emerged only
thereafter. Now the tribal areas of India can be broadly
divided into six regions viz.:
1)
Central Tribal Region:
a) South-Central Tribal Region
b)
North-Central Tribal Region
2i
Western Tribal Region
3.
4.
North-Eastern Tribal Region
North-Western Tribal Region
J.
Southern Tribal Pockets, and
6)
Oceanic Groups.
Each region has some distinguishing charactersties
of its own. They differ considerably amongst themselves in
terms of the geo-climatic conditions, resource potential and
demographic characterstics (vide Annexure - II & III).
1
-
-
Tribal Development:
In the recent years there has been increased emphasis
on tribal development. It is well known that the strategy for
integrated development led to the launching of the Tribal Sub
plan concept in the Fifth Plan period. Three basic parameters
of the tribal situation in the country were recognised in the
formulation of the concept. First, that there is variation in
the social, political, economic and cultural millieu among the
different scheduled tribe communities in the country. Second,
that their demographic distribution reveals their concentra
tion in parts of some States and dispersal in others. Further,
that the primitive tribal communities live in scheduled regions.
Hence, the broad approach to tribal development has to be
related to their level of development and pattern of distri
bution. In predominant tribal regions, area approach with
focus on development of tribal communities has been favoured,
while for primitive groups community oriented programmes have
been preferred.
This new strategy for tribal development can there
fore be broadly divided into four parts to cover the entire
tribal population of the country :-
(i)
States/Union Territories having majority
Scheduled Tribe population (more than JO
per cent) - Four States viz: Meghalaya,
Nagaland, Mizoram and Arunachal Pradesh,
and Two Union Territories: Dadra and Nagar
Havtli, Lakshadweep;
(ii)
Areas of tribal concentration;
(iii) Dispersed tribals; and
(iv)
Primitive tribals.
Areas of tribal concentral in the country, i.e. areas
where more than JO per cent of the population is tribal have
been identified and project approach has been adopted through
- O
the formulation of Integrated Tribal Development Projects
(I.T.D.Ps.).
On the whole 181 I.T.D.Ps. have been established
in 17 States and 2 Union Territories covering 27 districts
fully and 97 districts partly and 633 blocks fully and 280
blocks partly. These progrannies through I.T.D.Ps. are being
implemented to bridge the gap of socio-economic disparities
between the tribal and non-tribal people. Development of
human resources of the tribal communities has been identified
as a crucial element of such programmes.
It has also been
realised that improvement in the health and nutrition status
in the tribal grpups is fundamental to any programme of human
resources development in such communities.
Such programmes
for improving the health and nutrition status in tribal
communities require a multi-disciplinary understanding and
approach and need to take into consideration the cultural and
economic aspiration of tribal communities.
Health and Nutrition Programmes for Tribals:
The project (I.T.D.P./I.T.D.A.) reports are supposed
to subsume within it all aspects of development within the
project area. The essence of I.T.D.P. approach or Sub-plan
approach lies in the key-word "integration" - integration in
planning in execution through a single individual i.e., the
Project Administrator in financial arrangements at the State
and the I.T.D.P. levels. For primitive tribal groups special
Micro Proj ects are operating throughout the country. Therefore
any health/nutrition programme whether of adhoc or long term
nature, need to be fitted into the planning, implementations!
and financial frame work of the I.T.D.P. or the Micro Project.
Monitoring and evaluation should also cover health and
nutrition aspects.
Tribal Health Research:
Comprehensive research studies pertaining to health
and nutritional status among different tribal groups of India
are very few, very scanty and often completely lacking. Again,
one feels a®ixa£t«B that there is a lack of broad inter
disciplinary approach to study this problem.
Clearly the time fa
- 7has come to take a fresh look at the priority health
problems of the tribals, which have been neglected for a
long time and therefore, this vital problem of health, nutri
tion and genetics of the tribals can be investigated and
studied only by using a multi-disciplinary approach which
should necessarily be based on an integration of such
components as :(a)
Assessment of the health status
(b)
Study of dietary habit and assessment of
nutritional status.
(c)
Indepth study of genetic diseases and
disorders (including chromosomal anomalies
and haemoglobinopathics).
(d)
Demographic studies (specially mortality
and morbidity statistics).
(e)
Basic assessment of the environment.
(f)
Socio-economic assessment, and
(g)
Study of health, culture and health
related behaviours.
Recently the Indian Council of Medical Research (CMR)
has also initiated a number of projects to study systematically
various health problems of the tribal population and unique to
hilly areas. The health and nutrition problems of the vast
tribal population of India are as varied as the tribal groups
themselves who present a bewildering diversity and variety in
their race, language, culture and are at widely divergent stages
of socio-psychological orientation and economic, cultural and
educational development.
Because of these striking differences
in their levels of development, each group has a number of
problems of its own closely allied to its socio-economic situation,
eco-system, historical experience and patterns of political
articulation.
Thus the health, nutrition and medicogenetic
- s—
problems of most of the tribal groups are also unique and
present a formidable challenge for which appropriate solutions
have to be found by planning and evolving appropriate strate
gies which should be need based and problem solving in nature,
e.
i.
, identifying the problem, defining the factors causing
the problem and generating alternative solutions to the
problem.
Priority Areas in Tribal Health:
Recognising the inter-regional differences in the
tribal situation in the country add recognising the differences
in the problems of the tribal communities, it would seem that a
different kind of effort for health care delivery in each case
is called for. At the present juncture it mi;ht not be possible^
or desirable to study the health and nutrition problems of all
the tribal groups of the country. Therefore, in tribal health,
programmes for the primitive tribal communities deserve top
priority. Primitive groups require sensitive and delicate
>
handling, some of them are very small in size and often face
the problem of bare survival.
Therefore, in the case of primi
tive tribal communities indepth research studies on health,
nutrition and genetics have to be given priority.
The next item
in the priority list should be health services operational
research in tribal concentrated areas because transformation
of the already existing knowledge/research findings into
practice is woefully lacking. In the areas of tribal concentra
tion since the I.T.D.P. appears to be the smallest administra-
tive and operational unit at which the activities of different
sectors are co-ordinated, it is this unit, which we suggest
should be studied in the context of health services in order
to find functional gaps in respect of various health/medical
facilities in the I.T.D.P. area; and to achieve operational
efficiency in the health care delivery programmes.
£
*9The problem of Tribal Health is not only a complex problem
but is also profoundly human in nature,, The urban classes in our
country have been the fortunate receipient of uptodate and modern
medical care facilities during the past four decades, and the rural
masses, in general, have been coming in for some attention,. The Tribals
have been more or less on the periphery; the primitive Tribal groups
have suffered from a total umbra,, From the limited data we have, it
appears that due to their isolation, endogamous marriages,and higher
coefficient of inbreeding they represent a concentration of genetic
and other specific disorders such as Sickle-Cell Haemoglobin, Glucose6-Phosphate-Dehydrogenase(G-6-PD) deficiency etc. But the available
information on these aspects among the primitive tribals is very meagre.
This type of data is so erucially important that it may be the deciding
factor between their survival or extinction.Thus,there is a danger
that these groups might perish altogether,,If they do,we shall be x
answerable at the bar of history.lt is a challenge to the society,
it is a challenge to we one and all present here and we must respond
to with earnestness and vigour.
The magnitude and gravity of the health
problems of the tribals of India,compounded as they are by wide spread
poverty,illiteracy,ignorance and lack of health education,are daunting.
Nevertheless,much can be done to improve the health standard of the
tribal people if location-specific and need-based health planning is
done .Apart from Governmental bodies ,Voluntary Organisations can play
a notable part and can act as vital bridge-heads between tribal cibnimunities
and governmental agencies.We should also make use of the genuine social
organisations and leadership among the tribals.Finally,it will be really
worthwhile if this Workshop attempts to evolve some practical guidelines
in the fieldx of health care delivery for the tribals.
ANNEXURE-I
SIZE AND DISTRIBUTION OF SCHEDULE TRIBE POPULATION IN DIFFER® T
STATES / UNION TERRITORIES
State/ U.T.
Population
1.
Andhra Pradesh
3,176,001
2.
Bihar
3.
4.
Gujarat
Himachal Pradesh
Karnataka
5,810,867
>+,848,586
Percentage of tribal population
________ with respect to___________
Total Tribal
Total population
Population of of their respectiv
India
state
6.15
11.26
7.76
197,263
9.39
0.38
8.31
14.22
4.61
1,825,203
261,475
3.54
0.51
4.91
1.03
11,987,031
5,772,038
23.22
22.97
11.18
9. Manipur
10. Meghalaya
387,977
1,076,345
0.75
9.19
27.30
80.58
11. Nagaland
650,885
6.
7.
Kerala
Madhya Pradesh
8.
Maharashtra
12. Orissa
13- Rajasthan
14. Sikkim
1j. Tamil Nadu
16. Tripura
17- Uttar Pradesh
18. West Bengal
19- Andaman & Nicobar
Islands
20. Arunachal Pradesh
21. Dadra & Nagar Haveli
22. Goa, Daman & Diu
23. Lakshadweep
24. Mizoram
INDIA
2.09
1*
26
5,915,067
4,183,124
11.46
73,623
520,226
0.14
1.01
583,920
1.13
0.45
232,705
3,070,672
222,361
441,1 67
81,714
10,721
37,760
8.10
83-99
22.43
12.21
23.27
1.07
28.44
0.21
5-95
5.63
0.04
0.85
11.85
0.16
78.82
0.02
0.99
93.82
461,907
0.07
0.89
51,628,638
100.00
Source: Census of India, 1981, Primary Census Abstract,
Scheduled Tribes, Series 1. India, Part II-B(iii),
pp.xix-xxiii.
69.82
93.55
7-76
ANNEXURE-U
THE TRIBAL POPULATION IN TRIBAL CONCENTRATED REGIONS OF INDIA
Region
SI.
No.
Tribal
population
in States/
Union
Territories
Percent
Percent
with respect with res
to total
pect to
population
Tribal popu
of State/UT lation of
India
1. CENTRAL TRIBAL REGION:
1.
2.
3.
4.
5.
Madhya Pradesh
Orissa
Bihar
Andhra Pradesh
West Bengal
11,987,031
5,915,067
5,810,867
3,176,001
3,070,672
22.97
22.43
8.31
5.93
5.63
2g, 9.52a 638
13^
5,772,038
4,848,586
4,183,124
81,711+
10,721
14,89 6,183
9.19
14.22
12.21
78.82
0-99
22.09
1,076,31+5
441,167
650,885
387,977
1+61,907
583,920
73,623
3,675,821+
80.58
69.82
83.99
27.30
93-55
28.44
23.27
58.14
197,263
232,705
1+29,968
4.61
0.21
1,825,203
861,1+75
520,226
4.91
1.03
1.07
2-34
(5.155
11.85
93.82
(0.12)
(58.03)
2. WESTERN TRIBAL REGION;
6.
7•
8.
9.
10.
Maharashtra
Gujarat
Raj asthan
Dadra and Nagar Haveli
Goa, Daman and Diu
(28.85)
3. NORTH-EASTERN TRIBAL REGION:
11.
12.
13.
14.
15.
16.
17.
Meghalaya
Arunachal Pradesh
Nagaland
Manipur
Mizoram
Tripura
Sikkim
(7.12)
4. NORTH-WESTERN TRIBAL REGION:
18. Himachal Pradesh
19. Uttarpradesh
(0.83)
2.41
5. SOUTHERN TRIBAL POCKET:
20. Karnataka
21. Kerala
22. Tamil Nadu
2.606.904
6. ISLAND REGION:(Onaan10 Tribal Groups)
23. Andaman and Nicobar
22,361
2b-. Lakshadweep
37,760
All India Total :-
60,127
51,628, 638
52.83
100.00
ANNEXURE-III
REGIONS OF TRIBAL CONCENTRATION WITH SOME IMPORTANT CHARACTERISTICS
SI. Region
No.
(1)
(2)
1. Central Tribal
Region:
(a) South
Central
Components
States/UTs
(3)
Main Tribal
%age of Tribal
population with Communities
respect to total
Tribal popula
tion of India
(4)
(5)
Geo-climatic
& charactersties of the
Region
Maj or
Diseases
(7)
(6)
58.03
Andhra Pradesh, South
M.P., South Orissa
Gonds
(b) North
Central
Bihar, West Bengal,
North Orissa,
East M.P.
Santhal,
Oraon,
Munda,
Kolho
2. Western Tribal
Region
Rajsthan, Gujarat,
Maharashtra, Dadra
Nagar Haveli, Goa,
Daman and Diu
28.5?
Bhills,
Dhodla,
Gamit,
Warli
3. North Eastern
Tribal Region
Meghalaya, Arunachal
Pradesh, Nagaland, Manipur
Mizoram, Tripura, Sikkim,
Assam
7.02
Naga4.,Khasi, Highest rainfall .
Mizo, Miri, area
Tripuri
Shifting Cultiva
tion.
Extensive forests a
with low pressure a
of population,
a
T.B., Malaria,
Heavy soil erosion,a Lepsory, Polio,
Extensive shifting a Xaws, V.D./
cultivation.
q
Malnutrition.
0
High Population
a
Pressure,
a
Richest mineral
q
belt/Industrial
*
belt.
v
Arid/Semi arid
T.B., Skin
region(Rajasthan)
diseases,urinary
Heavy rainfall
stone diseases,
area (Western
diseases of dige'
Ghats of Maharastra) stive tract.
contd
T.B., V.D., Skin
diseases,
endemic Goitre.
•2
(1)
(2)
(3)
(M
(5)
(6)
(7)
4. North-Western
Tribal Region
Western U.P.,
Himachal Pradesh
0.83
Jaunsaries,
Laholies,
Kinnoras
Mountains and
High Altitude
Density of
population
very low.
V.D., Goitre,
Leprosy
5. Southern Tribal
Region
Karnatak, Kerala,
Tamil Nadu
5.15
Malayall,
Kurumba,
Soluga
Heavy rainfall
area and dense
forest.
V.D., Leprosy,
T.B., Malaria.
6. Island. Region
Andaman and Nicobar
and Lakshadweep
0.12
Onge, Great
Andamanese,
Sentendex,
Jarwas,
Nicobarese,
Shompen.
Equatorial climate
and rich vegeta
tion, Economy
based on Ford
gathering from
forest, hunting
and fishing.
V.D, Malaria
REGIONS OF
TRIBALCONCENTRATION !N
NAME OF SOME IMP.TRIBES OF THE REGIONS.
TAUNSARJS, LAHOL1S 3
KINNORAES.
I
NKGA,KHAGI,KAIZ.O
MlRUTRIPURL
bantalsho5
MONDA »ORAhi.
WHSLjGAtflT
WAR LI 5
DHODIA .
GOND 5 KONDH.
M AL AYALI s K U R U MB A 5
SOLUGA.
V
s
?
0
Gr-.ANDAMANESE}ONGES,
TARWAS s N ICO BAR ESE
SENTENLESE5SHOMPENS-
0
<)
C^TY) ft SA — 16
. REGION WISE PREVALENCE OF MAJOR DISEASES.
*
NDIA
WESTERN REG
T.R
nor.west. reg.
SKIN DISEASES
ENDMIC GOITRE,
LEPRO5Y,
ENDMIC GOITRE
V.D.
MALARIA
T.B
digestivetract
diseases
URINARY STONE
NOR.EA5T.REG.
DISEASES.
NOR.CENT. REG.
YAWS.
'Will
T.B ,
MALNUTRITION
MALARIA
SOUTHERN PEG,
SKIN UREASES
V-D.
SOU. CEN.RE6.
LEPROSY.
MALARIA ,
MALAR/A ,
LEPROSY,
T.B,
YAWS,
MALNUTRITION
ISLAND REG.
V.D
Malaga
//
/
.
Draft 05.0G.99
sanjiv kumar
Border Cluster Districts Project
Strategy Paper
I.
Background and justification:
The primary health care infrastructure has rapidly expanded since independence. The
population norms for the peripheral health institutions were revised to achieve these goals. The number
of subcentres and primary health centres ho 3 grown Io 136,339 and 22,010 respectively (as on
1.4.97)., The National Health Policy lays down lire goals to be achieved for achieving the 'Health For
All by 2000 A.D. India's commitment to lhe goals related Io maternal and child health have been
further reconfirmed when. India signed lhe 'Convention on Child Rights' and developed lhe 'National
Plan of Action' to achieve these goals.
. The RCH programme aims at making the health care system more .responsive to lhe
community needs. The Govt, has done away with the targets imposed from lhe top and lias asked (he
health workers to base lhe Family Planning work on lhe community needs. To make this approach
successful the community needs Io participate in health care more effectively. To facilitate Illis the
health workers need to be trained Io identify (he community needs and build effective partnership with
the other functionaries and lhe formal and informal influencers in (he community. The availability of
supplies needs io be reviewed and made more responsive to the local situation. The supervision needs
e to support the responsiveness of the system Io the community.
UNICEF has been supporting Government Of India in many programmes related to women
and children in lhe past. At present there is a need to accelerate lhe implementation of RCH
programme and bring a rapid decline in IMR and MMR so that we can achieve lhe goals related to
Maternal and child Health. GOI has requested UNICEF to work closely with the slate governments and
intensify the implementation of the RCH programme in selected border districts to bring down lhe IMR
and MMR by half in lhe next four years. The districts proposed to be covered in this project are from
lhe clusters of the districts al lhe border and are contiguous with lhe districts in (he neighbouring
states. These districts are far away from (he slate capital and have poor health performance indicators
hence need special attention. Being contiguous with adjoining stales ii also provides opportunity of
collaboration with lhe adjoining districts. This model may then be replicated in the other districts. The
clusters of border districts with lhe grouping of stales and lhe process to be followed in operationalizing;
Hie project has been given in GOI guidelines.
II. /
OBJECTIVES:
-T
Systems Objectives: the overall objective is to reduce the infant, child and maternal rilorla^ly
to half. r<= '
■
t
'
1'.
'
/
-To develop th? curative care capacity of lhe public health care system at the community level •
including referral of mothers and children.
,
*
5
1
2.
To improve present Icgisdcs system to assure availability of drugs and other supplies at the
community level.
Health Care Objectives :
--- ----- ---- - -- ---- - -•
1. To^sur£j[OOj^_Legis.tr.a.tLQQ_£: pregnancies
2. To increase immunization to 120% by reaching the unreached.
3. To reduce the number of childhood deaths due to diarrhoea, ARI, Malaria, malnutrition and vaccine
preventable diseases.
4. Jo reduce neonatal care in (he nstitutions and the community to reduce neonatal deaths.
5. Tojdentify the major causes of maternal mortality and work out strategies to reduce these.
6. Jo promote proper age at marriage, spacing between births and timely adoption of terminal
contraception
7. To improve.institutional deliver.es keeping in mind both the Govt, and private sector facilities
8. To improve functioning of FRUs including providing RTI/STI/AIDS related services.
Ilh.Areas.needing_special attention:
As the cluster border districts have special focus on reduction of IMR, MMR by half (he
following components of RCH reed special focus in these districts:
Newborn Caije: Neonatal modality accounts for about two third of infant deaths and this
propbrlioirhas been increasing as post neonatal mortality has shown faster decline.
Hence this period needs special attention to bring down IMR further. The strategies for
reducing NNMR have been developed with National Neonatology Forum. These need to
be adapted to suit the state needs.
Emergency .Obstretric. Care: Maternal mortality has not showirany appreciable decline
in India. Hence this is another area of special attention in the project.
IEC and Social Mobilization: The health of (lie people depends on their health care
taking behaviour at home and health care seeking behaviour. The decision to seek care
at an institution is taken by the individual and the family members, The timely utilization of
services depends on when they decide to go to these institutions. Tin's behaviour cai5
only be influenced through effective IEC activities. Social mobilization plays avery
important role in complementing IEC activities especially in areas where literacy is low
and reach of mass media poor. There is a need to identify and work with communication '
and health care providing partners in the community.
' £
Other areas needing special iccus in the districts need to be identified by the
legal authorities.
«'/
I
IV.
Components of the Strategy
The public health care system still remains the most important provider^ of preventive end
promotive health care and curative care to those who cannot afford to pay to the private set up. The
utilization of sen/ices from the public health care system can be improved upon if the services are
made more reliable by making the health worker available at the pre-decided and convenient limings
with regular supplies of drugs and other supplies, involvement of the community in the functioning of
the subcentre etc. The coverage by immunization sen/ices improved substantially in 'Universal
Immunization Programme' after the fixed day strategy was put into operation and the days were
decided by keeping the local needs in mind. The supplies and logistics system at present dees not
respond to the variation in demand for sen/ices at the subcentre level. The drugs, calculated based on
population norms..are supplied in kils which do not arrive al regular inten/als. Some of the drucs in the
kits get utilized fast whereas the others get piled up and expire. This system needs to be made more
responsive to the local demand. The subcenlres are the frontline of the primary health care svstems.'
The health worker ( female) is the most important frontline functionany in the deliveny of health care
sen/ices. She has the capacity to mobilize the influencers and the community to develop desirable
health behaviour. At present, however, the private sector provides curative health care for most
diseases in the community, both in rural and urban areas
.
The acceptance and prestige of Health Workers in the community will be' enhanced if they are
able to help the community by treating them for common illnesses. This will also improve' acceptance of
preventive and promotive care and the sun/eillance of diseases. The referral linkages between the
community and health worker and the PHC/FRUs and other referral institutions is another weak area
■which needs to be improved.
The following components may be included in the strategy :
1.
2.
3:
4.
5.
6.
1.
■
Community needs driven Subcentre service delivery.
Community based monitoring and management of Subcentre including financing.
Supportive monitoring and supervision including better mobility Strengthen
Drug supply and Logistics Strengthen Drug supply and Logistics
Improving referral services.
Capacity Development of health functionaries through training. •
Community needs driven Subcentre service delivery : The following major areas need
consideration in making health care system more responsive to the community needs
1.1.
1.1.1.
Providing Services at the sub-centre on fixed hours: The curative services should
be made available at the subcentre at predictable hours on certain days. The days
and the clinic hours should be decided based on the following:
' £
Number of villages covered by the subcentre: The subcentres which have only
one village to cover can practically run the clinic almost every day (except the day^ of
Block and sector level meetings). The subcentres with two villages may have the clinic
on alternate days. Similarly the subcenlres with three or more.yillag.^ may fix the
days of clinic. The days of the clinic should be fixed in a way that the outreach fixed
3
/
1.1.2.
day immunization services and other important oulreacfrsep/ices do not sffect.
Posting of Health Worker.fMale] or a second ANM: The.subcentres where HW(M) is
also posted, OT as in some districts under RCH where two ANMs are posted, the
clinic days can be alternated between the two workers. Where thpre is one worker,
the aim is to be available for two hours at least every other day.
The services in the identified area may be initially started in the sub-centers with smaller
number of villages, sub-centers with two workers etc. and then expanded to the other areas in a
phased manner. •
The health worker and AWW play a complimentary role and it is necessary that they work as a
team.
Building Health and Nutrition Team:
I
•
The health worker has many allies like Anganwadi workers (AWW), Members of Mahila
Swasthya Sangh, Panchas, schcc. teachers, TBAs in lhe community especially in mobilizing the
community for desirable behavioral change. AWWs are present in almost every village of the subcentre
and have many complementary responsibilities. Anganwadi centres can be used effectively as the
extensions of subcr-iitre into every village. The close coordination of health and ICDS workers can lead
to a true impact on reduction of health and nutrition problems.
This has been discussed in another approach paper.
. .1.3.
Mapping Health Care ser/ices and Utilization: The following components of health-care •
„
services and (heir utilization in lhe area covered by an institution will help in better
understanding and planning of health care sen/ices:1.3.1. Mapping distribution of population in the area: The distribution of population in villages ,
helmets, caste and group specific pockets should be plotted. The other important land marks,
roads, government institutions should also be plotted on the map.
1.3.2. Mapping Health institutions: This should include all the health are providers and institutions
in both Government and ncn-government sector in lhe area. This may be done at lhe
sector/PHC meeting.
1.3.3. Human Resource Mapping: The formal and informal health care providers and
. communicators need to be plotted to identify all the possible channels of health care and
communication related to health. It will include Private Practitioners, TBAs, AWWs/Health;
workers male and female etc.
’
1 .bi A. Treatment and cost profile: The treatment seeking.behaviour of lhe local community is very
'
~t
important to know. This can be done by interviews of individuals in the community, clients '
coming to the system, obsecration, prescribing practices and locally available drugs. Similarly,it
is important to get lhe cost profile of the health care in the area which should include lhe tjfct
of services, supplies, transportation to get services/supplies and opportunity cost.
•
1.3.1, 1.3.2 and 1.3.3 above may be done by doing Focus Group. Discussions in
* the
community, interview with formal and informal leaders or using lhe participatory’lea'rning for action ■
4
■ techniques elc. The information we gel from all the above areas will help us in finding some possible
activities to move further in response to in the following questions:
•
•
•
•
How do we extend ser/ices to the sections of the community where system dees not reach at
present?
How do we change the health seeking behaviour of the community?
How to enhance the competitive edgeof the Health worker?
How do we enhance the Healtn Workers ability to provide curative ser/ices?
1.4.
Community Convenience: The days of clinic should be decided in consultation with the
formal and informal leaders of the local village.
2.
i Community based monitoring and management of Subcentre including financing.
The community should be able to recognize the strengths and weaknesses of the service
delivery al the subcentre. Il will be important to define how the community can help and respond to
these in overcoming some of the difficulties the Health Workers face in providing these services. The
details of this can be worked out at the district level planning workshop in which health and all related
sectors should participate and finalized after the community needs assessment exercises..
This can be operationalized through a community subcentre advisory board. This board may
be created by expanding the existing mechanisms like Mahila Swasthya Sangh, 'Mahila Mandate,
Panchayal elc. The board should include lhe members of Panchayal, NGOs, if any, formal and
. .informal influencers elc. from each cf the village served by the sub-center.
This board should be empowered to review:
2.1.
2.2.
2.3.
2.4.
2.5.
/
'
2.6.
■ 1
Scivices utilization al the sub-center and what can be done to improve lhe situation.
Referral of cases, especially for emergency.care. The utilization.of funds, which have been
placed at Panchayal level under RCH programme for use in transportation of cases for
emergency referral, should be reviewed by them.
Availability of commonly required medicines and mechanism of procurement/purchase of
medicines from lhe funds generated at the local level should also be worked out by this board.
Maintenance of sub-center building including stay arrangements for the Health workers
should be looked after by lhe board. The board should also decide on if they need any
repair/additional construction in lhe subcentre building and the accommodation of the ANM.
1
Identification and decide the services, if any, for which the community should pay for and
which families in the village from (he deprived or the underprivileged groups in the village
should be exempt from payment of such charges. The mechanism of handling the fund by lhe advisor/board should also be agreed upon and reviewed regularly.
■x' ?
Review Meetings: The community board should meet every month or more frequently
if*
required and review the functioning of lhe subcentre. They should specifically look at‘the
following questions during review meetings:
. ,
•
How do we extend services to Hie sections of the community where system does’not
reach at present?
*’
5
•
•
•
•
•
How do we change ihe health seeking behaviour of the community?
How to enhance (he competitive edge of the Health worker?
How do we help the Health Worker to provide services?
'
How do we improve the physical condition of the health centre? .
How do we facilitate the working together of health care providers? etc.
Supportive Monitoring and supervision including better mobility:
It is very important that Ihe supervisors provide proper support and guidance to the field level
functionaries. At present this is one of Ihe weakest links in the health care delivery system in the
government system. One of Ihe reasons is that the role of supervisors is not clearly spelled out.. Hence
there is a need to clearly spell out Ihe role of supervisors both as supporters for the Health Worker in
providing services to the community and on the job trainers for the workers. A check list should be
prepared for use by the supervisors which'should be reviewed by the next level of supervisors. The
supervisor will need better mobility to carry out this role.
The role of AMM in supervising and supporting TBAs, AWWs and other influencers in the
community has net been adequately recognized. She needs to realize the importance of working with
these service providers as a team and take a leadership role. Her skills in this area need to be
enhanced. The functioning of iCDS/Health can be coordinated better through joint trainings of AMM
and AWW, LHV and LS and similarly for higher level officials and strengthening the existing
mechanisms of joint field visits and meetings.
. .4.
‘
Strengthen Drug supply and Logistics:
Supply of drugs and other supplies at present is irregular and erratic. One of the major
reasons for the community turning to private practitioners is that hardly any drugs are available for the
treatment of common sicknesses with the health worker. There is a need Io review the list of drugs ’.
available at Ihe subcentre and to include some more essential drugs Io treat common sicknesses at
this level. A series of focus group discussions may be organized with the community to identify the
common sicknesses they expect to be treated at subcentre level..
The essential drugs need to be identified and included in the regular supply to the subcentres
and all referral institutions. The supplies provided by Central and state level need to be coordinated . A
mechanism for community financing of additional supplies needs to be put in place.
5.
Improve Referral Services:
At present, referral of cases needing emergency care, gets delayed due Io various reasons.
Thj£ leads to the cases reaching referral institutions too late to be saved. This further erodes Ihe
credibility cf referral institutions. Community needs to be aware of:
7~T
5.1.
■ ■
5.2.
/
/
When and where to refer : There is a need for Ihe community to identify the conditions
j
needing institutional care and which institution is appropriate for which conditions. All ‘the
TEAs, AWWs, RMFs, formal, informal leaders and members of MSS/Communily advisory .
board should be aware of when and where to refer.
,
""
Transportation: Availability of transport for taking the emergency cases deeds to be worked
6
out in advance. The available modes of transport for reaching referral institutions need to be
discussed at the community level. However studies have shown'that the major delays take
place in arriving at a decision to transport rather than during transportation. Iff transport is
readily available and community is aware of the details in advance, this delay also can be
reduced.
;
6.
Capacity Buiic.’.'ig' through Training: The functionaries in the project will need to be trained
in improving quality of services, assessing community needs , improving communication skills
and building par-.ership with others in their area of work. The supervisors will need training in
improving supervisory and managerial capacity. Team trainings with related functionaries like
AWW and TBAs will also need to provided.
V.
Geographical Areas to be covered in the Project:
The proposed districts have been identified in consultation with GOI, Slate Govt and UNICEF..
VI.
Monitoring and Evaluation :
The OR project cn sub-center strategy should be properly monitored and evaluated. The
project should include:
1
1.1
1.2.
1.3.
Evaluation: This will include:
Baseline information: This should include curative care provided at Hie subcenlres,
community-based information collected cn morbidity and mortality of common and notifiable
diseases, immunization coverage, antenatal coverage, prevalence of malnutrition in children,
cases referred, availability of common drugs and other supplies etc. at the subcentres. An
effort needs to be made to get as much of the above information routinely lor concurrent
monitoring and evaluation. This will enable the project managers to take appropriate and timely
action in addition tc using it as baseline for periodic evaluations.
Mid-term evaluation: Midterm evaluation is important for evaluating the progress of the
project at a mid pcmt and deciding on changes if any required to be carried out in the project
and see the trend cf progress.
Terminal evaluation: Every project should be evaluated to get an objective assessment of the
project which will facilitate the decision on the expansion,'replication of the project.
Both mid-term and terminal evaluation will use the baseline information and compare the
change in the indicators due the interventions in the project area. This should preferably be)
carried out by an external agency.
2. /
Monitoring: The indicators for monitoring must be identified in the beginning of the project.
i•
The monitoring should include:
2Jt
Monitoring of identified-indicators through routine reporting, at block/district levelyoutine
meetings and look at performance indicators, training progress and community precesses. (
2.2.
Progress on Finance Related areas: This should cover activities related to Government $nd
,
community financing included in the plan.
2.3.
Utilization of Services: The utilization of services by numbers, illnesses, drucj stalus’/ahd
village/hamlet/pockeL'caste/group-wise etc should be done.
2.4.
Field Visits ; The checklist /notes prepared during field visits should also be used for
7
2.5.
VII.
monitoring purpose and made more meaningful for on the spot correction and subsequent
discussion.
i
Monitoring by the Community: The role of the community in monitoring of the services is
very important as the whole project depends on the community ownership. The indicators to be
monitored by the community may cover running of sub-center clinics, availability of supplies
and services and the action taken to improve the situation.
Activities and timeline:
Tire limeline lor activities will vary from state to state. However, the broad activities are listed
below
''
1.
2.
3.
4.
5.
6.
7.
3.
9.
10.
11.
12
13
Finalize districts with state/district level officials
Identify consultant
Orientation of the consultant
Development of draft district Flans
Orientation meetings
Collection of baseline information
Project operationalization
Monitoring
Mid-term evaluation
Incorporate changes into project
Terminal evaluation
Expansion of project area
Taking it to scale in the state
These are only the suggested areas in the district plan flower areas based on the local need and the
areas missed out in this paper need to be added.
J 2 ? 'W
Draft Note for Karnataka Task Force on Health final report
By
Dr. Thelma Narayan
8th January, 2001
Public Health and Primary Health Care : Understanding
the Synergy
As the mandate of the Karnataka Task Force on Health and Family Welfare is to improve
Public Health and Primary Health Care, these concepts, as they have evolved, have been
outlined briefly
1. Defining Public Health
Public health is an evolving discipline through which major health gains for
populations have been made in several countries of the world, since the early 19lh
century i.e., before development of antibiotics and vaccines.
It has been defined by
the International Association of Epidemiologists as follows :
"Public health is one of the efforts organized by society to protect, promote and restore
people's health. It is the combination of services, skills and beliefs that are directed to
the maintenance and improvement of the health of all people through collective or
social actions.
The programs, services and institutions involved emphasize the
prevention of disease and the health needs of the population as a whole. Public health
activities change with changing technology and social values, but the goals remain the
same : to reduce the amount of disease, premature death and disease produced
discomfort and disability in the population” (JM Last 1983).
2. State responsibility for health and health care
One of the key principles of public health, that the State is responsible for the health of
its people, was conceived by health philosopher Johanna Peter Frank (1745-1821)
leading to the Public Health Act of 1848. The importance of this social principle
remains and has been reiterated by several bodies such as the World Health Assembly
(WHA), WHO (1977), WHO and UNICEF (1978) and more recently by the Peoples
Health Assembly (PHA) in 2000. The role of the state remains critical, in present
times and for the future, particularly to protect and promote the health of the poor and
vulnerable sections of society in the current context of neoliberal privatization. Public
health has an abiding concern for the health and social conditions of the poor and with
the structural roots underlying poverty.
The political dimensions of health were
recognised by Rudolf Virchow over 150 years ago. The global primary health care
movement is attempting to overcome inequalities in health. The role of the State is
critical in bringing about this shift.
3.
Addressing determinants of health
Diseases like cholera and typhoid earlier widely prevalent in Europe and the USA,
were controlled by public health systems that ensured a mandated supply of clean, safe
or potable water, functioning sewage systems, garbage and refuse disposal Karnataka
has initiated measures for water supply and sanitation through different projects.
namely the Dutch assisted project, DANI DA, UNICEF and the World Bank assisted
Karnataka Integrated Rural Water Supply and Environmental Sanitation Projects.
However the need and demands of the public in this regard are yet to be fully met.
Water and sanitation related diseases still take a heavy toll in terms of sickness
(morbidity) (see section on communicable diseases) and person days of work lost. The
role of the DHFW will be in setting standards for water quality, use of chlorination /
other methods of water purification, monitoring through regular water quality testing
at local, taluk and district levels, and initiating quick containment measures following
any disease outbreak.
Related measures include intersectional collaboration at
different levels; health promotion with children, 8f women; and special training of
panchayatraj members as water and sanitation, fall specifically under their purview,
under the 73rd and 74lh Constitutional Amendments. The specific responsibility and
accountability of the male junior health assistant needs to be clarified. They also need
supervision in this regard. Provision of safe Water supply and sanitation form the
very' basic, first generation, public health interventions.
An early development in preventive medicine, closely linked to public health, started
in the 18th century relates to nutrition, another basic determinant of health. Use of
fresh fruits and vegetables was recommended in 1753 for the prevention of scurvy
amona sailors even before the causative agent was known. There has been tremendous
growth and development in the science of the nutrition since then. Our own ancient
PjfO e Task Force - T>T Public Health & Primary Health Care - 8th January.doc0l/08/019:06 PM
2
Indian systems evolved food, diets and methods of cooking that provided a balanced
diet in different seasons and suited to various physiological conditions. Despite rich
traditional and modern knowledge bases, recent date from the NFHS2 and NNMB
regarding nutritional status reveals widespread under nutrition particularly in young
children and among women in Karnataka. Nutrition has also been found to have been
very neglected by the DHFW.
Malnutrition in Karnataka is a major public health
issue and is being accorded the highest priority as an area for intervention by the task
force on Health & FW. It is therefore being covered in a separate chapter (Chapter
No. -) Deeper underlying issues of food and nutrition security are linked to irrigation,
agriculture and seed policies; in income and purchasing capacity; and in access to
public distribution systems.
4. 4. The second generation of public health evolved with the discovery of bacteria and
the growth of microbiology Development of diagnostics, therapeutics, vaccines, and
an understanding of disease transmission patterns made it feasible to initiate control
programmes for communicable diseases.
The current disease burden due to
communicable or infectious diseases in Karnataka has been outlined in a later section
(
) as it still comprises-a major portion of morbidity and mortality. Cost effective
public health interventions exist for most infection'diseases. For newer emergency
diseases such as HIV/AIDS, research is taking place at a fairly rapid pace.
The method of transmission of communicable diseases determines the choice of the
method of disease control to be used. Diseases with similar modes of transmission are
grouped or classified together e.g., Water borne diseases, faeco-oral diseases, soil
mediated infections, food borne diseases, respiratory infections that are air borne,
insect or vector borne diseases, diseases transmitted via body fluids, ectoparasite
zoonoses, domestic zoonoses etc.
Only important diseases that require priority
attention and intervention are covered in this report.
The faeco-oral group of diseases includes amoebiasis, giardia, gastro-entertis, bacillary
dysentery, cholera, typhoid,
hepatitis A & E, and poliomyelitis.
Breaking the
faecal-oral chain is the basis of control, namely by personal hygiene, increase in water
quantity, improvement in water quality, food hygiene and provision of sanitation.
P450 e Task Force - THFublic Health & Primary Health Care - 8th January.doc01/08/019:06 PM
3
Priority is given for control of infectious disease based on criteria such as magnitude
of problem severity and availability of effective, safe interventions. The task force
expresses deep concern that tuberculosis which was identified in 1947-48 as India's
foremost public health problem, continues to be so in Karnataka, despite having a well
dsn Pre
researched and designed control programme and/the availability of cost effective days
for treatment.
The NTP has not received adequate attention or resources from
politicians, decision makers, administrators and the DHFW.
Thus it has been
neglected and poorly implemented. In the RNTCP, Karnataka is the second poorest
performing State in the country.
The early successes of the National Malaria Control programme have not been
sustained. The increased number of cases and outbreaks in different parts of the state
are of concern. Malaria was controlled in Mysore State in the pre-DDT era, through
public health interventions including public health engineering.
Other vector borne
diseases also have a family high incidence and prevalence in certain regions e.g.
Filaria, dengue fever, Japanese encephalitis, etc.
Specific technical dimensions for
each disease are given later.
5. However there are certain health system prerequisites and primary health care
principles that need to be met, in order to achieve good communicable disease control.
The strategy of improving the functioning of general health services especially at PHC
and CHC level is important in providing diagnostic and treatment facilities as close to
the houses of people as possible. Diseases control interventions need to be integrated
into the functioning of the general health services as part of a comprehensive primary
health care service. This horizontal integration at primary care level is to be supported
by more specialized referral and support services at taluk/district and state level,
through a referral system. The primary health care service needs to be credible so as to
win the confidence of people. Only then will people utilize it to meet their basic health
care needs and for what government may consider priority health programmes, be they
communicable disease control or family welfare.
These basic tenets of a good community health care service have been found lacking in
our sub-centres, PHC’s and CHC’s.
The Interim Report of the Task Force
?J:'i e Task Force - TH Public Health & Primary Health Care - Sth January.docOI/O&tOl 9:06 PM
recommended 24 hour sendees at PHC’s with filling up of gaps in infrastructure
including residential quarters, water supply, electricity, vacancy positions for different
grades of personnel, supply lines for drugs and laboratory equipment/stains,
communication systems etc.
These are prerequisites for a good service and for
infectious disease control.
6. The Primary’ Health Care (PHC) approach, as a strategy to attain the international
social goal of Health for All by 2000, was articulated and accepted at a WHOUN1CEF conference in .Alma-Ata in 1978.
Recognising the limitations of medical
science alone in improving the health of people, it emphasized the need to address
determinants
of health
through
inter-sectoral
collaboration,
especially
with
departments of agriculture, water supply, sanitation, housing and education.
It
emphasis the need for equity and social justice in health, and health care
It
recommended shifting control over health care systems, with greater decentralization
and involvement of local people and communities in decision making and planning
health care systems, to suit their own social, economic ft-cultural conditions. It utilized
scientific methods of proven effective, safe, acceptable and affordable treatments and
interventions in the preventive, promotive, curative and rehabilitative areas, but also
encouraged indigenous and traditional systems of medicine.
It had a social goal of
improved health and quality of life; access to health care by all; maximum health
benefits to the greatest number; increased self-reliance of individual persons and
communities, and the promotion of social means of reaching these goals. Thus public
health went through another paradigm shift. Experience and thinking from India along
with those from other countries, helped in making this shift.
7. The following excerpts from the original documents are given for a clear
understanding of concepts. These are being given in some detail as they form a core
element of the task force recommendations.
“Primary Health care is essential health care made universally accessible to individuals
and families in the community by means acceptable to them, through their full
participation and at a cost that the community and country can afford. It forms an
integral part of the countries health system of which it is the nucleus and of the overall
social and economic development of the community” (WHO-UNICEF, 1978).
P4c0 e Task Force - TNPublic Health & pr^iary Health Care - 8th January.docrjl fi8 f)!7
t
5
"It means much more than the mere extension of basic health services. It has social
and developmental dimensions, and if properly applied will influence the way in which
the rest of the health system functions” (ibid).
“It is the first level of contact of individuals, the family and the community with the
national health system bringing health care as close as possible to where people live
and work, and constitute the first element of a continuing health care process {ibid)
8.
The four key underlying principles of primary health care are
Equity through equitable distribution of health resources.
a.
b. Community participation and involvement.
IntersectBsrra! Co-ordination between health and development.
c.
d. Use of appropriate technology for health.
The eight components of primary health care comprising the core technical package
are .
a.
Education concerning prevailing health problems and about methods of
identifying preventing and controlling them.
b.
Promotion of food supply and proper nutrition.
c.
Adequate safe water supply and basic sanitation.
d.
Mother and child health services including family planning.
e.
Immunization against major infection diseases
f.
Prevention and control of locally endemic diseases
g.
Appropriate treatment of common diseases and injuries
h.
Provision of essential drugs.
9. India was a significant contributor and signatory to the WHA, 1977 and the Alma Ata
Declaration of 1978.
The concept of comprehensive health care had already been
articulated in India through the Bhore Committee Report, in 1946, a document which
formed the early basis for India’s health planning. Primary health centres had been
initiated since 1952. The National TB programme, 1962, had the seeds of the primary
health care approach. The Shrivastava Committee report 1974, made links between
education and training of socially oriented doctors, all grades of health personnel and
community health needs. A national scheme for Village Health workers was launched
PJ:0 e Task Force - T.V Public Health & Primary Health Care - Sth January.docOl/O&'Ol 9:06 PM
6
in 1977. Post Alma Ata, in 1981. The Indian Council for Social Science Research and
the Indian Council for Medical Research brought out a publication Health for All in
1981.
The National Health Policy based on principles of primary health care was
tabled in 1982 and passed by Parliament in 1983.
It is still the operating policy
statement as of now. State governments including Karnataka accepted the HFA goals
and PHC strategies. The Ninth Plan document of the Government of India committed
itself to the goal of "Health for all, particularly for the underprivileged".
10. However some of the statements and commitments appear to be rhetorical. Analysis
reveals declining state expenditures on nutrition and lack of responsibility and
accountability for nutrition by the DHFW.
Intersectoral work to ensure potability of
water and provision of sanitation facilities is ongoing since the early 1990s, but
coverage is incomplete.
related diseases
Data reveals the continuing preventable burden of water
State health expenditure is stagnant and below norms.
A large
proportion of primary health centres continue to function sub-optimally. Coverage and
quality of basic antenatal care and immunisation continues to be low in Category C
districts. Diseases like TB continue to take a heavy toll with government health
services providing complete treatment or cure to only S-16% of expected sputum
positive pulmonary TB patients. School health services are of poor quality and have
limited coverage. Community mental health care programmes at district level have not
been taken up seriously, though the epidemiological burden has been well
documented. The essential drugs concept is not practised in spirit. Health education
and promotion receive little interest and is too focussed on Family Welfare. For these
and other reasons the Task Force has concluded that public health and primary health
care have been neglected and distorted.
P450'e Task Force - TH Public Health & Primary Health Cc-e - 8th January.doc0l/08.019:06 PM
7
5. IMPROVING- SERVICE QUALITY, ACCESS AND
EFFECTIVENESS IN PRIMARY HEALTH CARE SYSTEM
5.
1 Rsn&vating primary health. centres
There are 1685 Primary health centres (PHCs), including 9 urban PHCs. Of these, 1,000
which have buildings, are relatively better located and have greater access, have been
identified by the State government for renovation and equipping according t0 nonns.
While identifying them, priority has beat given to the seven backward category C
districts. It is estimated that these 1000 are in a position to cater to the needs ofover 70%
of the people residing in rural areas. It Is also proposed to map all PHCs, by the
population they serve and by road connectivity etc. through a Geographic Infonnation
System (GIS). This will give more precise estirrations of the population and geographic
coverage of different PHCs. A detailed Facility Survey has been carried out to identify
infrastructural gaps in each of the identified PHCs. The survey shows tliat most require
physical renovations and iirprovenwits. Lack of continuous water supply is a major
problem in many. Similarly, most PHCs are linked to the ratal feeder grid for their power
stppfy. As a result power stpply is uncertain, irregular, and has high voltage
fluctuations. In the older PHCs internal water supply and electricity lines also require
major repairs. The buildings require refurbishing — cracks have appeared on walls, roofs
leak, OTs and labour rooms have in many places become non-functional Many PHCs
liave no compound walls, as a result the boundary has not been demarcated, and the
physical surroundings do not appear inviting A conplete renovation of 1,000 PHCs will
be taken up under the project.
Annual rraintenance of buildings will need to be takat up tliroughout the project period.
Due. to the large number ofbuildings involved, minor repairs and maintenance work will
be taken
onceduring the project period,
5.1.1
Construction of PHC buildings
Tire department has carried out a study' to find out tire PHCs wiiich require their own
buildings. Of the 1685 PHCs, 509 have no buildings. Of these j 00 PHC buildings will
be taken up for consideration with this project. Only such PHCs wiiich serve large
population, and possess sites wiiich are easily' accessible and are on the roadside will be
selected. The existing PHC design will be reviewed to make the building design easily
accessible by the handicapped and the elderly. The area will also be reduced to keep the
costs down 50 ofthese buildings taken up will be in the backward districts of the state.
5.1.2 Equipping primary health centres
Besides repairs, the 1000 PHCs, require gaps in furniture, equipment, linen required
and consumables to be filled. A committee has identified essential equipment and
fimiiture for a PHC. Based on this, for each PHC tine gap will be identified and
procircmcnt taken up. Additionally, consumables required will be sqipliod on an annual
basis.
5.2 Family welfare services
11
Population stabilization through fertility decline has long been a goal of the national
family welfare programme Tliis fully centrally sponsored programme has been
accorded a predominant place in the services provided by lite Department of Health Sc
Family Welfare. The IPP I, LU, VIII and IX projects have provided sipport to
infrastructural growth, service delivery, training of health personnel, to EC and to
development of the I IMIS systems in the State,
Data from Karnataka indicates steady declines in birth and death rates. Declines in
growth rates occurred, particularly after 1981, when tire demographic inertia was said to
have been broken. 1 he momentum of the decline is likely to continue even without any
specific additional inputs. Tn several parts of the State there is a demand for services
which need to be met. The context and scope of IEC thus needs to be flexible and
responsive to changed situations.
The Total Fertility Rate (1FK) is 2.13 and lire effective Couple Protection Rate (CSFR)
60ka This the state is very near to reaching replacement levels of fertility. District wise
data (Rayappa 1998) indicates substantial declines in growth rates in 1981-91 in all
districts except the Gulbarga division. Even here declines occurred in Bellary district. It
is likely that this region is following a slightly later cycle and the peak in growth rates
may have just been passed. Gwen the relationship between fertility decline and
demographic transition with the Gender Related Health Index (GHI), Human
Development Index (HDI), and Reproductive Health Index (RHI) (ibid), and the low
level of these indicators in the districts of Gulbarga Division (GOK-HDR 1999). it has
been suggested by analysts that improvement in human social development, quality oflife
and gender development will hasten the process of demographic transition. This will be
an important component of the state strategy. Bangalore district had a peak in growth
rate 1971-81, attributed to a large extent to immigrat ion and inter-state migration
Keeping in mind the specificities of Karnataka and the National Population Policy 2000
guidelines, areas that will be. addressed during tliis project phase in regard to Family
Welfare and Rqiroductive and Child Health Services are,
■>
hiproving the detenninants of good health, viz., sanitation, water supply, nutrition
and literacy. Specific attention will be paid to girls and women.
o
Improving access to primary health care, by strengthening services through PHCs
and subcentres. Develop an integrated approach to health, nutrition, family welfare
and social development through convergence of services at village level
•
Placing two doctors in a PUS in Gulbarga division, with preferably one lady medical
officer.
•
Focussing attention on quality of contraceptive services with,
a
Careful choice of reproductive technology, that is safe and effective
b.
Maintaining good quality care including screening and follow up senice
c. Monitoring of side effects of contraceptives used tinough good recording
systems and undertalcing studies. A concern for instance is the very young age at
which tubectomies are done, and the resultant early menopause synptons and
sterilization regret,
d. Increas ing use ofmale methods.
e
Increasing use ofspacing methods, including condom promotion.
12
/.
°
Making efforts through education and awareness campaign to delay age ofmarriage.
no earlier titan 18 years and preferably after 20 years. Delay in age of first
pregnancy.
•
Registration of marriages, births and deaths at village'' community level Pilot
testing of 100%births, dentils and marriage registration in one district will be carried
out
®
Adequate training offield staff in Community Needs Assessments (CNA) so as to
make the Target Free Approach (TFA) a reality. Using adult learner centered,
problem solving approach to training
°
Training ofat least two dais (birth attendants) per village, witli provision of dai kits.
o
Over the last five years, the health department lias established cold chain
infrastructure all over rural Karnataka To ensure optimal vaccine quality’ and to
ensure universal immunization there is a need to cover some gaps in maintenance
o
Providing for adequate diagnosis and treatment of Reproductive Tract infections and
Sexually Transmitted Diseases at PHC level. This will require provision of
*
•
Enphasis on informed choice.
microscopes, stains, training of lab. technicians, dng supply and health education
I
o
Encouraging value based life skill and family life education of adolescent girls and
buys through uieDqiariment of Education and involvement ofNGOs.
1
o
Woman s empowerment training programmes focused on health and nutrition
®
Suppon to promotion of Child Health and Nutrition and reduction of infant and
under five cliikl mortality' rates.
o
Lowered maternal mortality by anemia prevention, complete coverage witli good
antenatal and postnatal care, maternity service including increased access to referral
emergency obstetrics care at CHJ and sub-district level
o
Decreasing the need for illegal abortions by provision of good contraceptive
'♦
sendees, counseling services and access to safe abortions when necessary. Provide
training and equipment for MIP.
o
Increasing the role of panchayati raj institutions in planning and implemetitation
through devolution of finances and administrative power and increasing their
knowledge base through training programmes.
®
The setting up of a State Commission for Population and Social Development.
•
There is an unmet need in acceptance of family planning methods (12% for spacing
anti 6? 6 for sterilization). Hence skill based training for health staff particularly' in
IUD insertion needs to be carried out
o
Urban mritnizaiion programmes will be planned in cities and towns to immunize
all children less than 5 years. Involvement of private practitioners by contracting out
immunization services will also be explored.
»
Training in MTP technique for MO'S ofPHSs and provision of necessary equipment
will also be carried out.
•
Perinatal care centres at identified health institutions will be set up to strengthen
perinatal care of the newborn.
13
I
5.3 Improving health of SC/ST
}
The Yellow Card initiative for health check ip of SC/ST lias received a vary good
response, aid ntuiy SC/STfamilies have benefited aider the scheme. However, there is
need to appraise the programme and both deepen and strengthen the interventions. There
is particularly need to inprove the follow up ancl referral systan under the programme,
by provisioning 01 transport for seriously ill patients, enliaticed drug supply, and conduct
of repeat followups to ensure early detection of diseases and unproved cure rates. An
improved nr>nitoring system also requires to be put into place. The emphasis should
also sliift more directly to SC/ST women Hie goal is to provide the SC/ST population.
along with others, to good quality' care at all levels of the health system
6. IMPROVING HEALTH AND NUTRITION STATUS OF
CHILDREN
6.1 Nutrition goals
The nutrition goals under the Project will be to improve the quality of existing nutrition
related services, enhance their coverage and effectiveness especially for under-two’s,
ensure better access to the underprivileged, emphasise care related aspects of nutrition
and accord greater priority' for nutrition so as to prevent and reduce malnutrition and iron
deficiency anania; and achieve virtual elimination ofVitamin-A and iodine deficiency
over the project period. A related goal will be to ameliorate die gender different ials in
growth and in 1-4 year old child mortality. Improvements in nutritional status will
inevitably result in better infant and clrild survival
6.2 Focus on prevention
The focus will be on luidet-lwo cliildren in the backward seven category C districts.
Presently only’ about 50% of the targeted under-two beneficiaries get. stpplemenlary
food. Apart from this, these vulnerable children get. little attention from the ICDS.
These are die most rcspoibive group to health education interventions. The project
approach is to reduce the numbers that become malnourished by lessening the extent and
likelihood of growth deprivations. Thus the lessening of growth faltering in the rapid ly
growing two years by growth promotion will ensure that we are able to avert to some
extent moderate and virtually' eliminate severe malnutrition.
Community based
rehabilitation of severe malnutrition is not only' expensive in time but requires a
tremendous degree ofpatience and faith on thepart of mothers and families. Even when
seriously malnourished children are successfully rehabilitated, the functional
consequences of malnutrition in tenrs of impaired cognition and reduction of adult work
cqpacity have major human and economic inplications for society.
6.3 Specific objectives and strategies
a. Strengthening ICDS
Giving nutrition greaterpriority
Improving quality ofweighing data and Monitoring Information System
1-1
Periodic deworming
Mobility supportfor ICDS Staff
Health check ups in the Anganwadis
Gender sensitization
Raising measles immunization coverage
In tersectoral coordin arion
b. Weaning food interventions
These are described under sections on reduction in regional disparities and in the section
on nutrition education and promotion.
c. improving the status ofurban slum children
Present!}' there are only 10 ICDS Projects in urban areas. A special initiative will be
launched in slums not covered by the ICDS Projects. Errphasis will be trade to cover
newly sprung ip urban slum colonies. Wherever credible NGOs are present, working
with the urban poor, their cooperation will be sought.
d. enhancing nutrition education
At present about only 50% of the beneficiary children between the ages of 6 months aid
2 years come to the Anganwadi centre This the families of the children of this most
vulnerable group susceptible to growth faltering and increased risk of malnutrition needs
io be reached though other alternative methods rather than trying to reach through
creation of more Anganwadi workers and centres. The following are preposed:
o
Nutrition education <& promotion
Massive connunication endeavor with messages focusing on care related nutritional
aspects and on the girl child will be launched. Breast feeding and weaning will be
given priority. Tire cooperation of the Govt Of India’s Food & Nutrition Board
Regional Office will be elicited for organisation of nutrition canps. Demonstration
of weaning food preparation, counseling of mothers and families of severely'
malnourished cliildren and Nutrition education of tire, community will be organised.
In the non-backward districts efforts will be made to get women's group involve in
preparation of weaning foods and in their promotion.
•
Nutrition training offunctional Stree Shakti groups
Karnataka lias recattly launched the Stree Sliakti Scheme for fonnation of credit
groups, t he groups are given initial seed money'. The project will seek to take
advantage of fimclional groujss so as to motivate them to take interest in nutrition &
health.
Tills will facilitate long term efforts of raising nutrition &. health
consciousness of the iocai corniimity.
e. Building nutrition capacity of existing women !s groups
This endeavor will build nutrition capacity of the existing women’s groups in the State
For instance; Mahila Sarrhakya lias formed vibrant women’s grotps. Similar women’s
groups including dial of NGOs will be involved. One objective is to assist die
Anganwadi workers hi improving the well being of children. Getting conmuuties
15
involved in the fitnctioning of the Anganwadi will go a long way in contributing towards
the rapid decline of malnutrition. Tliis failure to mobilise the community has bear a
major reason for the continued persistence of nralnulrition in Karnataka
7. REDUCTION IN REGIONAL DISPARITIES
7.1 Special package for category C districts
A special health and nutrition package is proposed for the category C districts. This will
include:
a
Construction and renovation
o
Renovation and equipping of existing PHCs
»
Degradation of selected PHCs to FRUs
o
Construction of irewPHC bilild ings
o
Staff quarters
As mentioned m previous Chapters, construction &. renovation in the above lour
categories will be a priority in tire seven Districts.
b. Special ininuirisatioil campaigns will be launched to alliance coverage.
c.
7.7.
Round the Clock services at PHCs . The Government of India nonre provide for
two doctors per PHC. Most Karnataka PHCs have only one doctor. One reason for
poor utilisation is that there is no 24 hour Nursing service available in the PHC. To
make PHCs functional for 24 hours, a second Medical Officer (preferably' lady) and
two staff Nurses will be appointed.
7 Special nutrition initiative -weaningfood intervention
A major weaning food intervention trial will be initiated from the next year in four
districts with the involvement of women’s grotps, by tire Women &. Child Department.
Based on the success and the lessons learnt this will be scaled ip to the category C
districts of the state The major objective here is to organise communities to prqiare
locally acceptable, less bulky and calorie densefoods forweaning and facilitating change
in feeding practices. Food material costs for six months to under two children would be
borne by tire Project
7.Z2 Specialproject management team
These special initiatives, as well as all the project components in these seven districts
will be inplaikiilcd though a special project mmaganait team to be basal at
Guibarga.
7.
1.3 Innovative programmes
16
Linkages with NGOs and formation of networks for instant District. Health Action
Networks, facilitating the creation of N3Os where there are none
Flexible support to comniinity based initiatives
Focus on health promotion and empowerment
7.1.4 Fertility decline
Provision of good quality contraceptive sendees and all Lite conponents discussed under
Famiiv Welfare,
8. COMMUNICABLE DISEASES, NON-COTOTOMCABLE
DISEASES, EMERGING AW KEGLECTED PROBLEMS
S. 1 Communicable Diseases
The development ofa disease surveillance systemwill be taken upwith a greater sense
of urgency.
8.2 Responding to epidemics and outbreaks
Rapid action teams with microbiologists / epidemiologists / public health personnel arc
already fonned at state level to take action following early warning signals. Presently
the media is still often faster than the surveillance system T .inkages could he established
in which they can continue to maintain their objectivity and freedom of expression
Divisional rapid action teams will also be developed. The routine responsibilities of
Taluk and District Health Officers in this regard will be strengthened A Reserve Fund
will be created under tire project for catering to epidemics.
8.3 Filling up gaps in existing national health programmes
Shortage of drugs, insecticides other stpplies and problems of mobility / transport have
been experienced, often at times when they are needed. Spraying of insecticides is done
at the wrong period because supplies were delayed.
Tlic project will liave provisions fur concerned authorities in the stare to release funds for
such requirements.
8.4 Proposed strategies for Mental Health
Mental health care requires special attention because of the stigma, prejudice, ignorance
and neglect that it has received so far and the fairly high burden of disease and suffering
caused by it
•
Develop district mental health piogramme in all 27 districts over tire project period.
Currently these liave been initiated hi three districts viz., Bellary, Bijapur and Kolar.
17
A district mental health team comprising of a psychiatrist, a clinical psychologist, a
psychiatric nurse and a psycliialric social worker will be based at each district
hospital (Tv enlu how many districts are already covered). They will provide daily
outpatient senrices; ten bedded in-patient facility; referral services to Primary Health
Centres, CHCs, and Taluk General Hospitals; follow up sendees; training and
creation of community awareness though health promotion activities.
a.
The Karnataka Institute of Mental Health, Dharwad, which was the only' state
govt, run mental hospital, has more recently' become only a Department of the
Karnataka Institute of Medical Sciences. The conditions there have been found
to be poor and a review committee has been set up to recommend improvements.
Tliis institution will be developed as a major specialty institute with adequate
facilities and staffing
b. improve teaching in Psychiatry and Psychology in the 25 medical colleges and
the nursing schools affiliated to the Rajiv Gandhi University of Health Sciences.
Workshops at the University and colleges to be organised.
c. At Primary Health Centres,
®
Eisiuc tumiiuiupied.supply of anti-epileptic dings (phenob aibltone and
phenvtoiri).
•
Supplv of basic psychiatric drugs in selected PHCs where PHC MOs have
been trained. Tills will Include Trio. Chlopromazine, Tab. Imipramine, Tab.
Ti ichexyphu uily 1 and Inj. Fluphenazine
»
Phased training of PHC MOs using the modules and manuals developed by
N1MHANS. as part ot their clinical skill upgradatiort
e.
Provide an enabling environment and some seed money/ grant in aid for
voluntary organisations and religious organisations to set up and manage day
care centres, halfway homes and vocational centres for chronically mentally ill
persons. Tire Richmond Fellowship, Medico-Pastoral Association, Atma Shakti
and others are examples ofsuch organisations in Karnataka
f.
A Mental Health Unit in the Directorate of Health Services will be created to
give direction and leadership to the State Mental Health Programme. It could
also develop life with NGOs and other private agencies providing counselling
and oilier services eg Helping Hand, Vishwas, CREST, Banjara Academy and
several others.
S.5
Care of the Elderly
With increasing longevity', all tliree levels of the health care system (primary, secondary'
and tertiary’) need to increase their knowledge and skills regarding tire special needs
concerning medical care, prcVctiiiviL, promotion and rdidbiliiatiuii foi tire elderly,
particularly women
8.6 Disability
Tliis is a neglected area and requires greater attention
18
. ce infen.'e^tious />? disability need to he medical, social and environmental. The
interventions at all levels of the health system will be :-
Rcducnig die Cveurrmce Ox utpairmcnt re.
ii'i-iy p> t vCftcfCrSt. Tills will
include eradication of poliomyelitis, early diagnosis and treatment of diseases,
adequate nutrition especially Vitamin A preventing blindness due to deficiency.
Folic acid supplementation to pregnant mothers to prevent neural tube defects in
infants, mid prophylactic penicillin every month for children with rheumatic
heart disease, etc.
Tltis will be addressed through improved coverage and
quality' ofprimary health care
‘
Disability limitation by pronpt and adequatefappropriate treatment at all levels.
Emphasis again is on primary health care, with referral io secondary and tertiary'
levels, whatever the necessity arises.
f
Reducing transition from disability to handicap by rehabilitation. This
envisages the combined and co-ordinated me of medical, social, educational and
vocational measures for training & retraining the individual to the highest
possible level of functional ability. It includes medical rehabilitation (restoration
of fi.uKt.ion), vocational rehabilitation (restoration of capacity to earn), social
rehabilitation (restoration of relationships) and psychological reliabilitation
(restoration of dignity). Tins is still a neglected area and will be provided
sipport.
*
Support to Community Based Rehabilitation (CER.) though established N3O's
working in the field will be actively' encouraged (eg Action-aid, Association of
thePhysicaliv Disabled, etc).
*
Apex institutes in the state will be assisted and consulted for various activities.
There tre rmny institutions in Karnataka for different types of Handicapped eg
ivluitally handicapped u'davrl IANS, etc)', plrysically handicapped, deaf ZL dumb
(institute or Speech &. Hearing), blind (schools for the blind), and
orthopaolicnlly handicapped (Sanjay Gandhi Institute of Accident and Trauma
Care, I lor.jiv k i, c<-v a Support •will be given for provision of t'tf&f'i'Cli- s&rvic&s
and conducting statewide training
'
.Assistance jor aids ana appliances to disabled persons who cannot afford them
This will be effectively monitored.
*
The Health Worker who is envisaged toplay' a key role will require training in
topics such as community development, psychological counseling child
development, teaching CER principles as well as how to work with specific
impairments.
1
They would require active support from the PHC staff as well as trained staff at
District / Taluk hospitals.
)
An inportant aspect of the CBR is Health Promotion especially to sensitize die
general population on the need to concentrate on the abilities of the disabled and
not. on their disability. They should realize that every' individual could be a
productive member of their society.
*
Community participation is the organisation of activities by groups of persons
who have disabilities (or their family members / friends), in conjunction with
others who do not to increase their ability to influence social conditions, and in
doing so to inprove tlieir disability situations.
19
8.7 Strategies fix' Non-Communicable Diseases
•
PHCs to have facilities to detect, manage / refer patients with diabetes, hypertension,
ischaemic heart disease ie. provision ofbasic diagnostic equipment.
•
Secondary hospitals to have needed anti-diabetic dnigs, including insulin
•
Prevention and early detection cum treatment of rheumatic hean disease
»
Support to pilot projects for cancer control in Mandya district.
»
To identity a few other districts tor the same.
»
Support to early detection and management of cancer cervix along the lines
developed by Kidwai Institute of Oncology.
•
Si inport to rrtncerprevenfion programmes
•
Ond luylth with dmttil surgeons in all district and Talii!' hospitals
•
Support to develcpircnt of occipational health programmes especially of
luiorganizeo scctoi til vollaboiaiion with the Regional Occipational Health Centre
(ROHJ).
9. HUMAN RESOURCE DEVELOPMENT
9.1 Quality of health services
Quality of care depends largely on tire clinical, technical, managerial and other skills of
various personnel at all levels. To improve the quality and effectiveness of staff, in
service training of all categories needs to be regularly carried out. There is also need for
sipportive sipervision systems to become fimctional, as a part of followup training.
The training components of National Health Programmes like RCH, RNTCP, NAMP,
Polio surveillance etc., are presently carried out separately, thus resulting in
duplication and wastage of 'taltiaole time. t herefore training in tins project will be
coordinated and telescoped in such a way that the training of the various staffwill be
done in a combined manner and with optimal utilisation of training funds. Team
iratiitjig will be conaucted,,,, appi oprtaie.
20
9.2 Training needs assessment
Tire State Institute ot Health & family Welfare (SH-1FVV) was entrusted with die task
to prepare Training Needs Assessment of various personnel and also to plan out detailed
training programmes for various categories of health personnel in the state The STHFW
recommended induction training for all categories of staff and subsequent refresher
course at least once every five years. Tire training deals primarily with enhancing the
participants knowledge, attitudes and skills in relation to specific procedures, activities or
tasks and to health progt amures in lire context of a locts on public health, integration and
implementation.. The training will be based on competency-based training or learning
by doing. It will be learner-centred. using methods suited for adult learners. It will also
be probi.ii'i ..'O>, mg m upprouclt, besides relating to the work and social context of tire
people of lire Slate.
9.3 Faculty development and strengthening
o
The faculty positions of State Institute of Health and Family Welfare will need to be
increased in view of the enhanced role Criteria for selection will be developed in
order to maintain high standards. Faculty attachments for persons with requisite
skills from academic institutions, private bodies and N3Os will be made
»
Library and Computer facilit ies will be upgraded.
»
Linkages between the State Institute of Health and Family Welfare and other training
facilities in the state eg, ANMTCs, DTCs etc., will be established.
a
Organisation of ‘retreats ’ fbr senior officers in multi-programme groups to be able to
discuss issues together, away from the administrative burden ofday to clay w'ork
®
Introduction of workshops on group dynamics, organisation behavior, neuro
linguistic programming, personal growth and interpersonal skills, etc.
10. WOMEN'S HEALTH
Given the current poor health and nutrition status of women and girls, efforts by the
State to improve women's health and increase their access to care would be a priority
under this project.
10.1 Strategies
Strategies to improve women’s health are nulti pronged and being part of an integrat ed
approach, crosscut all levels &. components A gender perspective would form tire basis
of the strategy. 1 he gender approach to health recognizes that the biological differences
between men and women are unchangeable, but believes that socially constructed
differences that are inequitable can be changed. It recognised that social divisions and
disparities in interrelationships between men and women detennhie differentials in
exposure to risk; health status differentials; disparities in access to health care and
technology; different rigjils and responsibilities and low control by women over their
own lives (.WH3-SEARO, 1998).
a.
V health empowerment (mining will be an inportant mechanism used. This
lias been pilot tested in five districts of Bidar, Kopp al, Bellary, Chamarajnqgar and
BangaioicRuial, during the period 1993-2000, wifii support .from the Govaorient of
India English training kits/ manuals were developed, modified and translated into
Kannada for district level trainees and for women leaders. Mahila Samakhya in all
their districts and bXJOs are involved. There is scope for greater involvement of
field level government health limctionaries and elected women’s representatives. A
cascade approach is used with training of district trainers, who train women leaders
(two per sangha to ensure sustainability), who in turn train their sangha members and
then women m the coirnxnuty.
b. Sp ec iai aitent ion to tire nutrition ofthe girl child.
c.
Immunization coverage to be optimal Specific attention to be paid to Guibarga
division Additional ANM posts will be created, that will support all aspects of
MCHvrork
d. Coverage and quality of maternal health services to be improved statewide raid,
more specifically in Guibarga division, flic components of Antenatal care have
been found wttntine even in Bangalore city, with recording of blood pressure, urnie
testing and hemoglobin estimation not always done Tlris project will aim at
improving the quality of iiuicmal health services. Greater efforts will be made to
increase access to emergenev obstetric care, with provisions tor transport to be
subsidized, and payment of private practitioners and specialists. Linkages with
professional bodies and d ie private sector has been established with LCGSh fliesc
are being translated mto field linkages m Bellary district and special provision wilt
he rmde for Guibarga divieinn
e. The provision of cnimeeHng services at District and later Taluk hospitals will help
respond to emotional distress and mental health problems.
f
Counsellors could also help build positive self image and positive mental health of
women and sipport / train local groups to act as lay counsellors. It will heip to cope
with alcoholic husbands /fathers, violence etc.
g
Gynecological services to be available at all CTICs and Taluk hospitals to handle
referred gynecological complaints. Conditions such as low' backache, osteoporosis,
uterine prolapse etc to be given priority.
li Provision of technical / healtli, management and financial support to women s
groups and NGO's who run shelters for battered women, self help groups and
community health programmes focussing on women’s health.
i.
Support for research into women’s health needs.
10.2 Violence against women
Violence against women is an issue of pdblic health magnitude with health related
causes and consequences. There is a need for intervention by : variety of agencies
including the dqiartmetn of health.
Science take: several forms incktdirgfemalefoeticide, infanticide, Iriglier fanale cliild
moiiaiity rates, hjgjitr levels of under nutrition in girls under 5 years, lower access to
health care, poor coverage of maternal care, child abuse, domestic violence, sexual
harassment arid abuse at home and in lire work place and unnatural deaths of youqg
vwiiul
Strategies include sensitization workshops for medical professionals, along with training
for diagnosis, treatments recording and reporting of violence; inplsnarlation of PreNaial Diagnostic Tevluiiqucs (Regulation) Act of 1994, provision of counseling services,
support towomen's groips and promotions of only sate contraceptives.
11. HEALTH PKGStiOTIOlff, HEALTH EDUCATION ARD
PWTP nWRPKTR.IgT
Integrated^ and oernprehensa® health promotion strategy
«
I he newer approach to health promotion as a process of enabling people to increase
control over, and to participate actively in improving their health, will be internalized
by the Department of Health and used for all health promotion activities.
•
Workshops will be conducted with personnel from State and District Health
Education Bureaus, along with NGOs and experts specialising in health promotion
and communication. These would evolve a framework for a conprdratsive health
promotion strategy covering major health problems and issues, also allowing
flexibility to respond io local issues and even individual problems.
»
Ongoing orientation programmes will be held at state, district and taluk levels so that
an integrated approach to health promotion is maintained. Health education
packaaes will not be resource, donor or programme driven. Health promoters will
uitcraci wiui
about health ielated problems faced by them
•>
Pnouiy ateas io be coveted include.
a.
Nutrition education
b.
Health promotive education and activities for school age children. This will include
ieactia training developing ntuiuaLs and educational nutei ial, cl did to cl did methods
and life skill education for adolescaits.
c.
Health empowerment training for panchayat members.
d.
Woi i bu is cn powern ki it for 1 lealll l
e
Conrnuniy mobilization for health using local folk media and cultural form.
buildipg on existing groups working in tire state
23
12. PROJECT COSTS BY COMPONENTS
Detailed costing of project conponents and year-wise phasing has not been attempted.
Table 121 slrows an indicative costing which will undergo considerable changer, ®
detailed project design and development is taken ip.
24
Table 12.1
Project cost by strategies
(In Rs: Crore)
1
ej
T
invesuiieiii.
Costs
Prrnect ^trnfesies
i No.
i
l i
1
I- ...
1__ 2
Strengthening institutions aid capacity
building.
Liprovfiig access quality and eSectivcaiess
of Pnrnarv Hea Iti i Care s ervic es
r... '
1 3
improving nulnl ton
__
__________
~
Recurrent
Costs
■ Total Costs
70
60
130
190
70
260
-.............
10
40
50
Reduction in regional disparities
20
30
50
;5
Comtrunicable diseases, emerging and
neglected prob Ians.
10
50
60
1 6
__
1
.Human Resource Development
10
50
60
„ 1,1
ricailh
pi uiiijuon atiu cHTpovvcrniau
0
»
50
8
Woii'ctVs health.
o
in
10
9
Partnerships
0
30
30
*
<
ritxilUl 1U1OHJ fclUUlJ S) sicill
20
40
Q
10
10
330
420
Physical contingencies
20
0
20
13
Price contingencies
20
10
30
15
Project Total
370
430
__________
800
i____
! 4
i
____
in
Project managanent. monitoring and
research
11
Total Base Cost
20
_____
750
L
Price ana physical contingencies
r
n
17.
TABLE - 1
GROV.TH OP HEALTH SERVICES AND MANPOWER RESOURCES
19,50 - 1971
CATEOORY/u'.iT
1950/51
1955/56
1960/61
1965/66
8,600
113,000
10,000
125,000
12,600
185,600.
14,600
240,100
NIL
725
2,800
5,000
5,183
56,000
15,000
8,000
521
1,800
3,500
NA
65,000
18,500
12,780
800
6,4-00
4,000
HA
70,000
27,000
19,900
1,500
11,500
6,000
42,000
86,000
45,000
48,500
4,200
40,000
31,700
42,000
115,725
66,000
NIL
133
107
390
438
390
497
393
535
11
15.1
48
24.6
48
NA
no
NA
1970/71
HOf?r.?AL ?IS?}"^?PErs
EiSTITUTIOl.S
BEDS
pri"fET ir'-LTH
o
-- -
;.?'~?0"7?
doctorsNURSES
KID’. IV: S a A”*’ S
IRALTH VISITORS
tJjTSE-DAlS
JZTARY INSPECTOR
PH’J.LIACI f-j? 3
rATTr^T,
<n
a)
ULUS
POPULATION COVERED
(millions)
—
b) FIT-A-TA
units’
IC
O
£
b.c.u. t;_-,.:s
|.M
H
NIL
«>
g
H
■
i ■
!
IS 7 -
o
POPULATION COVERED
15
no
NIL
10,371
119
160
3
22,000
167
220
10
26,500
167
2^20
15
34,500
272
532
17
37,000
d) LTIE'OSY C~~VEFS
NIL
33
135
235
NA
e) V.D. CLI'ilCS
NIL
-
83
189
288
f) N.C.H. CHORES
1,651
1,856
4,500
10,000
NA
CLrics
T7EiEr:& c: :32'7s
B
(Maternal <1 Child)
(Health
)
NA -
HOT AVAILABLE
SOURCE
1) RAO (1966)
2) INDIA (1972)
ccrfCf
/Aew/s
* M.B.B.S. and LICENTIATES
18.
TABLE - 2
GROWTH OF MEDICAL EDUCATION (1950 - 1972)
CATEGORY/UNIT
1950/5L
MEDICAL COLLEGES
ANNUAL ADMISSIONS
1955/56
1960/61
1965/66
1971/72
30
42
57
85
103
2,500
5,500
5,800
11.,100
13,000
DENTAL COLLEGES
4
7
10
14
15
ANNUAL ADMISSIONS
150
231
281
400
680
"'POSTGRADUATE
INSTITUTIONS
NA
33 (’58)
57 (’64)
'-DEGREES/DIPLONAS
HA
NA
82 (’68)
3,424 (’62) 7,025 (’68)
SOURCE - RAO. (1966)
INDIA (1972)
* CBHI
(1968)
TABLE - 3
EXPENDITURE ON HEALTH SERVICES AND 'iEDICAL EDUCATION. 1 - IV FIVE YEAR PLAN
____________________________ (IN HILT-IONS OF RUPEES)______________________________________
1 U.S. 1 =7.5 RUPEES
CATEGORY
1 PLAN
11 PLAN
111 PLAN
IV PLAN
TOTAL OUTLAY
HEALTH OUTLAY
% OF TOTAL OUTLAY
23,600
1,400
5.9
4-6,000
2,250
4.9
82,000
3,418
4.2
159,040
11,555
7.2
HEALTH CENTRES/
250
HOSPITALS
EDUCATION/T RAINING
216
COMMUNICABLE DISEASES 231
CONTROL
370
617
1,662
350
563
982
690
705
1,270
OTHER HEALTH
PROGRAMMES
204
90
210
421
FAMILY PLANNING
7
30
270
3,150
WATER SUPPLY/
SANITATION
490
720
1,053
4,070
SOURCE - PARK (1970)
19 .
TABLE IV.
MANPOWER - POPULATION RATIOS
1946
CATEGORY
1972 _ 2nd of (h)
IV PLAN
POPULATION
300 million
540 million
DOCTORS
1 : 6,000
1 : 4,300
NURSES
1 : 43p000
1 : 6,400
DENTISTS
1 : 300,000
1 : 68,000
MIDWIVES
1 : 60,000
1 : 11,700
SANITARY
INSPECTORS
NA
1 : 18,300
SOURCE (a)
(b)
BHORE REPORT
(1946)
INDIA
(1972)
NA - NOT AVAILABLE
Health and Family Plamnig Services in India
56
medical colleges and other academic bodies. It has also established two
Regional Medical Centres, one at Bhubaneshwar and the other at Port
Blair, to promote research in some areas which are of local interest.
Earlier, research in Indian systems of medicine and homoeopathy was
coordinated by a similar government-financed autonomous institution called
the Central Council for Research in Indian Medicine and Homeopathy.
However, recognising the need for much greater efforts in this area, the
following separate research councils have been set up :
(1)
(2)
(3)
(4)
Central Council for Research in Ayurveda and Siddha
Central Council for Research in Homeopathy
Central Council for Research in Yoga and Naturopathy
Central Council for Research in Unani Medicine
INSTITUTIONS FOR TRAINING PHYSICIANS
As in the case of public health, four post-graduate medical institutions play
pivotal roles in medical education. As recommended by the Bhore Com
mittee (Government of India 1946a), the All India Institute of Medical
Sciences (AllMS) was established in New Delhi in 1956 with the following
objectives (All India Institute of Medical Sciences 1979) :
developing approaches to undergraduate and post-graduate medical
education suited to conditions prevailing in India;
(2) training teachers for other institutions for education of physicians
to enable them to attain self-sufficiency in post-graduate medical
education;
(3) bringing together at one place, clinical facilities of the highest order
for training of personnel in all important branches of health
activity; and
(4) conducting high quality research.
(1)
Institutes similar to the AIIMS were also established at Calcutta,
Chandigarh and Pondicherry.
Considering the complex problems involved in setting up a medical
college, the progress in this field has been phenomenal (Government of India
1983c: 85-86). In 1948 there were only 25 medical colleges (Table 5.1).
The number rose to 41 by 1957; to 60 by 1961; to 87 by 1966 and 106 by
1976. The increase in admissions capacity of these colleges was equally
phenomenal (Table 5.1). There were 106 medical colleges in the country
in 1982. The 100 Medical Colleges (from where information is avail
able) have 11,054 seats for undergraduate medical education. The
Tl9nstitutional Framework
Table 5.1 : Number of Students Admitted in 1st Year MBBS Course and
Qualified Final MBBS in India in Selected Academic Years
1947-48 to 1982-83
Year
1947-48
1950-51
1955-56
1960-61
1965-66
1970-71
1974-75
1975-76
1976-77
1977-78
1978-79
1979-80
1980-81
1981-82
1982-83
No. of students
Total no.
of medical
colleges
Admitted
25
28
4!
60
87
95
105
106
106
106
106
106
106
106
106
1,983
2,675
3,660
5,874
10,520
12,029
11,615
11,281
11,176
11,162’
1 1,053’
10,988’
10,934’
10,749’
11,054
Qualified
•
959
1,557
2,743
3,387
5,387
10,407
11,911
11,982
11,981
14,156
12,370"
13,083"
12,170”
12,278"
N R.
)
N.R. Not received.
Note :
’Data not received from 1 Medical College in 1977-78; 3 in 1978-79; 2 in
1979-80; 1 in 1980-81; 6 in 1981-82 and 1982-83.
**Data awaited from 5 Colleges in 1978-79, 2 in 1979-L0, 4 in 1980-81 and 6 in
1981-82 and 1982-83.
Source : Medical Council of India.
statewise admission capacity and turnout of these colleges are given in
Table 5.2.
A significant aspect of growth of medical colleges in the country is the
coverage of population in different states. As will be seen in Table 5.2, the
number of admissions for each lakh (100,000) of population varies enor
mously. At one extreme, the figure is 2.73 for Karnataka, 2.36 for Jammu
and Kashmir, 2.34 for Maharashtra and 2.31 for Kerala. At the other, it
is 0.29 for Orissa, 0.76 for Bihar and 0.96 each for Uttar Pradesh and
Haryana. This differential coverage has wide implications, quite apart
from production of physicians. The attached hospital of a medical college
makes available a high quality of medical care to the local population.
Correspondingly, most facilities for post-graduate medical education are
also concentrated in states which have a high ratio of admission in medical
colleges. Distribution of medical colleges thus provides an important
indicator of disparities in terms of health institutions and health manpower.
59
T/te^flliliilional Framework
Table 5.3 : Specialitywise Scats Available and Number of Students Admitted
Health and Family Plannit^Kervices in India
58
in Post-graduate Medical Courses, 1978-79
Table 5.2 : Population Coverage of Medical Colleges (MBBS) in India
seats available
1980-81
States/Union Territories
No. of
medical
colleges
•
1. Andhra Pradesh
2. Assam
3. Bihar
4. Gujarat
5. Haryana
6. Himachal Pradesh
7. Jammu and Kashmir ■
8. Karnataka
9. Kerala
10. Madhya Pradesh
11. Maharashtra
12. Orissa
13. Punjab
14. Rajasthan
15. Tamil Nadu
16. Uttar Pradesh
17. West Bengal
18. Delhi
19. Goa Daman and Diu
20. Pondicherry
21. Other and Union
Territories
Total
No. of
students
admitted
(1st year)
1980-81
No. of
admission
per one lakh’
population
Speciality
Entitle
ment of
medical
colleges’ ’
1
8
3
9
5
1
1
2
9
4
6
13
3
5
5
9
9
7
4
1
1
911
N.A.
531
659
124
66
141
1,013
586
509
1,468
75
300
460
566
1,074
915
763
461
70
1.71
N.A.
0.76
1.94
0.96
1.56
2.36
2.73
2.31
0.98
2.34
0.29
1.80
1.35
1.17
0.96
1.68
12.31
42.69
11.68
11
4
14
7
3
1
1
7
5
10
13
5
3
7
10
22
11
1
—
—
1
135
1.92
1
106
10,927
1.58
136
"1,00,000. N.A. Not available.
"'According to Health Survey and Planning Committee norm of one college per 50
lakhs of population.
Source : Government of India (GDI), Directorate General of Health Services (DGHS),
Health Statistics of Indio, J9SI.
About two-thirds of India’s medical colleges have facilities for post
graduate education in one or more fields. These were, in 1978-79, able to
oiler admission to 3,851 for post-graduate degree courses and 2584 for
post-graduate diploma courses. Table 5.3 lists the specialities covered, the
number of institutions offering training in them and the level of admissions
in 1978-79.
pc
fc
f(_
No. of
insts. having
(PG degree/
diploma
course)
2
50
Anatomy
54
Physiology
30
Biochemistry
35
Microbiology
52
Pathology
53
Pharmacology
4
Biophysics
Applied Biology
47
Medicine (General)
48
Surgery (General)
64
Obst. and Gynaec
23
Forensic Medicine
Preventive and Social
36
Medicine
60
Aneasthcsiology
57
Ophthalmology
29
Chest Diseases
42
Child Health
49
Orthopaedics
58
Paediatrics
53
Radiology
3
Public Health
9
Plastic Surgery
5
Thoracic Surgery
16
Psychiatry
3
Occupational Health
. Physical Medicine and
Rehabilation
10
<2 Cardiology
12
(2 Neurology
51
Otorhinolarvex
C
Vcncroriology and
29
Dermatology
3
Gastrocntrology
10
Genito Urinary Survey
3
tu Hospital Administration
<■ Nutrition
* Virology
.•>
■ Maternal and Child Health
2
r Industrial Health
1
;■ Health Statistics
JkdmissionsfW^L
—
Diploma
Degree
4
5
6
3
156
169
98
103
177
154
2
—
48
70
73
65
147
62
2
9
373
108
*421
19
390
22
356
7
53
324"
234'
155
*
247
89"
57
205"
72
77
224
205
40
30
263
195
123
209
76
54
146
63
70
5
65
2
■—
—
\1T
■—
22
382
*
373"
39t
33
105
240"
218
43'
149
255
140
40
17
14
66"
14
9
15
45
124
56
10‘
8
2
10
16
146
252
121
36
17
3
37'
167"
91
6
6
30
14
5
4
64
2
13
38
117
33
9
109
54
7
3
9
70
5
4
13
10
2
Health and Family Pla/n^l^Services in India
60
2
3
4
5
6
Health Education
I
Basic Medical Sciences
—
Speech and Hearing
1
Medical Lab. Technician
I
• Endocrinology
1
Immuno Haematology
and Blood Transfusion
1
1
Nephrology
1
Urology
Mycology
1
Master of Dental Surgery —
All Specialities
■—
—
30
15
—
12
1
—
—
9
—
—
30
8
—
12
1
—
—
2
**
119
3,197 -1-
2
4
—
—
—
2,025
1
10
—
—
—
—
2
4
—
—
•*
—
223
3,851 _— 2,584
— Nil
'These are institutions which have not indicated seals available against admissions
made. In such cases, the number of seats available has been taken as the number of
admissions made.
•'Information not available.
Source : GOI, DGHS, Health Statistics of India, 1981.
INSTITUTIONS FOR TRAINING IN TRADITIONAL SYSTEMS OF
MEDICINE AND HOMOEOPATHY
In 1981, there were 95 institutes providing under-graduate training in
ayurveda with a total annual capacity of 3,306. There were 16 institutions
for undergraduate education in the unani system, with a capacity of
admitting 535 students. One institution with a capacity of 75 provides
training in siddha. There are 122 colleges of homoeopathy with a total
annual capacity for 7,513 students. The details are given in Table 5.4.
The wide variations in the statewide distribution of number of colleges
providing education in the three Indian systems of medicine and in
homoeopathy is quite evident (Table 5.4).
INSTITUTIONS FOR EDUCATION OF DENTISTS, NURSES,
PHARMACISTS AND OTHER HEALTH WORKERS
India has 22 dental colleges with a total capacity for training 722 dentists
annually. Fifteen of them have facilities for post-graduate education, with
a capacity for admitting 152 students (Government of India : 1983c : 92).
There were only 4 undergraduate dental colleges in 1950-51.
There are 21 colleges of nursing offering graduate degrees is nursing
with a total admission capacity of approximately 163 (Government of
3 oc. .
: l-lajrF
DIRECTORATE GENERAL OF HEALTH SERVICES
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
NIRMAN BHAVAN. NEW DELHI-1 10 011
STATEMENT XV
HEALTH MAN POWER WORKING IN RURAL AREAS
MEDICAL SPECIALISTS WORKING AT UPGRATED PHCs/CHCs
S. No.
Surgeons
States/UTs
S
P
V
S
P
V
S
P
V
S
P
V
S
P
V
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17 18
1
Obst &: Gynaes
Physcians
Paediatricians
Period
upto
which
infor
mations
to
Total
Specialists
1. Andhra Pr.
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 31.3.85
2. Arunachal Pr.
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 31.3.87
3. Assam
4. Bihar
8
4
4
8
6
2
**
2
**
8
6 INR INR INR
INR INR INR INR INR INR INR INR INR INR INR INR
5. Goa, Daman & Din
4
4 NIL
3
2
6. Gujarat
58
39
19
44
1
43 INR INR INR
7. Haryana
21
8
13
21
5
16
24
12
12 30.6.87
NR INR INR 1.4.84
1 NIL NIL NIL NIL NIL NIL
7
6
1. 30.6 87
44
7
37
146
47
99 31.3.87
25
52 27(+)
88
68
20
8. Himachal Hr.
INR INR INR INR INR INR INR INR INR INR INR INR
30
9. J & K
INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR
10. Karnataka
11. Kerala
12. Madhya Pr
*
13. Maharashtra
21
3
18
3
30.9.87
27 30.9.87
3(+)
10
7
3
6
9 3(+)
2
46
47
NIL NIL NIL
4
4 NIL
4
4 NIL NIL NIL NIL
8
8 NIL 30.9.87
90
96
90
6
96
90
18
96
21
6
6
12
96
10
90
6 384
*
INR INR INR INR INR INR INR INR INR INR INR INR
412
1(+) 30.6.87
360
24 30.6.87
409
3 30.6.87
14. Manipur
7
3
15. Meghalaya
5
5 NIL
16. Mizoram
1 NIL
17. Nagaland
4
1
7 NIL
7
7
2
5
7
1
6
28
6
22 30.9.87
2
3
7
5
2
1
1 NIL
18
13
5 31.3.87
3 NIL
3 30.9.87
5
1 NIL
1 NIL NIL NIL
1 NIL
1
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 30.6.87
6
25
20
5
134
121
13 31.3.87
6 NIL NIL NIL
22
16
6
66
51
15 31.3.87
20. Rajasthan
INR INR INR INR INR INR INR INR INR INR INR INR
425
375
50 30.6.87
21. Sikkim
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 31.3.87
18. Orissa
42
40
2
25
25 NIL
19. Punjab
22
19
3
22
16
22. Tamil Nadu
33
31
2
31'
42
36
’31 NIL NIL NIL NIL NIL NIL NIL
64
62
2 30.6.87
23. Tripura
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 30.6.87
24. Uttar Pr.
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 30.6.87
25. West Bengal
22
22 NIL
22
22 NIL
22
19
3
2
9 NIL
68
65
3 31.3.85
26. A & N Islands
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL Nil. NIL NIL. NIL 30.6.87
27. Chandigarh
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL "NIL NIL 31.12.86
28. D & N Haveli
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 30.6.87
29. Delhi
NIL NIL NIL NIL NIL NIL NIL NIL NIL
30. Lakshadweep
NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL 31.3.87
31. Pondicherry
NIL NIL NIL NIL NIL NIL
Total
337
Note :
286
51
299
211
88
1
214
1 NIL
1
1 NIL NIL NIL NIL
171
43
236
199
I NIL
1
1 31.3.86
1 NIL 31.3.87
37 1953 1654
299
S - Number sanctioned, P = Number in position N - Vacant posts INR = Information not received
* = Revised figure received from Madhya Pradesh.
** = Including Paediatricians, as separate figure are not available.
Dated 9.11.87
(Figures are provisional)
DOCTORS AT P.H.Cs
S. No.
THIRD M.O.S. IN POSITION AS ON 30.9.87 Period
Post of Post of
3rd
Ayur
Homeo Unani TOTAL upto
3rd
Allowhich
M.O. to M.O.
pthic
vedic
pathic
infor
be filled sanc
mation
tioned a >
on
relates to
30.9.87
S
P
V
19
20
21
22
23
24
25
1. Andhra Pr.
1248
914
334
420
420
232
15
2. Arunachal Pr.
NIL@
NIL@
NIL
NIL
NIL
NIL
3. Assam
584
584
NIL
146
146
4. Bihar
2121
2121
NIL
587
5. Goa Daman & Diu
52
52
NIL
6. Gujarat
782
622
7. Haryana
666
8. Himachal Pr.
States/UTs
26
27
28
29
7
10
264
31.3.85
NIL
NIL
NIL
NIL
30.6.87
NIL
NIL
NIL
NIL
146
30.6.87
587
587
NIL
NIL
NIL
587
31.3.85
15
15
10
NIL
NIL
NIL
10
31.3.87
160
251
251
217
NIL
NIL
NIL
217
31.3.87
476
190
89
89
89
NIL
NIL
NIL
89
30.9.87
307
249
58
77
34
34
NIL
NIL
NIL
89
30.9.87
9. J & K
*
INR
INR
INR
NIL
NIL
NIL
NIL
NIL
NIL
NIL
31.3.85
10. Karnataka
3493
3071
422
269
191
191
NIL
NIL
NIL
191
31.3.87
11. Kerala
607-
607
NIL
NIL
30
**
30
NIL
NIL
NIL
**
30
30.9.87
12. Madhya Pr.
2556
1986
570
465
465
317
NIL
NIL
NIL
317
30.6.87
13. Maharashtra
3924
3058
866
428
428
428
Nil.
NIL
NIL
428
30.6.87
14. Manipur
109
82
27
25
25
25
NIL
NIL
NIL
25
30.9.87
15. Meghalaya
75
53
22
22
16
NIL
NIL
NIL
NIL
16
31.3.87
16. Mizoram
16
13
3
12
NIL
NIL
NIL
NIL
NIL
NIL
30.9.87
1
2
21
20
1
14
NIL
NIL
NIL
NIL
NIL
NIL
30.6.87
18. Orissa
1061
945
116
314
314
163
36
37
NIL
236
31.3.87
19. Punjab
317
303
14
129
112
92
NIL
NIL
NIL
92
31.12.86
20. Rajasthan
961
861
100
232
232
211
NIL
NIL
NIL
211
30.6.87
21. Sikkim
35
20
15
15
10
1
NIL
NIL
NIL
1
31.3.87
1369
1369
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
30.6.87
23. Tripura
75
96
21(+)
27
23
NIL
NIL
NIL
23
31.3.87
24. Uttar Pr.
1026
1026
NIL
907
907
573
NIL
NIL
NIL
573
30.6.87
25. West Bengal
600
554
46
335
197
115
NIL
NIL
NIL
115
31.3.85
26. A & N Islands
12
12
NIL
2
7
NIL
NIL
NIL
NIL
NIL
30.6.87
7
NIL
NIL
NIL
NIL
NIL
NIL
NIL
NIL
31.12.86
2
NIL
NIL
1
NIL
NIL
1
30.6.87
17. Nagaland
22. Tamil Nadu
*
27. Chandigarh
7
27
28. D & N Haveli
8
8
NIL
29. Delhi
29
22
7
8
3
3
NIL
NIL
NIL
3
31.3.86
30. Lakshadweep
9
9
NIL
7
NIL
NIL
NIL
NIL
NIL
NIL
31.3.87
1
NIL
NIL
3
31.3.87
53
44
10
3612
31. Pondicherru
Total
Note :
INR
S
@
*#
*
Dated 9.11.87
29
29
NIL
12
5
2
22099
19169
2930
4810
4517
3505
Information not received.
No. sanctioned, P = No. in posotion V = Vacant posts
The pattern of PHCs does not exist in this state
Village Health Guide scheme was sanctioned in two districts of Kerala in May 1985.
Alternative Health Guide Scheme is functioning in these States.
(Figures are provisional)
(_o rv\
'-S 0--
SPECIAL FEATURE: BAPUJI EDUCATIONAL ASSOCIATION
Contributing to healthcare
The JJM Medical College, run by the BEA in Davangere, has modern infrastructural facilities in a range
of specialities.
RAVI SHARMA
num, while on journals it is Rs.65 lakhs.”
Most of the students hail from outside
Davangere; rhe hostels accommodate
1,100 boys and 750 girls. The JJM Col
lege has 342 well-qualified teachers; with
telemedicine catching up in a big way,
exposure to information technology has
been stressed upon.
Maintaining the college has not been
easy in financial terms. Said Dr. M.G.
Rajasekharappa, Principal: “With most
of die seats being taken away from the
management and rhe prescribed govern
ment fees being insufficient, it is an up
hill. task to maintain the high standards
di?i the MCI and div University want us
to maintain.”
Attached to the JJM College are die
948-bed Chigatcri Government Hospi
tal, the 950-bed Bapuji Hospital, the
150-bed Bapuji Child Health Institute
and Research Centre and the govern
ment-run 100-bed Women and Chil
dren Hospital. Said Rajasekharappa:
“Besides these hospitals, in a bid to ac
quire exposure to rural conditions JJM
interns go to primary health centres near
Davangere and also to the Taluk Hospi
tal at Chennagiri.” According to Raja
HE piece de resistance of the Bapuji
Educational Association’s numer
ous institutions is undoubtedly the JaBlguru Jayadeva Murugarajendra (JJM)
Medical College at Davengere. This is
the only institute that allows the Associ
ation to cross-subsidise its other ventures
in education. Started in 1965, the Col
lege was initially affiliated to Mysore
University. Now it is affiliated tc rhe
Rajiv Gandhi Health University. Il re
ceived recognition from the Med.Lal
Council of India in 1987. Admission for
under-graduate courses with an intake rd
245, post-graduate courses with a;i in
take of 107, and diploma courses with an
intake of 90 are mainly through a State
government-conducted
examination,
leaving a handful of sears available for the
management.
Eighteen specialities — microbiolo
gy, community medicine, forensic med
icine, general medicine, general surgery,
obstetrics and gynaecology, paediatrics,
jOLimatology, psychiatry, ENT, ortho™_dics, ophthalmology, anaesthesia, ra
dio
diagnosis,
pathology
and
pharmacology — are of
fered. The college has
superspeciality depart
ments such as neurology,
neurosurgery, cardiolo
gy, cardiothoracic sur
gery, gastroenetrology,
urology and nephrology.
The infrastructure
that is available at the
college is surprisingly
modern for a college of
its period. Located on a
25-acre campus, it has
an impressive 72,000
square
feet
library,
which can accommodate
up to 1,500 students.
Chief librarian P.S. Ma
hesh, said: “We have
35,000 textbooks and
we subscribe to 295
journals. The expendi
ture on textbooks alone
is Rs. 15 lakhs per an- The Bapuji Pharmacy College.
T
96
sekharappa, with over 500 out-patients
visiting the Bapuji Hospital every day,
there is no shortage of clinical material
for rhe students.
The Bapuji Hospital, which was
started in 1970, has over rhe years be
come a referral centre for patients from
far-flung places such as Shimoga, Hospet, Bellary and Raichur. The hospital is
equipped with a full-fledged 24-hour
biochemistry diagnostic laboratory with
CT Scan, portable X-ray machines, facil
ities for colonoscopy and endoscopy, and
so on, speciality' clinics in areas such as
neurology, neonatology, cardiology,
plastic surgery, and so on, a three-unit
dialysis department, a cardiac laboratory,
three ventilators, exclusive neo-natal and
cardiac intensive care units and 11 oper
ation theatres (OTs). The college has 11
lecture galleries too.
Said Dr. D. Mallikarjuna, Superin
tendent, Bapuji Hospital: “The hospital
has been regularly performing such pro
cedures as angioplasty', angiography, ecocardiography, coronary artery surgery,
valve replacement, total knee replace
ment surgery, keyhole surgery, ortho
paedic and laproscopic surgery and gall
FRONTLINE. DECEMBER 20. 2002
BAPUJI EDUCATIONAL ASSOCIATION
P.J. EXTENSION, DAVANGERE - 577 002 ( KARNATAKA STATE )
Telephones :(0819) 251302, 253550, 250659, 230236 Fax: 91-819-231201
BAPUJI DENTAL COLLEGE & HOSPITAL,
DAVANGERE
Bapuji Dental college & Hospital was established in the
year 1979 and was only the second Private Dental College
in the country. Within the next 4 years it proved its worth
to the Dental Council of India. The Dental Council of India
had no reservation in granting its recognition. In 1985-86
the college saw yet another break through, the opening of
Post Graduate Training Programme in various specialities.
In 1988 the college commenced the Dental Mechanics and
Dental Hygienist courses, which were approved and recog
nised by the Dental Council of India.
Courses Offered:
Under graduate BDS (Bachelor of Dental Surgery) 100 seats
per annum. Post Graduate MDS (Master of Dental Surgery)
SEATS
—
4
Oral Medicine & Radiology
1.
—
Oral & Maxillofacial Surgery/
6
2.
—
6
Pedodontics
3.
6
4.
Orthodontics
—
c
Periodontics
5.
.
—
Conservative & Endodontics
6
6.
—
7.
Prosthodontics
6
—
3
Preventive & Community Dentistr
8.
—
3
9.
Oral Pathology
affiliated to RajivGandhi University of Health Sciences,
Bangalore.
Admission:
Application form and prospectus can be obtained from the
Principal, Bapuji Dental College, Davangere - 577 004.
Karnataka or, payment of Rs.500/Advance Reservation:
Due to h.-,rush 'or seats, during the admission time, a
row seats !•
been set aside for advance reservation.
Enquiries to tivs effect can be made to the Chairman,
Bapuji Dn.itat College, Davangere This facility closes by
tne end of April, every year.
Contact Phone No.0819-220573, 220574, 220575, 220579
LP.Vishwaradhya
Chairman
COLLEGE OF DENTAL SCIENCES
DAVANGERE
College of Dental Sciences
Dr.Sadashiva Shetty
Prinicipal
B.D.S. Course
M.D.S. Course:
1. Oral Medicine & Radiology
2. Oral & Maxillofacial Surgery
3. Pedodontics & Preventive Dentistry
j
4. Orthodontics
Q
5. Periodontics
6. Conservative Dentistry & Endodontics
7. Prosthodontics
8. Community Dentistry
9. Oral Pathology & Microbiology
O Dental Hygienist & Dental Mechanic Courses.
I P Vishwaradhya
Dr.Subba Reddy
Chairman
Principal
J.J.M.MEDICAL COLLEGE, DAVANGERE
Post Graduate Degree / Diploma Courses
Degree Course:
1. M.S ANATOMY 2. M.D.PHYSIOLOGY3. M.D.BIOCHEMISTRY
4. M.D.PHARMACOLOGY 5. M.D.PATHOLOG 6. M.D.MICRIBIOLOGT
7. M.D.COMM.MEDICINE 8. M.S.OPHTHALMOLOG 10. M.S.E.N.T.
11. M.S.ORTHOPAEDIC 12. M.D.DERM.& VENER 13. M.D.ANEASTHESIA
14. M.D.PAEDIATRICS 15. M.D.GEN. MEDICINE 16. M.S.GEN. SURGERY
17. M.D.OBST.& GYNAE. 18. M.D.RADIODIAGNOSIS 19. M.D.PSYCHIATRY
DIPLOMA COURSE:
1. D.G.O. OBST. & GYNAECOLOGY 2. D.C.H. PEADIATRICS
3. D.V.D. DERMATOLOGY, VENEREOLOGY 4. D.A. ANAESTHESIA
5. D.M.R.D. RADIODIAGNOSIS 6. D.C.P. PATHOLOG
7. D.F.M. FORENSIC MEDICINE 8. D.O. OPHTHALMOLOGY
9. D'ORTHO ORTHOPAEDIACS 10. D.L.O. E.N.T 11. D.P.M.PSYCHIATRY
S Shivashankarappa
Chairman
J.J.M.Medicai College
Dr. M G Rajashekarappa
Principal
SPECIAL FEATURE: BAPUJI EDUCATIONAL ASSOCIATION
Big strides in dental education
RAVI SHARMA
HE two dental colleges run by the
Bapuji Educational Association, the
Bapuji Dental College and Hospital,
and the College of Dental Sciences, both
at Davangere, have a combined annual
intake of 200 students at the undergrad
uate level. None of the seats has re
mained unfilled unlike in several dental
colleges in Karnataka, and this fact
points to the high standards that rhe two
colleges have maintained
Said I.P. Viswaradhya, Chairman of
the two dental college•_< ‘Both the colleg
es are equipped w:rh sufficient dental
surgery chairs ana each college has its
own dedicated hospital. Both hospira!-.
conduct maxillo-facial surgery, which :
helpful in oral cancer ri : jiwk. A.L-a.
with a busy highway aassi.'ip ,’vc.i.
Davengere, rhe present o: A.•• • !■
tals is crucial for the rr.
. i...
dreds of motor accident •. :
A-A
the colleges are recognised by r ?, i
Council of India.”
The equipment available ar d?. cA
leges includes high-end, multi-purpose
and stereo microscopes, which arc con
nected to an LCD (liquid crystal dis
play) projector to enable a large number
of people to view the slide, high-end X-
T
ray machines such as the orthpantomograph (which enables rhe X-raying of the
whole jaw), a ceramic furnace, an induction-casting machine and a motor
cast (for ceramic and metal casts), soft
tissue analysers and microrones for both
soft (up to five microns) and hard (upto
75 microns) tissue biopsies. According
The College of Dental Sciences.
bladder/cyst removal”. The hospital warmers, phototherapy units, ventilators
conducts cleft-lip and palate surgery for and exchange transfusers and a biomed
children as part of the American-spon ical diagnostic laboratory. The institute
sored ‘Smile Train’ project. On call at also has a 14-bed paediatric ICU, which
the hospital are 140 doctors and 250 staff is equipped for echocardiograms, perito
nurses. “Occupancy rates hover between neal dialysis, ultrasound tests and com
50 and 60 per cent,” Malliputerised tomography.
karjuna said. According to
The institute has 12
Rajasekharappa the hospital
doctors and 35 specially
has been recording losses of
trained paediatric nurses; on
up to Rs.75 lakhs a year be
an average the institute gets
cause the charges have been
150 out-patients every day.
kept as low as possible.
The operations performed
Adjacent to the Bapuji
at the institute include those
Hospital is the Bapuji Child
related to intestinal obstruc
Health Institute and Re
tion, imperforate anus, oesearch Centre. Established
sophagealatresia, and so on.
on Children’s Day in 1993,
Only serious cardiac and
the institute aims to provide
multi-systematic anomalies
quality healthcare for chil
are not performed at the
dren. It provides round-the- R. Ramanand,
institute.
clock casualty services, has a chairman, Bapuji
According to Dr. G.
20-bed neo-natal intensive College of Pharmacy
Guruprasad, neonatologist,
care unit, which is equipped and Bapuji School of
35 per cent of all admissions
with incubators, radiant Pharmacy.
were to the 14-bed fully
98
to Viswaradhya, the combined assets of
the two colleges exceed Rs.50 crores.
One of specialities of the Bapuji
Dental College and Hospital is orthog
nathic surgery, which helps correct de
formities of the face. Explained Dr. K.
Sadashiva Sherry: “Hardly four or five
institutions are doing this kind of sur
gery in the country. It involves pre-surgical splinting, and then surgery. This is
performed when the jaw is protruding.
equipped paediatric ICU. “We are a us
er-friendly hospital. For example, all the
beds are normal sized. This is because in
India young children generally sleep with
their mothers. There is also a separate
parental area where parents can cook and
eat. We also have training programmes
for mothers (in breast-feeding), doctors
and nurses, and programmes to create
awareness on the prevention of motherto-child transmission of Acquired Im
mune Deficiency Syndrome (AIDS).
Part of the BEA’s initiatives in the
medical field are the Bapuji School of
Pharmacy, which was started in 1977
and the Bapuji Pharmacy College, which
was started in 1992. While the former
offers a two-year diploma in pharmacy
and has an intake of 60, the latter offers a
four-year Bachelor of Pharmacy course
with an intake 60 and a two-year Master
of Pharmacy course with an intake of 8.
Admissions are done through the Direc
torate of Medical Education, with a small
percentage of seats reserved for rhe manFRONTLINE. DECEMBER 20. 2002
BAPUJI EDUCATIONAL ASSOCIATION
P.J. EXTENSION, DAVANGERE - 577 002 ( KARNATAKA STATE )
Telephones :(0819) 251302, 253550, 250659, 230236
Fax: 91-819-231201
Smt. PARVATHAMMA SHAMANUR
SHIVASHANKARAPPA RESIDENTIAL SCHOOL
& JUNIOR COLLEGE, DAVANGERE
P.S.S.R. School is a high profile Residential School meant for ereating virtuous future Citizens of our country. It is situated at
serene, calm atmosphere, 10 k.m. from Davangere at Tolahunase.
The School is to be affiliated to C.B.S.E., New Delhi. This CoEducational Institution is from 5th Std. to 10th Std. & Junior
College.
Smt.Parvathainma Shamanur
Shivashankarappa Residential School
& Junior College
Special Features :
Well Guarded campus, Spack. ..
Well fuDished Dorr
"ate for Boys & Girls. Well Stocked Central Library
Well equipped Laboralor:--vifn faciiftwis »cr. . ■
Medical facilities, Modern Computer Centre,
attractive Fine Arts sec . ■ •
■ 1 •"xictjus
is for effective teaching - learning process backed
up by sound tutorial sy.'Tr
.c:.: P-e.. m .. • -L
, r 21 st Century Teacher-student ratio is 1:10.
Well trained, experience i S. . .
facilities all at affordable rates, Children are
nurtured through affection.
< f.mrriK.
For prospectus and Application ter. F .. . Cuntacl .
Principal, P.S.S.R. SCHOOL, Ph:(08132) 84322, 707471603'10 (R)
Pay Rs.400/- By Cash / M.O./D.D. drawn in favour of P.S.S.E.M. School, Davangere - 02.
S.S.Ganesh
Chairman
Shamanur Shivashankarappa
Hon.Sec., B.E A. & Ex-MP
BAPUJI COLLEGE OF NURSING
OFFERS:
1. Diploma in Nursing (School of Nursing)
2. Degree in Nursing (College of Nursing)
3. Post Graduate in Nursing
A S Veeranna, FCA
Chairman*123
Bapuji College of Nursing
BAPUJI PHARMACY COLLEGE
DAVANGERE
OFFERS:
1. Diploma in Pharmacy
2. Degree in Pharmacy
3. Post Graduage in Pharmacy
A S Veeranna, FCA
Chairman
Bapuji Pharmacy College
,
SPECIAL FEATURE: BAPUJI EDUCATIONAL ASSOCIATION
We diagnose whether the problem is
purely one of the teeth or involves both
the teeth and the jaw. If the problem
involves both, we first take up the ortho
dontic part (teeth are made ideal), then
perform oral surgery on the jaws.”
The Bapuji Dental College and
Hospital, which was started in 1979, has
an intake of 100 at the under-graduate
level and 48 at the post-graduate level.
Said Shetty: “The college has 250 dental
^jirs and occupies 175,000 square feet
^Rpace. In all, we have around 800 stu
dents. Our library has 5,800 books and
nearly 1,700 journals, and a video and
audio room where students and the staff
can avail themselves of free Internet fa
cilities and present case studies.” 1 he
college has a 25-bed hospital. i he ful
ly comprises mostly of forma s
.
of the institute.
According to faculty mt;. i
an average around 200 out
the college every day. The ■’< / ■
Department conduct • reguia • cjii.i- • .
schoolchildren and ; • ■is rural cat
, ■
ing die college’s mobile clinic.
The Department of Qu! Dm-.-ty
has remained in the li nclight lor k- im
pressive performance in the area of maxillo-facial surgery. Said Di. David
Tauro, a senior surgeon in the depart
ment: “We have been doing a lot of
k
*
■h
with accident and head- and- neck
ramour/cancer patients. In a recent acci
agement.
According to Dr. C.V.S.
Subrahmanyam, Principal, Ba
puji Pharmacy College, the
Rs.6-crore institute is equipped
with a pilot plant for the manu
facture of capsules, tablets, injec
tions, gels and syrups, 13
laboratories and a computerised
library. Added R. Ramanand,
Chairman of the two pharmacy
institutes: “Both the school and
the college have been rated as the
best in the State by the Pharma
cy Council of India (PCI) and
the All India Council for Tech
nical Education. After consider
ing the work done at our
Research Centre, the PCI has
given us a grant of Rs.8 lakhs.
We have applied for a further
Rs.70 lakhs as aid. Ours is the
only college that has started a PG
course in the region.”
Ramanand felt that rhe State
FRONTLINE, DECEMBER 20, 2002
tober 2002, our college
dent case, we augmented the
| was chosen by the Diplo
(deformed) cheek bone from
mat Nationale Board for
the hip. The operation was
performed not by making an
s the conduct of practical
^examinations in four spe
incision bur through rhe oral
cavity (mouth).”
cialities — oral surgery,
In 1991, the dental col
“orthodontics, conserva
lege was bifurcated and die
tive and endodontics and
College of Dental Sciences
prosthetics.” The colleg
was formed. In 1996, it
e’s out-patient depart
moved to a new 100,000
ment receives at least 350
patients every day.
sq.ft building. The college
has an intake of 100 students
Each of the college’s
departments has a semi
and 47 students ar the un
nar
hall,
which
is
der-graduate levels and post
equipped with a slide and
graduate levels respectively.
overhead projector for
It is equipped with 320 den I.P. Vlshwaradhya,
presentations. Said Satal surgery chairs and has a Chairman, Bapuji Dental
dashiva Reddy: “We have
10-bed hospital. Of die col College and College of
a 225-seat auditorium
lege's 594 students. 65 pel Douta! Sciences.
and, besides all the state<.cnt and 50 per cent ar the
uf-rhe-art equipment that is required by
rmder-graduatc and posrg
j ■speu.ivjy ,v. :
I h< •:
.< top-notch dental college, we have an
in era-oral digital camera, which enables
m equipmemmau.
rhe making of slides. It can also be con
aat die iiapuii Dema1
nected to a video cassette recorder. We
Hospital.
Tso undertake oral health counselling in
I he college ha-, me Ji-."
rural areas and have adopted five pri
ing rhe fust in South -I..;
chosen as an examination centre ' y the mary health centres, four in Davangere
Centre lor Evidence Basu; Dentistry district and one in Haveri. Camps are
and Informatics, Oxford. The college conducted at these centres — three days
has undertaken 36 dental educational for screening the patients and one day
for treatment. During the past three
programmes over the past four years.
Dr. V.V. Subba Reddy, Principal, months, we have been receiving nearly
College of Dental Sciences, said: “In Oc 150 patients every day. ■
Dr. M.G. Rajasekharappa, Principal, JJM Medical College.
s government was adopting a step| motherly attitude towards phar5 macy education, compared to
a medicine and engineering. “The
admission process is also affect
ing us badly,” Ramanand said.
The BEA also runs a school
of nursing, which was establish
ed in 1970, and a college of nurs
ing. While the school, which has
220 seats, offers a three-year di
ploma course, the college, which
has 190 sears, offers a four-year
degree course. The college start
ed a post-graduate course in
Community Health Nursing
and Medical Surgical Nursing in
2002. Student nurses are given
free accommodation in the hos
tels. According to A.S. Veeranna, Chairman of the governing
body that oversees the two in
stitutions, rhe association has ap
plied for an increase in the
intake. ■
99
SPECIAL FEATURE: BAPUJI EDUCATIONAL ASSOCIATION
Technical excellence
Imparting quality technical education is the mission of the Bapuji Institute of Engineering and
Technology, which is rated as one of the best in Karnataka.
RAVI SHARMA
ITH a number of innovations to its
credit, the Bapuji Institute of Engi
neering and Technology (BIET) stands
out both among the institutes run by the
Bapuji Educational Association (BEA)
and among the 110 engineering colleges in
Karnataka. Recently, it was voted as one of
the top 10 institutes in Karnataka. It is
affiliated to the Visveswaraiah Technolog
ical Universit}7 (VTU). Belgaum.
Established in 1979 on a 50-acre cam
pus at Davengere. the BIET has rhe pro'--;
sion of quality technical edi •. :-:«n • ■
students from the rural and sc-.:“
nomically backward com nr in;.
goal.
The institute started v. a r ■
es at the undergraduate level and . ■ i..
of 192 students. Today, it concL ;; . '
dergraduate studies in 12 branch
branches are available und • die v i . j
and has a student intake of 660. Ln the
academic year 2002-03, the institute start
ed undergraduate courses in Biotechnol
ogy and Bio-Medicine.
Postgraduate programmes such as
M.Tech are offered in disciplines such as
Textile Engineering, Machine Design,
Computer Science, Business Management
and Computer Application (52 courses at
the postgraduate level are available under
the VTU). There are adequate facilities at
the institute for research programmes that
lead to the Ph.D degree in subjects such as
Mechanical Engineering, Industrial Pro
duction, Computer Science, Environmen
tal Science, Chemistry and Textile
Technology.
The BIET is one of the 10 engineering
colleges in Karnataka to be accorded ac
creditation by the National Board of Ac
creditation
for
its
Mechanical
Engineering, Industrial Production Engi
neering, Electrical Engineering, Textile
Technology, Electronics and Communi
cation Engineering and Civil Engineering
branches for a period of three years from
April 2001. In addition the Computer
Science and Engineering and Instrumen
tation Technology courses have been ac
credited by the Institute of Engineers,
Kolkata.
W
too
The institute has excellent infrastruc
ture with well-equipped, independent, de
partmental and laborator}7 blocks, a large
(seating capacity of 600) and fully stocked
library (30,758 books and 166 journals),
in-house medical facilities and a captive
power plant, which cost more than Rs.20
crores. So far, the Institute has produced
over 6,500 engineers in various disciplines
and has bagged 264 ranks in Mysore and
Kuvempu universities since 1984. The cu
mulative average result of rhe institute
since its inception is 76 per cent.
Prof. Y. Vrushabhendrappa, Principal,
BIE i, said: “Sir
■ ur students
come from a rural badoound and are
■■ -■ --'ilv from .. - r
vally poor
' t i wc ha\ e
>
much
■ • • • i . big
cent are girls. vTushabbmdaappa has
served as the Principal of the college for
nearly 14 years, the longest period served
by the principal of any engineering college
in Karnataka, in 200 ’, he won the coveted
Bharathiya Vidya Bhavan National Award
for the best engineering c f.egc principal.
The BIET’s initiatives include the es
tablishment of‘continuing education’ and
product development cells, training of ar
tisans and the signing of a memorandum
of understanding with the informatia^
technology major IBM to train studJ^
for additional skills on hardware and soft
ware. The institute has been chosen by the
VTU as one of the 12 centres in Karnataka
to impart distance education.
The BIET has been adjudged rhe lead
college by the Karnataka State Council for
Science and Technology (KSCST) at their
annual jamboree on at least four occasions.
Vrushabhendrappa said: “Over the past 20
years, the KSCST’ has sanctioned 309 of
our student projects, of which 100 secured
prizes. We have been chosen as No. 1 for
excellence both in terms of the number of
projects selected for the exhibitions and in
terms of participation in seminars.”
According to Vrushabhendrappa, in
the past two academic years, though there
were no takers for as many as 6,000 engi
neering seats in Karnataka, the BIET
managed to fill almost all the seats. “In tin is
academic year we have filled up 75 of
90 management seats,” Vrushabhendn^"
pa said.
One of the outstanding departments at the Bapuji Institute of Engineering and
Technology is the Department of Textiles.
FRONTLINE, DECEMBER 20, 2002
SPECIAL FEATURE: BAPUJI EDUCATIONAL ASSOCIATION
One of the outstanding departments at the
BIET is the Department of Textiles. Es
tablished in 1982. it offers undergraduate
and postgraduate courses in Textile Tech
nology. It offers a Diploma in Textiles and
a vocational Textile Technician course.
The department is actively involved in re
search and consultancy projects with the
financial/technical assistance from the All
India Council for Technical Education,
the Department of Science and Technol
ogy, the Tata Energy Research Institute,
gfcjtIL Designs, the Karnataka Power
^F>m Development Corporation, Sun
Micro Computers and the Swiss Agency
for Development and Cooperation
(SDC). So far, the BIET has received
around Rs.4 crores by way of grants.
The collaborative sericulture develop
ment programme between the Ministry of
Textiles. Government of India, and ST 'C,
called rhe Seri 2000 program m
*,
Ji •>
being implemented in Kama?
-.'i!
Nadu. Andhra Pradesh and V
aims at enhancing the susta:
dian sericulture by impro-: >
productivity. The BIET, M
,
in the programme, made h..
in the commercial produciim:
■
ted fabrics and garments tisl.-.
mulberry- silk.
This technology augurs - :
industry' as it provides access to a
■
segment in both domestic and export marMore importantly, rhe fabric is devel^pcd using Indian mulberry silk, whereas
the bulk of current Indian silk exports de
pends on imported yarn. The BIET has
produced more than 40 varieties of silkknitted fabric structures that can be used
to produce inner as well as outer garments.
In order to market and manufacture the
silk-knitted fabric, the BIET has signed an
agreement with Stallion Garments, Tirupur.
Another spin-off of the Seri 2000 pro
gramme has been the BIET’s ‘Bapuji Seri
2000 Hank Dyeing Machine'. Dr. H.L
Vijaya Kumar, Head of the Textiles De
partment, said: “At present, rhe technol
ogy of dyeing silk yarn is not colour
guaranteed. To solve this yve developed
our hank dyeing machine. The semi-auto
matic machine, which yvorks on rhe coun
ter-current principle of dyeing, has a
number of advantages — needs no skilled
personnel to operate it, requires loyv main
tenance as compared to imported ma
chines, has a highly efficient spray sy r.-m
md a solenoid (temperature < in b fore
be i.onirol'ed), and most imp'.;-. •
/ ih-ji- •
and better coka‘ kilogram macl:’:- ; >>
I-.'.:.’
!c the five-Irik-J u-‘,bj. US iakhs."
• I - -■
■
’ •.-j-pc.i ?. iccb.iology v. i,.v
i?cd .c manufacture rhie.. wrier
be
used as yarn for furnish1’.:
carpets ot
apparels. It has also developed reennoiogy
for weaving silk waste into cotton cloth
(again tor fiirnishings), a computer-based
machine that measures the ‘hand’ (sheer,
thickness,
compressibility,
tensile
The Bapuji Polytechnic, which was started In 1984.
FRONTLINE, DECEMBER 20, 2002
strength and bending properties) of a fab
ric and costs a fracrion of its Japanese
equivalent; and proposed a project for the
development of silk and modal (an alter
native to viscose) for apparels.
Other departments have not remained
idle. The Mechanical Department has
used dry maize stems and areca fibres to
make laminated blockboards, developed a
technique that can be used to cut glass (up
to 20 mm thick) using hot air, and de
signed a pedal-operated silk-reeling ma
chine.
Over die past four years, the institute
has spent over Rs.50 lakhs on its Envi
ronment Study Centre. Said Vrushabhendrappa: “One of the projects that this
centre took up (it yvas sponsored by the
Government of Karnataka) yvas to exam
ine the potability of borewell water in the
districts ol Davangere, Dakshina Kanna
da. Haveri and Udipi. We rested the water
in over 15,000 yvells. The study showed
that 70 per cent of the water was nor pota
ble — fluorides, nitrates even lead and
chlorides yvere present beyond permissible
limits."
Over die past five years, the centre has
also been monitoring the Tungabhadra
rive- for air, water and pollutants.
According to Kassal S. Vittal, Chair
man, BIET, “most projects start off as stu
dent projects but get enlarged as
staff/commercial projects once they are
successful. Most projects are also the cul
mination of the efforts of more than one
department.’’ Vittal said further: “While
many of our projects are import substi
tutes, our facilities are regularly used by
industrialists from Karnataka and from
rhe neighbouring States as well."
The Bapuji Polytechnic is another ini
tiative of rhe BEA in technical education.
Started in 1984, the institute has an intake
of 260. According to Principal K.S. Veeresh, most of the 470 students (30 per cent
are girls) hail from a rural, non-Englishspeaking background. The institute offers
full-time three-year courses in Civil, Me
chanical, Electronics and Communica
tion, Computer Science, Electronics and
Electrical Engineering and Textile
Technology.
Given its record — results have ho
vered around the 70 per cent mark as
compared to the state average of 40 — the
polytechnic’s facilities have been chosen
by the Union Ministry of Human Re
source Development to train people.
Besides MCA and BCA courses, the
BEA is planning a BTech course in fash
ion technology from next year. ■
101
g
SPECIAL FEATURE; BAPUJI EDUCATIONAL ASSOCIATION
which came into being because of the lack
of guest lecturers who were prepared to
take time off from their busy schedules and
travel to Davangere to interact with the
students. Just as a ‘floating university’ takes
students around various countries, the ‘In
stitute on wheels’ rakes its students to the
metros and urban centres. Interaction with
business leaders, seminars and industrial
visits are arranged at each stopover in order
to expose rhe students to the rough and
rumble of the business world.
According to Narasing Rao, it is mo^
strenuous for an institute like the BIMJ^®
raise the academic standards of the stu
dents to an acceptable level, especially in
comparison to the Indian Institutes of
Management (IIMs). “While the IIMs get
the best students, we don’t. This is why we
have to work twice as hard,” he said.
With regard to job opportunities, Na
rasing Rao said: “The BEA has opened a
placement and consultancy centre in Ban
galore to facility c a better, faster and more
eifecrive coordination between, industry
and rhe institute, better interaction be
Prof. R.P. Narasing Rao, coordinator or
: TT- <
at A.::s STM a
tween personnel from industry and the
students at a conference.
cudents. The centre has a database of all
60
dems (the Association is uying co die students who are passing out and their
RAVI SHARMA
increase the figure ro 100). According ro curriculum vitae will be made available to
HE managements of most of DavanProf.R.P. Narasing Rao, coordinator, prospective employers. Campus interviews
gere’s once-famous textile mills may Bl MS, a large percentage of die students will also be arranged.” During the first year
have declared bankruptcy and closed shop. come from places in and around Davan of its opecirion, the centre was able to
But the principles of management are be gere, but there are students from Kerala, placof its 60 MBA students, mostly in
ing taught with gusto and panache in the Andhra Pradesh, Gujarat and Maharashtra
Bangalore, Hubli and Dharwad.
m
The BIMS campus also houses wP
city, at the Bapuji Institute of Manage too. Around 35 per cent of the students arc
ment Smdies (BIMS). Started in the aca girls. He said the student community had BEA’s Bapuji Institute of High-Tech Edu
demic year 1996-97, the college was shown a marked preference for manage cation, which offers a three-year Bachelor
initially run on the campus of the Bapuji ment courses. “This is why we have sought of Computer Applications (BCA) pro
Institute of Engineering and Technology' an increase in the college’s intake to 100.” gramme. The programme, which is affil
(BIET). However, in 2000, it was shifted
The college offers specialisation in iated ro Kuvempu University, has an
to a swanky' 60,000-square-foot premises, marketing, finance, human resources and annual intake of 80 students. Founded in
which has classrooms, a computer labora information technology. It has 10 faculty' 2000, the institute has a faculty that in
tory', a library, an auditorium, faculty members, who have distinguished aca cludes four permanent teachers, besides
chambers, guest rooms, and so on, with demic and professional records.
those who have been engaged on a tempo
state-of-the-art facilities.
The vision is to make
rary basis.
The college offers a two-year Masters the BIMS an “internation
According to Veeran
in Business Administration (MBA) Pro ally reputed management
na, buoyed by' the success
| of the MBA programme at
gramme, which is approved by the All In training institute” that will
dia Council for Technical Education. It is equip the youth “to become
the BIMS, the Association
affiliated, along with the BIET, to the Vis- effective managers and to
wants to launch a similiar
veswaraiah Technological University, Bel- morrow’s leaders”. The in
> exercise in Bangalore. “An
gaum. Said A.S. Veeranna, Chairman of stitute’s MBA programme
MBA college in Bangalore
the MBA programme: “Although six of offers training in quality
will allow us to interact
Davengere’s nine textile mills have been management through lec
more closely with industry.
closed, three sugar factories have come up.
With this in mind we have
tures, case studies, semi
Besides, Grasim Industries is also active in nars, group discussions,
identified some land at
the region. Management graduates are re continuous counselling and
Yashwantpur. The insti
quired. And we wanted to encourage rural guided study tours.
tute, which will have an in
students
to
learn
management
Another feature of the
take of 60, will come up in
techniques.”
MBA programme is the A.S. Veeranna, chairman of a couple of years,” Veeran
Currendy, the college has an intake of ‘Institute on
Wheels’, the MBA programme.
na said. ■
Making managers
The Bapuji Institute of Management Studies aims at emerging as
an internationally reputed management training centre.
T
102
FRONTLINE. DECEMBER 20, 2002
A PSM APPROACH TO PRIMARY. HEALTH CARE
The Declaration -»f Alma Ata marked a histories step in the
history of health.
it was the first clear international decla
ration that health which is . a state of complete physical, mental
and social-wellbeing,
and not merely the absence of disease or
infirmity, is a fundamental human right and that the attainment
of the highest possible level of health is a most important world
wide social goal whose real! zation requires the action of many
other social and economic sectors in addition to the health
sector' 1.
The Alma-Ata declaration was a major step forward for it
was beased on an understanding and implied that
(a)
'the main roots of poor health lie in the living
conditions and the environment in general,
and more
specifically in poverty, inequity and the unfair
redistribution of resources in relation to needs, both
inside individual countries and internationally.
(b)
That the people have the right and duty to participate
individually and collectively in the planning and
implementation of their health care.
(c)
a
Primary health care,
defined as "essential health care,
based on practical,
scientifically sound and socially
acceptable method and technology...
at a cost that the
community and country can affort to maintain atevery
stage of their development in the spirit of,
self-reli
ances & self determination., is the key to attain the’
target of health for all by 2000 AD'4.
Unfortunately despite the brilliant polemic and sweep of this
declaration, its implementation lags far behind,
since its adoption in practical tepms,
great slogan has had little impact.
and now 22 years
at least in India,
this-
Unfortunately the World
Health Organization who gave this call, has its contacts limited
to the health ministries and to medical and allied professionals,
and it is to these sections that the task of implementing this
programme went.
One critic ruefully comments 'Handing over the
implementation of PHC to the medical establishment was similar
to handing over the implementation of land reforms to landlords.' \
O^e outcome was to attach 'health for all by 2000 AD'
as a slogan
to already existing or on-going programmes or to set new series
of targets and then to device a series of selective vertical in
terventions- on immunisation, on iodization of salt on family
planning etc and to claim of all of this as part of a primary
health care implementation programme.
Not only is this a negation
of the primary health care approach, even the targets set in sele
ctive areas were seldom realized.
...2/-
The other major thrust of the present primary health
cave programme,
as it is in India, is the establishment of
primary health centres and the deployment of community health
workers-both at subcentres 'and .at village level.
run into serious problems.
This too has
Net only is the number’of health
workers that have been trained and deployed far short of what is
needed, but even those who are .deployed yield only a limited
quality of health service.
The selection,
training, monitoring
and motivation of the community health workers is so poor that most tend
tend to drop out & some even migrate and set up as quack medical •
practioneers themselves.
'Community participation', one important
planned feature, is in most places completely absent.
Almost
no research, planning or training goes into identifying- the
—
X
problems and working out the tactics of health care delivery.
—_
f
For the medical establishment, it is business as usual.
The last 10 years have seen the mushrooming of corporate private
hospitals and a number of private capitation-fee based medical
colleges.
A top few eminently 'successful' doctors preside
over medical association,
act on medical councils,
governments on health policy,
advise
serve on its commitees and working
groups, influence governmental decisions by virtue of their
physician-level
’’ersonal contacts with decision makers and in
many ‘a case even dominate research and private practice.
The
entire primary health care campaign and the Health for all by
2000 AD slogans are seen as empty politician's slogans or at
best as the department of P k.SM's responsibility.
Clearly
no major change is likely to be contributed by these sections.
It must be recognised that members of the medical profession
can do little in their professional capacities to achieve this
goal.
Medical & paramedical professionals are well positioned
to investigate the causes and consequences of ill health.
However they can rarely tackle the root cause of ill-healthhunger, poverty,
shelter, water,
sanitation,
employment, leisure
etc., Without tackling these basic questions-primary healthcare
as spelt out by the Alma-Ata declaration is not realizable.
This differentation between the wider concept of primary
health care and the narrower concept of primary health services
or basic medical services was not made in the original declaration.
But subsequent discussions and debates have repeatedly pointed
it out.6.
The basis or primary medical services realte to curative
services for simple ailments, & injuries, care for the pregnant
woman,
family planning, immunization,
and some degree- of health
education—all traditional areas of activity of health professionals
.. .3...
: 3 :-
It. is possible with adequate political backing and administra
tive will to immediately achieve,
large areas of the country.
such medical care at least in
It is possible for socially minded
doctors, helpted by donations or grants to provide such basic
medical services in remote rural areas or even in urban areas
where the poor have limited access to such health services.
There
is a record of numerous doctrs from a wide variety of backgrounds
the catholic hospitals associations,
the work at Nagapur,
Andhra Predesh,
have undertaken such work.
the people's polyclinics of
at Chikmagalur etc., who
Such work is a valuable contribution
but in terms of the a’ctual contribution to the health of the
community as measurable by indices the impact has only been’
Impact on health itself can only take place’by the
marginal.
implementation of primary health care in its broader concept.
Though provision of health services and essential drugs are a part
of the concept of primary health care, they are not the major part
or the focus of primary health care.
This should not however be interpreted to mean that health
professionals have no role in the implementation of primary health
The word 'doctor' is itself the derrivative of the word
care.
'to teach'
The doctor and other health professionals are looked
upon as a source of knowledge about health and disease.
Today
many of the ideas prevalent about disease, both right and wrong
and most of the health policies have been contributed by the medical
professional.
To view disease as an affliction of an individual
by a germ and lose its social dimensions is the result of a curative
bias,
that the PHC approach sets itself against.
The result of
such a bias in the sphere of health policy is to search fortechno-
logical or managerial solutions to what are essentially social
issues.
The doctor has contributed to such a bias and the doctor
can contribute to its unmaking also.
The people's Science Movement and indeed all other individual
group's & organisations desirous of realizing the goals enchrived
in the Aliaa Ata declaration need to plan for intervention to
prevent the demise of a powerful concept-Health for All, by
2000 A.D." A great concept should not be allowed to dissolve
into platitudes.
One of the primary areas that people'.s science
movements
can address themselves to is to create an awareness of what health
is,
to educate people of the causes of disease & ill health and
the ways of preventing disease.
most of the deaths,
To ppread the understanding that
especially in infants, in India are preven
table by very elementary measures and that it is possible to
provide health for all-is itself a great step forward.
....4...
4' :-
Health education has many limitations and pitfalls.
Much uf the health education current today is technical,
fragmented and culturally in-appropri ate, other than being for
that situation irrelvent.
Thus a health worker may deliver a
one hour lecture on diarrhoea, without ever mentioning that the
water source in that village should be safe.
probably preach a sermon on cleanliness,
Instead she would
suggest using boiled
for water all drinking purposes and finish with suggesting
oral vehydratioh therapy.
By the time' she reaches the most
useful part, both sympathy and inevest would have-been lost.
Or a class on nutrition may tell all mothers assembled that
they must give milk,
eggs,
fish,
fresh fruits & vegetables to
their children - when most of them are going hungry for want of
ability to purchase rise.
Even in many a people's Science
movement lecture we tend to leave out social causes and
possibilities of remedial collective action and instead stress on
technical causes and individual solutions.
It would of course be of little use if health education
lectures were only polemical or philosophical in nature and
discussed and curative knowledge will need to be imparted.
But
where collective action is the only real solution and the basic
problem is a health determinant like water or nutrition or
sanitation, health education should be aimed at exposing such
causes and appropriate remedical collective action.
The
health professional should provide the technical information,
if such is needed,
to justify,
a PSM effort to organising such
action.
Could health by itself serve as an entry point for
collective action?
The health worker-can she become the agent
of social change? . Can oppressed people be organized around
and for health issues.
Though this debate is far from over
some Indian experiences have replied in the negative.
'Health
work they feel has only weak political implementation and
without a proper political context not much of genuine people's
participation can be achieved in community health work done.
However most are agreed that 'health should be one of
the activities of a group trying to organise the rural poor
70
for justice and for development' '
.
The reception and popular response to proper health
education is also limited by the dominent culture of seeking
a pill or an injection as an instant remedy instead of trying
f»r a more scientific understanding of the cause of disease.
They come to the health professional for a 'cure'
knowledge.
and not for
Many health education strategies therefore choose
to combine therapeutic services with oral education-both within
the governmental and in the non-governmental sections.
Thus
the women waiting to see a doctor in the queue before a primary
health centre are given an half-hour lecture before he arrives,
or while they are waiting for their turn.
Or else after seeking
the.doctor they have to see a social worker who spends a few
minutes talking to her aoout her disease.
Both these of course
and only in an occassional centre, usually
are rare events,
run by a socially concious doctor do they really occur;
Experiences in the.pec-pi©'s science movement,
though
undoubtedly limited, have found greatest success where the health
education has been done in the form of a mass campaign’.
media used has been popular lectures,
slide shows,
The
strefet-theatre
(.the Kalajatha), posters and to a limited extent video.
The
popular response from the audience has been very positive but it
is difficult to evaluate the gains of such general health campaigns.
Campaigns focussed on specific issues especially on pro
vision of essential drugs and the drug policy have had a much
greater impact.
The KSSP in particular by its wide dissemi
nation of books on essential drugs and on hazardous or irrational
drugs, have been able to make a mark on drug consumption and pres
cription patterns.
To this end they have held seminars and guest
for doctors, campaigned in the local press, used posters
lectures
and .■ ’’ news papers and kalajathas to disseminate their views on
drug policy.
Their successful efforts to expose multinationals
selling anabolic steroids by intervening in the usual 5 star hotel
drug promotional campaign also won them popular support and media
coverage.
Such a wide variety of activities and on such a
scale needs a major organisational network and this the KSSP
had.
The KSSP organisational growth is a result of the wide
varieties of activities the KSSP takes up-covering issues like
environment,
science, education, health,
rural technologies
Science popularization, book publication and sales etc., to name
a few.
Undoubtedly the presence of such a wide base contributed
to the success of such a campaign-for the KSSP membership and the
oeople involved in the campaigns were from all walks of life-not
only health' professionals.
-------- * , . <-,•
e"".
*.
-■
~
other PSMs
This same advantages of
.
jiC~. - -J
r
k.
’ '
' '
being a
<5 i_.
(
f.2 ;
-an z .y'_
.. 6...
a
6 :a broad-based organisation ha's helped all PSMs in carrying out
effective health campaigns.
The K.R.V.P. the Lok Vigyan
Sangatana are some of theother PSMs who have held such campaigns on
held. th.
• .~
•
Another factor in the success of many KSSP programme is
their educational campaigns not only on health but also on en
vironment, do not stop at awareness generation but go on to
mobilizing people for collective action.
The scope for such
health education campaigns which lead on to direct collective
interventions by the people have not been adequately explored
by other PSM groups & health activists mamnly due to their
organ! sational weaknessess.
But as the PSMs continue to expand the scope for such action
increases exponentially.
It is possible non to plan for campaigns
for total immunization or control of diabotical diseases.
It
is also possible and needed to campaign for implementing iodized
salt distribution in the Terai & other iodine deficient areas
of the north while at the same time opposing the ill advised move
common salt, commercialize salt production-handing it over
to ban
to large monopoly houses all in the name of preventing a wide
incidence of goitre that, is far from established.
It is possible today to campaign extensively for ensuring
provision of the 25 essential drugs within 1 km of any habitation
and for banning hazardous drugs.
In select areas it may be even
possible to launch health education combined with collective action
against diseases like gyirieaworm
infestations which are poten--
tially easy to eradicate and even against di eases like leprosy,
ta measles which are potentially eraSicable even within the present
system with exi ting medic 1 knowledge.
Successful health education work however needs a lot of
careful planning and knowledge of local conditions and culture.
It also needs an analysis and understanding of the health problems
involved.
Given the bi - s of the medical establishment and official
structures today, one is seldom able to rely of official
documents and pronouncements alone to evolve a people's unders
tanding *
f
the issue.
As a r.sult one major area of people's
intervention has been to study health issues critically,
subject
them to meaningful debate and evolve an understanding on major
issues
7
7 :
There are many groups not-.' ly the groups associated with
Medicos friends^circule,
A.I.D.A.N.
Helhi Science Forum,
Karala Shastra Sahitya Pari shat,',,F.M„R. A.I • who".-’have made
major contributions in this regard.
Though due to their organisa
tional structure most such group-s" have limited themselves to presenting
such critiquSs are essential for -future action.
critiques,
Thdri
critiques could have formed the basis for collective action by
• ther groups Xike youth movements, women's organizations eta. but
in practice such a cross-fertization has°pvt occurred to any
significant decree.
Most such analytical,
theoretical contributions are desk
work relying largely jn secondary date or compilations from
various published scurces.
There are however a number of
significant health surveys and field studies by health activists
which has formed the basis for critiques.
Health problems
consequent tn the Bhopal gas tragedy, occupational disease in '
selective areas & industries,
the general health survey and the
study of primary health centre facilities in Kerala are some
examples rf such intervention.
It“needs be printed out that
the majir medical research institutes with elaborate research
facilities seldom study such topics.
The marked reluctance of
such institutes to undertake study on areas of immediate
relevance to people, especially if the topic'is likely to be .
controversial ano go against local vested interests in well
V
'
Unless health activists intervere actively in such
kro-.-n.
areas of research work, the PSM's and democratic groups wi ll be
unable to intervene in both the formulation of health policy
or even identify the deleterious effects o’f ill cuncieved
health-or developmental strategies.
'
Even theoretical work, based on analysis of published data
has a significant role to play.
The drug policy is one area
where health activists in India can take pride as being the
sole force to have oppossed the government1 s consistent pro
industry and anti-health policies.
And most of this inter
vention is based on study done by various health activists
themselves.
Similarly on patent law and on iodisation of salt,
official policies have been subjected to critical analysis and
have become or are becoming, the basis for collective action to
press for a charge.
However despite the few areas in' most fields,
the PSM s
and even all the health activists command inadequate knowledge,
Training,
experience and resources to present meaningful
..8..
8
critiques cr ev»lve alternative strategies.
There is an urgent necessity
for health activists to widen its contacts ami/ng trained and
sincere health professionals-who can help.
A large number ,of
doctors, e so crirail 1 y junior doctors and medical studentsand
many with good academic backgrounds are interested in a social
activity *
f
the medical system and willing, to contribute to it.
Their participation in the work of PSM should be ensured.
1
‘
Can PSM s go beyond health education campaigns (both general
health awareness and on specific issues)
and beyond presenting
critiques and critical reviwcs of health policy?
Can it attempt
to tackle the concept of primary health care in its entirety?
Can it by it^s work raise the level of health in a measurable
fashion or'•on tribute to such a rise in health status?
One approach" to these questions i s to work fcn a modeltQ take up an area varying in size from a village to a taluk
»,
• r district and in this area attempt to render primary health
a
care.
Teo eften what is rendered is only basic medical services
and then in the long run the results are not adequately rewarding.
However there are attempts t» integrate in such a model, basic
medical services with major health educational campaigns,
introduction of scientific inputs to upgrade existing rural
technologies andlartuching rural development schemes that
generate employment, provision of better nutrition not only
toirough income generation but by a more optimal use »f available
resources especially for children, provision of safe drinking
water and elementary1’sanitation and above all literacy education
and scientific awareness^.
The pe«pie' s science movement is
better equipped than me st groups to implement such an approach.
™
It has within it foldsponsiderable experience in rural technologies,
and .non forftial education, in running campaigns on
in literacy.
issues espeitally using local art-farms as a vehicle far new
ideas, in drinking-water and sanitation work - and in running
tj.asic health services.
It should be th@s
possible for such
a model to the built up with the available experience in the PSM s.
When building such models one deeds remember the past PSM
experience, that success ful campaigns need a critical size for
raising enthusiasm & for success.
diversions,
success is less and the project merely peters »ff.
What w
uld
*
del?
*
m
If work is too microscopic-. in
be the socio-p.litical implication
such a
At this time it is t>o- premature to make any prediction.
Definitely given existing social inequities such a model is npt
..9..
. /
:9 sautomatically replicable all over the country, by virtue of
its being successful in one place.
Even for the model area to
succeed social inequ.'ities will pose a problem but we need not
assun-e they are insurmountable ones.
(Such a model cannot therefore
be posed as the road to success of primary health care).
Then what would such a model contribute?
It co.uld by its
very presence and success help to pose the issue of an alternative
strategy to health care and development.
It could demonstrate
that health for all is possible - now, given the administrative and
It would help bring, by virtue of its experience,
political will.
the issue of health on to the agenda of national priorities where it is there notionally but not in practical terms.
In
organizational terms it would mean mobilizing new sections into
PSM activities and adding a newer dimension to activity.
aimed-
at social change.
What we should not do when the PSMs take up primary health
care work is to confine it to health services,
professionals.
and to health
Thereby we would be going back to locating health
issues as separate from other social problems and nurture the
belief that good health can be won by technological or managerial
inputs alone.
PSMs can organize people around health issues
only - if they link it up.
with other issues of development -
especially literacy, education andemployment.
One area of expanding PSM activity that offers immediate
scope for linking with the health issue is literacy.
The concept
of functional literacy as understood by ' ~ us, includes an
understanding of health.
Literacy,
and education by themselves,
independent of all otherfactors have been shown to be major
determinant of health status.
Women's literacy in particular
has been shown to affect, independent of other parameters, women's
health,
attitudes to family planning, number of children born and
infant mortality.
The process of imparting literacy is a useful
vehicle for the generation of scientific awareness of which health
awareness is an important aspect.
One major new area of contribution of PSMs is in adult
literacy.
With the landmark success of the Ernakulem campaign
and the subsequent initial experience of the on-going total
literacy campaign in PondicherryxGoa and Kerala it is likely that
PSMs can contribute significantly to health and literacy by their
role in evolving and cai§3Lyzing mass campaign approaches to total
literacy.
The Ernakulam literacy project is now being followed
. ...10....
by operation smiles - a project for 100% immunization in
Ernakulam district.
Diaorrheal .deaths & mortality have come
down significantly.
in pondisherry too a health phaseis likely
to follow the total literacy campaign.
The coming Bharat Gyan Vidyan Jatha, being organized by the
people's science movements of India isone major avenue for health
activists to enlarge the scope of their work.
The B.G.V.'i. aims
to organize one cultural groups of volunteers from all walks of life
in each of the 500 odd districts of India.
In each of these
districts the jatha will give performances at 120 to 150 centres.
Their performance is aimed at creating an awareness ef literacy
and science.
The basic organizational task of the BGVJ is to
organize 60,000 centres all over India to receive thesetroupes.
Each centre will also identify a resource persons to give 10
lectures each onetopic'.
One of these topics is ’Being Healthy1 -
a basic talk expalining the causes of diseases and the need and
nature of primary health care.
The generation of such wide and diverse voluntary network
of activists by the people's science movement opens up vast
potentials for future action by the peOp]_ et>ssci ence movement.
Literacy is ^©finitely the major follow-up action envisaged - and
definitely the issue we need to address ourselves to most urgently.
But it is not possible to open up actual teaching work in all
these 60,000 centres as follow up, nor will we be able to
sustain even the
active centres with a single point programme
of literacy alone.
Health is definitely one major thrust area
for follow up work in these centres.
The follow-up work may
take the form of health education campaigns or even of intervention
in areas like immunization, guinea work eradication etc.
Or there may be areas where we could attempt comprehensive
primary health care.
I .. i s premature at this stage when the
60,000 centres exist only on paper to plan for a detailed follow
up but we need to start thinking about it.
We can however state
confidently that the very, attempt to train 60,000 voluntures
to give a talk on primary health c'?-r® in every village of India,
is an unique attempt that is bound to throw up a major manpower
resource for futurehealth activities.
The People's Science Movement are only in an embryonic stage in
most of the states in India and its health work as an even smaller
pread.
This paper has touched on some areas and types of activities
for this movement to undertake but it is no means comprehensive or
final.
It is only presented as . a starting point for growing strate
gies and activttesthat will pool the available experience amongst
health activists and PSM activitsts.
We must use the opportunities
presented by the expanding PSM movement, especially the BGV?J for
developing a genuine peojble's health movement, and we must base such
a people's hea’lth movement firmly on the concept of primary health
care.
for schools and colleges ope
rated by the voluntary sector.
The principle is that every
citizen has a right to both
health care and education. The
duty of providing education
and health care devolves pri
marily on government. There
is an immense energy and re
sources of buildings and per
sonnel in the voluntary sector
in India, which at least at this
stage should not be jettisoned
by nationalization. The need is
to come to the assistance of
the voluntary system so that
those who conduct it can rea
lize their original goal of ser
ving a large number of poor
people in the area of their ins
titutions.
There is also need both at
the state and national levels
for a government commission
or other appropriate body
which can dialogue with volun
tary agencies and creatively
assist them especially for deter
mining goals, selecting priori
ties, for area planning, and
eventually for financing, so
that the maximum service may
be provided for the largest
number of people, till even
tually we can say that health
services, at least at the primary
level, are available for all our
people. We can be inspired to
believe this is possible, be
cause even now every citizen
can receive a letter through the
government
postal
service.
.Similarly, we cannot have
peace with a sense of responsi
bility until every citizen can
have the privilege of at least
elementary
education
and
primary health services.
An effective way of reaching
this goal, is by a joint and
planned effort of both govern
ment and voluntary agencies,
on a basis of mutual trust and
shared resources. This improve
ment cannot take place in the
present laissez-faire attitude of
government toward voluntary
hospitals and health cen
tres. There is need of recogni
tion by government of the
value of the national resource
we have in our vast voluntary
hospital system in India, and
to assist this system to contri
bute in the most effective way
possible to the realization .of
a more just society, and the
recognition of the human dig
nity of all our people, but
especially of those who are
most neglected.
COMMUNITY HEALTH CELL
326, V Main, I Block______
Koramangala
Bangalore-560034 '
India
13 paise for your health
How much money does the government spend on your health?
Given below in rupees are the per capita expenditure incurred
by each state on health
State/L.T.s
1974-75
1975-76
Nagaland
Pondicherry
Goa, Daman & Diu
Arunachal Pradesh
Meghalaya
Sikikm
Himachal Pradesh
Punjab
Jammu & Kashmir
Manipur
Kerala
Maharashtra
Rajasthan
Tripura
West Bengal
Haryana
Karnataka
Tamil Nadu
Gujarat
80.84
38.84
35.20
—
18.52
17.10
12.34
15.77
16.20
12.87
13.52
12.11
11.09
9.78
9.99
8.81
9.81
8.57
75.84
50.04
47.59
43.12
24.81
23.06
19.36
17.88
17.02
16.98
14.12
13.41
13.27
13.22
12.31:
11.19
11.26
10.94
10.68
ALL INDIA
9.44
10.63
Assam (including Mizoram)
Orissa
Andhra Pradesh
Madhya Pradesh
Uttar Pradesh
Bihar
9.56
6.93
7.85
8.38
5.08
4.09
10.27
9.13
8.86
6.98
5.36
4.46
But if you are in the villages
your share dwindles further.
As ■ Dr M. P. Mangudkar,
Chairman of the committee
appointed by the Government
of Maharashtra to study the
state of health services in
Maharashtra reported, out of
the total health expenditure of
3
Rs 156 million by the Govern
ment in the state, 80% was
spent on 3 cities — Bombay,
Pune and Nagpur; 6.2% was
spent on the district towns;
4.5% on the villages and 0.9%
on the tribal areas. Per capita
per year health expenditure
in the village was 13 paise 1
in the news
c m a i biennial, ch a convention
the major recommendations
of the convention was to ini
tiate diocesan health plans in
every diocese with a view to
integrate the
health services
rendered by various institu
tions and tailor their function
ing to the needs of the com
munity.
ENDORSING PRIMARY HEALTH CARE IS VicePRESIDENT B. D. JATTI welcomed bv Er Bernard
Moras, Executive Director, CHA.
Primary Health Care and
Community Health are no
more the controversial topics
they once used to be. This
issue of Health For the Mil
lions reports on the endorse
ment the world
community
has given to these concepts.
The Catholic Hospital As
sociation held its national hos
pital convention and exhibi
tion in New Delhi a month
later. A galaxy of experts ad
dressed the delegates on all
aspects of primary health care.
The scientific sessions made
detailed action plans. One of
Vice-President Mr B. D.
Jatti who inaugurated the con
vention
described
primary
health care as a “means of
humanising health care, which
has generally been performed
in a detached and coldly scien
tific manner with the least per
sonal equation between the
doctor and the patient.” Ac
cording to him primary health
care visualises the involvement
of thousands of workers. Peo
ple in large numbers will have
to take part in it.
“Perhaps,” he hoped, “as
we gather experience, it may
be possible to evolve a simple
technology more suited to our
conditions, thus reserving the
more advanced hospitals and
medical institutions for solving
more complicated problems.”
Nearer home both the Chris
tian
Medical
Association
(CMA1) and the Catholic Hos
pital Association of India,
CHA, two very large associa
tions of hospitals and health
care personnel have in their
recent annual meetings com
mitted to redefine and re
arrange their services to the
needs of the communities.
The three day biennial con
ference of CMAI, concluded
on September 14 at Kottayam,
was attended by 600 delegates.
The General
Secretary said
“Health services as currently
generated and offered to the
community by our institutions,
requires to be rearranged,
wherein it would become a
community based programme
and into which the hospital is
to find its relevance as an
essential component in the
spectrum of health care.”
WHAT’S COOKING UNDER PRESSURE? CHA thanks
Dr James S. Tong, a former executive director, and till
recently a member of its advisory board. Presenting the
token of gratitude is Sr Sara Kaithathara SCMM, Secre
tary, Executive Board, CHA.
4
at aima ata
world votes for primary health
The world's first International Conference on Primary Health Care concluded at AlmaAta, Soviet Union with a call to all nations to make primary health care for all people a
corner-stone of socio-economic development policy.
The six-day Conference,
sponsored by the World Health
Organization (WHO) and the
United
Nations
Children’s
(UNICEF),
focused
world
attention on the failure of exist
ing health services to serve
rural populations and the ur
ban poor. It sought a firm
commitment from governments
to remedy this situation.
The 140 nations attending
the Conference endorsed a
strategy aiming at a compre
hensive approach to the pro
motion of health, coordinating
all related activities with the
health services as such. Com
munity
participation
and
health education in the plan
ning and delivery of services
appropriate to each country’s
needs are key factors in the
strategy.
Stressing the need to ensure
coordination of health care
efforts with other sectors of
development,
the DirectorGeneral of WHO. Dr Halfdan
Mahler said nations must give
“absolute priority” to allocat
ing health resources for the
benefit of the most needy com
munities. He called for reforms
that would ensure availabi
lity of the needed trained man
power and technology to pro
vide primary health care ser
vices everywhere within 20
years. Dr Mahler urged govern
ments to formulate health care
patterns that they could afford,
and after reviews of health care
systems within the next two
years, to draw up national ac
tion plans.
Drawing special attention to
the urgent health needs of the
world’s children, the Executive
Director of UNICEF, Henry
R. Labouisse, said 15.5 million
infants and children die every
year for lack of health care.
Governments would have to
“drastically
re-order
their
priorities” if nationwide health
care was to become a reality.
This change of attitude would
have to begin at the top level
of government and national
leadership.
The challenge facing deve
loping countries was to devise
programmes capable of reach
ing everyone and still keeping
within the limits of available
resources, Mr Labouisse said.
The problem was not to extend
existing health services out
ward, but to “begin building
at the other end”, in villages
and city slums, and mobilize
the people themselves to im
prove health standards.
He
stressed the need for an inte
grated development approach,
in which primary health care
was vigorously supported by
concerted action on other
fronts such as safe water sup
ply, housing and better food
production.
Princess Ashraf of Iran
(Vice-President) pointed out
that primary health care im
plied true decentralization and
restructuring of community
organization on a democratic
basis. Effective power must be
delegated to the people con
cerned, rather than to a com
bination of vested interests
such as local chiefs and land
owners, she emphasized. She
also warned against the import
of “ready-made” health care
solutions that might not be
suitable to local conditions.
The importance of national
political commitment, the role
of the medical profession and
the recognition that health
care entails inter-sectoral effort
were some of the focal points
of the Conference’s delibera
tions.
Developing countries high
lighted funding and manpower
constraints to the development
5
of badly needed basic health
services.
While stressing the impor
tance of political will, some
delegates pointed to chronic
“brain drain” problem of doc
tors migrating to developed
countries as a major impedi
ment to national health pro
grammes.
Delegates emphasized that
health care went far beyond
provision of medical services
and called for a, concerted
developmental effort encom
passing nutrition, education,
environmental sanitation and
housing. It was a part of
over all national development
planning.
Divergent views emerged on
the question of whether ade
quate health care could be
provided without country-wide
deployment of qualified medi
cal workers. Some countries
urged large-scale expansion pf
medical services manned by
doctors and nurses, and felt
the use of grass-roots workers
could not meet the people’s
health needs. Others held that
primary health care was not
a second rate substitute for
conventional health services. It
was an indispensable first level
in a graded scale of health
services.
Debating national and inter
national commitment to prim
ary health care, many coun
tries stressed national policy as
the first pivot and urged selfreliance and equitable sharing
of available resources. This
had to precede outside assis
tance, it was felt. Each country
had to base its strategy on its
own situation and means. The
need for national plans that
suited each nation’s level of
development was underlined.
Some countries felt the bulk
of health funding should go to
THE NEED TO TRA
IN AND MOT1VATE
DOCTORS FOR RU
RAL SERVICES was
stressed at the confer
ence. Some countries
drew attention to the
high cost of medical
training. Many felt the
bulk oj health funding
should goto community
based health services.
community
based
primary
health services, and drew at
tention to the high cost of me
dical training. But others
stressed the need to also train
and motivate doctors for rural
services and develop different
levels of health services.
Hailing the Alma Ata Con
ference as a unique event be
cause it had brought diverse
nations together to discuss a
basic human right — the right
to health, .Senator Edward
Kennedy of the United States
condemned the persistent toll
taken by disease and lack of
health care as “an outrage”.
More than fifteen and a half
million children aged under
five will die this year; more
than 15 million of them would
be from developing countries,
be said.
Behind these statistics were
the faces of millions of people
“dying of diseases we can treat
or prevent entirely”. The world
would not tolerate a fraction
of this death toll if it occurred
during a war. The size of the
health problem generated a
feeling of hopelessness, and
nations needed the vision to
use available simple approaches
to solve the problem. The hu
man tragedy called for action,
not despair, he said.
He called upon nations to
help realize the WHO goals of
immunizing all children against
disease in the next decade.
This would give meaning to
the coming International Year
of the Child (IYC).
According to the declara
tion, primary health care
“(1) Reflects and evolves
from the economic condi
tions, and socio-cultural
and political characteristics
of the country and its com
munities and is based on the
application of the relevant
results of social, biomedical
and health services research
and public health expe
rience;
“(2) Addresses the main
health problems in the com
munity, providing promo
tive, preventive, curative,
and rehabilitative services
accordingly;
“(3) Includes
at least
education concerning pre
vailing health problems and
the methods of preventing
and controlling them, pro
motion of food supplies and
proper nutrition, an ade
quate supply of safe water
and basic sanitation, mater
nal and child health care,
including family planning,
immunization against the
major infectious diseases,
prevention and control of
locally endemic disease, ap
propriate treatment of com
mon diseases and injuries,
and provision of essential
drugs;
“(4) Involves, in addition
to the health sector, all re
lated sectors and aspects of
national and community
development, in particular
agriculture, animal husban
dry, food, industry, com
munications and other sec
tors and demands the co
ordinated efforts of all
those sectors.
6
“(5) Requires and pro
motes maximum community
and individual self-reliance
and participation in the
planning, organization, ope
ration and control of prim
ary health care, making the
fullest use of local, national
and other available re
sources, and to this end de
velops through appropriate
education the ability of
communities to participate;
“(6) Should be sustained
by integrated, functional
and mutually supportive re
ferral systems, leading to
the progressive improve
ment
of
comprehensive
health care for all, and giv
ing priority to those most in
need; and
“(7) Relies, at local and
referral levels, on health
workers, including physi
cians,
nurses,
midwives,
auxiliaries and community
workers as applicable, as
well as traditional practi
tioners as needed, suitably
trained socially and techni
cally to work as a health
team and to respond to the
expressed health needs of
the community.”
The declaration says: “An
acceptable level of health
can be attained for all the
people of the world by the
year 2000 through a fuller
and better use of the world’s
resources, a considerable
part of which are now spent
on armaments and military
conflicts.”
C7
(T
voluntary agencies
what can they do?
Excerpts from a paper presented by the World Federation of Public Health Associations,
at the Alma-Ata Conference. This paper is the outcome of a series of consultations among
non-governmental organizations in official relations with WHO and UNICEF, as well
as with other interested non-governmental bodies, national and international. The paper
stressed the vital contributions non-governmental organizations can make to development of
health care programmes.
In the field of health, the
voluntary organizations have
long helped to set standards
for practice, training, and con
tinuing education and to define
the role of health workers in
national programmes. Others
have concentrated on a parti
cular disease or activity (e.g.,
cardiovascular diseases, lep
rosy. tuberculosis, program
mes for the disabled).
The diverse programmes and
competencies of numerous or
ganizations, not directly in
volved in health care, also con
tribute in one way or another
to total human development.
They include projects to im
prove nutrition, food produc
tion. ano housing, provide safe
water, promote literacy, pro
vide educational and other
instructional materials, further
community development, pro
vide training in a broad range
of skills, protect the environ
ment, etc. In short, they are
helping to create conditions
conducive to the protection,
promotion and maintenance of
health and the prevention of
illness.
Recent years have seen a
growing capacity of non
governmental organizations to
develop patterns of coopera
tion among themselves, locally,
nationally, and internationally,
for consultation and exchange
of information, or for joint
action.
Non-governmental
organi
zations support the view that
the promotion of primary
health care • must be closely
tied to a concern for total hu
man development. The totality
of human development, and in
fact, a holistic view of health
encompasses the
physical,
mental, social, and spiritual
well-being of the individual.
Ill-hcalth comes to rich and
poor alike. However, much illhealth is a result of poverty
and in itself is a serious bar
rier to breaking out of the
bondage of poverty. Thus sub
stantial improvements in the
well-being of people cannot be
expected merely as a result of
belter health care, but require
a whole range of social, eco
nomic, political and cultural
activities, i.e., primary health
care must be an integral part
of the overall development of
society.
Human development cannot
be fragmented.
Social and
economic factors are closely
inter-related
and
• inter
dependent. It is not enough,
for example, to disseminate
health and nutrition education
if land tenure and utilization
preclude the production of
adequate food for local con
sumption. It is futile to pro
mote
a health insurance
scheme if employment oppor
tunities are so limited that
participation is beyond the
reach of many. Provision of a
source of clean water to a
communitv will have impact
on water-borne diseases' only
in so far as the community
is educated in its use and
management.
The integrated approach to
human development embodies
a concern for “people” rather
than
merely
“economic
growth". It takes into account
the needs and aspirations of
the population and aims at
providing the community with
the means to promote its own
well-being and to participate
in its own health care. All
factors that improve the qua
lity of life must be integrated
7
and made available. Meeting
community needs is the basis
for the design and implemen
tation of such activities and,
in satisfying those needs, pro
mote a confidence within the
community for further involve
ment in development activi
ties. Initiation of health care
services often provides the
opening wedge for a broader
approach to community deve
lopment. Efforts to secure the
fullest possible participation of
the community in all aspects
of this process arc dictated not
merely by considerations of
economy and efficiency but by
the conviction that this is an
enhancement of the individual,
a necessary part of achieving
a basic human right which is
presently unattainable in con
ditions of poverty. Where the
patterns of poverty, depen
dence, and marginalization are
engrained, a motivational pro
cess is needed to create an
awareness in those who believe
there can be no change, that
possibilities in fact do exist
for change.
There are several approaches
to health care and none is uni
versally applicable. The ap
propriate form of primary
health care will vary with the
differing needs of the commu
nity. There should be a ra
tional balance among the cura
tive, preventive, promotive,
and rehabilitative components.
Education of the community
is essential for maximum use
of the “primary” approach
and for increasing the respon
sibility of individual families
for their own health care, such
as well-informed self-medioation and modification of life
styles.
Ample opportunities for a
self-sustaining style of health
care can be realized by relat
ing the health care system to
other community development
programmes, such as fishing
and
farming
cooperatives,
credit unions and insurance
schemes.
Overfinancing
of
primary health care is as se
rious a problem as under
financing. It tends to create
unsustainable structures and
institutions, and to reinforce
patterns of dependency. ■ Levels
of external assistance must be
appropriately limited in order
to promote the self-reliant use
of local resources.
4. They can establish means
for greater collaboration and
coordination of primary health
care activities. This can be
done with voluntary sector,
and between government and
them, locally, nationally and
internationally.
5. Voluntary
organizations
can contribute to primary
health care in many ways
through programme implemen
tation. They can:
(a)
provide assistance to de
velop and/or strengthen
local voluntary organiza
tion capabilities and acti
vities with particular at
tention to local commu
nity development groups;
(b)
conduct reviews and as
sessment
of
existing
health and development
programmes
and assist
communities in the exer
cise of their own role in
such reviews. A greater
emphasis on evaluative
techniques will render
all new programmes more
accountable to real com
munity needs;
effective measures
1. At all stages in the deve
lopment of primary health care
programmes, voluntary orga
nizations can be effective. Re
cognition by government of
the contributions voluntary
organizations can make in
support of primary health care
will ensure maximum benefits
of these contributions to the
national health programme.
2. Voluntary
organizations
can work for greater under
standing and positive attitudes
toward primary health care
by:
fa) promoting dialogue with
in the vountary sector;
tor;
fb) sustaining dialogue with
governmental authorities;
(c)
providing information and
creating new ways of ex
plaining primary health
care to the general pub
lic; and
(d)
strengthening means of
communication to accom
plish this.
(c)
develop innovative pro
grammes placing prim
ary health care in the
context of comprehensive
human development;
td) ensure that their existing
programmes and new ini
tiatives promote full par
ticipation by individuals
and communities in the
planning, implementation,
and control of these pro
grammes;
(e)
expand
their
training
efforts to respond to the
needs of primary health
programmes, e.g., train
ing of health workers,
supervisors,
administra
tors, planners and various
agricultural
and deve
lopment workers. Includ
ed would be training
schemes which build on
the skills of traditional
healers and midwives;
(f)
extend their efforts to de
velop locally sustainable
and appropriate health
technologies and use of
resources, with
particu
lar attention to energy,
water, agriculture, sani
tation and medical care;
(g)
contribute to the creation
of new and effective me
thods of health educa
tion which enable both
individuals and communi
ties to assume greater res
ponsibility for their own
health:
(h)
recognize the essential
role of women in health
promotion and in the full
range of community de
velopment concerns; and
(i)
further extend their capa
city of work with poor,
disadvantaged, and re
mote populations, en
abling them to break the
cycle of deprivation, and
in this way contribute to
the search for greater so
cial justice.
NEW INITIATIVES
TO PROMOTE PAR
TICIPATION :
Health Workers train
ed by voluntary organi
zations speak the local
dialect and idioms and
ore better understood
by the community.
3. Voluntary
organizations
can assist national policy for
mation in the areas of health
care and integrated human
development. They can present
health care needs based on
their contacts with communi
ties, and they can also inter
pret primary health care plans
to relevant donor agencies.
8
primary health care
a muslim response
.. .P' ' !C*,lr'a Mathews and her team have increased the awareness in the predominantly
i iushm community of Malappuram, Kerala. Women who have earlier refused to go outoors are now trained as community health workers and are becoming instruments of social
change. When health comes development does not lag behind.
e
tions and impure water supply
will cause infectious diseases.
In order to-improve these con
ditions, the centre has with
the cooperation and participa
tion of the people, launched
programmes for repairing and
deepening existing wells, pro
viding water sealed latrines
slabs to those who dig enclos
ed latrine pits, and for digging
compost pit. There is already
a marked decline of worm in
festation, diarrhoea, dysentery,
and typhoid in areas where
these programmes have been
started. Exhibitions, teaching
demonstrations of well balanc
ed and low cost diets, supply
of seeds for kitchen gardens,
have all helped reinforce nutri
tion education.
The cilinics pay special im
portance to treatment of T.B.
and leprosy, and provide lep
rosy patients with special shoes
at subsidized costs. A signifi
cant effort is made by the cen
tre to train local dais and basic
health workers. The role of the
9
local dais is very important
for the promotion of health in
the project area. The tradi
tional job for dais is to con
duct home deliveries and also
take care of the mother and
the baby for a few days. They
are illiterate and untrained
people.
So these local dais
are trained by the public
health nurse for a period df
nine months to conduct safe
home deliveries and also take
care of the newborn babies.
They direct the abnormal and
complicated cases to the main
centre. Along with other basic
health workers, these dais are.
ialso taught the basic aspects
of health. So far seventy-two
Muslim women between the
ages of 20 and 45 years in the
project area have been trained
in four batches as both dais
and basic health workers, and
three other women have re
ceived training as basic health
workers only. It is worth not
ing that the Muslim women
who always remained in their
homes.
1
HEALTH EDUCATION IS THE SECOND PRIORITY.
Basic health workers, many of whom Muslim women.
are also active health educators. They carry flash cards
and other teaching materials while on regular house visits.
COMMUNITY HEALTH CELL
326, V Main, Block
Kbrsmongala
Health education is the se
cond priority.
Basic health
workers, health visitors, auxi
liary nurse Midwives, local
dais,
and
public
health
nurses are all taking an
active interest in this through
regular house visits in addi
tion to conducting classes at
the clinic centres and the main
centres.
People are taught
that unhygienic living condi-
India
Project areas are selected
from the municipality and
panchayat, and at present
cover a population of almost
20.000. Among
the various
projects undertaken in com
munity health work, the first
priority has been given to ma
ternal and child health care.
Weekly antenatal clinics are
conducted at all
centres as
well as the main centre. This
work includes medical check
up; detection and correction
of toxemia,
anaemia, nutri
tional deficiencies; teaching
personal hygiene and diet; im
munization against tetanus.
The underfives clinics maintain
growth charts of the child
ren, immunize them, treat them
for minor ailments and worm
infestation. The community is
also advised on the advantages
of the small family norm
Bsngaloro-560034 -
Malappuram, a
predomi
nantly Muslim area in Kerala
has the lowest literacy rate,
and the highest incidence of
population growth, infant mor
tality, and T.B. in the entire
state.
Recognizing the need
for a few outreach approach
to the health problems of the
community, and
acceptance,
approval and their active co
operation, the Christian Wel
fare Centre started a commu
nity health project under the
direction of
Dr Victoria
Mathews and Mr Tharyan
Mathews in February 1972.
without participating in the
social activities are now pre
pared to go out of their homes
with the approval of their
men folk, to attend health
training classes conducted by
the centre. It is no exaggera
tion to state that there is a
craving for knowledge and also
an awakening among these
women and men in the Muslim
community.
Once they complete their
training, the basic health wor
kers conduct house visits, bring
children for immunization and
and pregnant mothers for
check up. promote family plan
ning, conduct health educa
tion, giving cooking demons
trations, help in the MCH and
underfives’ clinics, and work as
intermediary personnel bet
ween the community and the
centre.
Caring for the physical
health needs is not enough;
and mental health is closely
related to economic stability,
in areas where exploitation and
illiteracy have been the pass
word for ages. Tn order to
help people help themselves
economically, the Christian
Welfare Centre gives profes
sional training to girls who
are unable to continue their
academic studies. The centre
also gives interest free loans of
Rs 100 to Rs 200 for invest
ment in a small business or
industry like buying and sell
ing poultry and fish, cultivat
ing vegetables, making char
coal, etc. So far, almost every
one has repaid the loan by
monthly instalments.
The centre, which works in
close cooperation with local
community health leaders, local
doctors, primary health centres,
paramedical workers, and other
women’s organizations, will
take on school health program
mes, using teachers as media
for promotion of health; start
adult education; and supply
scholarships to needy and eligi
ble students in project areas to
continue their education.
Community health program
mes under the Christian Wel
fare Centre have created a
great awareness among the
TO PROVIDE HYGIENIC LIVING CONDITIONS the
Centre with the cooperation and participation of the people
has launched programmes for providing water sealed
latrines. There is already a marked decline of worm
infestation, diarrhoea, dysentery and typhoid.
traditional and orthodox peo
ple in the project areas. They
realize the possibility of con
trolling diseases and also im
proving their existing living
conditions economically and
healthwise by their own efforts.
Diseases like worm infestation,
diarrhoea, respiratory disorders
and
nutritional
deficiencies
among the people in the pro
ject areas have been reduced
considerably. Change is no
more looked upon with dis
trust, but has become a way
to a better life.
important opportunity
health based community
development course
The Voluntary Health Association of India plans
to run a four to six weeks residential course on “Health
Based Community Development”. This course will be
held in the Comprehensive Rural Health Project of
Jamkhed, Maharashtra, from 4 January to February 14,
1979.
Candidates for this course should be already involved
or about to be involved in a Community Health Pro
gramme. The number of candidates will be restricted.
Those interested in this course should write to :
Miss Ruth Harnar, VHAI, C-14 Conununity Centre,
SDA, New Delhi - 110 016.
10
industrial relations act
fair to one fair to all
Hosnitals
6 C»-°SC ,otTtlle monsoon season of Parliament, end of August 1978, the
of Emnlovnwnt n'-C 1°?’ Institutior* (Conditions of Service of Employees and Settlement
h-.nnvPt„\T? D,lpujes2 Bi" No 141’ 1978’ "‘is presented in u.c
the mm
Lok □Sabha. We are
employ ees bSerVC that *’C B111 k favo,,raWc
the benefit of hospitals,, patients and
We now point out in summary of the notable features of the Bill.
Purpose: To consolidate
and amend the law relating to
the conditions of service of
employees in hospitals and
educational institutions with a
view to securing the welfare
of such employees, and for the
investigation and settlement of
disputes between such emp
loyees and
their employers,
and for .matters
connected
therewith or incidental thereto.
Possible Exemption :
The
appropriate government (state
or central) is authorized to
exempt an institution from the
operation of the Bill, if the
government is satisfied that
the grievance
procedures of
the institution are equivalent
to those required by the Bill,
and arc found to be working
satisfactorily'.
Coverage: The Bill applies
equally to all hospitals, gov
ernment, voluntary and com
mercial.
Special Character of Hospi
tals Recognized : The Bill re
cognizes that hospitals and
educational institutions have
special
characteristics,
and
an atmosphere which eschews
conflict has to be maintained in
them. For this reason hospi
tals and educational
institu
tions arc excluded from the
general Industrial Relations
Bill. This hospital Bill, how
ever, does intend to provide
adequate protection for emp
loyees, and set up a rational
procedure for settling of dis
putes.
Small Institutions Exempted:
Institutions
employing
less
than
twenty persons
are
exempted from the provisions
of this Bill.
Employee: The word is
meant to include those who
arc not serving in an adminis
trative capacity, and who
draw less than Rs 1,000 per
month.
of the association may be a
person who is not employed
in the institution. If the re
quisite conditions are fulfilled,
the employer shall recognize
the association.
Consultative Council: Every
hospital or educational insti
tution shall establish a Con
sultative Council for the ins
titution. The
Consultative
Council shall consist of not
less than six and not more
than twelve members repre
senting both employer and em
ployees. The number repre
senting the employees
shall
equal the number represent
ing the employer. The emplo
yer may nominate the chair
man of the Consultative Coun
cil.
Strike and Lockout Prohi
bited : No employee of a hos
pital or educational institution,
in breach of contract, may go
on strike, and no employer
shall lockout his employees.
Central Requirement of the
Act: Every hospital or edu
cational institution must set
up a Grievance Settlement
Committee. This committee
must have not less than four
and not more than eight mem
bers representing both emp
loyer and employees. The re
presentatives of the employees
must equal in number those
of the employer. The employer
may appoint the chairman of
the committee.
Term of Office : For both
Grievance Settlement Commit
tee and Consultative Council
the term of office of members
shall not be less than two years
and not more than five years.
Employees May Have an
Association : If the majority
of the employees desire to
have an association for the
benefit of the employees and
the institution, they may have
it. However, no office bearer
11
Arbiters: The appropriate
government must maintain a
roster of arbiters to assist
when necessary in the settle
ment of disputes.
However,
the parlies to the dispute are
not obliged to choose an ar
biter on the government list,
but may agree on one of their
own choice.
Certain Regulations to be
Formed : Every employer ins
titution shall
make regula
tions pertaining to method of
recruitment, qualifications for
appointment and eligibility for
promotions, and procedures for
settling disputes before appeal
is made to the Grievance
Settlement Committee, as well
as regulations concerning the
procedures of operation for
the Grievance Settlement Com
mittee.
Arbitration: If the dispute
cannot be settled agreeably
by the Grievance Settlement
Committee, or by private ar
bitration, the next step is to
proceed to arbitration by an
arbiter or a board of arbiters
appointed by government. The
decision of the arbiter will
normally be final. Before arbit
ration, however, every effort
should be made to settle the
problem by the Consultative
Council of the institution or
by the Grievance
Committee.
Settlement
Rules for
Implementation
of This Hill (Act, if Passed):
The appropriate government is
authorized to make suitable
rules for the implementation
of this Bill when and if passed
into an Act. A copy of the Bill,
which is eighteen pages, may
be obtained free of cost from
the office of the Voluntary
Health Association of India.
All readers and members are
requested to read the Bill and
to send their comments dr
suggestions for improving the
wording of the Bill to :
Executive Director, Volun
tary Health Association of
India, C-14 Community Cen
tre,
S.D.A., New Delhi 110016.
health in parliament
In Gujarat, eight districts
have been brought under the
Community Health Workers
Scheme. In these districts, the
reorientation training under
■Multipurpose Workers was
completed by April 1977. It
has also been introduced in
one primary health centre
from each of the remaining
districts.
Earlier, Mr. Yadav had in
formed the Lok Sabha that
about 42,000 CHWs have
been trained in three batches
all over India. Another 14,000
such workers are presently
undergoing training in the
fourth batch.
against blindness
The government has launch
ed a programme of “Prophy
laxis against blindness due to
vitamin A deficiency among
children between1 to 5 years
of age." Linder this program
me children between the spe
cified ages are given a dose of
vitamin A in oil every six
months. The programme which
started in the Southern and
Eastern states during 1970-71
has now been extended to
cover all of India.
provide immediate eye relief
through mobile units in the re
mote areas, and also under
takes surveys of the commu
nity including pre-school and
school-going children for early
detection of eye trouble. The
programme aims at develop
ing permanent infrastructures
for comprehensive eye care
services at the primary health
centres, laluka and district
hospitals,
medical colleges,
and
Regional Institute of
Ophthalmology.
handicapped
The government, gives assis
tance to voluntary organiza
tions for the establishment and
maintenance of SET Centres.
The Department of
Social
Welfare, under its scheme of
“Assistance to Voluntary Or
ganizations for the Handicap
ped” gives financial assistance
upto a maximum of 90 per
cent or deficit to those volun
tary agencies which propose
to create or expand services
for the education,
training
and rehabilitation of physical
ly handicapped. These include
cured leprosy patients.
**
In order to take eye care
closer to the people^ the gov
ernment has also launched a
programme for Prevention of
Visual Impairment and Con
trol of Blindness. This pro
gramme. the Minister said,
will educate the community in
eye care measures so as to
preserve sight and
prevent
visual impairment. It seeks to
The expert committee on
population projections has esti
mated that the expectation of
life at birth for males and fe
males will be 52.62 years and
51.55 years respectively as on
1st September, 1978.
This was stated in the Lok
Sabha by the Minister of State
for Health and Family welfare.
drugs
small percentage
*
life expectancy
Mr Yadav acknowledged that
only a very small percentage
of patients suffering from
Sexually Transmitted Diseases,
go to the general hospitals for
treatment.
He informed the
House that at present there
are 237 STD clinics and 106
medical colleges where proper
diagnosis and free treatment
are available.
12
The Minister of Petroleum,
Chemicals & Fertilizers, Mr
H. N. Bahuguna, told Lok
Sabha on August 28th that a
close watch is maintained over
the availability of essential
drugs. The supply position of
drugs and pharmaceuticals is
by and large satisfactory.
Occasionally reports of short
ages of patent or proprietary
products are received but in
these cases equivalent substi
tutes of other produces are
available.
Recently
reports
about the non-availability of
proprietary and non-proprietary
substitutes in respect of the
following formulations have
been received :
1) Dapsone Tablets.
2) Adrenaline in Oil Injec
tion.
3) Neoepinine Tablets.
4) Clinestrol Injection and
Tablets.
5) Gas-Gangrene
Anti
Toxin.
6) Insulin Lente.
7) Ethyl Chloride Spray.
8) Mycostatin Tablets.
Suitable action to relieve the
shortages has been taken in
consultation with the manufac
turers concerned.
news from delhi...
□ The Union
Ministry of
Health and Family Welfare is
introducing a new scheme to
more fully involve traditional
midwives, “dais”, in maternal
and child health care in the
rural areas.
The scheme will be intro
duced first in twelve districts
of Bihar. Orissa, Madhya Pra
desh. Rajasthan,
and Uttar
Pradesh. These districts have
been chosen for their high con
centration of tribal, scheduled
caste and backward class po
pulation and their high inci
dence of infant mortality.
The emphasis of this scheme
is on improving antenatal care,
reducing mother
and child
mortality, and
popularizing
small families. Each subcentre
in the district will have four
dais. These dais will notify
pregnancy cases in their areas
to the officer in charge, ensur
ing supervision from the early
stages.
They will
conduct
normal deliveries, advise on
the advantages of small fami
lies. distribute condoms, and
assist the health worker in
getting the children immuniz
ed. Cases that are complicated
or those needing medical ter
mination will be referred to the
officer in charge. The dais will
also be trained to recognize
signs and symptoms of com
municable diseases.
Under this scheme,
the
dais will be paid an honora
rium of Rs 50 per month.
Announcing the scheme, Mr
Jagdambi
Prasad
Yadav,
Union Minister of State for
Health and Family Welfare,
said that this would, for the
first time, take maternal and
child health care to some of
the most backward and in
accessible areas
in these
states. He stressed the relation
ship between high incidence
of child mortality and large
families.
Improved maternal
and child health care, he was
confident, would lead people
to accept the small family
norm.
The scheme is estimated to
cost a little over one and a half
crores rupees during the entire
■Sixth Plan period.
□ The Community Health De
partment of the Holy Family
Hospital, Delhi organized a
seminar on Community Health.
It was attended by twenty
participants from dispensaries
around Delhi. Sr Anne Cum
mins,
Ruth Harnar
and
Ashok
Subramanian
from
VHA1 led sessions on commumunity health planning, pro
ject review and the village
health worker.
and the states
kerala
The Annua] General Body
Meeting of the Kerala VHS
was held on July 19, 1978. Dr
S Joseph from MGDM Hospi
tal and Sr Philomena Marie
were re-elected as President
and Secretary respectively.
□ A two-day seminar on Per
sonnel Management in Hospi
tals was held in Kottayam in
July. Topics discussed included
problems of personnel manage
ment, the merits of group in
surance scheme as a staff wel
fare measure, disputes, grie
vance procedures and machi
nery for settlement of disputes,
and the Supreme Court judge
ment.
□ A three-day seminar was
held at the Post-graduate Ins
titute of Social Work, Kalamassery, on Social Aware
ness. The discussion covered
the need for change, analysis
of the socio-economic condi
tions, adult literacy program
me and its role in overall
development.
karnataka
□ Our Lady of Lourde, Charit
able Hospital, Kelgheri Road,
Dharwar and Karnatak Ayurved Vidyapeeth Society’s Hos
pital, Dharwar have been en
rolled as new members of the
Karnataka VHA.
13
□ The Karnataka VHA orga
nized a seminar in Hospital
Finance at Fr Muller’s Hospi
tal, Mangalore from September
12 to 16. Two representatives
from six- hospitals and two
medical colleges were invited.
Fr Norhona, who has succeed
ed Fr Moras as the Adminis
trator of FMCI, inaugurated
the seminar.
The seminar was unique in
that the participants discussed
certain theoretical aspects of a
good accounting and financial
hospital system, broke up into
groups and observed each area
in actual operation at Fr Mul
ler’s Hospital. The main sec
tions included in the observa
tions were billing, payroll, ac
counting and financial report
ing and purchasing and stores.
One area was selected for an
aftenoon session of discussion
and comments for each day.
Besides the above, sessions
were held on hospital legisla
tion, financial management in
cluding proper use of hospital
resources and financial analy
sis.
Much of the success of the
seminar was due to the time
and effort given by Mr George
Sebastian, Finance Officer of
FMCI. Most of the partici
pants were appreciative of the
fact that the accounting staff
of the hospital did not hesitate
to show all the records, ans
wer questions and indicate
cate areas where the system
still could be improved. The
participants agreed that discuss-
inn a specific system in rela
tion to theory was much
more meaningful than merely
classroom exercises.
respondence the needs, prob
lems and expectations of the
members.
bihar
Besides
Mr Nabert of
VHAI. experts on Income
Tax. financial analysis and
auditing assisted Mr George
Sebastian in conducting the
seminar.
Gujarat
□ The- Western Region VHA
secretaries met in Ahmedabad
from July 12 to 15. Present
were Fr Urrutia, Dipti Dikshit,
Sr Terezina Dias, Dr Porwal,
Denis Carlo. Marjorie Hill and
Ruth Harnar of VHAI. Dis
cussions included the job des
criptions of the organizing sec
retaries, goals and priorities
of VHAI and the VHAs, rela
tionship of the organizing secre
tary to the executive boards of
VHAI and the VHAs, and
the future of state associations
with particular reference to
financing.
As a result of the discus
sions, the participants agreed
on the need to share informa
tion about legal matters, re
sources and project through
periodic newsletters, act as a
liaison between the govern
ment and the association mem
bers, organize seminars, and
discover through visits and cor
n A training programme for
the -‘Trainers of Village Health
Workers” was held in August
at the Kurji Holy Family Hos
pital in Patna. Sr Anne Cum
mins and Ruth Harnar of
VHAI participated. A similar
programme was held earlier in
March at the Kodarma Holy
Family Hospital. The Patna
team, which attended the
March programme, started an
initial training programme for
village health workers of eight
villages at Beriarpur alongwith" tiie adult literacy camp.
As a result, the VHWs initiat
ed the cleaning of a few village
wells with the total support
and participation of the com
munity. They have also suc
ceeded in involving the gov
ernment and the people to
gether in their massive immu
nization
programme. Over
1000 people below the age of
twenty have been administered
B.C.G. The opportunity pro
vided by the campaign was
fully and
effectively utilized
for health education.
□ Five dispensaries in the P'alamau district. Bihar, are plan
ning an integrated health pro
gramme. With the assistance
of Simone
Liegeois
and
Manab
Chakravarlhy
of
VHAI they are conducting a
study of health needs and their
economics in their area of
work, and planning out pro
grammes and priorities.
n A total education camp was
organized at Khadigram near
Jamul, Bihar, Fr P. J. Manthara for the Santhal popula
tion of Lakshmipur Block.
The camp aimed at helping
the people realize Gandhiji’s
dream of “Real Swarajya”. The
participants discussed all their
problems in the socio-econo
mic. political and health con
texts.
Literacy classes for children,
young men and women gene
rated' much interest. There was
a weekly evaluation session.
In the health field, a medical
team from the Holy Family
Hospital. Patna, trained village
health
workers
for
five
weeks on maintenance of
health through nutrition edu
cation, family welfare, child
care, immunization, recogni,
lion and treatment of common
diseases and sanitation. In ad
dition, a lady was elected to
function as a midwife.
The camp which lasted al
most seven weeks helped the
participants gain awareness of
their rights, and the need for
unity in attaining them.
Maharashtra
MOVES IN THE WESTERN FRONT. Marjorie Hill
from Madhya Pradesh, Sr Terezina Dias and Dr Porwal
from Rajasthan and Fr Urrutia of Gujarat at the Western
Region meet.
14
The Catholic Relief Services,
Bombay, organized a work
shop
on Training Village
Health Workers at Jamkhed
from July 17 to 27, with the
help of Sr Anne Cummins and
Ruth Harnar of VHAI. Dr
Arole and his staff members
explained the philosophy and
the beginning of their project,
and the selection and training
of village health workers. The
role of the members of a health
team was discussed along with
community organization. The
session on nutrition gave par
ticular emphasis to the CRS
nutrition education programnlc- tncluding role clarification
ot the consignee.
o rvj
■
COVER STORY COMMUKJTV WHAITH
more socio-epidemiolsgically oriented political and ecological dimensions.
Understanding health in its d. more democratic oriented
whohstit sense — which involves the
More participatory and democra
biological, social, economic, cultural, tic in its growth, planning and
decision making process.
Box Ko 14
e. more accountable
health. They thus have to be fully
THE AHW8P MANIFESTO FOB
Increasing subservience of medi
and really involved in the making of cine, technology, structures and
PRIMARY HEALTH CAf^E
decisions which affect their professional actions to the needs
Academicians, community health
health, including of course, the and hopes of the people, the patients,
specialists and practitioners from
provision of health services.
the consumers, the 'beneficiaries'
several industrialised and Third
World countries
gathered in * Health services must provide and the communities which they
both curative and preventive care, seek to serve.
Antwerp, in November 1985, for 2
as well as promotive and
, day seminar where they took stock
This confrontation of value
rehabilitative measures. This has systems and re-orientation will help
| of the achievements of the Primary
to
be
done
in
a
coordinated
and
i Health Care approach.
the superstructure and its different
integrated way which responds to elements to emerge from their !
Since the 1970 Alma Ata
the people's needs.
present ivory-towered isolation and I
Conference, the member states of
The
Primary Health Care appro irrelevance and gradually become
the World Health Organization
agreed that this Primary Health ach is being used with success in supportive infrastructure of a more
' Care strategy, which sees people as many parts of the world. Being a just and healthy society. However
active partners, is the most suited to continuous process, much remains this change cannot be miraculous or
based on just good intentions or any
\ answer their needs and can provide to be done.
This manifesto is issued because amount of wishful thinking. It must be
the basis for Health for All.
However, in Third World countries, the proliferation of selective health a serious commitment to social
: in spite of the lessons of history and intervention programmes under analysis, participatory evaluation and
-eater
j of past experiences, major national mines the health services at the critical self-searching fc
relevance
by
all
those
c
icerned
exact
moment
when
they
try
to
I and international donor agencies are
■ Diverting scarce resources into a reorganise themselves towards with planning and decision making in
the present superstructure.
' short term approach known as Primary Health Care.
It
is
issued
also
because
these
I “selective primary health care". This
I approach concentrates exclusively interventions purport to offer "quick COMMUNITY HEALTH:
I on certain interventions claimed to solutions" and "instant success" for IS A MOVEMENT EMERGING ?
be the most efficient and aimed only which they divert scarce resources
A study of the dynamics of j
j at sections of the population. This from the solution of the real community based health action and i
self-contradictory term should be underlying and continuing problems, the evolving approaches from micro
e-.el exoeihenee show that 'corrmubanned, since at their best, such thus helping to maintain ill health.
y 'itarj-j'jJr; •ueu'j'-it
trog-sm.TSS can triiy xe corsitiereo
in atranxtr., Experience Tee. taugnt
as "selective health status interven us that selective interventions tend i movement linked to a wider
tions". This approach is in total to become permanent even though development and socia_[ change
contradiction with the fundamental they are presented as "interim" process in the country. I here are
principle underlying Primary Health responses only. In fact, they need many positive trends which support
specific structures which a country this possibility. However, there are
Care.
<
could not easily get rid of at the many negative trends as well whic1These principles are:
could become major obstacles for a
★ The main swts of poor health lie in moment it decided to reorient its
genuine health movement in the
health
policy
towards
comprehensive
living conditions and the'environ
Primary Health Care.
country.
ment in general, and more
And, above all, the selective The positive trends are —
specifically in poverty, inequity and
the unfair redistribution of approach rules cut the possibility of i. Policy reflections of the Government
Policy documents and expert
resources in relation to needs, people's participation in decision
committee reports have been
both inside individual countries making about their own health.
The undersigned thus wish to echoing new approaches. Many
and internationally.
: * Since health is only one of the reaffirm the principles of Primary decision makers, administrators and
'
concerns of people, it is self- Health Care in its comprehensive technocrats within the entrenched
defeating not to consider them as form, and reject other approaches medical system are aware of these
partners who are able to play a instituted and propagated as new approaches.
ii. “Village Health Worker Army"
j
great part in the protection and "selective primary health care".
t. grc.wr.rg army of z." age's and la /
the improvement c! their cron
more 'community' oriented
Understanding health in its
community sense and not just as the
problem of individuals.
b.
c.
L
HEALTH ACTION JULY 1989 •L’T
C 'r> r - ) \ ■
THE NEW ORIENTATION
OF HEALTH SERVICES, WITH RESPECT
TO PRIMARY HEALTH CARE WORK
COMMUNITY HEALTH CELL
326, V Main. I Block
Koramungala
Bangalore-560034
India
The booklet entitled "Health Work for Human Development"
contains the conclusions reached by a Working Group set up
by the Pontifical Council COR UNUM in 1976 in order to
examine Primary Health Care.
A second group was convened in Rome from 31 March to
2 April 1977, to examine the new orientations of health services
to fit in with this Primary Health Care policy.
Experts drawn from many different areas of the medical and
health care profession put forward their viewpoints based on
their own experience and research in a very useful series of
discussions. They looked at Christians' responsibilities and
those of the religious congregations in the light of the new
orientations. Being all too aware of the way in which situations
can vary one from another, and of the complexity of the
problems, they rejected the idea of prescribing formulae on
methods to be used. Any comments made regarding structures
at whatever level were only attempts to concretize the
problems in order to be able to search for the most suitable
solutions.
1.
1.1.
THE CHRISTIAN APPROACH
The attitudes taken by Christ
Christ took pity on people and came to their aid, whether
they were spiritually ill as a result of sin or physically sick. His
1
• ,• (■
attention was given to the sick person with whom he frequently
talked, showing his preference for the poor, but without
excluding anyone in need who appealed to him. Accounts of
his miracles have been recorded where he restored people to
health, teaching us that we also, with whatever means we have,
must be concerned for those who suffer sickness, and do what
we can to comfort and heal them.
1.2.
Populorum Progressio
Jesus considered suffering and sickness as forming part of
the "less human" situations which the Encyclical "Populorum
Progressio" asks us to endeavour to make "more human" (cf.
Populorum Progressio. 20). If we wish to be faithful to Christ
and take up his attitudes with regard to our fellow-men, we
must work for the overall development of each man, and focus
on the sick person more than on his sickness. Since develop
ment also means solidarity, we must necessarily turn our
attention towards the human community of the patient, his
family first, but also his neighbourhood or village. This means
we must practise community medicine.
The "quality of life" of his environment is important to
ensure that the sick person will be restored to physical
and psychological health, so that with the aid of his human
community he can duly take charge of his own evolution towards
a more human state, thereby becoming the craftsman of his own
development.
The grassroots community responsibility for Primary Health
Care work has the advantage of following the principle of
subsidiarity. Health-care personal, following this principle,
serve at the same time, their own personnel development.
Mastering their impatience, they listen and learn before they
organize. They are more concerned with fostering action than
undertaking it themselves.
1.3.
Evangelii Nuntiandi
As Christians, we are evangelizers, as the apostolic
exhortation "Evangelii Nuntiandi" reminds us. We are bearers
2
the Good News, of the whole and jointly responsible salvation
of man in Christ. We proclaim this Good News through the
witness of our lives, and by taking up the saving attitudes
manifested by Christ towards each person, his environment and
his traditions. Through us the Church evangelizes men and
their communities. Through us and our commitment to health
care work, the Church proclaims evangelical liberation to the
millions of human beings whose physical and spiritual health
is affected.
1.4.
The need for conversion
The mission that we have been given is a call for a true
conversion of our hearts and also of our methods. Secularization
is spreading in people's hearts from the industrialized and
technological world to the developing world countries. We
need to be converted all the time in order to bear witness as
Christians to the sick who, through our work, will discover the
love of Christ. The rapid development in the field of health
service technology has often meant installing expensive
equipment in the hospitals, requiring a large number of staff for
a. relatively low number of patients, while in many of the
same countries in the world, up to 80% of the population
are still without health-care services. Since Christians are
the leaven, we must reach out towards the masses by
providing simple, accessible and promotional health care
according to our own possibilities, modest as they are, or in
conjunction with the public services, where this is allowed.
Let us ever be mindful of the fact that service to the sick
begins and continues to operate through the patient's humani
environment. Community health care Is therefore part of the
comprehensive pastoral work of the Church.
2.
2.1.
PRIMARY HEALTH CARE IN THE LOCAL COMMUNITY
National health service policy
Any primary health-care organization in local communities
must take account of the health service policies laid down by
3
the authorities of the country in charge of the general running of
health services.
2.2.
The basic principles of W.H.O.
The organization of primary health care services must help
each individual person in his own community. The true
needs of this community must bo taken into consideration and
it must be encouraged and helped into contributing to its own
development. Primary health care brings health services to the
patient and is concerned with prevention of disease as well as
early treatment where this is needed. In this respect, we
follow the basic principles laid down by the Executive Council
of the World Health Organization at the January 1975 meeting
in Geneva, ratified subsequently by the various governments
concerned.
1. Primary health care should be shaped around the life
pattern of the population it should serve.
2 ■ The local population should be actively involved in the
formulation of health care activities, so that health care can be
brought into line with local needs and priorities.
3. Health care offered should place a maximum reliance on
available community resources, especially those which have
hitherto remained untapped, and should remain within the
stringent cost limitations that are often present.
4. Primary health care should be an integrated approach of
preventive, curative and promotive services for both the commu
nity and the individual.
5. All health interventions should be undertaken, at the
most peripheral practicable level of the health services by the
worker most simply trained for this activity.
6. Other echelons of services should be designed in
support of the needs of the peripheral level, especially as
this pertains to technical supply, supervision and referral
support.
7. Primary health care services should be fully integrated
with the services of the other sectors involved in community
4
development (agriculture, education, public works, housing and
communication.)
2.3.
The local community
It is vitally important to be aware of the sociological situa
tion of the community. This includes the composition and
growth trend of the local population. Its traditions and custo
mary laws, the various social and economic problems and all the
conditions on which the overall and balanced development of
the community depends, including its health—an integrating
factor which cannot be neglected.
The members of the community must be helped, where!
necessary, to become aware of their own problems and to I
express them so that, here again, they become the craftsmen
of their own development. They alone are in a position, for
example, to explain why they are afraid of the hospital, why
they seek medical care late in the day, why the womenfolk
prefer to give birth at home, what dying with dignity means to
them, surrounded by their family, etc.
2.4.
The community health worker
These profoundly human factors make it possible to share
out the responsibilities for organizing primary health care. There
is a wide variety of different things to be done, and some of
them were brought to the attention of the Working Group. In
the examples which follow, there is no desire to impose a
specific pattern or model for the programmes which are to
be implemented. They are simply a way of illustrating what a
primary health care service in a local community can be. In
some countries, a grassroot Community Health Committee is
formed whose members are chosen by the community. They
may be dignitaries in the community, government officers, etc.,
or simply persons whose personality or capability makes them
suitable for such a task. This Committee makes known the
health care needs of the people they represent and appoints the
community health worker. Whatever be the title given to this
5
person, and this varies in different countries, he or she is the
one selected by the community. He (or she) is given the
basic training to be able to provide primary health care, usually
on a part-time basis, while still continuing his/her normal daily
work.
The health worker's tasks depend upon local conditions,
but in general they may bo summed up in the words of the
WHO in "The Primary Health Worker" (Experimental edition,
1977, pp. 4-5).
"1. care for the health of the inhabitants and look after
community hygiene;
2. give care and advice, in accordance with the instructions
written down in the guide or given by his supervisor, to anyone
who consults him;
3. send patients to the nearest health centre or hospital in
any case in which the guide instructs him to do so (evacuation
or referral) and In any cose not covered by the guide. The
PHW should therefore confine his care and treatment to those
cases, conditions and situations described in the guide;
4. with authorization from the local authorities, visit all
dwellings and give those living in them advice on how to
prevent disease and learn good habits of hygiene;
5. make regular reports to the local authorities on the health
of the people and on conditions of hygiene in the community.
Get the local authorities and the people to give him the help- and
support he needs for his work;
6. keep in as close contact as possible with his supervisor
so as to be able to give of his best in his work and to obtain
the equipment and supplies he needs;
7. promote community development activities and play an
active part in them."
The training required, which may be graded in complexity,
should initially be given on the spot by slow and gradual training
process, given while actually "on the job". Unless the individual
concerned is so talented that the training is going to be
followed up at a later stage to "professional" level, the
training should not be so advanced that the individual is pushed
6
beyond his capacity. Sometimes it is a good idea to train local
healers or traditional "doctors" to becoftje community health
workers, If they are willing.
Although each community Is called upon to look after its
own health care problems with its own means as far as it is
able, in accordance with the principle of subsidiarity, thereby ,
enabling it to work out its own development, it should not
be loaded with so many responsibilities that it finds it cannot
cope with. The public authorities, who have drawn up an
inventory of the immediate resources available (personnel,
drugs and medical supplies etc.) must allocate them fairly for
the benefit of the local communities as well.
3.
QUALIFIED HEALTH SERVICE PERSONNEL
Each individual country has the task of determining the
type of personnel required, and their respective role, In the
light of the training to be given. A great many experiences
and ventures undertaken in the past have shown that a unified
terminology would be very helpful and in this, assistance of
WHO would be appreciated.
We simply wish to mention certain constants that our own
experiences and generally recognized requirements have shown
to exist in the various types of personnel required, and their
respective tasks. These constantswill enable us to see in what
direction we should be moving in order to play our part,
especially since we are often numbered amongst the promoters.
3.1.
Health care auxiliaries
One of the first levels of health service personnel is that of
auxiliaries, whose responsibilities, recruitment, training and
motivation need to be examined. These are people who should
be able to undertake tasks on their own. They also have to
assist the doctor to perform many tasks in preventive and cura
tive medicine. They work both in medical centres and with the
community health workers. The latter's training may be given
by certain auxiliaries, whose supervision they will accept. This
7
Supervision not only gives them security but also provides them
with on-going training, since it is not so much a question of
controlling them, as counselling them as they carry out their
work. The auxiliaries are recruited both from those who apply
for the work directly, or who are nominated by the local commu
nity, as well as from among those community health workers
who show the right sort of ability and know their human
environment sufficiently well. It must not be forgotten, how
ever, that they do not always continue their work on a long-term
basis, and this is a cause for concern.
Their training, which should be also given on an ongoing,
continual basis including the period they are actually performing
their health care work, can be at various different levels of skills
and responsibilities. It should be provided by professional per
sonnel such as the medical team that supervises them. The res
ponsibilities which are entrusted to the auxiliaries under this
new primary health care policy demand serious motivation.
They must consider their function not so much as a form of per
sonal development as a service to the community. It is a service
which demands the highest moral conscience if dangerous devia
tions are to be averted. The auxiliaries must never lose sight of
their own limitations in terms of medical skills, and of their need
to be in continual training. Their professional conscientiousness
must constantly keep their spirit of service alive in their minds.
The nursing staff
On account of their qualification and skills, nurses frequently
have to aid the local people to grasp the fact that their health is
in need of attention, and to encourage them to aspire to im
proved health and a changed way of living. Since they will give
top priority to prevention and health education, they will also
devote their efforts to training community health workers and
auxiliaries. They can be helped by the qualified midwives who
can undertake some of the same tasks, and they also assist the
doctor in organizing primary health care services. This new role
for nursing staff of both sexes, and of qualified midwives,
demands the right training on a continuous basis, as well as
deep motivation. This is a need of all the health care personnel.
3.2.
8
3.3.
The doctor
COMMUNITY HEALTH CELL
326. V Mein. I Block
Korarriongnlo
Bangalore-560034
India
This new health care policy alters the role of the doctor,
but does not make it any the less essential. The doctor needs
not only new motivation, but a training that will enable him to
respond to all the demands that will be made on him as a mem
ber of a health care team. He must be capable of coping both
with the challenges of sickness and those of under-develop
ment. He must learn to consider his vocation as a doctor as a
call to be of service to the community rather than a means of
personal development. The reluctance to go out and serve in
rural areas, which is far too widespread, has to be overcome.
3.4.
The health care team
Since the health care is entrusted with the task of promoting
health in a context of true community development, and it is not
merely a means for accomplishing routine work such as distri
buting medicine, there should be a genuine team spirit among
them.
I his health care team usually comprises the following mem
bers : the doctor, the nursesand the auxiliaries, and also the
community health workers and traditional midwives. The fact
that they have different educational background and training,
different tasks to perform and different degrees of commitment
to the service of the sick and their communities, sometimes in
evitably leads to tensions or psychological conflict within the
health team. It is the leader's responsibility to restore harmony,
if he is unable to prevent them occurring In the first instance.
The responsibilities of this health care team include planning
the various tasks the team has to carry out. The team must also
provide medical treatment, nursing care, hygiene education and
be sensitive to the psychological problems and comprehensive
needs of their fellow-men. This shows how important it is for
the members of the team to have a comprehensive training and
background.
9
4.
THE THINKING UNDERLYING THE CHURCH'S
NEW APPROACH TO HEALTH CARE
The emphasis given to the new primary health care policy
has shown the vital importance of a whole motivational approach
on the part of those who work in the health field or for health
improvement. Unless this new approach on the part of the per
sonnel In Inculcated through npoclal cournnn that need thorough
planning and Implementation by highly qualified staff, the new
orientation to be followed by the various health services will
simply not come about. The "Christian approach" outlined
above looked at the motivation underlying the Church's parti
cular interest In this new approach to health services for which
the Church and its personnel take on direct responsibility.
4.1.
The health care centre
The health care centre stands midway between the village
and the hospital, and must have a dispensary with a few beds
for emergency admissions. The number of emergency bedswill
depend on the population served by the centre and the distance
from the nearest hospital. The team must look after a certain
number of villages which will be using their services for more
complicated cases ; the centre is in charge of preventive, curative
and development work.
The team must also help the community healil? workers in
the various communities by providing them with continuous
advice, supervision and supplies.
A team motivated and oriented in this way will really partici
pate in the implementation of the new health care policy.
4.2.
The hospital
The rural hospital is the point of reference for a number of
health centres which refer the patients they cannot handle to it,
or those in need of surgery.
The hospital team is most important. It must look after all
the hospital's needs, as well as provide continuous training and
10
Supervision to its health care centres. It may be called upon to
make up mobile health teams. Eventually these may be nucleus
of a new health care centre.
Where the team includes a pharmacist, he or she can help in
the training of personnel and, where appropriate, can help edu
cate the local people in basic public health, hygiene and simple
nutrition, though this latter is more usually done by n nutritionist.
I ho category of personnel known as health Inspectors can
be very valuable members of the team and provide aid both to
the health centres and the community health workers.
To the hospital team falls the responsibility of handling the
hospital administration problems. Where the hospital falls under
the responsibility of a Board of Governors or Directors, a
Management Board or a similar kind of body, the local commu
nities must be represented on it.
The doctor and one paramedical staff representative are
habitually ex officio members of such a board.
In a larger town there is usually a regional hospital to which
the rural hospitals in its catchment area refer the patients whom
they are unable to treat themselves. The medical team in these
hospitals needs to be larger and more highly qualified to be able
to meet all of its responsibilities. In order to avoid overburden
ing this hospital with the basic needs of the local population, it
may have an annexed dispensary, either adjacent to it or even in
another part of the town.
4.3.
Childbirth
K new orientation could also be introduced in the case of
maternity units which would only be used for the difficult births.
Very serious difficulties would of course be referred to the hospi
tal. Childbirth could normally be organized In the mother's home
once the health care services really do cover the whole of the
local population, particularly through careful training given to
the traditional midwives. Maternity units can be independent
units or wards attached to the health centre.
The maternity units also have the task of training the mid
wives. Part of their instruction should include the teaching
Cor-JM
• M li
mii. c ■
st
n.-. ■
■ ■ 01.
, l.vad
methods by which they can help their patients toward respon
sible parenthood using natural methods for child spacing in
the general context of the promotion of the family.
5.
CHRISTIANS' RESPONSIBILITIES
5.1. Evangelical motivation
Christians are citizens just like anyone else, and must be
committed to the struggle against under-development. The
example and the teaching of Christ and the exhortations of the
Popes shed light on this commitment and serve as a guide and
encouragement to them in their work which they undertake for
the love of God and their fellow-men. If they work in the field
of medicine and nursing, the evangelical reflections mentioned
at the beginning will lead them to ongoing conversion of heart
to provide a better service on behalf of the suffering members of
Christ and to awaken the communities of men to their responsi
bilities in this area.
—
5.2.
Relations with the government
In the past, the laity or members of the religious congrega
tions have often pioneered healthcare work in many countries.
In some instances today, their work is being taken over by the
government which sees health work as a part of its duty towards
its citizens and for which it accepts responsibility. Far from feel
ing discouraged or useless as a result of this new state of
affairs, they must see it as a golden opportunity to play an active ;
part in the national endeavour to bring about integral and J
mutually responsible human development.
The religious congregations are called to reinforce their ’
basic attitudes of cooperation with all organizations at whatever
level, and in particular with the governments. This cooperation,
respecting the specific role of all concerned (for example, the
vocation and constitutions of the religious) should always be
offered with the one concern of attending to the true needs of
the sick and their communities.
—
The hospitals and health care centres for which the congre
gations are responsible and where they provide a Christian spirit
of service, are there for the benefit of the whole population with
out any racial or religious discrimination. They must be ready
to provide their services in those areas out of reach of the public
health network, insofar as their personnel and financial resour
ces permit.
Where they run schools for nursing or auxiliary staff, the
training curriculum, animated by the Christian spirit, must con
form to the requirements laid down by the government, so that
the personnel trained there will have a state-recognized quali
fication and can, one day, join the public health service if they
wish. Wherever religious personnel undertake tasks alongside
professional people in the public sector, they must demonstrate
their constant concern to bo fully integrated Into the medical
teams running the areas in which they work.
' situation
While this new primary health care policy is taking shape.
members of the religious congregations must take a good hard
look at the current conditions under which they are working in
order—where necessary—to re-direct them. It sometimes
happens that as a result of changes which not everyone is
necessarily aware of, too many of them work in hospitals and
health centres that have become too expensive for the majority
of the population, and are only within reach of the pockets of a
certain' elite" who can afford them. In this case the leaven is
too far removed from the loaf.
5.4.
New orientation
The religious congregations are by no means ill-equipped
to take part in the necessary new orientation process. Although
it may happen that in some cases some of their hospital workers
are somewhat distant from the masses, so many others are work
ing closely with local communities and are in close contact with
the people in rural areas or poor urban areas.
12
13
Their experience can be profitably used by everyone,
since they really know the true needs and deep-seated aspira
tions of the local people. Before they take part in this new
health care policy, those in charge of religious congregations
must see if they have the necessary means to do so, especially
in terms of manpower, trained and suitable for the work, and
with the right motivation.
Having the right kind of training for the personnel will be
valuable to the country. Special care must be devoted to training
foreign1 personnel so that they have a good knowledge of the
environment and the psychology of the people with whom they
will work. Local and foreign1 personnel must be spread over the
various services in the local community and the hospital accord
ing to their skills and qualifications so that the population
everywhere may have increasingly free access to health care
services. They must never forget that they have the duty to aid
everyone to develop wholly, bearing in mind that all develop
ment is a community matter, in a spirit oi mutual respect and
brotherhood.
Religious congregations, therefore, have a chance here to play
a role of promoters and pioneers in the health field by educating
some of their members for the important tasks in the primary
health care field, such as public health specialists trained to im
plement this new health approach as well as skilled in planning
and running staff training courses.
CONCLUSION
By setting up a hierachy of values and a policy regarding the
means to be used on behalf of the sick people requiring care and
the human communities needing to be helped to roach their full
development, the Church has already provided a substantial con
tribution. It is ready to doeven more in order to bring health
to the sick and to awaken the conscience of the people. Work
ing on behalf of the very poorest, the Church is enabling them
to know their essential needs and to undertake the responsibility
for their own development in a healthier existence.
1 (The word ' foreign" here refers to non-local personnel)
14
PARTICIPANTS TO THE WORKING GROUP
Fr. HENRI DE RIEDMATTEN. O.P.,
UNUM Secretary.
Pontifical Council COR
Dr. LIESELOTTE BAUER DE BARRAGAN, Director "Fundacion
San Gabriel" (Bolivia).
Fr. NIVERSINDO A. CHERUBIN, M.I., Superintendent "Sociedade Beneficiente Sao Camilo" (Brazil).
Prof. VICTOR-ARMAND DE GROOTE, Pharmacist (Belgium),
Former Director "Institut de Medecine Tropicale du Zaire".
Fr. HENRI FOREST, S.J., Secretariat COR UNUM.
Dr. ANNE MARIE GADE, Former Regional Adviser MCA/WHO
(Denmark).
Sr SUZANNE LEURS, Director "Bureau des Oeuvres Medicales
de la Conference Episcopale" (Zaire).
Dr. URSULA LIEBRICH, Associate Director "Christian Medical
Commission" (Geneva).
Fr. ROGER DU NOVER, M.E.P., COR UNUM Under-Secretary.
Dr. ARNOLD RADTKE, Health Adviser to MISEREOR (Germany).
Dr. ELEONORA AGATHA
CEBEMO (Holland).
SCHRODER,
Miss GHISLAINE VAN MASSENHOVE,
CIAMS (Belgium).
Health Adviser to
General Secretary
Dr. Sr. FRANCES WEBSTER, Member, Central Team, "Medical
Missionary Sisters" (United States).
On the basis of the findings of the Group, the Secretariat
of COR UNUM is producing the present pamphlet whose text
was reviewed and approved by the Council's Plenary Assembly
(3-6 November 1977).
6 OM H s A- •
COMMUNITY PARTICIPATION.- ROLE OF DIFFERENT
AGENCIES IN MULTI-SECTORAL APPROACH
'by
Dr. K.S.Sanjivi
Ex-UNICEF Consultant on Primary
Health Care
Before any discussion of the topic assigned to me is commenced,
I wish to comment on the term "Community Participation" itself.
Is
there in modern India the feeling, awareness of the community in the;
sense of "for a nighbourhood/body of people living in -same locality";
riot in the sense of "the antagonistic religious and racial communites
in a district".
Both these quotations are taken from the Concise
Oxford dictionary.
The politicians in India should be thanked - or?
will "blamed" be the correct term - for this position in which
"community" has beccme a dirty word and not understood in the same
way as it should be in any modern society
*
It is therefore essen
tial that we should as a first step restore a proper community feel
ing as an area, neighbourhood feeling that was part.of our ancient
culture .
Primary Health Care must necessarily have its origin in the
most remote villages where the problems arise.
It
will be better
therefore to talk about community action with participation by the
Government or organised voluntary health agencies.
The programme
should be conceived and executed by th?community with whatever
technical and financial support may come from the Government or
other agencies.
To reiterate that the organizations for Primary Health Care should
start in the villages is in consonance with Sutton's Law.
Sutton,
an Australian Bank robber when asked why he was robbing banks in
particular, gave the simple reply "because the money is there";
likewise the problems.of health care are in the villages, and urban
slums and not in New Delhi.
A distinction should be made between voluntary agencies which
on par with the Government can be regarded as dohors, and the indi
viduals in the community, the consumers of health services who are
the recipients.
Cur effort should be to alter the role of the
community from that of a passive recipient to that of an active
initiator.
Therefore I shall start with the illiterate citizens
who to a large extent are the beneficiaries.
Here the mistake is
often made in thinking that an illiterate person is un-intelligent.
God, or if you like nature, has endowed all human beings with a
basic intelligence and the villager who has not had the opportunity
to go to a university is nevertheless very intelligent and capable
of providing excellent support to the health team.
In 1973, the
WHO World Health Day's Theme on April 7th was "Health begins at home",
We conducted a number of meetings, to stress how the most important
reliable and dedicated para-medical worker in a health team, is
"
t te mot he r in t he house.
Field 'experience si nee then has further
given support 'to this co nee pt'that if only she can be properly in
volved many cf the targets can be achieved.
In our programme we have local action committees, who
have been told clearly that the health centre is their project
to which the medical profession, with its auxilliaries, only
provided the technical skills.
It should not appear to be a
paternalistic condescending gift of better off persons to their
inferiors.
The Community Health Volunteer/Lay First Aider is the one
individual who cen make maximum contribution to health education. ,
In her training, therefore, we emphasise environmental sanitation
personal prophylactic ntthods, improved nutrition with locally
available products, mother and child care, and family planning.
Talking of environmental sanitation, one notable area
in which community involvement has failed is in ths individual
families putting up their own cheap latrines even when they could
afford it.
i
.
’ .
Taking another example, the resurgence cf malaria is not
due so much to the resistance developed by the mosquitoes to
pesticides or by the malarial parasites to chloroquine, as it
is due to the failure to build up the infrastructure.
The infra
structure should require every householder to take care of th:
mesquite breeding foci in his own surroundings and report every
episode -of fever to the MHC/CHV.
This is'a clear example of
community involvement without which public health measures cannot
succeed.
We often talk of health care delivery.
It should be realised
that health care cannot bo delivered; it is essentially a "do it
yourself" proposition.
For example, drug addiction, alcoholism,
smoking and sex permissiveness are four, recent important addi
tional causes of disease. None of these can be controlled in the
oommu nity unless the individuals involved are motivated to co
operate in their cure and prevention.
Likewise patients in need
of prolonged treatment (eg. pulmonary tuberculosis, leprosy)cannot
obtain a cure even with modern, wonder drugs if they default in
taking the drugs.
Health Education therefore is of the utmost importance.
Health Education specialization is a profession practically non
existent in India.
It is questionable whether we can afford a new
category; every health worker should therefore be a health
educator.-
Briefly the objects of health education are (a) to educate
people and alter the behaviour, where necessary, to promote and
maintain their health; (b) to impart the minimum knowledge
required for people to be aware of the factors that affect 1 he alth
and recognise the early symptoms of disease; (c) to assure the
people of the availability of the needed services and the acce
ssibility cf those services to the poorest family.
3
It has been shown that it is comparatively easy to achieve
success in situations depending on techniques eg. vaccinations,
mosquito control.
But where techniques play only a minor part
and. people must be persuaded to change their habits, the situation
becomes much more, difficult eg. choice of correct food, smoking,
family planning.
It will thus be seen that health education must adopt diff
erent approaches and must be continuous and simple.
Most authorities believe that mass media do not produce as
consistent and good results as personal man-to-man approach.
Ob
viously the latter will require many mere teachers of health edu
cation; that is why health education is stressed as the most import
ant function of the CHV.
The ideal set-up for community health must provide for the
following essential requirements:
A health post manned by a lay first-aider/community health
volunteer for every 1000 population.
A male and a female multi-purpose worker for every 5000
population;
/\ doctor being available at the min i - nt re for atleast
three hours a day on three days a week;
The identification of, and liaison with, a referral
hospital within a reasonable distance.
The LFA at the Health Post is in fact the most effective volun
teer in health work and all organised voluntary health agencies are
only subordinate to these Queen Volunteers.
The mother in the
h .use has been justly acclaimed as the most dependable medical au
xiliary.
In view of her importance we ensure that the LFA is
selected, trained and supervised in the proper way.
"The effects of a world wide plan of action on behalf of
Primary Health Care, extend wall beyond the frontiers of health
itself and into the economic and social fields" said Dr.Mahler
(Director General,WHO) at Alma Ata.
Of the many facets which one may consider in "integrated/total
rural development" abolition of illiteracy, maximised through NonFormal Education, is very important and should be regarded as a
project that can be taken up even by health agencies.
Among tne
.reasons for the failure of community participation in health pro
gramme s set up for their own benefit is tJne lack of k nowledge of
the average citizen on the possibilities of modern medicine and the
availability of solutions to his problems.
He now has considerable
fear and diffidence in reaching those, who can deliver the goods.
The inaccessibillity to the health service's really arises cut of
illiteracy and, true democracy and illiteracy are incompatible in
as much as the former demands on1the part of its citizens a know
ledge of all its institutions.
4
Here the National Service Corps in the various colleges
should be mobilised for non-formal and for health education in
a big way.
To my mind giving thorn such jobs as building roads
is a rather futile exercise.
It is understood that most Uni
versities in India have taken a firm decision that community
service should be compulsory for every student and that marks
will actually be allotted for the same.
More than the decision
itself is the exact method of implementing the decision in such
a way that the entire community gats maximum benefit, quite apart
frem the good it will do to the s indent's motivation.
Next in importance is the production and utilisation, at
the local level, of nutritional needs -obtainable from agri
culture (staple carbohydrate); horticulture (vegetables and fruits/"
animal husbandry (milk) and poultry (ecjgs).
Unorganised community/citizens/sharing an old traditional
customs is not to be given up for the western models of centralise ,
impersonal, official ridden institutions.
CHARITY is to^ronounced
as SHARITY, the CH as in Chicago.
The poorest citizen in a welfare
state need not ask for charity; he is entitled to share the
available rcsources/facilities with the richest.
The challenge is tofind the solutions for poverty and apathy;
local community action, under proper guidance and leadership,
can cure the latter atleast and that wille><an essential fore-runner
for curing the former.
Shultz (Royal College of Medicine, Inter
national Congress Symposium No. 24, P. 57) has underlined the
importance of stressing on self interest which is a natural fact
and an intrinsic aspect of human nature.
Ergonomics is the management of people.
It is time one
forgets New Delhi, metropolitan elite and conce ntra
on the
poor people where they live and change their attitudes if
passible.
We have no doubt that a very effective way of involving the
community,iis to get a monetary contribution from each family.
The principle of obtaining such contributions from the community
is no longer disputed. . No Government in the world can offer to
provide all health services free, i.e. on its own general revenues.
Besides such a personal co ntt r ibu t io n will ensure the cooperation'
and wholesome participation of the community,
Any service which
is entirely free at the point of consumption is bound to be
abused and is bound to encrmously increase in cost year after
year, as has been demonstrated in UK National Health Service.
In our scheme of Medical Aid Plan and Mini Health Centres
it has been provided that each family should contribute, o )
behalf of all its members, 0.5% of its annual income subject
to a minimum ef Rs 12/- per annum and a maximum of ffc 200/- per
annum.
Here let me. quote Dr.Mahler, Director General cf WHO'.
"Are the costs exorbitant ?
Recent small scale studies have
shown that considerable improvements in people's health can take ■
place for as little as 0.5 to 2$> of the yearly gross national
product per person— or what amounts to a few dollars a year.
5
This is by any standard a reasonable cost, around a hundredth c.f
what is ppent on health by people in many rich countries.
So cost
factors should net hinder Governments when they consider if, and
tc what extent, they' should commit themselves to the target of
health for all by the year 2000"
(World Health, November ’79)
In addition, at the Health Posts manned by the Lay First
Aiders, which form an integral part of the Mini Health Centre scheme
there is a prevision for collection of 25 paise from the patient
for the symptomatic treatment given by the LFA.
Pat ients normally
seek curative treatne nt only from the Mini Health Centre and they
go t□ the LFA only when a sudden symptom arises at odd hours and
she gives the symptomatic treatment, based cn the complaint, for
once only after collecting the 25 paise.
She also tears off a
coupon, writes on the back, the name, the complaint and the treat
ment given.
The LF/1 has b^en rovided with a Hund.i box 'in addition
to the kit bag.
The llundi box has two slits, one for..-the coin and
the other for the coupon.
The supervisory staff open the box at
fortnightly intervals; the coupon provides both a financial and
technical check an the LFA's performance.
This charge is to
ensure that the LFA is not taxed without a real need. She has also
been empowered to waive this payment in □ really poor patient and
enter the fact cn the coupon.
The pre-payment plan is better than payment for each service.
A combination cf both systems is effected when 0.5% of the annual
income is charged for the community health programme and further
charge, if any, made when the need for referal arises.Of. course
it is understood that while the family will contribute according
to its ability to pay, the services provided will depend on the
medical needs and will have no relation to the quantum of the
family's contribution.
It is therefore imperative that, u.n behalf of their employees,
the Central and State Governments should offer 0.5% of the salary
of each employee living in the MHC area.
This will be towards the
individual's/cemmunity1s contribution and will have nothing to do
with the expected Government grants (totalling 75% from the Central
and State Governments) to meet the annual recurring expenditure.
Likewise the 0.5% contribution on behalf of ircustrial workers
covered by the ESI Corporation must be transferred to the MHC
entitled to it.
I began by saying the community initiates and the Governments
should participate; likewise at the end I wish to focus evaluation
not on the lowest level of the LFA^iCHV but on the highest level.
For example, will Governments and ESI Corporation contribute on
behalf of their employees?
As regards the financing of health care
there are several methods which need to be urgently evaluated
particularly on their content of preventive services.
These
schemes like, the Central Government Health Scheme, The Employees
State Insurance scheme, the "awards" given by large employers like
the Life Insurance Corporation and the Nationalised Banks really
provide very little for prevention of disease and maintenance of
good health.
Cost-benefit studies are sc difficult in the area
of health delivery.
6
Finally, 1st us consider organised'voluntary associations.
It is good to remember that voluntary health agencies have played
a significant r.'le in the development of health care in India.
Their main assets are (a) in their capacity tt. enlist the services
of devoted workers, particularly doctors, (b) to tap private finan
cial resources for the development of health and (c) to work out
operational experiments due partly to the; personnel they can
command and pertly to the grater academic and administrative free
dom they ordinarily enjoy.
Their main handicap is the inadequacy
of financial resources available and this inadequacy is incre .sing
continuously because private charity is being spread too thinly
□ ver an ever increasing .number of voluntary organisations.
It
is obvious, tnerefore, that the voluntary organisations can play
a very vital part in the reconstruction of health care if the
three principal assets mentioned earlier are recognised and devel
oped to the full and if their principal handicap is obviated
through special financial assistance.
EXTRACTED FROM THE REPORT OF A SYMPOSIUM ORGANISED
JOINTLY 1'Y INDIAN CCUl’CIL OF MEDICAL RESEARCH AMD
IHDIfiN COUNCIL CI SOCIAL SCIENCE RESEARCH ON -ALTER
NATIVE APJROACIE5 TO HEALTH CARE" AT THE NATIONAL
IISTITUTE OF NUTRITION, HYDETAFAD FROI 27TH TO 30TH
OCTOBER.. 1976.
SERVICE RESPONSIBILITY OF A DEPARTMENT OF CONI UNITY
MEDICI?^ THROUGH A HEALTH CO-OPERATIVE
E. WIIADEVAN
*
Background
■ Health facilities in rural areas in the country wore provided
•through Primary Health Centres 9(PHCs) started as part of an national
rural development scheme called "Coiamvnity Frogramides" in 1952, with a
very modest staff in each centre to form the nucleus of integrated health
services and cater to the need of about 60,000 population in a Block.
There arc now over 5,200 PHCs, each Centre caters to a population ranging
from SO,000 to 1,20,000. Each PHC therefore has to take care of a very
large number of persons. The scheme was extended to involve Medical
Colleges in rural health work and through deliberations of many committees
the status of PHCs was improved both qualitatively and quantitatively.
An integrated approach of providing health services to the rural people,
with the provision of two doctors to every PIIC and a Basic Health Worker
(EHW) with. an Awnliary Nurse Midwife (ANN) to every 10,000 population,
was attempted.
A pilot Mobile-cum.-Training-cum—Services Hospital Scheme was
introduced in some Medical Colleges with a view to involve medical and
nursing students in rural community medicine. The intention was to
establish ultimately one mobile hospital per medical college. More
medical Colleges were established with t’c sole purpose of providing
rural health services. Specialist camps were organised for cataract
operations, vasectomy and tubcctomy. Alt' ough the government's idea is
to train doctors for rural areas, these doctors arc not attracted to
such places. The migration of Indian doctors to the more developed
countries continues. Even passing a Parlie: ent A_ct which empowers
government to oblige doctors and engineers below the ago of 30 years
to work for a period of four years in rural areas, the problem remains un
solved due to the inability of providing reasonable living conditions. ■
for them in villages.
Some medical colleges like vcllorc Christian Medical College
incorporated, in their teaching program.c, the rural dimension in signi
ficant way. The organisers of the comiunity Health Centre, have found
that it costs about Rs. 5.50 per person per year, which includes
preventive, promotivc and curative services. The administration is not
very happy about this project due to the high recurring costs.
*Maj. Gen. B. Mahadevan PVSM, A.VSM Professor and Hoad of the
Department of Community i'cdicine, St. Join's Medical Col1 ego Bangalore
(Karnataka).
....2/-
- 2 -
The Kerala Government with Government of India's initial
one tine arants, have established Health Co-operatives in 11 districts.
Doctors are "encouraged'to seek self-employment in these co-operatives
.
*
Doctors and paramedical staff take shares in these co-operatives. A
*
ccrta
’n foe is levied on services, and medicines arc aloO paid. for.
One is looking forward anxiously to
* the success of tee scheme. The
initial reaction of the people haS been good.
Voluntary agencies have established a large number of
hospitals in urban areas. However, funds arc not available to these
hospitals for any significant rural health work, although an increasing
number of dispensaries arc. being opened in the rural sections of the
gountry.
Prom the facts and figures just given, it is clear that
the government in S'itc of its herculean efforts has not been able
to seriously tackle the problem. and. with t -o scarce allotments made
for the health services, no tangible improvements is possible in the
near future, Ho voluntary agency can hope to etibaik on a scheme where
even the government has failed but is in a better position to try out
new methods through pilot projects.
When planning rural health services, one lias to consider
two components, namely the delivery of package of rural health
services' in vil 1 ages and recruit.-cnt of personnel who will deliver
the same. At the same tir’d, there is an inescapable need for com
plementary services which will develop the villages economy and
education of the rural people, iiany rural health sober os taken up
enthusiastically at the beginning flounder for lack of popular support
that has to be expressed by financial contriiitions. 'This is the
crux of the matter • /my health del '.very scheme should bo a selfsufficient fiscal entity. This may be a limiting factor but the only
sound way of attempting to solve rural health pro’ lev’s, .is to
* start
it in places whore conditions are favourable for the introduction of . .
self-supporting scheme.
’
Funds for rural health schemes may he raised through many ways
1.
Tagging health services to co-operatives.
To start hcaltb co-operatives-by themselves is difficult
as health holds a low priority in the felt needs of the people
and may not get the required support in the initial stages. The
procedure of tagging on health services to existing co-operatives
has many advantages - good leadership, a readymade frame work of
Community administration for introduction of effective health
services and community cnvolvcment, as channels of communication
with the people have already been established. Co-operative Dairying
and Marketing Co-operative of different commodities like grains,
cereals, dottago industrial products etc., lend themselves admirably
to this type
*
of health services.
2. Running health services wit’’ assistance from factory
administration where labourers arc from villages nearby.
,
»
A minimal deduction at the source of salary and a contri
bution from the factory management will help to build-tip the required
funds and formation of a health co-operative. Geographical location
of industries and rural labour in close proximity arc 1imi tlng factors
but the scheme is worthy of trial, in special areas.
3.
Assistance from Panchayats.
Please where Fhnehayats and the people are interested in
health services’ and arc tilling to contribute to th, same, may venture
on this method, but unless sufficient funds arc forthcoming regularly
and persistently the scheme will, collanso.
'
.—r.*.-
■
"
’-o?.- ■
’
*-.;-<
x
- 3 -
L devoted team of health workers can establish thcmsblves
in a village and build-up the required clientele and popular opinion.
The people can then be induced to form a co-operative and directly
employ the doctor end essential paramedical staff. Until such time,
a central agency or other funding agency may have’ to >acot the expenses;
This can be attempted even without forming a co-operative in areas of
affluence, where people arc willin'.’to pay for the health services and
employ the doctor and other staff through collection of revenue for the
purpose.
The ’.fallur
ilk Co-operative (ifi’iC)
.
..
Ifallur is a village in Kolar district of Karnataka, situated
about 6C km. from the city of angalorc. The ’b.llur . Hk Cooperative
(11C) was an established concern with a sound and progressive leader
ship said has been functioning for many-years. In addition to production
and sale of riilk, it provides other benefits like provision of fodderand cattle foods, tractor facilities and loon- at low. rates of interest.
Besides the people of 7 allu.r, two other villages, ifather
and Kachahalli arc members of the Co-operative and the total
population covered is a' out 3,000. These villages have a sill-:
farm cooperative besides cooperative dairying. The economic..
position was satisfactory, and therefore all. conditions were
favourable for the introduction of other self-supporting schemes.
>
The inspiration for establishment of a Comprehensive
Health Care Program-c for the cooperative members and their families
of those villages,- came from Sr. Anno Curtins of Coordinating Agency
for Health ELannin. and Fri Jones of the Catholic Bishop Conference
of India. With these pioneers, the Dean and the Department of
Coiriunity licdicinc of St. John's ?bdical College, representatives
of the Karnataka Government and angalorc Government Dairy with
loaders of the MIC worked out a scheme for ta- -?ing on a health
services to it.
The main objectives of the ijallur Health Project orc:
1. To study and devise methods by which, the financial
base needed for effective health services could
emerge from the people themselves in a self-sus
taining manner;
2.
To help in the establishment of rural health centres
, with the. staff and rendering of effective health ser
vices to a vide circle of needy people without
distinction of race, caste or creed;
3« To study the required'strategy and methodology for
the effective rendering of primary health care in
rural areas by trying to determine th.. nriority
areas in health care and devising the structure
found suitable to village conditions;
4« To help in those developmental activities which
are very necessary to ensure effective rendering
of health services in rural areas; and
5» To train intern doctors, nurses and other medical
and paramedical staff for the purpose of rendering
assistance in. rural areas.
...V-
" 4 ~
The St. John's Medical College and its Department of
Com unity Ibdicinc were- to be mainly concerned in acting as a
catalytic agency, in the formation of self-sustaining rural com
munity .health sc- emo, fulfilling the above objectives.
Sponsorship was by the -following -agencies organisations
1. -.lie.
2. Coordinating Agency for Health ELanning
3.
Catholic bishops Conference of India
4» St. John's Medical College (Dept, of Opim-unrty
ikjiici(ie).
Source of funds
It was estimated that a monthly budget of fs. 2,500-3,000
will d be reouired for running the Health Co-operative and financial
support was forthcoming by a wint contribution of throe paiso per
litre of "H1 lr from the '■ I iC and Bangalore Dairy, in a phased formula.
as shown in Table 1 below. Ultimately the
was to completely
finance the scheme.
Table 1 - Contribution to the Health Co-operative.
1
Year
i
_
First
Second
Third
J| •
1!
!
:
1
Contribute. <jns/litro
I
Milk Co-opcrativo
■[ . Bangalore Dairy
2p
3P
I
-I
!
j
2p
1p
nil
* Paiso
This budget was adequate to support a health programme,
organised by a -'odical Officer, Hursc Compounder and an Ayah. The
staff were appointed by the Health Co-operative Conaiittco.
The Health Co-operative Committee included the following
members:
Chair, an, luiC
Secretary, liJIC.
Dean, St. John's Medical College Bangalore.
Head of the Department. of Community—
Medicine, St. John's -odical College.
Dircctor/Gcncral I onager, .Bangalore Dairy.
Representative of State- Health Service.
i-fodical Officer I-allur Health Co-operative (Secretary)
The composition ensured integrated planning between the
iIC and. Health Co-operative.
The Health Co-operative got off to a good start by being
inaugurated on 19 ifarch 1973 by the Sinister of Animal Husbandary.
Dr. V.K. Eajkumar, a Senior House Officer in St. Martha's Hospital,
joined as Resident Medical Officer in-charge of the Co-operative.' This
Medical Officer by dedicated work ar.d self-sacrifice, ''ado the 1-allur
Health Co-operative a successful enterprise.
Coverage, services and benefits provided
The St. John's icdicol College adopted this Health’Co
operative as a rural training centre for interns. Visits by
specialists of other departments including specialists camps
were organised. At present, four interns axe attached at any one
■time for whom residential accommodation has been provided by the
?--C on a rental basis. The interns conduct baseline demographic
surveys, immunization and school health programmes, special health
projects and mass health education programmes.
The Health Co-operative Committed) meets by turns, at
Ifellvr and at St. John's ibdical College, to discuss progress and
plan for the future.
■The Health team comprising Dr• Ecjlaimar, lass ib.ria and
interns under the technical, supervision of department of
Community medicine has ma.de good contact with the villagers and
a comprehensive health are progra'nc has boon introduced. The
community of I allur and other member villages with a population of.
3,000, actively participate in all programmes. They have no
unreasonable expectations or demands, as the hcalt’’ project is their
own contribution. This is a basic difference, .between Health Centres
organised through cooperatives and governmental agencies. The
leaders arc actively involved in the plannin and organisation as
the Chairman, --C is the Chairman of the Health Co-operative CoiiEiittpo
and the Secretary i i .0 is its member. Paramedical workers arc drawn
from the village co.ciunity and trained for community health work.
. ...
The young Farmers Association actively assists in many of the
health programmes. They help interns in their surveys, programmes
of immunization and environmental sanitation, including chlorination
of wells and construction of sanitary latrines. They also organise
the physical -arrangements for the mass health education programmes.
The lahila l-'andal under the dynamic guidance of lies.. Rajkumar, runs . .
a nursery school and acts as a forum where health education, applied
nutrition program.’os and mother crfcft arc taught to-the"womenfolk of
the village.
The health tea?’ and interns organise the following
services with comt .unity participation:
Personal services
1• Curative Clinic (daily outpatients):
2. Maternity and child health services:
(i) antenatal care,
(ii) midwifery (domiciliary),
(iii) postnatal care, and
(iv) under five clinics (domiciliary).
School health services for village schools.
Immunization program-os for smallpox, triple antigen,
tetanus toxoid, BCG, typhoid and cholera.
5. Tuberculosis (TB) and Leprosy-case detection,.
treatment and follow-up.
3.
4.
6.
Motivation for family planning.
7.
Specialist camps at ballur (periodical visits by
St. lartha’s Hospital specialists).
8.
Hospital referrals.
9.
Family record maintenance .
Community Services
1• Protection of well water supplies by chlorination.
2. Forila.risati.ou m1 construction of s nltary latrines.
- 6 3.
Collection of health data through periodical- surveys.
4.
Coordination and cooperation with government health
personnel in national health programme activities.
5 • Health education at personal., group and village levels.
6.
Nutrition education and nutrition supplementation
Programmes.
Members of the iilk. Co-operative and their families arc
entitled to all the above mentioned services free of cost. Non
members coming from other surrounding villages pay .for drugs/
dressings and minor surgery. All preventive, and promotive work arc
given free to all categories. Table U shows the number of member
and non-member families in each village.
Table II - Number of member and non-member families in
■ each village.
Fami1ies
Village
Non-member
Total
.17
6
202
124
21
14
18
390
187
51
.'31
24
304
379
683
Member
Ifellur
i'uthur
Kachahalli
Bhatorcnhalli
Harrulunagonahalli
188
63
30
»
45 percent
55.5 percent
Personnel, facilities, resources and mode of payment for personnel
The Health Co-operative in November 1973 was joined by
another dedicated worker, Iaria, an Italian Public Health Nurse,
She with her companion Cathy, a volunteer from Canada, looked after
the maternal and Child health work.
Within five months of 'starting the project (August 1973),
the cost of fodder went up and mi Ik production of the milk Co-operative
fell as some members began to sell out on higher rates. The 1-2X3 took
a decision, much to the discomfiture of the Government Dairy Authorities,
to sell■directly to private parties in Bangalore, who offered better
prices. The Govt. Dairy, therefore, stopped its contribution of two
paisc per litre of milk as health subsidy, and the Health Co-operative'
was in a critical situation. It is at this stage a momentous decision was
taken by the responsible village leaders who were more than convinced
of the positive role of the Hee 1th Centre and its staff in improving
the health status of the people in lallur and other villages. The 1-fi.llc
Co-operative was doing well and decided to contribute five paisc per
litre cf rill: for health and took over financial responsibility forrunning the Health Centre.- This financial strategy on tho part of
village loaders resulted in the project becoming a viable unit. The
Itilk Co-operative has borne the entire recurring costs of the health
project over since, and Table IH gives the Incomc/Exponditurc position
for the period July 1974 to June 1975-
Table IH - Recurring Costs - Year - July = 1974 to Juno 1975Total milk production
6,27,89# litres
Income estimated at five paisc/litrc Rs .31,394-90
Actual income received from iS'IC .
Rs.33,100.00
Total expenditure for the. year
Rs .33,790.74
Present position: Salaries:
At present the I ilk Co-operative is supplying about 2,000
litres of milk per -'ay to Bangalore. Each"member is now contributing
six poise per litre of milk a day. The contribution towards the Health
Centre is Rs .3,600.00 ph" month.
The actual expenditure per month is indicated below:
--Salaries
(iicdicr.l Officer, Clerk, Compounder,
A.l-U. and Ayah)
' Rs. 1,600.00
Drugs
Rs. 1,500.00
Rent and electricity
Rs.
200.00
Miscellaneous
Rs.
250.00
TOTAL :
Rs. 3,500.00
In ease the actual expenditure exceeds this amount, the
extra expenditure is met by the Milk Co-operative. The Staff of the
Health Centre consist of a Medical Officer, ar ANH, a compounder, an
Ayah and a clerk.
In addition, members of the Youth Association, women’s
Association'and- Village Fanebayat participate in the activities of
the Health Centre.
Although the kallur Health project is mainly financed by'
the Mallur Milk Co-operative, it also receives help and technical
direction from St. John's Medical College and the Government Health
Services. Those inputs arc shown in Table IV.
Table IV - Inputs from ether agencies/organisations.
Source
>
Capital
Recurring
1. Mallur Milk
Cooperative
Buildings, furniture,
refrigerator health
education viatcrial
Salaries, rent/
electricity, drugs,
general stores and
petrol.
2. St. John’s Medical
College
Physicians and mid
wifery kit, minor
surgical equipment,
motor cycle (on loanthrough U.HCRF)
Interns services,
specialist services
and rent for interns
quarters.
3• Government
Health Services
Vaccines, vitamin A,
Iron and folic acid
supplement, family
planning devices, sur
veillance of communi
cable diseases (through
HIC, Sidlaghatta),
health education films
(tlirough Health Edu
cation Department of
Director of Health
Services).
Factors affecting. quality of services, difficulties faced, methods of
enforcement of control rd evaluation
- 8 The experience over the last two and a half years lias shown
that:
(i)
A health function can be grafted on to an economic co
operative ;
(ii)
A sound cooperative such as iliC can support substanti
ally the recurring costs of a- health programme;
(iii)
Tagging oh of a health function to a cooperative benefits
not only the members aid their families but also the
nonmembers who get indirect benefits of professions!
services, preventive and promotive programmes.
The Department of Community 1'edicino and its staff were
mainly concerned in actin.; as a catalytic agent, in the formation of a
self-sustaining rural community health scheme. An oxporiement was
embarked upon and the Ifellur Project is this experiment. A total
health care programme esn be effectively delivered through a cooperative
in rural areas. The iMC is even contemplating construction of a 15
bedded hospital at liallur,• with the help of government and its own funds.
Further, the Health Centre with its working philosophy, has
indirectly helped the Department of Community I'edicinc to conceptualise a
primary health care system for.training of future physicians, so that they
play their rightful role in a contemporary society.
The health team and interns have played an important role
in the development of the village in general and health aspects in
particular. Attempts arc icin'’ made to increase the membership.
of the milk cooperative by purchase of more cows and increasing
enrolment. Other economic activities such as development of village/
cottage industries and handicrafts and ensuring sale of products, are
contemplated. It is fully realised that in the planning of such selfsupporting programmes, the health team lias to be actively supported by
other members who will attend to the social and economic development
problems of the community. Success or failure would depend on tackling
the financial side efficiently.
The quality of promotive and curative services would have to
be improved. Simpler skills, cheaper' drugs and intermediate technology
have to be introduced to suit rural conditions. A drive to improve! the
education of the people, including health education, is to be attempted
through the use of Village Level Workers. Their training Programme is
being organised. Whether there lias been an improvement in the morbidity
and mortality statistics at I'allur, subsequent to the introduction of
those cooperatives in comparison wit other areas in the vicinity, needs
study and this has been taken ur.as a health project.
The question of introducting such self-sustaining Co-op
erative Schemes to other areas around Bangalore is under active con
sideration. These arc challenges that have to be met in rural India and
it is hoped that with tie cooperation and participation that arc readily
forthcoming from the simple rural folk, the economic and health projects
will meet with success.
Conclusion
A good and well informed faculty with modern concepts of
medical education, has a capacity for extensive research in the organisation
and delivery of health services through experiment, models and pilot projects.
Medical educators in general, and faculty staff of departments of Community
Medicine in particular, must assure their share of responsibility for meeting
the quantitative as well as qualitative needs of the people and must be
concerned not only with tlic basic mission of the university or government
which is learning, but also actively help the people of a locality or
region in organising and running their own primary health care services.
....9/-
_ o _
For establishing an effective and via’lo primary health care
system, the cooperation of the local cow-unity must be ensured• J-n fact,
the people should be adequately motivated, involved in decision making
and actively participate in health program- os, so that ultimately it
becomes their own"peoples programme". Local resources such as cooper
atives, agriculture, manpower, buildings and most important of all
local leadership, should bo used to solve cd finance the local programmes.
It is desirable that tlie primary health earn system should be a self-suffi
cient fiscal entity. Community priorities arc more likely to.be met if the
people themselves raise and spend the resources required. A "total health"
approach is essential, promotional, preventive and curative care need to bo
completely integrated.
0O0 -
<Conn y | S' A .
rRI’iARY HEALTH CARE THROUGH IPP-III(K) IN KARNATAKA
\
The India Population Projects are a series of developmental
projects financed by World Bank, Government of India and the
respective State Governments to support the effective
implementation- of Family Welfare, MCH and other Health
Programmes by providing infrastructural facilities, manpower,
IEC, Training, Research and Evaluation.
India Population
Proyect-I was taken up in the five districts of Bangalore
Division during 1973~&0 with very beneficial results as
reflected in the achievements in F.-J and MCH Programmes.
The current IPP-III has been token up in the six Northern
districts of Gulcarga, Raichur, Bidar, Belgaum, Bijapur and
Dharwad from 1934 with a budget outlay of Rs,71.51 Crores,.
The main objectives of India Population Project-III(K)
ar e: (i)
To support attainment of IndiasPopulation goals,
(ii)
To create awareness in the Population regarding the
Family Welfare and MCH Programmes,
(iii) To generate demand for their effective implementation
at field level,
(iv)
To improve accessibility and availability of Health
Services at the rural levels and
(v)
To improve the ^professional and managerial skills and
training of the Staff.
Through effective implementation of the project, it is
aimed at achieving the IMR by .reducing from 125'to below 60,
CDR from 14 to 9, MMR from 5 to below 2, GBR from 35 to 21 and
CPR from 23.6 to 60.
India Population Project-III(K) consists of the following
components.
i) Service Delivery, (ii) Project Management, (iii) DemandGeneration, under which the IEC activities and Population
Education play major role and (iv) Research and Evaluation,
These components are being carried out extensively for
the effective implementation of the Project.
0
Under Service Delivery component 2451 building are to
be taken up of which 2060 buildings have been completed by •
December 1989 and Rs,3836.55 lakhs have been spent.
Centd...2/=
■
-2-
This activity includes 700 XK ANM Sub-centres, 255 SHC buildings,
17 Dormitories, and other buildings under facilities and
residential quarters.
1292 incremental posts are created in these districts,
to assist in the Project Management and implementation.
665 Vehicles of various types have been provided to the
Service Institutions, for Service Delivery.
Equipment and Furniture worth .Rs.520.99 lakhs are
provided to the various service units, for surgical, laboratory
and patient wards.
Under, India Population Project-Ill, I.E.C, is an
important component which aims at educating and guiding the
people
especially the rural folk on the
importance of Health of the Mother and the child.
The Key tasks outlined in both W, Mother and child Health
requires Demand Generation and acquiring of new skills through
Information, Education and Communication activities.
This
Programme is being implemented through community Education,
Extension 'Education and Mass communication.
Under Community Education, 6024 Orientation Training
Camps have Deen organised at a cost of Rs.2.40 lakhs to train
leaders in rural areas.
Under Extension Education 2700 Health Education Kits
at a cost of Rs.9.54 lakhs have been produced and additional
16,500 Health Education kits at a cost of ?.s.29.70 lakhs
will be produced during 1989~90.
18 Strip Films with 5528 prints
at a cost of Rs.2.57 lakhs have been produced.
Eighteen
16 m.m. films at a cost of Rs. 13 • 52 Lakhs have been produced,
with necessary prints.
Under Mass Communication, nine 55mm films with 45 prints,
each have been produced at a cost of Rs.18.42 lakhs
' 1"> have been produced.
Ten types of Cinema
slides each with 115 copies have been produced at a cost of
Rs.0.22 l^ikhs.
20 dramas and 20 songs on Health and Family
Welfare have been recorded in 800 Cassettes at a cost of
Rs,2.62 lakhs.
..3/=
-510 Folders and 16 posters have been produced by spending
Rs.2.69 Lakhs, 'Twenty eight thousand copies of Male and
Female Health Workers Manual, 2000 copies of O.T.C Manual,
1200 books on A.I.R lessons etc., have been published.
To motivate the Public to accept
the small family norm,
5 intensive campaign on spacing methods, Area specific
strategy for educating the rural masses in C.P.R poor villages,
at the rate of two villages per P.E.C, per year, Radio
listening programme in 300 sub-centre Villages, Honouring.
1000 Kalyana Matha's during 1983-39 and training them during
1989-90, special campaign to involve minority groups,
involvement of voluntary organisations in Bidar district
in Family Welfare Prgramme etc., were undertaken
It is proposed to provide 150 colour T.V.sets to
India Population Pro jcct -III(K) districts, during 1989-90.
Different types of training programmes are being
conducted.
Training in Inter-personal-Communication to
Para Medical Staff, Management Training to Medical Officers,
Communication Training to Health Educators, Training for
teaching Faculty, Continued Education Programme and
basic training for Multi-purpose workers etc are being conducted.
Population education programmed like Lectures to college
students, production of training and educational materials
etc., are being carried out through the Director of State
Education, Research and Training, with a special cell for
implementation of the Programme.
To assess the effectiveness of different IPP-III
Programmes, Research and Evaluation work is being carried
out by the Population Centre, Bangalore.
The centre has taken
up the study and Research Activities to evaluate the programmes,
through baseline survey,MIES and other studies.
The facilities provided and the programmes undertaken
under IPP-III(K) have given greater impact in improving the
Health Status of women and children xHxiPPxiiix and also
in improving the performance of National Health Programmes
in these districts.
* * *
* *
*
THE LANCET
side-effects and thek.,
otulinum toxin nright?
>r for retreatments, f
posteriorly, close ten'
welling near the infe<
■d by the toxin is
for 2-3 months.5*
?
treatments are requ;t •
affects compliance j.,
owever, the duration'
>nds to the time reqyj.^
anal sphincter and all^
tmay represent a tool^
i the pathophysiology
ance with all the oil?
tmical denervation of tk.
pathogenic rather than,
anal fissure.
15 primary care essential?
B3^ra Starfield
primary care is widely perceived to be the backbone of a
tional health services system. But is this perception
Some see it as an anachronism in the present
pedical era, denying and delaying the specialist attention to
ffhich patients are entitled. When primary care physicians
gCias “gatekeepers” to specialist services, what is the effect
on outcomes? How many general practitioners are needed
in a primary-care-oriented system? In this paper I address
these and other questions. Let me begin with definitions.
What is primary care?
n and colon. 4th cd. New
The conference convened by the World Health
gy and pathophysiology. Ssj
Organization at Alma Ata in 19781 used 100 words to
describe primary care; they included essential, practical,
in fissures: cause or effect?
scientifically sound, socially acceptable, universally
acceptable, affordable cost, central function and main focus
lent of chronic fissure; a •
i Rectum 1984; 27 : 475-78.
of overall social and economic development, first-level
Tbotulinum toxin. N Engl]
/contact, and first elements of a continuing health care
process. Serious planning for primary care requires a
►ckmann A, Bentivoglio'AR, ;
. conceptualisation that is easily and uniformly understood,
•t for blepharospasm,
-m. Eur Neurol 1992; 32:
|implemented, and amenable to measurement
’
.'/Primary
care
is
first-contact,
continuous,
uiinum toxin for achalasia?
^comprehensive, and coordinated care provided to
•ic role of ano-rcctal funcuod ^populations undifferentiated by gender, disease, or organ
ent of faecal incontinence. ’ /system. The elements of first contact, continuity,
comprehensiveness, and coordination are included in most
loccafortc P. The role of, •
by professional organisations,
. Du Colon Rectum 1982; 25: y definitions proposed
, agencies, and commissions.2’5 When viewed from the
ermayer C. Topography.of& / perspective of populations as well as individual patients, a
chronic, ^dmary anal fissure. ; health system that seeks to achieve these four elements will
■ he achieving what was envisaged in the Alma Ata
Declaration.
’ife
• Primary care is only one level of a health system, albeit a
$?.ntral one. Other essential levels of care include secondary
•i Anastasio md. G Maria.
*®)
tertiary care, and emergency care (especially for
i. AR Bentivogliomo, .• •
*enous trauma). Secondary' and tertiary care arc
Sacro Cuore,
stinguished by their duration as well as by the relative
? Unc°nimonness of problems that justify them. Secondary
.^r? is consultative, usually short-term in nature, for the
■
Pose of helping primary-care physicians with their
gnostic or therapeutic dilemmas. Secondary care may be
m. ! .
by informal consultations of secondary-care
.
sicians with primary-care physicians, by regular visits
1 ^Scc°ndary-care Physicians to primary-care facilities for
i pariPUrpose 0I" advising on management of patients with
• of n^^ar c^SOf^ers ■
diabetes), or by short-term referral
■ v,,ith lknts‘ 1 e"’ti;iry care» in contrast, is care for patients
■
borders that are so unusual in the population
°*
Policy and Management, Johns Hopkins
<b5-V'' Schr.cl of Hygiene and Public Health. Baltimore,
^•5, USA -
that primary-care physicians could not be expected to see
them frequently enough to maintain competence in dealing
with them. When the disorder has a substantial impact on
other aspects of a patient’s health, the tertiary-care
physician may have to assume long-term responsibility for
most of the patient’s care, consulting with the primary-care
physician for problems and needs that primary-care
physicians are better equipped to handle. All of these other
levels of care require integration with primary care for the
patient to receive clear and consistent advice.
Roles and functions of primary care and their
measurement
All countries, faced with ever-increasing costs of health
care, are experimenting with reorganisation.6 To assess the
extent to which a health system is adequately providing
primary care, and the extent to which reorganisations are
adversely or beneficially affecting the provision, we need
some way of measuring the elements of primary care. An
early attempt was made by a committee of the Institute of
Medicine in the United States in 1978. This committee
recognised that primary care is a practice environment
rather than a set of services or a professional discipline, and
it developed twenty-one questions to assess the
achievement of accessibility (necessary for first-contact
care), comprehensiveness (ability to handle problems
in the population), coordination, continuity, and
accountability.7
In a subsequent approach to measurement I postulated
that two characteristics are needed to assess each of the
unique attributes of primary care—one that addresses a
structural feature that provides the ability to achieve the
attribute, and one that addresses the actual performance
(“process”) that succeeds in achieving the attribute.8 Thus,
first contact involves assessment of both accessibility of a
provider or facility and the extent to which the population
actually uses ihe services when a need for them is first
perceived. Longitudinality (person-focused care over time)
is assessed by the degree to which both provider and people
in the population agree on their mutal association and also
the extent to which individuals in the population relate to
that provider over time for all but referred care.
Comprehensiveness requires that the primary care provider
offer a range of services broad enough to meet all common
needs in the population, and assessment includes the extent
to which the provider actually recognises these needs as
they occur. Coordination requires an information system
that contains all health-related iniorm./.’.on; and assessment
again includes the extent and speed with which the
information is recognised and brought to bear on patient
care, in this approach to measurement, accoiintability is
considered a feature <-f all levels of.,dth svstem. and no'
unique jo primary care
1 r.c>e r.ormatix e approaches to measurement are distinct
from the more common vand less useful, measures
involving assosmvr.i of characteristics that are merely
descriptive /‘empirical'’’ Primary care is often defined by
the type of practitioner who delivers it. Most commonly, at
least in Europe, this is the general practitioner. In the
Americas, however, primary care is considered to include
both general internists (for the care of adults) and general
paediatricians (for the care of children), as well as family
and general practitioners; thus when attempting
measurement we cannot assume that these types of
practitioners are equally skilled in providing primary care.
In fact, one study showed systematic differences in the
training
experiences
of general
internists
and
paediatricians, according to whether the training
programme was specifically directed at training in primary
care or not? A second approach to assessing primary care
assumes that it is equivalent to a set of specific services—
I such as prevention, diagnostic and therapeutic services,
health education and counselling, and minor surgery. Data
from practices indicate that many if not most acknowledged
specialists provide the same spectrum of services. For
example, the practice of most ophthalmologists (at least in
the United States) has a large element of prevention as well
as diagnosis, treatment, follow-up, and minor surgery.
Similarly, most cardiologists are engaged in health
education and counselling as well as the more standard
aspects of their care. Primary care is more usefully seen as
an approach to providing care rather than a set of specific
services, with its practitioners or facilities judged on the
degree to which they implement this approach. This fucu.s
on measurement allows for different types of practitioners
(including nurses as well as physicians) as well as for teams
to compete for designation as “primary care practitioner”,
and for training programmes in primary care to emphasise
those aspects of practice in which their graduates should
excel.
How many primary care personnel are
needed?
Opinions differ on the proportion of practitioners that are
needed for the adequate provision of primary care. In
Canada the proportion of primary care physicians is 50%;
in the United Kingdom it is 70%?° If primary care means
care for all but the most uncommon disorders in the
population, the number of different types of practitioners
should be determined by the distribution of disorders in the
population and the frequency with which disorders need to
be encountered for practitioners to maintain their
competence in dealing with them. The epidemiological data
to perform these calculations are generally lacking, but they
may well emerge from more organised forms of practice and
new information technologies. On present assumptions,
between 75% and 85% of people in a general population
require only primary-care services within a period of a year.
The remaining proportion require referral to secondary
care for short-term consultation (perhaps 10-12%) or to a
tertiary care specialist for unusual problems (5-10%).
These projections are amenable to empirical testing; the
proportions will probably vary from place to place and for
populations with special health-care needs. When the data
become available, it will be possible to calculate the
appropriate proportions of primary-care practitioners and
specialists, instead of relying on demand-oriented
projections that reflect the current state of practice11 rather
than rational planning.
1130
noted below, cou
oriented toward- ;
highcr satisfactm
populations, and
distinction, in r<
resources and spec
to discern an imp
outcomes—in con
relation between t
status.
Is a primary care oriented health system
better than one based on specialty care?
The phenomenon of medical practice variation., whjck
exists across different health care systems'-- as well as witf^ :
them.1-’ has been difficult to explain. One recent study ■
unique in its examination of the effect of a specialty, 1
oriented health system, indicated that medical practice ■■
variations are heavily related to differences in direct access I
to specialists, at least in the case of cataract surgery rates.” I
Roos et al15 had previously shown that both the |
appropriateness and the outcomes of tonsillectomy and
■fho gaJokaeph
adenoidectomy were better when patients had been referred
The
mechanisms
to specialists by primary-care physicians than when they
had been self-referred. 15 As early as 1945 Bakwiij ; specialty care, op.
related at least in
demonstrated the “threshold” effect—whereby medical
,f. ■ first-contact featur
experts judge a similar proportion of successive waves of.referred patients to need intervention. This means that . not visit specialists
self-referred patients will have higher rates of unnecessary’® primary-care prac
greater users of te
interventions than referred patients, so it is a plausible
hypothesis that much of the variability in both hospital p: interventions have
admission rates and surgery rates results from differences in ; (as well as a cost
primary care is pr
primary care resources.16 What is more surprising is that
unnecessary proced
this important feature of health systems is seldom
What of the conv
considered in research on medical practice variations. •'
undertreatment th
It is not intuitively obvious, however, that better health
specialty care. T
will result when services are organised so that primary care
■ demonstrate; indeec
forms the first level of care. With increasingly sophisticated.
■ association bctweei
populations, it might be that self-selection of the most
:. outcomes, once c
appropriate type of specialist is more efficient and?
► account.24
effective.17 Comparisons of specialist care with generalist/
/ ’ In many areas (p
care indicate that specialists are more efficient for some
: first-contact aspect i
diseases but by no means for all.1” Furthermore, it H
>’ free choice and thimportant to remember that much of primary-care practice’
/ (competitive) appro;
is focused on problems that are not and may never.Ki
•■ reasonable compron
resolved to definitive diagnoses.
‘g|
? primary-care source
Recognition of the importance of primary care within US
primary-care person
health services has lately resulted in a few studies in which
oftrustinafreely chi
primary- care had been explicitly addressed. In each cased
; acceptable to have a
primary-carc orientation has proven more salient than. : referrals, particular!
other variables in analytic models.
monitoring and sun
For example, Shi’s19 analysis of 50 US states and the
Well, as primary) ca
District of Columbia showed a consistent relation betwee?
^edical care organis
the availability of primary-care physicians and health
levels—as assessed by age-adjusted and standardised.
Primary car© and
overall mortality, mortality associated with cancer and.
view
heart disease, neonatal mortality, and life expectancy-?-.
least among west.
even after controlling for the effect of urban-rur^
differences, poverty rates, euuvmxvu,
education, auu
and lifestyle factort....
| '' ?ri«>tation Of
(smoking, seatbelt use,:, and obesity rate). This stud)'j-, . °ciatcd with lower
and similar study
. u at’on with its h.
confirmed the findings of anearlier
__________________
. ..
■ “ ^medication use
showed the ratio of primary-care physicians to popula^j
ratios to be the only consistent predictor of age-spec»H
mortality rates, even when considering such
characteristics as rurality, percent of female-head^g; .
rates.20 The increase in effective care is coupled
*“arana
decrease in costs, as demonstrated by Welch et al>?7,|
found that expenditures for care among the elderly in
US (all of whom have health insurance
the f
v. under
u..dv. vl.e
:
of the couo
^4
Medicare programme) were lower in areas
:
with high ratios of primary-care
iiuy-caie puysicians
physicians to populate
popula11000' K...
aiMs
At clinical level, a case-c■control study showed that the^Bimportant determinant of uncontrolled hvnertension,
hypertension, e',—
------------above factors such as the presence of insurance, was At /
unavailability of a source of primary care.22 And, as W1* I |_Aa,"<sfOrprlniar?
Vol 344 • October 2-
I
IF
-—
"Ob«22, 1994
THE LANCET
This conclusion emerged from a study in 11 countries
during the mid-to-late 1980s,8 in which the primary-carc
orientation was characterised by a score derived from an
average of scores on eleven different features of primary
care. Five of these features were characteristics of the health
system in general—universality of financial access to
i
sources and specialty care resources has made it possible
services and the extent to which it is guaranteed by a
discern an important effect of medical care on health
publicly accountable body; extent to which the country
utconies—in contrast to earlier work that showed no
explicitly regulates the distribution of health-service
felation between the availability of physicians and health
resources to achieve or encourage equitable distribution;
status.
the assignment of a primary-care function to one particular
type of physician rather than to more than one type or to a
Tlie gatekeeping function
multiplicity of types; earnings of primary-care physicians
The mechanisms by which primary care, in contrast to
relative to those of specialists; and the percentage of active
specialty care, operates in improving health status are
__ physicians. _who_ are primary-care . physicians. The
•related at least in part toits “gatekeeper”'role.23 24 The
remaining six characteristics reflected the extent to which
first-contact feature of primary care implies that patients do
primary-care practice explicitly attempts to achieve a
not visit specialists without a recommendation from their
higher level of performance for the specific features that
primary-care practitioner. Since specialists are much
define primary care and for two additional related ones.
greater users of tests and procedures, and since all such
These six features are: first-contact care as assessed by the
interventions have a finite risk of iatrogenic complications
extent to which access to specialists is principally by referral
(as well as a cost-inflating effect), the interposition of
from primary care; longitudinality as represented by the
primary care is protective for patients in reducing both
explicit assumption of responsibility to provide care to a
unnecessary procedures and adverse events.
defined panel of patients, irrespective of whether they have
What of the converse effects of gatekeeping—the risk of
specific diagnosis or ailments limited to specific organ
undertreatment through failure to refer for indicated
systems; comprehensiveness as represented by the breadth
specialty care. These have been more difficult to
and uniformity of benefits for preventive care; coordination
demonstrate; indeed, there is little evidence for a systematic
as assessed by the use of formal mechanisms for the transfer
association between the gatekeeping function and poor
of information between primary-care physicians and
outcomes, once confounding factors are taken into
specialists; family centredness as reflected by the explicit
account.24
assumption of responsibility for care of families; and
■ In many areas (particularly in the United States), the
community orientation as assessed by the use of community
first-contact aspect of primary care is regarded as a threat to
or other epidemiological data in planning for and evaluating
' free choice and therefore incompatible with a market
services. Information on these characteristics was derived
(competitive) approach to the delivery of health services. A
from published data, supplemented by interviews with
reasonable compromise might be to ensure free choice of
knowledgeable individuals in each of the countries.
‘.primary-care source where there is a sufficient supply of
Information on levels of satisfaction with health services
.primary-care personnel to permit choice; the development
was obtained from the nationally representative surveys of
of trust in a freely chosen primary-care source might make it
Blendon and colleagues25 26 in which individuals were asked
. acceptable to have a more limited choice of specialists for
whether they believed their country’s health system to
referrals, particularly if there were an ongoing system of
require only minor changes, fundamental changes to make
. monitoring and surveillance of the quality of specialty (as
it belter, or a complete rebuilding.
well as primary) care across areas and across different
Information on levels of health was obtained from
medical care organisations and centres.
reliable sources including the Organization for Economic
Cooperation and Development,27 the World Health
Primary care and health—an International
Organization,28 the US National Center for Health
view
Statistics data bank (courtesy Robert Hartford and Sam
At least among western industrialised nations, a primary
Notzon), and the Centers for Disease Control.29 Fourteen
care orientation of a country’s health service system is
indicators were available in comparable form for each of the
associated with lower costs of care, higher satisfaction of the
countries—namely, low birthweight ratio; neonatal
Population with its health services, better health levels, and
mortality; postneonatal mortality; total infant mortality;
lower medication use (table).
life expectancy for males and females separately at ages 1,
ted bel°w» countries whose health systems are more
n°. telj towards primary care achieve better health levels,
her satisfaction with health services among their
Halations, and lower costs of services overall. The
Junction, in recent studies, between primary care
Primary care
Outcome Indicators
Art rage
rank for
ranking
States
kstralia
^Iglum
^anyCWest)
Canada
tenmart(
Rnland
Malands
^Kingdcm
11 0
80
90
10 0
65
30
30
30
50
65
1 0
Satisfaction
bpend tuee oer head
Health indicators
Medications per head
80
50
11 0
60
40
80
10 0
30
50
70
20
90
80
50
11 0
95
30
6 5
6 5
20
40
1 0
To
30
1 0
20
7 0
40
60
Ranks for primary care and "outcome” indicators
“outcomes"
85
53
70
74
55
35
53
43
40
OL'S A
• AUS
©CAN
• SWE
OSP
©DEL
DKCftNTH
• GER
oFIN
• USA
OUK
u1
i
01
i
i
i
234
i
i
56
I
I
i
i
:
i
i
7S9
10
500
1000
1500
2000
2500
i
’
Average rank for satisfaction, expenditures per head,
14 health indicators, and medications per head
Health care expenditures per head. 1989
Figure 2: Primary-care score vs health-care expenditures
Figure 1: Primary-care score vs ‘‘outcome” Indicators
NB. rank 1 is best, rank 12 worst.
65, and 80; age-adjusted life expectancy; and years of
’"“potential life lost. (Information was also available on an
additional five indicators but not for all of the countries,
depending on the indicator. Findings, including these
additional indicators where available, were consistent with
those in which indicators from all of the countries were
used; thus only the latter are included, so as to achieve
uniformity of comparisons across all of the countries. For
comparisons including all indicators, see ref 30.)
Information on expenditures for care derive from the
World Health Organization data bank and the Organization
for Economic Cooperation and Development?1 and data
concerning medication use from the calculations of Rublee
and Schneider?2
Countries were ranked according to their primary-care
score, and these ranks were compared with “outcome”
indicators including total health-care expenditures per
head; the level of satisfaction as determined by subtracting
the percentage reporting major changes from the
percentage reporting only minor changes needed;
^Expenditure per head for medications; and health levels as
^Characterised by the number of the fourteen indicators in
^which the countries were in the top third of the distribution
for all countries minus the number of indicators in the
bottom third of the distribution. Figure 1 plots the rank on
the primary-care score against the average ranks for
satisfaction, total costs, costs of medication, and health
levels (when data were available). The average rank for the
“outcome” indicators generally parallels the rank on the
primary-care score, as does the rank for at least three of the
four components of the combined outcome score (perhaps
excluding satisfaction), suggesting that the primary-care
orientation of a health system is associated with lower costs,
- —
less- medication use,—and better health levels;—Of
considerable interest are the differences among countries in
the three groups shown in the table. The countries in the
top group are market health systems, which are driven by
demand?3 The countries in the bottom group are those in
which the supply is regulated according to perceived need
for resources. Canada has characteristics of both, and is
correspondingly intermediate.
The rankings on primary-care orientation are similar to
the ranking of countries according to the disparity of wealth
within the population?4 That is, countries with more
equitable distribution of wealth are, in general, countries
that attempt to distribute health resources equitably and
with a focus on primary-care services. They are also the
1132
countries best able to control total health-care costs (fi
2), to satisfy their populations, and to achieve high levi
health (figure 1).
improving the state of science and the art of
primary care
The international comparisons presented in the previous
section suggests that certain features of health systems,
especially those concerned with a primary-care orientation.
arc conducive to better outcomes. There are, however,
great voids in knowledge about the effect of other health
system features of care that arc related to primary-care
practice. The differences among countries in these
characteristics arc greater than the similarities.-’5 Some of
these differences may account for the less than perfect
correlation between the primary-care score and outcomes;
as noted on figure 1. Some countries rely chiefly on family
physicians to deliver primary-care services whereas others
rely on a combination of family physicians, internists, and
paediatricians. In some countries, specialists are restricted
to practice in hospitals, whereas in others specialists do
most of their work in outpatient settings away from the
hospital. In some countries (for example, Denmark), only
certain specialists are restricted to hospital practice. Some
countries allow direct access to certain specialists while
generally requiring referral from a primary-care physician
for access to other specialists. In some countries primary:;
care physicians admit patients to the hospital whereas ipj
others hospital-based specialists must do so. There arealsQdifferences in the extent to which primary-care physicians.assume responsibility for care when their patients
admitted to hospital. Modes of payment of physicians
some countries favouring fee-for-service, others capita^0-1'
or salary; the system for paying primary-care physicians^,
not always the same as that for specialists, even, within3,1
individual country?6 There are also differences in
extent to which cost-sharing is required in primary care;1?.
general, countries with better regulated systems have leS$
cost-sharing for primary care, although some are instim^
small co-payments to discourage apparently excess^?
utilisation?7 Some health systems organise their primly
care services in health centres rather than in individu>|
offices. The effects of each of these characteristics and tn ..
effect in various combinations and permutations
unknown, although there is information on some of t* 1 -J
characteristics individually from multi-site studies
the effect of co-payments, in the US-Rand Hc3- ■
Insurance Study)?8
5|
Vol 34-1 • October 22.
THE LANCE*.'
any conclusion be drawn about fee-for-service
•nients? A descriptive international comparison39
^ucgeSlc^
’n Pr*mary-care practice this method
jjscoura^eS I°n8’tudinal relationships with patients,
\Vhere fee-for-service predominates, referral rates are
nerally lower as arc the number of encounters with
atients per week. Fee-for-service reimbursement seems to
associated with a greater frequency of home visiting,
ossibly as a means of competing with specialists in systems
fvhere there is no gatekeeper. Fee-for-service also seems to
associated with longer consultations, but with less
equitable distribution of physicians in the population.
Gatekeeper arrangements did not generate public
dissatisfaction and seemed to be associated with a
community orientation of primary-care practice'as well as
total numbers of visits per head. However, gatekeeper
systems are not necessarily cheap to run; the impact of
gatekeepers cannot be divorced from the mode of financing.
Although the data in this paper provide strong evidence
of the importance of a primary orientation in health
services, there is room for speculation on the individual and
. combined effect of specific characteristics of primary care
- and on the impact of the reforms of the early 1990s.
Subsequent papers in this scries will expand on the
challenges for the future in understanding, delivering, and
improving primary care.*123456789
References
:
1 World Health Organization. Primary health care. Geneva; WHO, 197K:
25
2 Millis JS (chairman). The graduate education of physicians. Report of
the Citizens Commission on Graduate Medical Education. Chicago:
American Medical Association, I‘JOO1 37.
3 Alpert J, Charney E. Tnc education of physics .ns for primary care.
Publication (HRH) 74-3113. Rockville, MD: US Department of
Health, Education, and Welfare, Public Health Service, Health
. Resources Administration, 1974.
4 Kimball H, Young P. A statement on the generalist physician from the
American Boards of Family Practice and Internal Medicine. JAMA
1994,271: 315-16.
5 Maternal and Child Health Bureau. Primary health care for children
and adolescents: definition and attributes. Rockville, MD: Health
Resources and Services Administration, 1994.
6 Organization for Economic Cooperation and Development. The
reform of health care: a comparative analysis of seven OECD
countries: Paris OECD. 1992
7 Institute of Medicine. A manpower policy for primary health care: a
report of a study. IOM Publication 78-02. Washington, DC: National
Academy of Sciences, 1978.
8 Starfield 13. Primary care; concept, evaluation, and policy. New York:
Oxford University Press, 1992.
9 Noble J, Friedman RR, Starfield B, Ash A, Black C. Career differences
between primary care and traditional trainees in internal medicine and
Pediatrics, /bin Intern Med 1992, 116: 482-87.
Burner S, Waldo D, McKusick D. National expenditures projections
trough 2030. Health Care Finance Rev 1992, 14: 1-14.
" USDDHS. Graduate Medical Education Advisory Committee to the
Scrcretary. GMENAC summary report. Washington DC: Health
Resources Administration. 1980: Pub no (HRA) 81-651.
McPherson K, Wennbcrg J, Hovind OB, Clifford. Small-area
variations in the use of common surgical procedures: an international
comparison of New England, England, and Norway. .V Engl J Med
1982; 307: 1310-14.
13
Eisenberg J Doctors’ decision and the cost of medical care. Ann
Arbor: Health Administration Press Perspectives, 1986.
14
Escarce J. Would eliminating differences in physician practice style
reduce geographic variations in cataract surgery rates? Med Care 1993;
31: 1106-18.
15
Roos N. Who should do the surgery? Tonsillectomy and
adcnoidcctomy in one Canadian province. Inquiry 1979; 16: 73-83.
16
Bakwin H. Pseudodoxia pcdiatrica. Ar Engl J Med 1945; 232: 691-97.
17
Volpp K, Schwartz JS. Myths and realities surounding health reform.
JAMA 1994; 271: 1370-72.
18
Flood AB, Fremont AM, Bott DM, Jin K, Ding J. Comparing
disease-speci fic practice patterns of generalists and specialists.
Presentation at annual meeting of Association of Health Services
Research, Washington, DC, June, 1993.
19
Shi L. Primary care, specialty care, and life chances. Ini J Health Ser-.
(in press).
20
Farmer F, Stokes CD, Fiser R, Papini D. Poverty, primary care and
age-specific mortality. J Rural Health 1991; 7: 153-69.
21
Welch WP, Miller M, Welch HG, Fisher E> Wennberg J. Geographic
variation in expenditure for physicians’ service in the United States.
N Engl J Med 1993; 328: 621-27.
22
Shea S, Misra D, Ehrlich M, Field L, Francis C. Predisposing factors
for severe, uncontrolled hypertension in an inner-city minority
population. .V Engl J Med 1992; 327: 776-81.
23
Somers A And who shall be the gatekeeper? The role of the primary
physician in the health delivery system. Inquiry 1983; 20: 301-13.
24
Franks P, Clancy C, Nulling P. Gatekeeping revisited—protecting
patients from overtreatment. N Engl J Med 1992; 327: 42-1-29.
25
Blendon R, Leitman R, Morrison 1, Doneland K. Satisfaction with
health systems in ten nations. Health Affairs 1990; 9 (2): 185-92.
26
Blendon R, Donelan K, Jovell A, Pellise L, Lombardia E Spain’s
citizens assess their health care system. Health Affairs 1991; 10 (3):
216-28.
27
Schieber GJ, Poulher J-P, Greenwald LM. US health expenditure
performance’ an international comparison and data update. Health
Care Financing Rev 1992; 13 (4): 1-87.
28
US Congress, Office of Technology Assessment. International health
statistics: what the numbers mean for the United States. Background
paper OTA-BP-H-116. Washington DC: US Government Printing
Office, 1993.
29 Centers for Disease Control. Marb-d Mortal Weekly Re,' 1)90; 39 (Ik
205-09.
30 Starfield B Primary care. J Ambulatory Care Manage 1993; 16 (4):
27-37.
31
Schieber G, Poullicr J-P Greenwald L. Health care systems in
twenty-four countries. Health Affairs 1991 (Fall); 22-38.
32
Rubice D. Schneider M. International health spending: comparisons
with the OECD Health Affairs 1991 (Fall); 187-98.
33
Ellis R, McGuire T Supply-side and demand-side cost sharing in
health care. J Econ Perspect 1993; 7: I 35-51.
34
Wilkinson RG. Income distribution and mortality, a ‘natural'
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35
Krishansen I, Mooney G Renumeration of GP services: time for mor:
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36
American Medical Association Center for Health Policy Research
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Employees Benefits Research Institute Issue brief’ 1990.no 106;
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Manning W, Newhouse J, Duan N, el al Health insurance and the
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39
Gervas J, Perez-Fernandez M, Starfield B Primary care, financing an;
gatekeeping in Western Europe. Fant Practice (in press .
12
Strategy
Primary Health Care
PRIMARY HEALTH CARE
Talk given at STOLA - Rotterdam on the 18lh of Nov. 1997.to 3rd and 4th year medical
students
Introduction: 5 -10 mts.
Introduction of the participants and of myself.
A brief history of conditions before PHC - inequitable health care and ineffective medical
care.1
Brainstorming on PHC:
5 mts.
What are your ideas about PHC? (accessible, involvement)
What is PHC?2
Primary Health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology;
made universally accessible to individuals and families in the community
through their full participation and at a cost that the community and
country can afford to maintain at every stage of their development in the
spirit of self-reliance and self-determination. It forms an integral part both
of the country’s health system, of which it is the central function and main
focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family and
community with the national health system bringing health care as close
as possible to where people live and work and constitutes the first
element of a continuing health care process.
Sounds very heavy, doesn’t it? Well I shall try to make it easier and simpler. Grouped the
underlined words into 4 groups, based on level of care, type of care, strategy and philosophy.
Took the example of the treatment of a cut to demonstrate the levels of care (self care primary - secondary - tertiary)
Let us start with ESSENTIAL HEALTH CARE.
What is essential health care? - there have been various interpretations of this idea ranging
from a very comprehensive range of activities to a very selective one. For example an
accepted idea is a package of curative, preventive and promotive activities depending on the
local reality. Thus in sub-Saharan Africa, this would mean curative care for diarrhoeal
diseases, respiratory infections, malaria etc; and preventive care against measles, diarrhoeal
diseases etc. Now in Rotterdam, this set of diseases would be naturally inappropriate, and so
the package would have to be modified to include curative care for influenza, psychiatric
illness (I am told that Netherlands spends half its health budget to treat psychiatric illnesses)
etc, and preventive care against myocardial infarctions and strokes etc. Thus the basic idea
is that the care is tailored to the local situation, but will include the comprehensive range of
curative, preventive and promotive care.
To simplify matters WHO has made a list of the activities that need to be done to qualify as
Primary Health Care. These are
1. Health education
2. Adequate food supply and proper nutrition
3. Adequate water supply and basic sanitation
4.
5.
6.
7.
8.
Maternal and child health
Immunisation
Prevention and control of locally endemic diseases
Appropriate treatment of common diseases and injuries
Provision of essential drugs
The advantage of this list is that it is easily comprehensible and verifiable. The disadvantage
is that it is very simplistic and gives rise to the theory that PHC is not needed for the
Developed nations - only for the developing countries. Also there have been instances of
countries doing only this set of activities and claiming that they are implementing PHC. While
PHC is more than providing health care.
The Americans carried this list to a more extreme limit - they calculated the costs of
implementing the above activities and said that it would not be cost-effective. So they
targeted a list of diseases which they said was cost-effective to treat and told the whole world
that they (the world) must focus on only these illnesses (GOBIF). This was called Selective
PHC and was very popular with donors during the eighties. Thankfully it has died a natural
death, but only after wasting tremendous resources in terms of time, money and effort.
So one can see that the concept of essential health care ranges from a comprehensive
definition to a limited set of activities to a very selective and narrow range of tasks. I
personally would favour the first definition.
Whatever the interpretation, what is important is that this care is scientifically sound and is
acceptable to the community for which it is being offered. This implies that there is a process
of dialogue with the community and a common agenda is drawn up.
So much for the contents of the care - the next question is WHO WILL DELIVER THIS
CARE?
As per the definition, PHC should be delivered by the staff of the National health system who
are at the FRONTLINE, i.e. those staff with whom the community consults first. This again is
very context specific - e.g. in sub-Saharan Africa this will mean the Medical Assistant in the
Health Centres, inmost of Asia, America and Europe it would mean doctors. For example in
the Netherlands, the people consult their GPs and they are the best professionals to deliver
PHC. Why do I say this?
Firstly, the FLHS is close to the people - so they are accessible, unlike hospitals which are
far away and relatively inaccessible.
Moreover, the staff at the FLHS are close to the community (not merely distance wise, but
also culturally, socially and economically) and so there is a better understanding of the
individual’s/family’s/community's problems and needs. Thus the care has a chance of being
holistic. Unlike care provided in the sterile and ivory tower environment of a hospital which is
totally cut off from reality.
In that case what is the ROLE OF THE HOSPITALS in PHC?
This is yet another contentious issue. Many health professionals feel that PHC is only for the
GPs and Public Health nurses, but this is not so. The hospitals have a very definite role in
Supporting PHC. E.g. One of the main functions of the hospitals is managing those illnesses
which cannot be managed within the community or by the GP. The hospital thus should
negotiate with the FLHS on the criteria for referral, on the counter referral etc. This would
ensure that there is continuity of care.
The hospitals can also support the FLHS by supervising them, by providing training, logistic
support (e.g supply of drugs, staff etc)
Thus there should be a reorientation of the hospitals towards PHC and the whole system of
GPs and hospitals should form an integrated whole which works towards a common
objective - better health of the community.
Is PHC ONLY ABOUT HEALTH CARE? NO I
PHC is a philosophy, an ideal, a concept. It is about equity, about social justice, about
community participation, about efficiency, about intersectoral collaboration, about
development, about self reliance and self determination.
Equity in health care means that the health professionals should ensure that EVERYBODY
(and not only the haves in society) has equal access to health services. This is one way of
reducing the existing disparities.
Social justice implies more than health care. It implies that as a Primary health care provider,
one may have to look beyond the bio medical cause of illness - e.g unemployment, domestic
violence, marital discord, landlessness, etc. Depending on the circumstances, the health
professional maybe able to do very little, but at least he/she is sensitive about it and this itself
will make a difference in the care
Community participation implies that we as health professionals recognise that the individual
and the community have a right to decide on the health care that they need. From this arises
the corollary that one should negotiate with the community on all health matters and arrive at
a mutually acceptable plan of action.
Efficiency implies that one provides health care which is in keeping with the available
resources. This is as much true for Developed countries as for developing countries. Just as
India is struggling to finance its health sector, so is Netherland. Resources are finite. Only the
scale is different. So one has to remember that providing the BEST for a particular patient
may be at the cost of another patient. As medical students this may seem sacrilegious but
that is the reality of practise today.
Intersectoral collaboration implies that the health sector interacts with other sectors (social
sector, housing, education etc) to improve the quality of life of the community that it is
working with.
Self reliance and self determination are self explanatory.
Now does this definition make more sense, (read out the first definition)
Any questions ?
If there isn’t maybe we can go onto the next issue - why PHC? Yes, we know that there was
inequity and the Health services were ineffective to meet the needs of all the population - but
is PHC the answer?
Politically and idealogically it appeals because one is talking of transferring power from the
hands of the technocrats to the community - thus empowering the latter. But this may not be
a sufficient answer for many of you. So I shall provide an answer in health services terms g the effectiveness and efficiency of PHC.
e.
A study done at John Hopkins and published in the Lancet compares the PHC orientation of
countries with their health status, the satisfaction that the health system generates, the
amount of drugs used and the health costs.3
P
H
C
’ = Effectiveness
s
= Efficiency
c
o
r
e
r
a
n
k
i
n
g
Ranking as per effectiveness and health
expenditure
As can be seen from the above graph - the more oriented a country is towards PHC, the
more effective its health system is, the more satisfied its population is vis-a-vis the health
system and the more efficient it is.
With this I rest my case for PHC and reiterate that it IS NOT A SOLUTION FOR THE POOR,
FOR THE HAVE-NOTS, BUT A SUSTAINABLE AND BETTER SOLUTION FOR THE
ENTIRE WORLD.
Some questions:
Your study on effectiveness of PHC is based in industrialised nations - is there a similar
study in III world countries?
If this is a good system - why is it that all countries are not accepting it? What are the
barriers?
Ref:
Barbara Starfield, Is Primary care essential? Lancet
WHO - UNICEF. Alma-Ata Declaration (RM 162)
Hannu Vouri. Health for all, primary health care and general practitioners. Journal of the
Royal College of General Practitioners.(RM 242)
Julia Walsh, Kenneth Warren. Selective Primary Health Care. NEJM. (RM 309)
JP Unger, James Killingsworth. Selective Primary Health Care: A critical review of methods
and results.SSM (RM 310)
1 OHT -1 on inequity and OHT - 2 on technocrats/charity based medical care.
2 OHT - 3 giving the definition
3 OHT - 4 the effectiveness of PHC
Position: 3636 (2 views)