POLICY AND STRATEGY DEVELOPMENT TO PROMOTE COMMUNITY HEALTH PRIMARY HEALTH CARE IN INDIA
Item
- Title
-
POLICY AND STRATEGY DEVELOPMENT TO PROMOTE COMMUNITY
HEALTH PRIMARY HEALTH CARE IN INDIA - extracted text
-
COr^i H '2Z>- I
RF_COM_H_20_SUDHA_ PART 1
MEMISA MEDICUS MUNDI
short outline of policy
MEMISA is the largest Non-Governmental Organisation in the Netherlands for
development of Health Care in Developing Countries. In 1990, the organisation
celebrated its 65th birthday. More than 150 medical and paramedical professionals of
MEMISA are offering support to local population in developing countries to build up
their own system of health care. Moreover, MEMISA provides financial and material
assistance t6 structural projects as well as emergency aid.
Official name:
Stichting MEMISA Medicus Mundi
Visiting Address:
Eendrachtsweg 48, 3012 LD Rotterdam
Postal Address:
P.O. Box 61
3000 AB Rotterdam
The Netherlands
Tel.: " 31 - 10-414 48 88
Fax: " 31 - 10-404 73 19
Telex: 24541 memis nl
General Goals:
-
Ensuring and improving health care to the poor: "Health for ail in the year 2000"
Enabling partner organisations working for health care to become self-sufficient and
independent of outside assistance.
STRATEGY:
With the WHO, MEMISA is of the opinion that the most effective way to reach this goal
is to pursue the Primary Health Care (PHC) strategy, as formulated in the Alma Ata
declaration (see annex). On this basic policy, MEMISA acts as a development
organisation, rather than a charity organisation.
Many different interpretations exist, so we feel the need to clarify that for MEMISA, the
PHC strategy ideally starts with Community Based Health Care activities, in which the
population actively participates in planning, execution, and evaluation of the activities
meant to ensure and improve their health.
This community process needs the back-up of services of professional health
personnel to:
- take care of those health problems (diseases) that cannot be solved at village level:
basic health facilities with referral service
- train village workers to enable them to effectively execute the village activities and
enable the population to take part actively in the process
- to assist in the future planning
- to liaise with government and other authorities.
In short: to have an effective PHC strategy, effective community participation needs to
be coupled with effective basic health care institutions and other development sectors.
The main actors in this approach are the community members together with skilled
health personnel.
The smallest area where an effective PHC strategy can be realised is the district
(District Focus). It is estimated that at this level the population, health personnel, and
other sectors can interrelate and complement one another to reach full coverage.
Co r m kt co-1
MEMISA MEDICUS MUNDI
short outline of policy
MEMISA is the largest Non-Governmental Organisation in the Netherlands for
development of Health Care in Developing Countries. In 1990, the organisation
celebrated its 65th birthday. More than 150 medical and paramedical professionals of
MEMISA are offering support to local population in developing countries to build up
their own system of health care. Moreover, MEMISA provides financial and material
assistance to structural projects as well as emergency aid.
Official name:
Stichting MEMISA Medicus Mundi
Visiting Address:
Eendrachtsweg 48, 3012 LD Rotterdam
Postal Address:
P.O. Box 61
3000 AB Rotterdam
The Netherlands
Tel.: **31 - 10-414 48 88
Fax: **31 - 10-404 73 19
Telex: 24541 memis nl
General Goals:
-
Ensuring and improving health care to the poor: "Health for all in the year 2000"
Enabling partner organisations working for health care to become self-sufficient and
independent of outside assistance.
STRATEGY:
With the WHO, MEMISA is of the opinion that the most effective way to reach this goal
is to pursue the Primary Health Care (PHC) strategy, as formulated in the Alma Ata
declaration (see annex). On this basic policy, MEMISA acts as a development
organisation, rather than a charity organisation.
Many different interpretations exist, so we feel the need to clarify that for MEMISA, the
PHC strategy ideally starts with Community Based Health Care activities, in which the
population actively'partrcip’afes Tn planing? execution', and evaluation of the activities
meant to ensure and improve their health.
This community process needs the back-up of services of professional health
personnel to:
- take care of those health problems (diseases) that cannot be solved at village level:
basic health facilities with referral service
- train village workers to enable them to effectively execute the village activities and
enable the population to take part actively in the process
- to assist in the future planning
- to liaise with government and other authorities.
In short: to have an effective PHC strategy, effective community participation needs to
be coupled with effective basic health care institutions and other development sectors.
The main actors in this approach are the community members together with skilled
health personnel.
The smallest area where an effective PHC strategy can be realised is the district
(District Focus). It is estimated that at this level the population, health personnel, and
other sectors can interrelate and complement one another to reach full coverage.
However, some conditions/criteria are:
- an organisational structure and communication strategy that allows exchange
between all concerned
- co-operation between non-governmental and governmental authorities
- the presence of basic health care facilities accessible to the whole population, in
view of their income level
- a certain level of autonomy to plan and execute the directly necessary activities
- clear and,obvious integration of each new project within the national/regional and
local PHC construction, which should already be apparent in the first application for
assistance
- a set of objectives described in operational terms, based on parameters chosen
from the essenti'al elements of PHC, which can be evaluated
- projects being a contribution to the decentralisation of the health care system, as
decentralisation is imperative for involving the target group in controlling and
running the system with the proper means and know-how
- absence of political objectives when the choice to provide or not provide assistance
is being made, 'though the political implications of the choice made should be
accounted for. The only considerations regarding the choice made are solidarity
with and compassion for the groups placed at a disadvantaged position in society
- contributing to transfer of knowledge and awareness towards both target population
and local professional health workers.
Programme areas are:
- CBHC programmes
- AIDS control, care and prevention programmes
- malaria community based control programmes
- mother and child care, safe motherhood and family planning
- water and sanitation
- essential drug programme
MEANS:
MEMISA's main function is to supply to our partners in the developing countries the
means to put the PHC strategy into effect. The real work can only be realised by the
local organisation who is, with MEMISA, committed to this goal.
Thus, the means which MEMISA can supply are:
- finances to initiate activities or to establish facilities
- personnel (doctors, para-medical personnel, trainers, experts)
- basic health care equipment
- essential drugs
- sponsorship for training, preferably in one's own region
- expert advice/research/evaluation
MEMISA can also be of assistance in some other ways:
- in case connections/communications between our partner and European suppliers
are difficult, our Purchasing Department can act as liaison and do the purchasing
and supping, or advise on matters concerning purchasing of drugs, equipment and
shipping facilities
- medical relief assistance in case of disasters
WHO ARE MEMISA'S PARTNERS, PARTNER ORGANISATIONS:
We consider as partners Non-Governmental Organisations (NGO's) in the Developing
Countries, that share with MEMISA the goals formulated above.
As awareness in the developing countries grows and MEMISA becomes more widely
known, contacts with other NGO's are increasing.
In some instances a governmental body together with an NGO become our partner,
when the need of the population and the commitment of all concerned request such
co-operation.
In order to ensure continuity and to stimulate self-sufficiency, we try to focus more and
more on:
long-term (3 years) or medium term planning programmes
strengthening of partner organisations
strengthening of co-ordination within a region or country
SHORT DESCRIPTION OF PRIMARY HEALTH CARE (PHC)
PHC deals with essential health care:
- based on methods and technologies applicable in all situations
- scientifically justified
- socially accepted
- accessible to individuals and families in the community
- organised and maintained in full co-operation with the people of the community
- financially accessible to the community and the country, taking in account the
different phases of development
- contributing to ljberati.QQ.pf disease, and striving to self-reliance and autonomy
- including valuable, locally applicable and acceptable traditional health care
PHC elements:
- public information on health care
- promotion of good nutrition and eating habits, including stimulation of breast-feeding
and careful counselling after the breast-feeding period
- promotion of public hygiene, sanitary provisions and availability of safe drinking
water
- mother and child care including family planning and education of women and
(expecting) mothers
- general immunisation against infectious diseases
- prevention and controlling local diseases
- treatment of the most common diseases, affections and injuries
- general distribution of essential drugs
- promotion of rehabilitation of handicapped persons within their own community,
including counselling of the terminally ill
- promoting essential mental health care in the immediate surroundings of the habitat
Enclosed is an Outline application form.
MEMISA
DRAFT
Medische hulp ?an de derde wereld
Health for all in the Third World
OUTLINE APPLICATION FORM FOR LARGE HEALTH PROJECTS
Title of the project
Country
Province/state
Village/city
Applicant: Name
Address
Function
Nationality
Responsible institution:
Name
Address
Fax/Tel.
Organisation
Legal status
Approach and strategy
Objectives of the organisation
Administrative set-up
Operational area of the organisation
Activities of the organisation
Number and competency of the staff
Background information project area
Geographical situation
Catchment area:
a. number of population
b. means of existence
c. standard of living
d. health situation (quantified as much as possible)
Health infrastructure: in project area/district (private and
governmental)
Project
General/specific objectives
Area of operation
Target group
Problems of the area/target group
Proposed activities
Time frame
Implementation strategy (as specific as possible)
Expected outcome (qualitative/quantitative)
Monitoring and evaluation
Reporting
Follow-up and sustainability
Staff of the project
Recruitment of staff
Detailed budget
Relations with other development projects/health institutions (if any)
Please enclose if possible:
1.
Recent annual report (activity and financial) of the
organisation
2.
Recommendation letter from Memisa*s national counterpart or a
legal health authority
3.
Banking details
4.
List of other donors to whom the project (or parts of the same'
project) has been submitted.
STICHTING MEMISA MEDICOS MUNDI
]
Etndnchtiwej <8, Poitbus 61
48 Eendrachtsweg. P.O. Box 61
3000 AB Rotterdam, The Netherlands
3000 AB Rotterdam Nederland
Tel. (010)4144888 Fax (010)404 7319
Phone (31) 10-4144888, Telefax (31) 10-40473 I 9
Telex2454l memisnl
Telex2454l memisnl
Bankiers: ABN-AMRO 42.65.64.448 ING 70.70.70.295 Postbank 5657
Bankers: A B N-A M RO 42.65.64.448 IN G 70.70.70.295 GiroS6S7
Memisa Mcdicuj Mundi is erkend door de We re Idgcxondhc idsorganisa t ie
Memisa Mcdicus Mundi is recognized by the World Health Organisation
MEMISA
DRAFT
Medische hulp ’an de derde wercld
Health for all in the Third World
OUTLINE APPLICATION FORM FOR LARGE HEALTH PROJECTS
Title of the project
Country
Province/state
Village/city
Applicant: Name
Address
Function
Nationality
Responsible institution:
Name
Address
Fax/Tel.
Organisation
Legal status
Approach and strategy
Objectives of the organisation
Administrative set-up
Operational area of the organisation
Activities of the organisation
Number and competency of the staff
Background information project area
Geographical situation
Catchment area:
a. number of population
b. means of existence
c. standard of living
d. health situation (quantified as much as possible)
Health infrastructure: in project area/district (private and
governmental)
Project
General/specific objectives
Area of operation
Target group
Problems of the area/target group
Proposed activities
Time frame
Implementation strategy (as specific as possible)
Expected outcome (qualitative/quantitative)
Monitoring and evaluation
Reporting
Follow-up and sustainability
Staff of the project
Recruitment of staff
Detailed budget
Relations with other development projects/health institutions
(if any)
Please enclose if possible:
1.
Recent annual report (activity and financial) of the
organisation
2.
Recommendation letter from Memisa's national counterpart or a
legal health authority
3.
Banking details
4.
List of other donors to whom the project (or parts of the same'
project) has been submitted.
STI CH TING MEMISA MEDICUS MUNDI
Eendrachtsweg <8. Postbus 61
48 Eendrachtsweg, P.O. Box 61
|
3000AB Rotterdam Nederland
3000 AB Rotterdam. The Netherlands
Tel. (01 0) <H<888 Fax (01 0) 404 73 I 9
Phone (3 I) I 0-4 I 44888, Telefax (31) 10-4047 319
Telex 24 54 I me mis n I
Telex 24S4I me mis nl
Bankiers: AB N-A M RO 4 2.6 S . 64.448 I N G 70.7 0.70.29 S PostbankS6S7
B a nkers: A B N • A M RO 4 2.6 S. 64.44 8 I NG 70.70.70.295 GiroS657
Mcmisa Mcdicui Mundi is er ken d door de Wcrcldgezondheidsorganisatie
Hemisa Me d icus Mundi is recognized by the World Health Organisation
ST Ch J
MEMISA
(confidential)
CONSIDERATIONS FOR THE APPRAISAL OF PROJECT PROPOSALS
1,
Does the project fit into the policy guidelines of Memisa
General policy: " To improve the health care in the Third World countries, specifically
for the benefit of the low income groups".
The PHC strategy of Memisa is based on the Alma Ata conference of 1978. All projects
have to fall within these guidelines in the way of workingmethod and objectives. Focal
points of the strategy are: food, water, hygiene, MCH, vaccinations, basic medicines.
Furthermore the four conditions: acceptability, affordability, adaptability, accessability.
2.
Limiting conditions: partner NGO
Financing of the project; from own budget or is co-financing requested
Personnel (sufficient supply of qualified candidates)
Professional capacity within Memisa (sufficient for backstopping of the project or is
external help needed)
3.
Limiting conditions: implementation of the project
Is the project proposal a consistantly set -up plan. The project proposal should give no
misunderstanding between Memisa and the project holder considering the
implementation of the project. Objectives and activities should be clearly described in
order to make a visualisation of the project and to enable a clear monitoring and
evaluation of the project.
The project holder should have a sufficient capacity (qua organisation, financing and
personnel) to manage and implement the project.
4,
Suitability/efficiency project proposal
Does the proposal contain a suitable strategy for the implementation of the project. Is
the proposal realistic qua workplan and time schedule.
Is there an optimal cooperation with the local health infrastructure (in order to avoid
duplications)
What is the price/output ratio of the project; what are the total costs of the project per
beneficiary.
5.
Sustainability
In order to provide structural aid or to start a development proces it is important for a
project to become self-sufficient eventually.
Will the project have sufficient income( internal or from outside) to continue the project
after the financing period of Memisa.
Is the project politically and culturally acceptable for the target population.
CONCEPT.
Guidelines/criteria for evaluation of block grants.
( T. Puls; 25-03-1991).
A.
1.
2.
3.
4.
5.
Original objectives.
Increase the independence of the partner.
Strengthen the partner relation.
Accelerate project processing/relieve administration at Memisa office.
Promote PHC/CBHC.
Activate/stimulate assess capacity of partner.
Condition:
Sufficient/adequate reports should be forwarded after implementation of
the project. Evaluation should take place in cooperation with Memisa
(comments and dialogue) with reference to the reports.
No 1 and 5 are closely linked with each other.
a. Is a protocol for decision making available?
b. Is an Advisory Board installed?
c. Who is represented in this Board (composition)?
d. Since when is this Board functioning?
e. How often does this Board meet?
B. Questions towards implementation of the project ( ad 1,2,5).
- What is the amount of funds involved with the block grant?
- How many project are involved ?
- How fast did expenditure of funds take place for implementation of the
projects and are all funds used?
- Does the partner have any other block grants available? If possible
details.
- What are the overhead costs of the partner?
Does the partner appreciate the block grant and can the partner agree
with the set criteria?
C.
Whatis
the time gap between the request and assessment of the project by
the partner and what is the time profit compared to projects handled by
Memisa office in Rotterdam?
What is the saved by Memisa within one year with regard to personnel time
and costs?
How many requests were received by the partner and how many were
rejected and for what reason(s)?
D. Assessment/evaluation appraised projects.
General.
-Are all funds received acknowledged by the project holders?
-Is information available on the actual expenditures of the project holders
(random test)?
Specific PHC/CBHC.
Are the expenditures in line with PHC/CBHC criteria?
How have funds be spent: target areas?
Conclusions/recommendations,
2T Cm
MEMISA
Medische hulp aan de derde wereld
Health for all in the Third World
SPONSORSHIP POLICY OF MEMISA
The request should be submitted by the management of the hospital, or. the Diocesan
Medical Coordinator together with a letter of recommendation from the (Arch)bishop.
The project description should contain, next to the standard background:
information about the institution applying - a recent annual report is
obligatory;
motives concerning the need for this particular training in view of improving
the healthcare services within the hospital/diocese, as foreseen in a midterm
or longterm healthplan and training scheme;
the qualifications of the candidate;
character statements of the candidate from 2 independent parties;
the future jobdescription of the candidate;
a copy of the bondage contract of 3 to 5 years between employer and candidate
(depending on cost and course duration);
confirmation from the school that the candidate can indeed be enrolled;
the curriculum of the planned course;
an itemised estimate for the training period of all cost involved;
the estimated local contribution.
MEMISA's principal aim is to assist the poor in acquiring adequate healthcare, and that
a sponsorship is thus looked at as one of the means through which we can assist our
partners in the developing countries to reach their aims in this field.
As our budget is limited, and as training received in the region is ofter better adapted
to the work environment of the candidate, MEMISA is reluctant to sponsor training
courses abroad and on other continents. A review of alternatives in the region should
be considered.
If t/e (Jiocese and the hospital are of the opinion that a foreign course In question is the
opfy option, it is imperative that we receive a clear and extensive motivation for this
Head Proj ects Department
nuary
993
STICHTING MEMISA MEDICUS MUNDI
Eendrachtsweg 48, Postbus 61
48 Eendrachtsweg, P.O. Box 61
3000 AB Rotterdam Nederland
3000 AB Rotterdam, The Netherlands
Tel. (010) 4144888 Fax (010) 404 7319
Phone (31) 10-4144888, Telefax (31) 10-4047319
Telex 24541 memis nl
Telex 24541 memis nl
Bankiers: AMRO 42.65.64.448 NMB 70.70.70.295 Postbank 5657
Bankers: AMRO 42.65.64.448 NMB 70.70.70.295 Giro 5657
Memisa Medicos Mundi is erkend door de Wereldgezondheldsorganisatie
Memisa Medicos Mundi is recognized by the World Health Organization
MEMISA
Medlsche hulp aan de derde wereld
Health for all in the Third World
SPONSORSHIP POLICY OF MEMISA
The request should be submitted by the management of the hospital, or. the Diocesan
Medical Coordinator together with a letter of recommendation from the (Arch)bishop.
The project description should contain, next to the standard background:
information about the institution applying - a recent annual report is
obligatory;
motives concerning the need for this particular training in view of improving
the healthcare services within the hospital/diocese, as foreseen in a midterm
or longterm healthplan and training scheme;
the qualifications of the candidate;
character statements of the candidate from 2 independent parties;
the future jobdescription of the candidate;
a copy of the bondage contract of 3 to 5 years between employer and candidate
(depending on cost and course duration);
confirmation from the school that the candidate can indeed be enrolled;
the curriculum of the planned course;
an itemised estimate for the training period of all cost involved;
the estimated local contribution.
MEMISA’s principal aim is to assist the poor in acquiring adequate healthcare, and that
a sponsorship is thus looked at as one of the means through which we can assist our
partners in the developing countries to reach their aims in this field.
As our budget is limited, and as training received in the region is often better adapted
to the work environment of the candidate, MEMISA is reluctant to sponsor training
courses abroad and on other continents. A review of alternatives in the region should
be considered.
If the diocese and the hospital are of the opinion that a foreign course in question is the
only 0[ tion, it is imperative that we receive a clear and extensive motivation for this
STICHTING MEMISA MEDICOS MUNDI
48 Eendrachtsweg, P.O. Box 61
Eendrachtsweg 48, Postbus 61
3000 AB Rotterdam, The Netherlands
3000 AB Rotterdam Nederland
Tel. (010) 4144888 Fax (010) 404 7319
Phone (31) 10-4144888, Telefax (31) 10-4047319
Telex 24541 memis nl
Telex 24541 mtmis nl
Bankiers: AMRO 42.65.64.448 NMB 70.70.70.295 Postbank 5657
Bankers: AMRO 42.65.64.448 NMB 70.70.70.295 Giro 5657
Memisa Medicus Mundi Is erkend door de Wereldgezondheldsorganisatic
Memisa Medicus Mundi is recognized by the World Health Organization
DvcjC'
(f)
C,OAV\y\
XO-X-
A PROCESS REYIEH PROPOSAL
Based on some preliminary discussions wtiich were held with Ms. Monique Lagro Project Co-ordinator, Asia/Oceania Desk, MEMISA on 07th and 09th of April,
1994 at
Bangalore and a very preliminary review of some summaries and memorandum sheets of
MEMISA partners in India, the following "Process Review Consultancy" is outlined for
consideration by MEMISA and its core partners in India.
1.
Backgrcxmd
.
“
MEMISA has approximately 107. project partnerships in India (May 1993). The State
wise distribution at that point of time was Andhra Pradesh - 26, Orissa - 24, West
Bengal - 14, Kerala - 11, Uttar Pradesh - 8, Bihar - 6, Karnataka - 5, Assam - 3,
Tamil Nadu, Rajasthan and Maharashtra - 2 each and Manipur, Meghalaya, Madhya
Pradesh and Himachal Pradesh one each. The three states of Andhra Pradesh, Orissa
and West Bengal account for more than 50% of the projects and 42% of the budget.
There is a felt need by MEMISA to get a comprehensive overview of this partnership
in the context of the larger 'voluntary health sector universe' in which these
project partners exist and are evolving.
A need has also been expressed to review
the overall approach adopted so far in selection and follow up of projects, with a
possibility of evolving new approaches in response to areas of greatest need.
Three
core partners of MEMISA in the States of Andhra
Pradesh
(CHAISecunderabad), Orissa (Xavier Institute of Management) and West Bengal (WB-VHA)
have been involved in preselection studies/review of project partners and the
monitoring and evaluation of projects thereafter.
It is suggested that thay be
active participants of this review process.
2.
The Review Process will have the following broad objectives:
a)
>
To undertake a Desk study of the current project partners supported by MEMISA
in India with a view to evolving a process, leading to a more comprehensive and
sustainabile partnership in Community Health Care.
The overview will assess the partnership (within the limitations of desk
in the following areas:
i)
ii)
iii)
iv)
v)
vi)
data)
broader context of the Volag sector in India;
the goals/objectives and situation of partners in terms of community health
orientation and focus on marginalised/ vulnerable groups;
the ongoing process of partnership;
the emerging needs in networking/information sharing/training and continuing
education;
the linkages between partners and emerging middle level/ regional resources
centres and core partners; and
potential problems and possible problem solving approaches.
2. .
: 2 :
b)
Though the review will have to be in the context of the existing MEMISA vision
statement and policy guidelines it will also explore new thrusts and possible
evolutionary changes in these guidelines from the collective partnership
exercise.
The Steea of the Process could be:
A) Desk Review
i)
- Two weeks.
Study and Analysis of the following Desk data.
a)
b)
c)
MEMISA vision stateroent/policy guidelines.
Project Memorandum of current partners.
Project reports and follow up reports of key project partners at 'grass
root' and 'middle' levels.
[Focus will be on those projects who have
been long-term partners or the most representative of the sorts of
progranroes MEMISA wishes to support. The choice is left to MEMISA, Asia
Desk and its core partners.]
d)
Any other papers/studies/information/reflection recommendations by Asia
desk and core partners to help the review process, in the light of their
own field experiences with project partners.
[This will be completed by
15th June, 1994 preferably].
B. Field Review Planning
(Nine days including travel)
i)
After the Desk Review Report is prepared in draft format, a copy will
sent to MEMISA and core partners for their corrroents/interactive dialogue.
ii)
A field review process can be initiated focussing on three states
Orissa, West Bengal and Andhra Pradesh.
be
primarily
This could be done by a staff member of the core partners in each state in
consultation or supported by one or two corcraunity health resource persons
from
that state identified by the review partners
through
mutual
consultation.
iii)
The Desk review consultant/s will visit the three core partners, spend 2-3
days with each one and evolve a field review framework and methodology so
that there is sortie consensus/consonance with the field review process in the
three states. Provisions will however also be made for regional diversity
and the special situation/problem in each state. During this short visit
one or two projects close to core partners could also be visited.
C. Field Review Process
The field review process could be dene over a period of time mutually
by the core partners and MEMISA.
decised
3..
: 3 :
D. Elan of Acticn through interactive dialogue with partners
The Desk review and field reviews could be presented and discussed at a meeting
of core partners and a representative sample of grass-root partners, so that a
plan of action for a more comprehensive and sustainable partnership can be
evolved through a participatory interactive discussion at the final step of the
review process.
4. Organisational Dynamics
i) The main data for the Desk review could be sent to the consultants by Asia Desk
- MEMISA, along with necessary translations if required ( not later than 20th
May 1994).
" ii) Supplementary
inforroation/reports could also be posted to the
consultants
by
the core partners in consultation with Asia Desk (not later than 20th May 1994).
iii) The dates for the 'field review planning exercise' (that is, visit to three
core partners will be fixed in consultation with them. These could be separate
visits of 2 - 3 days each or linked together if that is feasible.
iv)
In terms of funding provisions - the process review consultancy will
atleast provide for:
have
to
a) Cormunity Health consuntant/s for 2 weeks and 1 week (field review planning).
b) Travel grant to cover three field review planning exercise:
i) Bangalore - Hyderabad and back.
ii) Bangalore - Bhubaneshwar and back.
iii) Bangalore - Calcutta and back.
c)
Small additional provisions for secretarial
postage for Steps-A and B be begin with.
d)
Steps C and D will have to be budgeted for later but the estimates will
depend on the process that is evolved in consensus with core partners after
Steps A and B.
A
assistance,
photocopy
and
5. Since the consultant/s will be based in Aachen, Gernmany for the whole month of
August 1994, a two-three days visit to MEMISA Head Office for interactive
discussions with Asia desk staff and other MEMISA in-house resource persons could
be explored further. MEMISA - Asia Desk is requested to co-ordinate this with Mr.
G.Krause of MISEREOR, who is organising the Aachen based consultancy. The visit
to MEMISA would be good opportunity to explore further details and perspectives
from the Desk review and also be an additional opportunity for South-North
dialogue which is the main objective of the consultants sabbatical, (refer note on
Sabbatical Framework).
10th April, 1994.
GorvA H 3L.OVX (3 >
Draft
report
India
February
werkbezoek
1992.
P.W.Kok, Memisa Medicus Mundi.
Thursday 6/2.
Afternoon meeting with West-Bengal VHA.
Mr. Poddar is in Europe.
Mr. Aminal Ahsan and Dr. Soumitra Dutta and others.
The WB-VHA is an association with over 1000 members. Cooperation through consultation works well.
The VHA is doing project evaluations on behalf of donors, something other VHA's seem unable to do for
political reasons (dependance on members, preventing critical assessment). ?
VHA provides NGO's with leadership training as a priority as many NGO's have well motivated people
but lack managerial capacity. Community involvement is generally good, but one is not sure if it leads
to something. There appears a heed for management by objectives and to have a set of indicators.
Models of training like TOT and TOF training within the context of a PHC system were discussed.
WBVHA interacts with members bT the association, with training institutions as well as at grass root
level.
They train 1000 to 1500 people annually. They are planning a special course for the religious.
Their'publication of a VHW-magazirie reaches an edition of 10.000 copies. The content shows
interaction with and from the public.
'
In the second edition of "Where there is no doctor in local language, a chapter on AIDS will be included.
The limited office space shows a beehive of activities. The staff present is well motivated and they
know what they are talking about. Health education materials are present, printing quality is moderate.
Dr. Soumitra has a MBBS and 2 years further training. He is actively involved in the Essential drug
programme, something which, in the presence of an overcommercialized health care system, is of
great importance. However, the problem raised by having good and well trained staff is the expense of
employment, as other organizations especially the international ones may offer better pay.
It is advisable that Memisa discusses this issue with the director during his visit to Memisa.
VHA West Bengal functions also in an advisory capacity towards donors, something not entertained by
other VHA’s.
AIDS training
programme WBVHA.
A report on the first AIDS meeting was received. On the 12-13th of February their will be a meeting
with NGO’s on AIDS.
Dr. Swarup Sankar of NICED(National institute of Cholera and Enteric Diseases is an important person in
the AIDS programme. Some groups are active in the red light district. Testing is referred to the
virology centre.
A risk factor like migration is very much present in Calcutta with many people working in Calcutta
spending the weekend at home.
Anonymous testing can be done, but this issue should be followed-up and guarded.
'Limited counselling and treatment is available.
Counsellors are being trained.
The issue of voluntary blood donation is being taken up as a first activity of limiting transmission has
been taken up.
The Society for community development(SCD), turns sex workers into health educators like in the
Nairobi programme.
Condoms are available. Their popularity was low due to irritating lubricant and poor quality. Nowadays
the quality and availability is better. At each stall condoms can be bought.
Sex education at school is difficult. This makes linking of school education programme with HIV
information and education programme difficult.
AIDS is certainly not yet generally acknowledged or accepted as a disease that can spread though the
population. The newspaper tells the story of a doctor removed from the same building with other
private practices because he treated AIDS patients.
WBVHA is in favour of organizing PWA groups.
School
health programme.
This programme appears feasible. Implementation parameters in the form a KAP survey, pre and post
testing will be done. A pilot programme has been financed by Memisa, now they would like to proceed on
a larger scale. About a 1000 schools got an enquete. NGO and government schools are involved. The
Government is interested in the programme, but can offer little financial support. The school health
department is defunct, although there are some active people in it. The government is not prepared to
pay for 3 days leave or the per diem (Rs. 50-100) for the training of teachers. Training will therefore
take place in the same area to enable teachers to come and go on bicycle.
The Video material from Memisa is not used as only one film is present and no transport is available for
the transport of the video and screen. A small car could be considered and more film material has to be
obtained. Use of public transport only, limits the number of schools that can be visited, considerable.
Memisa is advised not to provide Video recorders unless picture material and transport is guaranteed.
Orissa State.
7-11
February
Visit to Boulakani village, Mohalkalpada Block, Cuttack district.
Organization: VAR RAT. Voluntary Association for rural reconstruction and appropriate technology.
GP 89 DIA 111; F. 67.400. Mr Mishra and Mr. Bisha.
This area consist of extensive waterworks providing the irrigation network for extensive rice fields.
Most the land is in hands of a few distant landowners, on which the landless villagers are employed for
short but intensive periods during the year. It gives the impression of extreme poverty amongst
abundance.
The meeting started with a colourful reception by a reception committee, representing health
volunteers from 30 villages in the area. A meeting ensued where an exchange of perceived
problem/needs took place. Lack of schooling, lack of income and poor water quality (salty or dirty)
were mentioned. Health problems clearly rank lower in priority.
The project started in April 1991. The staff consists of a sociologist, an economist, an ANM., a
retired health inspector and a homeopathic healer (specifically trained at the homeopathic training
school at Bhubaneshwar).
The programme has been followed-up by Cenderet, who has been critical about their work, especially
where it concerned the speed and efficiency of executing the programme.
To many
(sub)projects(women, day care centres, patchwork, coconut fiber, water), supported by Cebemo and
Danida threatens to overload the leadership.
In all 30 villages VHW have been elected and are active. They are well organized in 3 regions with a
regional leader and do have scheduled meetings regional and centrally.
Census and health data have been collected and await analysis at Cenderet and reporting.
Rapport with the district government health services is established which resulted in EPI and ANC
services becoming available to the local communities. If enough people are coming forward to these
mobile services, the government is prepared to have clinics at 2 different sites.
Hygiene, water and sanitation, MCH, ANC including FP are important programme elements.
The level of medical care is low. No essential drugs are available while the knowledge on rational drug
therapy is limited to the ANM and the HI. The lady homeopathic healer has some diagnostic skills, but
lacks any knowledge of essential drugs. Even a the simple penicillin tablet or injection to treat a
pneumonia in a child is not present. Such cases have to be referred to the Primary Health Care Centre
35 km away....public transport being virtually out of reach. Drugs available are expensive items
wrapped in silver paper or other fancy packaging. ORS is present and home methods are taught.
No weighing is done and road to health charts are not used. All typical WHO programmes are not known.
The available HE material is unspecific, but posters are present and used.
The community health expertise present is low. The need for expert advise is felt. Neither O-VHA
neither Cenderet is in a position to give public health advise. Cenderet does provide management advise.
The motivational level is rather high.
Dispensary building.
This building is not yet completed as funds run out. Especially the price of cement has gone up from 70
to 110 Rs per bag. The team even took a loan to continue the present phase of the building. (First floor
Concrete structure and foundation for two stories). Another 36.600 Rs is required, for which a
quantity survey estimate was requested and received 2 days later. Local labour is provided free of
charge.
An access road will be built at a later stage. The dispensary is well placed in relation to the 30 villages.
The functionality of this project and especially the function of the clinic in providing decent MCH and
ANC and curative services should be followed up. Staff training in PHC functions (MCH/ANC) should be
considered. The use of essential drugs, available from Bhubaneshwar at very low prices should be
promoted.
Transport, mopeds, for senior staff and circle(region) staff is present and adequate.
The quality of the government HC,
The matter of cost recovery
Visit Hospital Barati.
having 3 doctors, but usually hardly present, is reported as low.
at least as regards the curative side, was discussed.
11/2 hrs from Bhubaneshwar.
On the road to this cottage hospital we pass stone crushing sites where women and female children are
employed as day laborours at 18 Rs per day under unhealthy conditions. Severe silicosis may be
expected in some of the women employed in extremely dusty conditions.
This cottage hospital was started as a dispensary in the 50-ties by Mrs
following the Ghandi
philosophy of selfless help for the poor. Orissa state was at the time one of the poorest states. She has
a charismatic attitude. The place consists of a small OPD block, an office block, a maternity, a large
and well equipped theater and a large X-ray room with a 3 year old Siemens(lndia) X-ray apparatus
(1.5 lak).
There are 3 "doctors" of which one is homeopathic trained only.
The attendance rate is low, the number of clinical procedures offered is at the level of a dispensary,
including immunizations. To the management's surprise, the attendance rate went up after introducing
a small consultation fee of 2 Rs 2 years ago. The aim has never been self-reliance or on development,
rather soliciting donations and provide medical hand-outs to the people.
No essential drugs are used, no Road to Health chart is used, WHO/PHC policies are not known, a
laboratory for simple procedures is not functioning. ORS is used. The theater is not used because of
lack of skills from the 3 doctors present(we have no specialist anesthetist, and no surgeon!), the same
for the new X-ray which has made 78 pictures in 3 years. No x-ray laboratory assistant is present,
and apparently no other person or the doctor is trained to make simple pictures.
The maternity is functioning at a reasonable level. No waiting maternity facilities are present. The
place is clean, a jeep for patient transport is available.
The level of health care provided by the 3 medical staff is pathetic. The outlook on development is
lacking. Unless a new management and properly trained medical staff can be attracted, this project
should not be supported by Memisa.
Organization: Seva
Barati.
Phulbani .GP90DIA108.
Discussion Mr. Pattanail
A programme for community health has been apprroved by Memisa for the first out of 3 years.
They are active in training 40 lady village health workers in 20 villages.
They got a revolving fund for medicunes from Memisa. The advantages of the EDP were discussed, its
affordability and potential source of income to cover some running cost. The project does get support
from Cebemo.
They do also promote herbal medicine and gardens and had a 2 day seminar with TH's. It is a very
difficult area with poor communication and access. They recently had a meningitis problem (120 cases,
14 deaths)for which they used sulfadimidin. The support from the district health authorities is limited.
The training of the doctor in community health principles was advised. Evaluation to be done towards
the end of the firdst year to assess efectiveness. The need for baseline data was discussed.
Fish. Forum for Invention and services in Homeopathy.
Mrs. Shradhanjali Mekap, Mr. Pradhan (all homeopathic healers).
Fish is an Bhubaneshwar based organization with 20 homeopathic trained healers( 4-5 years) at the
homeopathic college at Bhubaneshwar. This training provides basic medical knowledge but not the level
of MBBS. Pharmacology has not been taught. Only homeopathic principles are provide, using Hannemans
textbook from 1854.
To my question why a foreign religious medical practice was introduced and became popular in this
area, the following answers were provided:
1. It is cheaper than allopathic drugs, and therefore the people can afford it.
2. The people like it better than allopathic drugs, which are known to cause side-effects.
3. It is very effective,
we had recently a "Scientific congress" in which the effectiveness of
homeopathic treatment was proven. The report was handed to me for study.
The scientific report consist of 8 presentations using homeopathic drugs. Not one of the papers does
contain any proof that any drug used had any action whatsoever. No drug was compared with giving
nothing or any other treatment, but other homeopathic drugs in which case contrary to the statements
no positive difference in effect could be shown.
What has failed Western science in 140 years to elucidate the value of homeopathic treatment, seems
to have failed here as well.
These findings however do not influence the religious zeal with which this imported type of medical
care is being promoted.
The staff of FISH runs an urban clinic in an apartment where also FP services are provided. There main
trust is however at the slum areas around the university and at the riverside. In these 2 areas they
attempt to introduce some hygiene and sanitation, providing limited MCH and ANC.
Next to a multitude of homeopathic drugs from the magic box, iron tablets, folic acid and vit A and B
are provided, and nutritional advise is given.
The OPD function is at a low level, no diagnostic facilities other than a stethoscope are present. Patient
do provide a small local fee (50 p).
This project does not follow the standard PHC procedures. Its curative value is if any of low standard.
Still the staff in the project is well motivated, appears to have a good rapport with the slum people on
the basis of which they can promote hygiene and sanitation which might result in better health for the
slum dwellers.
The main problems of the slum dweller however are not really addressed, as people could live better by
improving their housing standard if they were given the guaranty that their houses would not be
buldozed. This uncertainty prevents any investment in better housing and sanitation and water
facilities.
Advice: Memisa could consider a limited support for the hygiene, sanitation and health education
efforts made by this well motivated team.
However the level of public health and medical care is extremely low.
Jana Vikas
Phulbani district GP90D1A058
Fr. Augustinus Karinkuttiyll.
Phulbani is a very rural district, 260 km from Bhubaneshwar with a largely tribal population living in
difficult circumstances.
Jana Vikas has a board consisting of 1 Muslim Dr.Almas Ali(also Board of Governors OVHA), 1 Hindi
Dr. BK DAS, and 1 Catholic. This combination seems to work well as in this way no discriminatory
tagging on the organization can occur, while remaining its effectiveness to execute projects with the
rural poor. Fr. Augustin is secretary of J.V. , as well as Chairman of the Orissa State VHA.
JV executes a CBHC programme involving 42 villages with 60 CH-organizers, attempting to reach 126
villages in a period of 3 years. The requested financial contribution is Fl. 167.000. The project appears
to be willing to do too much in too short a period. There were also questions as how CHW are selected
and if local Mahila samities are involved.
Basic health services are provided through a network of 19 centres plus outreach. The organization
appears to be solid and can be expected to manage the health programme well. Through 6 HC 50 villages
are now covered.
Essential drugs are used in the project for malaria, dysentery, worms, scabies, e.o. David Werners
book in local translation is used as a guide.
Government drugs are poorly controlled- bribing by manufacturers of government officials results in
substandard or dangerous drugs.
The project intends to start issuing medicine kits to CHW after 6 months.
Patients will contribute to at least the curative provisions of the project.
The project staff will increase from 6 to 10 divided in 3 divisions: training; information(linking with
VHAl) with production of HE material, translating existing HE-material and administration. Road to
health charts will be introduced, a health newsletter is produced. Behavioral research in view of the
AIDS epidemic was discussed as a tool for specific and timely health behavioural intervention.
Existing nursing staff has been used, and upgrading (orientation) in training for 3 days was given by Fr.
Augustin. Survey methods for base-line data and there function were discussed as targets in the
project proposal were ill defined.
Immunization services are poor. Fridges are present to maintain cold chain and extend the services. The
field staff are all women, forming new groups.
Unicef does not make immunization services available to NGO's, even not in view of the shortcomings of
the government EPI.
The future need for a public health expert was discussed.
JV is active in the field since 1978.
After one year evaluation has to be done by Cenderet(opdracht geven).
Enough funds are present on the moment to bridge the gap in funding caused by the evaluation. This is on
account of infiation/devaluation.
Memisa's impression is that Fr. Augustinus and his team executes his projects with considerable
knowledge and experience. PHO elements are present within the programmes. Aspects of community
participation and self-reliance are part of the philosophy and practice of the programme.
No other donors are involved.
<
Orissa Voluntary Health Association.
OVHA.
Discussions on OVHA were held with the director Mr. Jayant Kumar Bag, and on separate occasions
with Dr. Almas Ali, (board member) and fr. Augustinus, (Chairman of the board) and Cenderet.
OVHA is not an effective organization according to Cenderet and Members of the Board of Governors,
which can be confirmed by Memisa.
The director lacks vision, technical skills and managerial skills to give leadership to the organization.
Also no technical staff is present to be of assistance to projects in the field. The training done by them
in Phulbani district was not successful at all. No public health expert is present. Within the Board of
Governors, substantial experience is available but these members have their own work and are not able
to spend much time on advising member organizations.
Political/personal ties prevents the board to appoint a new director. Presently OVHA is being
evaluated by "Child in Need Institute'(CINI) from Gujarat on behalf of Norad who finances the VHA at
the request of the Board.. Discussions with a member of Norad were held on the desirable functioning
of OVHA towards its partners in the field and its possible role as evaluating and advisory body for
partner organizations and donors.
VHAl is aware of the poor functioning of OVHA, but is constitutional unable to do much about it. Still
members did ask VHAl to consider assisting ailing VHA's in management and policy to maintain their
functional quality.
Although the office of VHA does produce some health education material and provides training, at the
level of the field one does not hear about any support received from OVHA.
AKSS
GP91DIA185
Mr
Subarna Keshari Baliyarsingh, 10-2-92
Community health programme Kanas block, Puri district.
3 years. Fl.69.000.
Discussed were some of the inconsistencies of the proposal submitted to Memisa.
Top down approach: "We have discussed with the people and they asked AKSS to implement the
scheme" . Village health action committees will provide a community bases. CHW are trained, one for
each 5 villages, which seems little to us leading to a type of health extension worker. Dais will be
trained. One doctor(MBBS) will be present and cover 5 villages in one day. They also would like to start
a health insurance scheme in view of self-reliance. Memisa suggested to start with contributions from
patients for the curative part of the project using available essential drugs.
In the mean time
experience from Prodata who is setting up an insurance scheme could be They intend to this after
proper training. The problem is that doctors are prescribing too many drugs.
Memisa should provide means for the training programme of the health workers. Attention to the
proper training in community health and the PHC approach of the doctor to be appointed, should get a
high priority.
Instead of a constant budget item for drugs, Memisa suggested a revolving fund for essential drugs.
Care should be taken that it does not become a service project only, sufficient development aspects are
to be stimulated and evaluated. Only properly trained local staff could ensure this.
Evaluation by Cenderet indicated.
GP89DIA039 and GP91DIA094
by Banabasi Seva Samiti, Mr. UC. Jena.
A 6- months evaluation report was submitted. Commentary from Cenderet is critical as regards the
development policy.
Evaluation to be done. Cenderet to be requested to execute the evaluation.
The 6-monthly report provides incomplete and inconsistent data on maternal mortality, crude death
rate and birth rates. Conclusions can not be drawn, because the rates are not expressed as rates by
absence of a denominator. The project clearly lacks public health expertise. The social sector is
strongly represented.
Memisa should make sure that in future project approval, sufficient PHC trained expertise is present or
available.
GP90DIA102.
SNAENA. Koraput, Orissa. M.Luther Raj.
They did not come for discussions with Memisa. Commentary from Cenderet: this organization should
be critically followed up and no further engagement without the advice of Cenderet. See evaluation
reports 1/8/91.
The project has not reached its target in community development, neither in
quantity, nor in quality. Follow-up was poor. Training targets were not met, and where given, done in
the wrong language. Village awareness training has been insufficient. No input and outcome surveys
were properly executed, and therefore impact can not be measured.
From the 3 years project 2 years have passed. The request for 1 more year is at Memisa's desk.
Cenderet has put forward changes to be made in the project. These concern mainly strengthening
technical staff and tightening objectives.
Looking at the whole programme, and especially as Memisa indicated in 1990 already the shortcomings
of the management, Memisa should not continue this programme. This advice to be communicated first
with Cenderet.
GP91DIA160
Antyodaya Seva Kendra.
Mr. Bhaktabastal Mohanty
Project In Keonjhar district, tribal area.
This proposal on Environment, literacy, health care and demonstrations had been rejected on account of
the very limited target group, the limited health component and the relative high cost/capita involved,
preventing self-reliance in due course.
Mr. Mohanty came to Cenderet, on their invitation,
with Memisa.
to discuss the project and the need for assistance
The area is 200 km away from Cuttack and the population belonging to the
threatened by extinction.
Juang & Bhuyan's is
Prof. S.K.Das visited the place for 1 months to analyses the situation. He recommends a limited health
programme. Memisa is the only organization requested
to support health activities in the area.
Concluded was that the organization would come up with a new proposal which would better
local health needs and local possibilities.
reflect
A new proposal was received 11.2.92.
It concerns a target population of 2964 people in a hilly poor area. There are 4 centres for ICDS(MCH)
in the area, but only 1 is functioning. Lack of support from regional HC(18 km). The programme now
limits itself to health, hygiene and sanitation. They intend to make use of paid trained health workers.
Better base-line data have to be provided in the first part of the project. It is advised to provide a
starting fund for better project planning. Local resources should be developed. Essential drugs should
be used. Total requested 1 year: est. F. 10.000.
Meeting with Mr. Shanti Ranjan Behera
of SODA.
11-2-92
SODA stands for Society for Developmental Action.
SODA is a legalized NGO active in Bihar and Orissa. It is an association of young academic
professionals. Fields
of activities: Non-formal education(NFE), research(child labour), training,
community organization, legal support to the rural poof and health in Mayrbhanj district Orissa and
Dumka in Bihar. 158 paid staff(part-time and full-time are working in different projects. The aim is
self-reliance through community participation from inception to completion of a project.
They have funding relations with Diakonia Schweden, Fastenopfer de Schweizer Katholiken, Terre des
Hommes, Puna; Unicef and Government of India.
Mr Bahera was the first one to express concern about the AIDS/HIV epidemic in India. We discussed the
various needs for launching an effective health education. Research in sexual health and behaviour are
very much needed for such undertaking. SODA may have the capacity develop a research and education
programme on sexual health with the aim of preventing STD's including AIDS. Their public health
strength, besides a study on ICDS, has to shown.
Mr Behera attended a programme on AIDS training in Indonesia. Heard of Memisa's Dr. van der Tas. He
has been engaged in Danida sponsored programmes. Is in favour of trying social marketing of FP. He is
a journalist-lawyer. He would like to attend the Amsterdam AIDS congress, which I discouraged at this
stage. Concentrating on regional meetings may be more useful.
Annual budget of SODA is 16 Laks.
Meeting with DNSS, Society for the poor.
Mr. G.C.Malllck (Managing director and Dr.
Basantibala Jena(ex-State Director of Medical Services) from Council for Tribal & Rural Development,
505 Sahid Nagar, Bhubaneshwar 751007.
Dr. Jena has considerable experience in health administration and has retired to an advisory function to
DNSS. The is the co-author of a book of health care in India, providing very useful information of which
Memisa was presented with a copy. Mr. Mallick is a former student of Xavier Institute of management.
They are a member of OVHA. There are 3 branches each with a project coordinator. Pati has a full
time job at the UniversityfPopulation council). His availability and Dr. Jena for project implementation
can therefor only be marginal.
Area representatives came to them to ask for help. A development policy was drawn up and they
intend to execute a programme for maximum 3 years enabling the community to be self-reliant. Under
the heading Each one teach one, they wish to establish a health movement.
Participation of women is foreseen. Of the 9 members of the board, 3 are at least women. Only 18 out
of 63 workers are women, they intend to involve more women.
They perform health camps-eye camps at village level. They entertain a mixture of modern and
traditional medicine.
An annual report for 1990-91 has been submitted.
Any project from DNSS
and CTRD should be evaluated by Cenderet on Its feasibility
for implementation.
Both organizations have submitted a proposal:
1. Integrated development of community health care project in rural areas(DNSS).
2. Demonstration family planning & MCH project, 3 years.(rather dated, updated for the
occasion of my visit, earlier submitted to
? ?).
Meeting staff and director Regional India Medical Research Council. 11.2.92
Prof Krishnamurthy has wide experience in epidemiology in various parts of India. We discussed the
relationship between research and public health policy. Main problems are malaria, EPI diseases,
Leptospirosis, and Leprosy. Bacteriological surveys are being done on diarrhoeal disease agents.
No Schistosomiasis is present in India, although vectors and a suitable environment are present.
As regards AIDS/HIV, IMRC is carrying out a continuous sentinel survey is hospitals in the state. Up to
now no case of HIV infection have been found. The authorities have acted against prostitution in the
town. They admitted to expecting through the transport routes from Calcutta to see infection entering
the state in the future. Not much is done on awareness as the problem does not yet exists in the state of
Orissa. (PK to send polio paper).
Kanpur Urban Primary Health care programme.
12-14 February 1992
Meeting with Christina de Sa, Senior Project Officer(VHAI).
Ms. Christina de Sa appears to have some problems with the Co-director Kanpur Medical College as well
as with Indo Dutch Project(IDP). The main reasons seems to be the lack of communication on where and
when they may expect her presence in the project area. So far she has been engaged in the training and
motivation of the Community Health Volunteers(CHV) and the Health Extension Workers(HEW).
This part of the programme has been established well. Still there is a need for a more structured health
education intervention and especially the design, testing and production or acquisition of the needed
health education material.
The SPO may not altogether function as SPO in charge of the overall process of management of the
Kanpur UPHC, a function that is called for but not supported by her job description of the inception
report. Besides she has work to do for VHAI in Delhi and also is engaged in activities for
Mirzapurfworkshop together).
Recently however, following Dr.Ory's intervention the tasks of the project are clearly delineated. Ms.
CDS will concentrate the following 3 months on the development of health education structure and
material.
Concept
beleidsnotitie
AIDS
AIDS POLICY
Memisa Medicus Mundi.
The AIDS pandemic as it is evolving in the nineties will influence deeply all health and social
services of the countries involved. MEMISA as donor organization in the health field has taking
up the issue of AIDS as a matter of priority from 1986 onwards.
It is clear that the HIV-infection is spreading fast to all continents, but will affect particularly
severely urban poor communities, extending rapidly into rural areas. AIDS among adults is
now the primary cause of death. Although posing a formidable medical problem, the AIDS
pandemic will primarily be expressed as a tragedy for individuals and families, and for
communities as a serious social and economic problem.
Policy formulation will have to reflect the different levels at which the HIV-epidemic unfolds.
It follows that health care will have only a limited impact on the prevention and control of the
epidemic.
in general all interventions should be placed within the concept of primary health care, being
made operational within the district (diocesan) health care system. In some countries other
social or health care structures can, exceptionally, be considered. Moreover, all health and
social programmes should incorporate prevention of AIDS as a matter of policy.
1.
The disease:
AIDS is caused by the Human Immunodeficiency Virus (HIV),belonging to the retrovirus group.
It attacks particularly the T-helper cell which is an essential element in the defense system.
Once the number of T-helper cells, characterized by the CD-4 locus, reaches a level below
200/ul., clinical, opportunistic disease usually follows. Disease is caused by a wide variety,
and often a combination, of pathogens: bacteria, viruses, fungi, yeasts and parasites. Some are
readily treatable (TB, fungi, some bacterial infections), some are very difficult to treat,
requiring levels of sophistication and expenses usually not available in developing countries.
Up to now the disease invariably leads to death. The average period between infection and death
is about 8 years in Africa, in children 1-2 years. Some long survivals are reported from the
US.
2.
Epidemiology:
Africa:
AIDS disease and mortality: 1.5-2 million adults, expected to rise to 3.1 million by
1995. Children 0.5 million death, expected to rise to 1.3 million by 1995.
HIV sero-prevalence 0.5 to 30 % of adult population. 10 million people infected, half
of them women(1993).
20-40% of children born to HIV infected mothers are HIV positive.
By the end of the nineties the annual AIDS specific mortality will be 3 to 4% of the
adult population in the presently most affected areas in Eastern, Central and Southern
African countries. Tuberculosis is increasing with 30% on account of the HIV epidemic
after years of gradual decline. In West-Africa both HIV-1 and HIV-2 variants are
present. STDs are present in 10-30% of the population; especially women are
affected with non-clinical disease.
AIDS POLICY MEMISA
1
Latin-America:
1 million people infected( 20% women). 0.1 to 1% of adults infected. Some urban
areas show a rapid increase. Mainly homosexual-bisexual men and IVDU's involved,
but also spreading into the hetero-sexual population. Caribbean 310.000 (130.000
women). Street children are a special risk group.
Asia:
1.000.000 HIV infected people, (30% women) mainly urban poor(Bombay, Delhi,
Calcutta, Madras, Manipur, Bangkok). Prostitution/lVDU's. Rapid transmission.
Other countries e.g. Birma, Malaysia, Philippines, Indonesia and the Mekong are
following.
In most countries women are infected at an earlier age than men.
Towards the year 2000, 40-100 million people will be affected by AIDS/HIV, after 2005 2/3
of infections in Asia.
Social
impact:
In affected areas, up to 30% of children will be orphans. The support structure will
come under pressure. Stigmatization, discrimination at local or national level. Labour
relations. Political changes. Risks involved in finding a life-partner. Religious and
cultural stress. Changes in customs. Role and status of women are affected.
Change in burial rituals. In some heavily infected regions a population decline may
occur after the year 2010.
Economic
impact:
Direct cost: for treatment, testing, information, education; care and counselling for
patients and families. Loss of income. Transport and funeral cost.
Indirect cost: loss of skilled labour. Loss of production, especially at the household food
supply level. Burden on health infrastructure and personnel. Loss of schooling for
affected families and children.
3.
Intervention
policy.
Prevention.
in the absence of a foreseeable treatment or prevention by vaccine, preventive measures are
the only way to diminish the rate of transmission of the HIV in populations.
The transmission rate of HIV in a community depends on only two major components: the
number of different sexual partners over time and the presence of an other Sexual Transmitted
Disease (STD). The first factor determining the chance of a HIV-positive sexual encounter, the
second factor determining the risk of actually becoming infected during such encounter. The
nature of sexual behaviour, being hetero or homosexual does not influence the rate of
transmission, it only determines the group in which transmission of HIV will take place.
IVDU's and bi-sexuals may form a bridge between such groups. Vertical transmission from
mother to child (15-40%) accounts for approximately 15% of transmission while blood
transfusion accounts for 5%. Some other minor cofactors have been indicated.
AIDS POLICY MEMISA
2
One can discern long term and short term preventive actions:
Long
term:
-Activities aiming at changing sexual behaviour; elevating the status of women.
-Prevention and treatment of STDs.
Short
term:
-Counselling HIV infected persons to prevent further transmission to partners and
children, and to increase coping with living with HIV and clinical AIDS.
-Provision of safe blood transfusions
-Establishing/promoting safe clinical procedures
-Promotion of use of STD prevention devices (condom)
Changing sexual behaviour is acknowledged as difficult, especially for groups of people who
because of their status in society have no or little say over their sexual behaviour. To this
group belong especially the rural and urban poor. Women and their children varying by
country and cultural setting are especially at high risk of infection, lacking the means to
protect themselves in situations of sexual, social and economic abuse. Economic systems
promoting migrant labour facilitate urban rural transmission. Also displaced communities due
to civil war or natural disaster are at high risk of infection. Prison populations and commercial
sex workers can be considered as high risk groups when adequate provisions and care are
absent.
A priority group for intervention is the youth as new sexual patterns are being developed.
School health education and information programmes are essential.
Changing relationships between men and women, sometimes contrary to established cultural or
recently in history grown habits, creates a formidable challenge. "The mental fixation that
glorifies traditions of male sexuality now hinders collective behaviour to stop the spread of
HIV.
Advocacy at the level of community and political leaders to prevent discrimination, to ensure
protection of the family and orphans, and to improve the position of women in society, and
especially improving literacy, can create the necessary framework for changing behaviour.
Policy and programmes should be aimed rather at whole communities than narrowly be focused
on risk-groups.
Vertical transmission of HIV can be prevented to a certain extent by counselling and the
availability of effective methods of family planning.
A strategy for the prevention and treatment of STD has to be followed vigorously. Early
detection and treatment of especially asymptomatic STD has to be integrated as part of maternal
service and health services for women. Education and counselling should be part of
epidemiological control programmes. STD protection devices (male and female condoms) have
to be made widely available to those at risk of infection .
Appropriate treatment schedules and drugs should be available at peripheral health units.
Training for its use should be provided.
AIDS POLICY MEMISA
3
Safe blood transfusions. All blood for donation should be screened by one appropriate HIV
antibody test with high sensitivity. No second or confirmatory test is indicated for this purpose
(see annex 1: HIV-testing policy).
Prevention of anaemia is most important as to lessen the need for blood transfusions,
especially in children and women. Malaria control and nutritional education therefore have a
high priority .
Safe hospital procedures should be ensured by regular training and supervision of all
departments that handle potential infectious material. Protective materials are indicated.
An AIDS Policy Committee (APC) should be present in all institutions and will be a condition for
support by MEMISA (see annex 2: safety in the work place ).
4.
Support of people with AIDS/HIV (PWA).
-Counselling of HIV-positive people
-Counselling and clinical care of PWA
-Home care and family support
-Support of orphans
Support programmes for the care of HIV infected persons and patients with AIDS at the level of
the hospital and the community are indicated. To be effective, care will be as much as possible
integrated within the primary health care strategy and aims to strengthen community based
health care.
Mobile teams for assisting and supervision of home care and community counselling may be
indicated. Any counselling programme should also include care for counselors.
In principal only essential drugs should be used, or drugs which can be safely used at the level
of the basic health services and are of proven value to deal with symptoms of AIDS.
Support of affected families and orphans in regard to medical and preventive care can be
considered . Other social and educational needs can best be dealt with in cooperation with other
multisectorial programmes.
Orphan support through direct assistance and the promotion of community care for affected
families should be supported. The training of community health workers or community social
workers and the possibility for establishing day care centres at the local level can be considered
for support .
In the programmes for education and information as well as in home based care programmes and
the organization thereof, PWA/HIV should be involved as active partners as much as possible.
They are often well motivated and their engagement provides an opportunity for living
positively with HIV/AIDS.
5.
Research, training and management.
Operational research in the formulation phase of an HIV/AIDS prevention and control
programme is indicated. These studies are specifically related to social- and sexual behaviour ,
STD prevalence, transmission, appropriate treatment schemes and health education
intervention strategies.
Training for project management, clinical care, STD prevention and treatment, counselling
and home care at the appropriate level are important fields for support.
Within the context of training, attending local and regional meetings (with the exception of
international meetings), on AIDS, STD and project management can be considered for support.
South-south programme exchange could be promoted.
In managing national or regional programmes, verticality in execution should be limited. The
aim should be in training trainers at local level as to enhance the capacity for sustainable
programmes.
AIDS POLICY MEMISA
4
At national level participation in the National AIDS Control Programme (NACP) and the
GPA/WHO policy is of great importance, as initiatives should follow mid-and long-term
national AIDS control programmes and as feedback from the NGOs to the NACP.
Support to NGOs who are established for HIV/AIDS only should be judge carefully. NGOs coming
forward from PWA/HIV (ASOs) for creating awareness and increase coping mechanism, should
be seen differently from NGOs targeting populations in general for intervention.
MEMISA will maintain working links with national and international networks on AIDS
prevention and control. Such networks can be supported in their functioning, including support
for international publications and advocacy work.
Criteria
for
funding.
Those have been formulated within the Caritas/CIDSE organizational structure (see annex) for
a wider range of activities than could be considered by MEMISA, as they include other
development sectors.
The following three basic and minimal criteria will be applied in the assessment of all AIDS
project proposals:
1
Criterion: AIDS project proposals should not stand alone but relate appropriately to existing
health or other development activities.
2
Criterion: AIDS projects should provide objective, non-judgmental and non-discriminatory
information and services.
3
Criterion: AIDS project proposals should as far as possible help to create and to strengthen
indigenous coping mechanisms which will be characterized by self-help and community
involvement.
It should be mentioned that concerning the criterion of integration within an existing health or
social structure, the emphasis on applying this criterion may differ for the various regions.
In Latin-America and to a lesser extent in Asia, NGO’s are often not actively engaged in the
provision of health care directly as this is done by the government. AIDS prevention and care
programmes in these regions could make a valuable contribution complementary to the
government services.
Health Service Department,
Dr. Peter Kok
Health consultant
MEMISA Medicus Mundi
P.O.Box 61
3000 AB Rotterdam
Netherlands
2/94
AIDS POLICY MEMISA
5
COrvi ) | /-£>■ S
Memisa Cebemo health care policy.
1. History
2. PHC
3. Policy dialogue
4. General Policy
5. Relationship to international networks
6. Specific concerns.
7. Ethics: Rome and Athens
8. Tanzania
9. General issues
10. specific issues.
1. History.
Mennsa started in 1926 as an initiative of private medical
practitioners and a priest in response of requests for health
care and advice for missionaries in the southern countries,
experiencing a very high mortality. As missionaries gradually
took up health care for the population amongst whom they
performed their missionary work, the role of Memisa gradually
expanded to advice and support health care delivery through
missionaries and congregations.
With the development of a professional church related health
service, Memisa and since the early seventies, also Cebemo
took part in the development of such services in the newly in
dependant countries.
Cebemo arose out of the possibility that Dutch church related
NGO
could get support from the Dutch government for their work in
developing countries.
Although Memisa and Cebemo are having their roots in the
Catholic
church,
neither Cebemo,
nor Memisa are Catholic
o r gah i sat i o ns
in the sense of falling under the hiarchy of the
Catholic church.
,
-•
■ |Memisa gets its funds from the Dutch community in response to
.<-/ j perceived health needs of the communities in the south.
" '■ At their request NGOs like Memisa,
Caritas Neerlandica and
i Lenten
Campaign, Cebemo can act as a co-funding organization. Besides
that the main
channel of funding for Cebemo is the co-funding
of
NGOs in developing countries.
2. Memisa follows largely the policy of PHC as laid down in
the
Alma Ata declaration, which reflects the health developments
which had taken place in the 60-ties and early seventies,
especially in the church related health services. Alma Ata was
not new, it was the result of health care initiatives of NGOs,
rather than governments. Memisa and Cebemo promote the
application of the PHC policy to the situation pertaining in
specific regions and countries in the developing world.
It
has
to
address
itself
to
the
issues
of
ill
health
It has
to
address
itself
to
the
issues of
ill
health
considering
and analyzing the determinants of health: poverty, political
violence and suppression, cultural and religious obstacles,
gender issues
affecting health; and
the environment as it has
a
physical expression
and
influence on health:
water,
waste,
soil
and air, height, temperature and rainfall. The social and
economic environment with factors as education, development
level,
ethnicity, population pressure, the
level of democracy
and
distribution of wealth are important determinants of health
status and determine possibilities to attain better health.
3. Policy dialogue.Funding agency policy is sometimes
experienced
as constrictive by the partner organization: are
we
not having our own policy? Don't you trust us?
Who is the recipient of aid/assistance- who is our partner?
Primary our partner
is
the "communi'ty~"whTch "can
only be
approached
by
their own
community
organization.
Our
partners are
therefore
both church and non-church related NGOs or where a legitimate
government is present also they can be our partner in
development. The main criterium is does the community benefit
f rom _t_h£ Jzunds provided by the Dutch community. The aim is
therefore not
explicitly to strengthen
the church, but
those
for
--- ----w'hom
the church can be meaningful
in improving the health
status
of the people.
4. Memisa and Cebemo are development organizations. The notion
of
development, aiming at self reliance, participation and
independence form the basic ingredients for criteria for
financial and other ways of assistance. Memisa is not a
recruitment bureau
for medical personnel,
such personnel
has
to
be engaged
in positions which are optimal to share
in
a
creative
development of health services within partner organizations.
5. Memisa and Cebemo relate to international bodies as WHO,
Caritas
Internationalis,
CIDSE
and
Medicus
Mundi
International is
as well as to national networks. From these association some
common policy is derived.
6. It
is felt as a moral obligation for the people in
the
north
to share wealth with those in the south, realizing that we are
part of the same global community. It includes an awareness of
the wholeness of
the creation and the common interest to care
for
this creation.
It. is also realized that this can only be attained by limiting
the consumption of non-renewable resources in .the. nort.h.
The obligation
of all lof us is to attain peace as without
peace
development is impossible.
An active policy to put our own house
in
order,
without
blaming
past historical events in the first place, is an obligation of
all of us.
As the world political constellation is not anymore divided
between eastern and western dominance, new positions and
political
arrangements are being sought.
This has
led
to
certain
instabilities in regions with significant religious and tribal
differences.
7. EthicsAlthough Memisa and Cebemo have
roots
in the
catholic
church,
their policy
is not determined by a particular brand
of
\ Christian
church and therefore not restricted by
internal
church
policies. Our partners, especially in the east are members of
ieastern religions, who have there own set of criteria.
■As far as they do not
contradict ethical
consideration based
on
universal notions of human rights, such organisations can be
meaningful
in
developing
health
services
for
their
communities.
We can not deny however that such ethics are mainly formed by
the
Greek tradition as expressed by Hippocrates and the Christian
churches.
Medical
action
is primary
determined by the
interest
■ of the individual and the community and only secondary by the
religious association. Also the catholic church does recognize
that it is the individual who has to take ultimately
responsibility for its own actions to preserve life.
8 ■ T an z an i a p o 1 i c y .
Historical changes. The changing role of the church in health
care asks for a r econs id eTatTofF' ofi fsi n t e r n a 1 management
structure
to
cope
with
the
legacy
of
the
past
and
the
challenges
of the future.
The assessment of the health service infrastructure has laid
bare the need for a reorientation in the management of health
services.
Memisa and Cebemo recognize
the need
for
a sound
health
infrastructure in
the attainment of health for
all at
some
fTme .
That essential
elements as
community participation
and
ef f icient
and effective response based on needs expressed by a
pair t i c i pa ting community or observed
and
researched
health
needs
are essential ingredients towards this goal, would not be
denied
government
should
be
complementary.
No
overlap but
constructive
cooperation at
local level is es'sen'tTal' as not'to was'fe scarce
resources? In" supporting each other parochial thinking’ can be
an"oB'staele".'"As already put forward at the Dodoma conferences,
designated health areas for
each unit should be determined.
The recent example of Bukoba district showns ways how such
concept can be designed.
13. The basic change
in the cooperation of Cebemo and Memisa
with
the partners in Tanzania is that the approach of supporting
unlinked activities will be replaced by a structural mid to
longterm cooperation. This will need a clear understanding of
each others role and
capacity. It
asks_ for an open dialogue
and a
complete transparency in its planning and execution.
Increasing the capacity of the diocese to take up this
responsibility will need a continuous training in all
of
running a health service, management in the first place.
fields
The basis of the church activities has to be formed by a
consistent diocesan health policy and plan. Without such basic
document,
there
will be
no firm
foundation on
which
cooperation
between the diocese and its development organizations, whoever
they may be, can take place.
Peter Kok
Medical advisor
Memisa Medicus Mundi.
September 1993.
Oom H -i_o. €
FIELD REVIEW OF ANDHRA PRADESH PARTNERSHIP OF MEMISA
A REPORT FOR PRESENTATION IN THE WORKSHOP FOR CORE PARTNERS OF MEMISA
i
-
3
AUGUST 1996 AT HYDERABAD
PREPARED BY
D SREENIVAS RAO
JULY 1996
COMMUNITY HEALTH DEPARTMENT
THE CATHOLIC HEALTH ASSOCIATION OF INDIA
157/6, STAFF ROAD
GUNROCK ENCLAVE
SECUNDERABAD 500 003
1
CONTENTS
I.
INTRODUCTION TO THE FIELD REVIEW
1.1.
OBJECTIVES
1.2.
METHODOLOGY
1.3.
PROCESS OF FIELD REVIEW
II.
PROFILE OF FIELD PARTNERS
1.
WHERE. ARE HFMISA PARTNERS LOCATED
2.
NATURE OF FIELD PARTNERS
III.l.
PAGE NO
PRIMARY HEALTH CARE/COMMUNITY HEALTH APPROACH
2. ACTIVITIES/COMPONEMTS
IV.
FACTORS AFFECTING HEALTH
a.
DIRECTLY
b.
INDIRECTLY
V.
EMPOWERMENT PROCESS
VI.
SUSTAINABILITY
VII.
ORGANISATIONAL CAPACITY
III.
TRAINING AND OTHER SUPPORT NEEDS
IX.
TRANSPARENCY
X.
NETWORKING AND COLLABORATION
XI.
STRENGTHS AND WEAKNESSES
FIELD REVIEW OF MEMISA PARTNERS IN ANDHRA PRADESH
I.
INTRODUCTION
The
desk review of the partnership between HEMISA and it's
in
India,
had
key
three
Narayan
of
CHC,
suggested a field review of all the projects
in
the
by Dr. Ravi and Dr.
conducted
Bangalore
partners
Thelma
of Andhra Pradesh, Orissa and West
States
complementary exercise to the desk review.
as
Bengal
a
CHAI, the cure partner of
MEMISA in Andhra Pradesh agreed to the idea of field review and after
a detailed discussion with Dr. Ravi Narayan and MEMISA had undertaken
the
assignment.
This paper attempts to bring out the
learnings drawn from the
insights
and
interactions with the field partners at the
grass root level which would be raised in the workshop be held from 1
- 3 August 1996 at Hyderabad for further discussions.
I.. 1. Objectives of the field review
a)
To
understand the feasible models of health care developed
and
evolved in the field by the partners.
b)
To learn the strengths and weaknesses of MEMISA partners.
c)
To
review the lessons learnt from partnership
MEMISA and partners
d>
To
understand
the
process
between
and give suggestions for future.
emerging needs of
partners
in
terms
of
training, continuing education and support to.programme process/
management and self development.
e>
To
assess long term sustainability of process and efforts
made
towards the goal.
1.2.
Methodology
a)
Check list for field review.
CHAI took the lead in developing a
check list for the field review and sent to MEMISA and
and
WBVHA,
the
respectively
based
for
core
partners
their comments.
in
CENDERET
and
West
Bengal
The check list
was
revised
Orissa
on the suggestions and was used for field reviews by
core partners.
the
to)
Field Partners for review :
Sampling
of
projects
supported
constraints,
are
about
16
Due
to
time
by MEMISA in Andhra Pradesh.
sample
a
There
was made
6
and
projects
were
selected for field review based on the following criteria.
a;
Projects managed by women exclusively
to ;<
Projects aimed at empowering Dalits and managed by
c)
Two projects run by Catholic Church
d)
Two projects by secular
Dalits
(fl. Is of CHAI)
NCOS
Out of six projects studied, five were recommended toy CHAI and one, ie.
Assist India has been supported by MEMISA directly.
Process of Field Review
1.3.
The field review visits began in mid April 1996 and concluded by
mid
Two members of the Community Health Department paired
up
July 1996.
except
for all the field reviews to avoid any subjective impressions
for
one project which was done by one team member due
to
personnel
and time constraints.
During
project
the
with
visits to six field partners, the team
the
had
holder, field staff and visits to
with target group
a
discussions
few
target
villages
and
keeping
the
checklist for field review in mind.
After
the
field
visits
the
respective team made reports for each visit
which
were
interactions
members
leaders
and
compiled into this report.
II.
PROFILE OF FIELD PARTNERS
II.l.
Where are MEMISA partners located:
There about 16 projects being supported by MEMISA as on 31 July 1996,
which
are
recommended
by CHAI and seems to be
two
more
projects
directly
supported by MEMISA in Andhra Pradesh.
16
projects
located
in 11 districts and the other two projects are also
located
in
one
of
the 11 districts.
4
These
Following table 91 v es
the
b r ea k
up
d i s t r i ct-wise 1ac a t io r > of the
projects.
S.N .
District
S.N.
Project Holder
1 ..
Waranoal
1.
Catholic Mission, Kamalapuram
aS a
.Mehaboobnagar
2.
RAISES, Shadnagar
••3/ n
Y.F.A.. Kothakota
3n
Ad i1abad
4.
C a t hoi i c Church
4.
Khammam
5«
CHRESHE
5.
Ananthapur
A.
CHAITANYA, Lepakshi
/ u
ARIDS, Bu kkapa t nam
8.
S A V E, V a j r a k u r
9.
Vimala
•
6»
Cuddapah
Community
Development
C entre,
Ma1iapuram
7»
10.
SEVAEHARATI, Tirup athi
11.
ROPES
Krishna
12.
SNEHA
Guntur
13.
Nava
Ch i ttoor
8.
Chaitanya
M.P.H.W.
(F)
•
T r aini ng
10.
P r a k as am
Di rectly
supported by
MEMISA
11 .
Srikakulam
Gufc
of 18
14.
SIR D, Be s t av a r 3 p e t
15 .
WELFARE
■j.
16.
ASSIST India (Guntur T. Prakasaffl)
}
17.
PA SC A
18.
Grama Abhivruddi Kendra
five projects are located in four backward
districts
of
Telangana, six in 3 districts of draught prone Rayalaseema and
seven
in Coastal Districts of Andhra..
field
Out of 6 projects visited for
review, two are located in Anantapur district (Chaitanya. and
ARIE’S),
one
in
Prakasam (EIRE1),
another one in Warangal
two in Guntur (St, Ann's
(Catholic Mission).
and
ASSIST)
ana
While the Telangana
and
Raya!aseema projects deserve support based on the backwardness of the
the other projects may have deserved support based on
area,
specific
health problems in particular area or their focus in Dalit or
tribal
groups.
Nature of field partners
II.2.
Rural & Urban :
All the six projects visited are rural based except the one
located in small municipal town hut not having any urban
(ASSIST)
programmes.
In the context of rapid urbanization process even in Andhra
Pradesh,
a few urban health projects may be encouraged.
Church 8>. non—church
Out
of
16 projects recommended by CHAI
four
are
Church
related.
church
related
The reamining are secular voluntary organisations.
Cut
of six voluntary organisations reviewed two are
and four secular voluntary organisations.
one
(Catholic Mission)
priest
and
the
congregation
Of the two church related,
other one is Social Service Society
which
a
Kamalapuram is a parish based group run by
by
local
The
four
run
has various developmental programme.
voluntary organisations are basically developmental organisations nut
exclusive health groups or organisation with health specialization.
Size
Majority
larger
in
(88%) are small and medium size and only two (ie. 12%)
voluntary organisations among those receiving MEMISA
Andhra Pradesh.
partner
as
well
This shows the conscious efforts from
as
organisations.
6
MEMISA
to
promote
smaller
are
support
the
core
grass
root
Management
One among the four secular groups (ARIE'S) is managed by a woman,
a Dalit by himself
by
(BIRD), the other two by two persons
experience with big NCOS.
previous
who
had
Of the two Catholic groups,
one
run by a Parish Priest and the other one by
is
voluntary
rive
women
organisations have? a Governing Board
Congregation.
about
with
The founders are the chief functionaries in all
members.
voluntary organisations who are the
one
'key' persons.
7
four
the
The role of Board
is very minimal in all voluntary organisations except in one.
All
the six, except one, have informal way of functioning
too
much of professionalism
disadvantages.
itself
to
in
with
out
which seem to have both advantages
and
But one organisation in the course of time, has grown
a bigger professionally managed
support of five to six funding agencies.
one, run by the Congregation,
a
number
of
the
has
Of the two- Catholic groups,
is also big with various programmes
areas of Andhra Pradesh, which is in
professionalised.
getting
was
group
process
of
supported
are
the
By and large, the groups,
in
small in size, committed and who can operate in smaller jurisdiction.
Focus group
Though
target group of all the six groups is by and
the
large
the
disadvantaged sections of the people, one group focuss exclusively un
Dalit
women,
one
classes,
women
and
large,
the
on women in general Dalit
three
and
backward
other
on the poorer sections without exclusiveness,
children in a tribal area including SC
Dalits.
focus group emerges to be women and children
focus on Dalits and tribals.
7
It may be a welcoming trend.
one
on
By
arid
with
more
Focus of work
focus of work of the six groups is mostly empowering
The
awareness
through
sanitation
while
building
besides
facilities
one
foccussed
health education.
on
providing
Almost
have various developmental activities as
organisations
social forestry, etc.
the
all
their
like non-formal education, thrifts, watershed, MCH (CRS),
training,
women
the
focus
vocational
Community Organisation
saving
and
schemes are common activities in almost all the organisation.
l.
III.
Primary Health Care/Community Health Approach
All the six groups have received support from MEMISA towards
Health
Care/Community Based health care programmes in the
years.
Out
of
six,
have
four
received
financial
last
4-5
support
for
community based health care programme, while
exclusively
(ASSIST
India)
ph ases
and
support for providing
received
Primary
sanitation
another one for 18 months M.F.H.W. training
group
one
two
in
Ann ' s
(St..
Soci a 1 Ser v ice Sor i ety) .
Many of them understand primary health care as integral part of their
developmental work.
to
increase
common health problems in the local
the
address
But they do understand it as a programme package
health consciousness among the masses.
that being a health programme,
areas
A few of them
it has to be meant for all.
was
grounds.
Basically it is taken as a programmatic approach
while
two
especially
they cannot
have
taken
it
as
differentiate
an
opportunity
to
by
many
organise
women
Dalits and conscientise them for empowerment.
understanding
and
consensus
health need be arrived at.
8
on the broader
vision
feel
health
for
people
to
The logic
expressed
that
and
of
A
common
community
111
Activities/Components of PHC/C.H
The
review
of
6 field projects
coalmanalities
highlight
projects
while some show diversity in their programmes.
of
on each programme component varies from one group
focus
other.
is the list of the activities as
Following
some
in
degree
The
the
to
of
their
CCHWS)/CHVs/VHWs
(£>>
part
P.H./C.H. programme.
Training
of Community Based Health Workers
This
one
is
Programme,
the important
observed
of
success
of
component
in almost all the
of
Community
programmes.
programme depends on C.H.Ws, there
the
Health
Though
the
seem
be
to
constraints in getting resource persons to train them properly.
Health Education <61
Another
component observed is health
important
The
education.
PHC/C.H programme revolves around this important activity.
Though
the focus of all the groups is health education, there seem to
be
cons t r a in ts/1 imi t at ion’s in this area also.
Majority (4) are involved in giving
groups
to
few (2) are
involved
to a certain extent.
consciousness
need
a
while
Dun'ts,
more thought about and
be
need
greater
'Health messages'
in
critical
developing
The content
and
systamatized.
support from outside
like Du's . &
in
methodology
smaller
The
these
areas
ie.
training and health education aspects of the programme.
Immunization
(3)
Importance of immunization and ORS are some of the common
aspects
of He a1 th Educat ion.
Increasing immunization levels of under five children and pregnant
women
is
one
of
their important
agenda.
Majority
of
these
Bove rnment
partners supp1 ement
B'
immun1
ope rat iona 1
areas
and large
acceptab1e wh ich
common
voluntary
and
organisations.
c amps
T, E
1 i k. e
are the primary
some
L ep ro
Byn aeco1ogxca1
o f suc h
c amp s ..
Camps
continuity of education and fol low
up action which doesn
seem
n on e
to note that the women's organisations of all the
v ill ages take the
of organising such
kitchen garden
Promotion
Walnutrit ion
one of the major health problems all the
fie1d
in
aspect
their health education..
the
to
camps.
44)
confront
Nut r i t ioi i educat ion
the target group
seem to be a successful programme
ab 1 e
ma i n t a i n
or lack of proper
are .
of
around all the Dalit
10
are
I n m any
people
k i t c h e n garden properly due
seems to be working
gardens
eed1ing
Various
them as p a r t o f the prog r a. m m e .
i mp o r t an t
kitchen
They promote
doesnot
m i ni mum
becoming
involved in
wou 1 d b e relev an t
supp 1i ed
NBGs
awareness and
the common d i s e a-
pos i t
high
very good outcome
their own
around
and
of almost al 1
from PHCs
5
to be
sually the one time
tivi tie
prob 1ems
the
(4)
Health ’ camps,
pupu1 ar
p1 aces
the coverage
of Government
Health Camps
in incceasing the
In one place
this
are
w ate r
we could
where
Sanitation programme
One
(1)
with
support
the
of
MEMISA,
State
contributions in a large scale in part of
a
latrines
of
of the six partners is involved in construction
and
local
coastal Andhra.
After
Government
process of health education for two to three years,
infrastructure
seemed to be necessary.
providing
In the expansion
of
the
education
was
and.
home
remedies to treat common ailments, which is positive to note.
As
programme,
sanitation
whether the same amount of
is a question.
gone in,
Promotion of Alternative systems of medicine
Out
of
six
groups five are trying to promote
herbal
are made aware of the preparations for some of the
people
ailments,
own which
them
(5)
they can manage some of the common ailments
leads to
empowering process.
on
their
At present all of
are trying to promote with limited exposure
and
knowledge.
They need to equip themselves to promote herbal and home
in an effective way.
common
This is culturally ac eptab 1e,
remed i es
low cost
and
Thrifts and savings is one of the most common activities, all
the
is accessible to more people.
Thrifts & Savings (6)
groups
are involved.
In most of the places, the groups
are organised around savings.
seem
to
enabled
be interested.
This is one activitiy all the women
In a few places <2-31 the
sanghams
to manage their own savings while in a few places
they have just started and so more controlled by the MGO.
places
women
of
(2), the community (group of women) meet once in
are
(2—3),
In a few
a
month
only for this purpose i.e to collect each individual's savings and
distribute loans to needy members.
11
Community Organisation (6)
All the six groups are involved in organising groups of women
(&)
and in a few places youth
of
(I).
The groups have taken a number
issues such as women's harassments
system (PDS)
distribution
(3), problems related to public
(ration cards),
infrastructural
local
facilities, such as bore walls and land pattas etc.
related
issues
health
organisations
community
seem
to
have come
on
Of late,
of
these
again.
They
agenda
the
which is positive to note
the
to be moving from providing health services to enabling
the
people to demand health as their right.
10.
Collaboration with Government
Government
the six groups are trying to collaborate with
All
ths
degree
poor with
developmenta1/wa1fare
The
of collaboration varies from one group to the other.
Gut
six,
two groups (ASSIST & St. Ann's) seems to
relationship
with Government and involved in
programmes,
while
aware
in
programmes.
reaching
of
(6)
of
excellent
implementing
others are trying to make the
Government
have
Govt.
more
community
programmes meant for the them
try
and
to
access such programmes.
The trend of involving NGOs is increasing more and more, MROs need
to think of this seriously and make a critical collaboration.
IV.
FACTORS AFFECTING HEALTH
DIRECTLY
a.
Following
are some of the activities/factors that seem
to
be
affecting improvement of health directly.
1.
Immuni z a ti on
2.
MCH
services (supply of iron and folic acids,
pregnant women)
immunization
to
of
Treatment
minor ailments through ANMs and
trained
health
worksrs.
b.
4.
School health
5.
Sanitation
6.
Promotion of Family Planning methods
7.
Use of ORS
INDIRECTLY
Following
are some of the .factors that affect
of
improvement
h e a 11 h i n d i r ec 11 y.
1.
Health Educa t ion
2.
Thrifts and savings
3.
Training of health workers and T.B.As.
4.
N u t r i t i o n e d u c a t i o n a n d d e mo n strati o n
5.
Community Organisation
6.
BalWad is
7.
Income Generation activities
8.
Provision of safe drinking water
9.
Making use of Government programmes.
EMPOWERMENT PROCESS
All the six groups aim at empowering the communities they are wr> r k i n g
Two
with.
women's groups and one Dalit group focus more
Awareness building and organisation of people is aimed at
the
community,
control
so that they could withstand exploitation
over their lives.
As far as health is concerned,
on
this.
empowering
and
take
they
are
becoming more aware of their health problems, causes of such problems
and
able
to take responsibility to do something on their own
certain extent.
to
Still in a quite a few organisations, when it
health, they still take soft line approach of providing
like MCH services,
to
a
comes
services
treatment of minor ailments, etc. though they
are
Developmental groups need to understand their health wort
mo r e
part of the empowering proce
o f t h e d i a ad v a n t ag e d g r oup s
SUSTAINABILITY
is one of the major
they have to grapple
Majority of these groups,
has any concrete plans
stainabi1i ty
strategies
community
communit
In
i d en t i f i c a t ion
a
such
organisations, and training
health
The knowledge and capacity
seem to be increasing
In man
one
the
they use might help in sustaining the programme
identified by the community.
workers
the
some
Dfcourse
committees/community
health
with
wo rk e r
heal th
p1ace s communi t y health workers are
one
parish
the
t ry i ng
based
out
In
of he a11h volun t ee rs th rough a health committe
w i th
the community health programme in about two
dispensary was supported
the
of support,
atisfied
feeling
continued interest of the women on health matters
be
withdrawal
see i ng
of
the
p rugramme
imp 1emen ted
a
issue need to be thought over right from the
planning
which does not seem to occur
VII
ORGANISATIONAL CAPACITY
All the groups except one have
informa 1 way of functioning,.
style seems to be democratic and
The
feasible in many places
have one man/one woman show though they have
Out of
t earn of community health workers where second line and third
1eaders
need to emerge.
Another
group,
which
14
quite big, has gone into
professionally
managed group with a care team of management <3 members),
monitoring
and evaluation, and training team with decentralisation of powers and
responsibilities (field centre wise) etc.
good system for planning, management,
job
discription,
other
groups.
They have developed very a
information systems, reporting,
line of authority etc. which could
be
learnt
by
be at this point
of
participatory,
democratic,
team
the same time many of the smaller group could come out of
single
Caution
so
professionalise
could
much
that
time,
not
to
functioning ethos of voluntary sector can be lust..
At
leadership and increase the management capacities
man
organise,
to
plan and manage well.
Information
and reporting in many organisations need
system
to
be
developed and improved upon.
TRAINING AND OTHER SUPPORT NEEDS OF PROJECT-PARTNERS
VIII.
One of the most important needs emerging is a good support group
could
help
them and guide the smaller groups in terms
grass
root
level workers in local language,
planning, monitoring,
who
of
training
educational
material,
information systems and documentation, creative
and innovative experiments are not many.
The groups should try to be
more creative in their health education process.
All the groups are facing limitations in getting resource persons who
grass root community health workers in
could
train
vision
and philosophy of their organisation.
are
not
able
to
give
right orientation
with
line
The local PHC
or
they
may
the
doctors
not
have
participatory training skills.
Similarly,
the
partners are not able to plan
15
and
carryout
health
effectively
education
which
PHC/Com.nunity Health programme.
skills to do it.
component
of
Either they lack enough material
or
important
the
rhey do need support and training in this aspect.
of them seem to lack participatory planning and
Majority
to run community health programme.
□kills
high
is
technological
management
need
Though they may not
management,, they still need
to
increase
their
skills in Participatory Planning & Management.
IX.
TRANSPARENCY IN FINANCIAL ASPECTS
It varies from one organisation to other.
A few smaller groups
to have transparency at the Governing Board level.
seems to have at the staff level too.
The bigger
group
In a few cases only the
Chief
has the knowledge about the find position.
Functionary
Budgets
many
places are nut always prepared in consultation with
and
the
Involvement of staff and the
people.
seem
in
the
staff
people
right
from
level
networks
of
planning the budget could be encouraged.
ADVOCACY AND NETWORKING
Out
of
four seems to be part of district
six,
voluntary organisation.. One of the partners was even the President of
a district for some time.
of
network
especially
A trend
networking
of
smaller
groups,
district
level
is
six groups have one way or the other association
with
the
the
Dalits
groups,
at
emerging in some parts of the State.
All
the
Government departments.
to
the Government in health camps,
involving
etc.
planning
programme.
financial
labour
Two or three groups have limited
and
making
people
more
themselves
immunization,
accessible
to
family
Government
Two or three partners have taken up programmes with
support
of Government.
rehabilitation
16
One group is
involved
programme in a big way with
the
in
the
child
support
of
Ministry of Labour, Government of India ?>■. ILU.
There
a history of networking of MGOS at the District
is
Levels in A.P.
the
Personal egos and vested interests
role coming in the way of
major
State
Attempts are made several times but there seems to be
in networking.
constraints
or
networking
play
positively
though
there are alliances emerging on particular issues or group interests.
X.
STRENGTHS AND WEAKNESSES
All the observations, made so far,
in different headings, throw light
Our focus
on different strengths and weaknesses of the partners,.
is
not to evaluate any project partner, and pass judgements, but certain
observations
may
be
given
here
in
the
form
of
strengths
and
weaknesses which may be useful for discussion and future planning.
Strengths
Majority
of
the groups supported
(4> are smaller
and
medium
groups who have commitment and can be effective in their
villages.
size
operational
Most of the partners come from the same areas and so
they
are aware of the local culture and local problems.
2.
Majority of these groups are community based.
3.
All
the six. field partners adopted integrated
development
approach
and health is seen as part of it.
4.
Majority of the groups are health action oriented groups.
5.
Majority of them are open to working with the Government.
6.
Networks of smaller groups is emerging.
Weaknesses
1.
Majority
of the groups seem to lack expertise in PHC/CH as they
are
primarily developmental groups.
.
Insecurity
several
among
smaller
sustainab i 1 i ty/cont inuat ion of support
17
groups
about
the
Non
availability of good resource persons to train
community
health workers in local language.
4.
Lack of planning and management skills among the smaller groups
5.
Lack of second and third line leadership.
6.
Lack of competent staff.
7.
Too many programmes and less staff.
18
level
CLe>rv\ H 1-0 •
CHECK LIST FOR FIELD REVIEW OF PROJECT PARTNERS
I.
Profile of the project partners:
in
existence,
1.
Since when
etc;);
2.
Vision, mission, objectives,
3.
Composition of Governing Board, no.
of women members,
representation from disadvantaged groups and the role
and
functions of the board.
4.
Composition,
competence
(qualification,
specific
trainings,
experience) of staff., no. of women staff
and
their role;
5.
Any other, as deemed necessary
location
target group and activities;
Conceptual understanding of P.P.
A.
II.
<rura1/urban/tribal
about CH T* PHC
1.
Components/Aspects considered essential for promoting
and CH.
PHC
2.
How do the project partners contextualise
overall
context of development.
the
3.
Approach of
the
Project oriented.
PHC/CH in
Project Partner - Process
What
are
the constraints.
oriented,
B. Understanding of PP's role in promoting CH and PHC
operational area
in
their
1 . PP's assessment of its role in promoting CH and PHC in the
target area/to the target group; (provider or enabler)
III.
Various activities of the Project Partner in the field
Community Health/PHC.
1. Which
activities have directly contributed
heal th?
of
to
better
2.
Which activities have indirectly contributed to
heal th?
better
3.
Are
there
negatively?
4.
Do the activities contribute towards the empowerment of
the community.
any
activities
which
affect
health
Assessment
IV.
V.
of
long
term
sustainabi1ity:
1. Which are the activities which enhance the knowledge
capacity of people.
and
in
the
2.
What
level/type
programmes.
participation is
observed
3.
Strategies used by
the partners
to
participation towards sustainability.
secure
4.
For which components of community health programmes,
financial
assistance,
support
and collaboration were
tapped from Government and other sources?
5.
For which other components of community health
assistance/support/col 1aboration
are possible.
6.
What
are partners' views and plans to ensure
sustainabi1ity.
of
people's
similar
long
term
Organisational capacity
1.
Planning,
monitoring
and
evaluation
and
information
systems exisits in the organisation and how far they
are
effective.
2.
The Management style of the project partners
organisation.
VI.
within
the
Training and other support needs of PPs:
-
What
are
the
areas of support,
assistance,
trainings
required
for Project Partner
in
implementing
PHC/CH
programme.
-
What capacities and skills need to be developed among
PPs
a. To respond to the grassroot needs.
b. To manage the organisation.
VII.
Strengths and weakness
VIII.
Transparency in financial aspects
* Within the organisation
- Board level
— Staff level
* With the target group
* Public at large
IX.
Involvement in advocacy and networking.
the
(programmes and processes:
a. With government, other voluntary organisations.
b. Are they part of any networking organisations?
c. If yes, does that have a positive influence.
Is the network membership any guarantee for professionalism?
eg. good standing. Are there criteria for membership related
quali ty?
***********
4.1
Our Mandate
The CHAI
Solden Jubilee evaluation study and the subsequent
action
plan have re-affirmed that promotion of community health should be our
first priority in the decades to come. Other priorities
identified,
namely health, healing and wholeness, preferential option for the poor
are in the ultimate analysis comp 1ementory to the over riding priority
of community health.
As a strategy to promote community health in India, the Projects and
Evaluations Cell of CHAI has been established. The overall goal is
to
promote community health
in
India through supporting,
guiding,
associating and assisting member institutions and other NGO groups in
various parts of the country.
With regard to project studies, the CHAI would be willing to take up
5.
which contain larger components of
community
1.
Projects/programmes
health.
2.
Projects/pragrammes which offer flexibility and
receptivity
incorporate and modify to the large extent of community health
to
STAKE HOLDER - ANALYSIS
The
following
individual organisations
and others who are
in
a
position
to
influence our work or place demands on us,
who are
effected by or who can affect our work, who have an interest
in our
work or who can lay claim to our work.
*
*
*
*
■*
*
*
*
*
*
*
*
*
#
*
*
#
*
Disadvantaged and vulnerable people of AP.
CHAAP - Regional Unit of CHAI in AP.
Peoples Movements.
Similar and Donor Agencies in AP.
Member institutions.
Board of CHAI .
Regional Units of CHAI.
Field Partners of CHAI.
Non-Governmental Organisations.
The Catholic Church in AP.
CHAI's Funding Partners, Bilance, Memisa, Misereor & Simavi.
National Health Organisations (CMAI and VHAI)
State Government of AP.
District Administrations
People of AP.
National Government.
Development Support Institutions in AP.
National Network Organisations (AIDAN and MFC).
CHAAP — ReqioNAl Un!t of CHAI In A P
Peoples Movements
SimiIar & Donor AqeNcies in A.P.
CHAIs FuNdiNq Partners
BilANce, Mem!sa, Msereor & Simavi
National HeaLtIi ORqANizATioN
CMAI & VHAI
MemBer
Institutions
State Government
of A. P.
Eoar<j of CHAI
AdMINiSTRATiONS
ReqioNAl Units
of CHAS
People of A. P.
Field Partners of
CHAI
NatJonaI Government
DisTRICT
Non Governmental
ORqANizATioNS
Development SuppoRT
Institutions In A. P.
TBe CATholic ChuRch in A P
NatIonaL NetworIi ORqANizATioNS
AIDAN & MFC
DisAdvANTAqsd & VuLneraBLe people of A. P.
stake holder map of chai for a. p.
6.
Strategic Issues
has identified the following issues for its involvement in AP .
CHAI
6.1
The external environment analysis of the region brings a wide range of
focus groups who are marginalised and deprived of their basic right to
have a healthy life
Some of the issues CHAI needs to reflect are
1. Should we work far all disadvangated
people in AP?
2. Who among
the disadvantaged are
in dire need
support and assistance. How da we identify them?
of our
Keeping our internal analysis and the external environment, CHAI
has
identified
the
following
focus groups based on
the criterias
low
literacy,
low
income,
low health
status
and
high
social
d i sc r i m i n a t i on.
*
*
*
*
-*
*
*
The women
The children
The tribals
The dal its
The fisherfolks
Urban slum dwellers
The agricultural labourers
6.2. In
the
analysis, we realised there are certain pockets in AP which
deserve better attention compared to the rest of the places in AP. The
socio-economic conditions of the people and the backwardness of
the
area due
to drought and other reasons and the large presence of
a
vulnerable groups etc. call for a different strategy far AP.
1. Shouldn't we have a geo-political
approach in AP?
2. Shouldn't we priorities our target areas?
3.
What should be the criteria far identifying
area?
the
target
Andhra Pradesh being so vast and an organisation
like CHAI with
limited
resources and
to make our programmes effective,
it
is
desierable
to prioritise
the areas (districts)
for our
intensive
involvement. Accordingly we have prioritised into three groups on
the
basis of
High IMR
Low female literacy and
High incidences of poverty.
1st group
:
Ananthapur,
Kurnaol,
Mahbubnagar,
Adilabad,
Warangal, Nizamabad, Srikakulam, Visakhapatnam, Medak,
Karimnagar.
IInd group
:
Ch it toon
Hird
group:
Nalgonda, Cuddapah, Khammam.
Nellore,
Prakasam,
Krishna,
West Godavari,
Godavari, Nizamabad, Ranga Reddy, Hyderabad.
East-
Another strategic issue to be addressed is
1 . Do we need to have an issue based approach?
Should we not take up health issues which affect the majority
the disadvantaged?
and
The
analysis of
the health status of the people shows that
the
following disease/health issues which affect all, but affect the poor
very severely deserve our attention, particularly because
there has
not been
any adequate
response from the government.
However,
a
vertical
approach may not be the
answer.
Instead an
integrated
approach is desirable. The identified health issues are
*
*
*
*
*
*
7.
7.1
HIV/AIDS
T.B.
Malaria
Filaria
High prevalence of Fluorisis - content in water.
The health problems arising out of prawn culture etc.
STRATEGIC AIM
To support innovative community health
initiatives focussing on
the
socially and
economically vulnerable commmunities and groups
<the
focus groups) in Andhra Pradesh would enable them to have control over
the situations affecting their health in a sustainable mariner.
7.1.1 Strategies
-
Support
and facilitate to get support for Mis and NGO activists
community based groups for community health programmes targetting
vulnerable and disadvantaged group.
-
Provide organisational and institutional support to groups to evolve a
community health programme.
-
Support action-oriented research and studies.
-
Assist
and support groups working with the focus groups and focussed
areas
to integrate community health into their ongoing developmental
activities.
-
To play a proactive role by identifying and supporting
working with the vulnerable and disadvantaged people.
-
Support
and guide the network of peoples organisation
the focus groups.
Consciously supporting
organisations.
7.1.2 Focus groups
The
The
The
The
The
The
The
tribals
Dalits
Fisherfolk
Women
Children
Agricultural Labour
Urban Poor
34
the small and medium sized NGOs
and
the
groups/NGOs
emerging
and
from
peoples
To identify and support programmes which would address specific major
health problems affecting majority of people.
7-2
7.2.1
Strategies
Provide organisational and institutional support to Mis /NGOs, health
activists in working with of people affected by the health issues.
Facilitating
interface between people, government,
NGOs
and other
relevant
groups
to
come
together
and
develop
appropriate
interventions, strategies to the issues.
Support or facilitate
research studies or
analysis on
the
identified health problems
strategy.
detailed
as part
Promote network of organisations working on health issues
related issues.
situational
of
advocacy
or
health
Equip the partners with knowledge, skills and expertise to address the
health issues and integrate in their ongoing activities.
-
7.2.2
Focus issues
HIV/AIDS
T.B., Malaria, Filaria
Flourosis, Health Hazards of Brackish Water/Aqua Culture
7.3
To strengthen
and develop the capacities of our field partners to
develop
a perspective plan based on the needs and
enable
them to
implement the community health programmes effectively and efficiently.
7.3.1 Strategies
CHAI
commit
itself for a long term association with
partners/groups for a minimum of 5 years.
the
identified
Support/recommend the projects/programmes for a shorter period (ie
months) as a preparatory phase.
18
Assist
the groups to develop a perspective plan on community based
health programme on
the understanding
and
experiences
from the
preparatory phase and support/recommend it for another 3 years.
Faci1itate/Organise training programmes to equip the groups with basic
skills on project management,
planning,
monitoring,
evaluation,
develop proper systems and procedures etc.
Provide
etc .
support and guidance through follow-up,
visits,
discussions
Organise thematic discussions/workshops for the field partners.
Facilitate interface between other groups, forums with a view to cross
programme learning and cross-country learning.
7.3.2
Focus group
The field partners of CHAI in A.P.
7.4
7.4.1
extended
teams'
To strengthen
the CHAI, its regional team and the
the development
their skills to facilitate
capacity and
enhance
an
appropriate
process emerging from the grassroot level and develop
intervention strategies.
Strategies
Initiate
and conduct studies, analysis and workshops on emerging
trends
in
economy,
society and the situation of vulnerable
and
disadvantaged people in A.F.
Develop
a gender perspective into the action plan of
regional unit.
CHAI
and
its
Gender
sensitisation
and
enhancement
perspective for our team, NSC sector.
awareness
and
the team with additional personnel at the central as
Support ing
as regional level .
we 11
of
gender
team at
all
levels
while
developing
the
regional
Involv ing
responsibility
programmes, perspective plans for A.P. and sharing the
accordingly.
Strengthening of the regional resource team with knowledge, skills and
resources.
institutional
To build our own internal capacity and systematise or
learning
process so as to enhance our effectiveness in everything we
do.
7.4.2
Focus group
CHAI team.
The regional team members of CHAAP.
The identified resource team in A.P.
7.5
agencies and
fund i ng
To make strategic
alliance with similar
agencies to support community health programmes in the region
7.5.1
Strategies
Meetings, discussions, participatory workshops, seminars.
Exploring
the possibility of promoting a forum m the
health and development issues are discussed and;
region
whose
Sharing of information on various aspects.
7.5.2
Focus group
Similar agencies like IGSSS, Caritas India, APVHA,
agencies - OXFAM, Action-Aid, CRY, ASW etc,
7.6
To facilitate networking of NBOs,
Societies
at
the regional, district
each others efforts, and to develop
lobbying on the issues related to the
36
ISI etc.
Funding
Mis,
Diocesan Social Service
and national level
to support
a platform
for
advocacy and
health of the people.
7.6.1 Strategies
Support meetings, workshop, to assess situation promoting
on
alternative health and development strategies among
groups.
discussion
the
focus
-
Provide fellowships and non-funding supports on issues identified.
7.6.2
Focus groups
NGOs
Mis
Diocesan Social Service Societies.
37
ANNEXURE
1
RURAL POVERTY LINES AND PERCENTAGE OF PERSONS BELOW POVERTY LINE
IN ANDHRA PRADESH
Year
Poverty line
NSS
Rounds
(Rs. )
1977-78
32
66.8
65.3
253.31
1983-84
38
101.8
54.5
232.07
1986-87
43
113.6
47.6
212.32
'/< of people
below the
poverty line
Source : Status of Women and Children - 1990
38
Estimated persons
below the poverty
line in lakhs
ANNEXURE
2
RETENTION RATES IN PRIMARY SCHOOL FOR SC & ST PUPILS
(percentage)
Year
Class
Scheduled Caste
Boys St Girls
Girls
Scheduled Tribes
Boys St Girls
Girls
1983-84
I
100.00
100.00
100.00
100.00
1984-95
II
38.82
38.84
49.32
40.48
1985-86
III
17.11
19.67
23.59
24.46
1986-87
IV
16.42
18.63
20.72
25.40
1987-88
V
15.28
18.90
13.79
19.,57
Source : Status of Women and Children - 1994
39
ANNEXORE
ACCESS/FACILITIES WITH REGARD TO ELECTRICITY, DRINKING WATER
AND SANITATION
SI No.
Rural
’/.
Urban */<
Safe
House
hold
drinking
Electri- Water
c 1 ty
24.83
24.06
25.74
31.54
32.86
33.30
32.52
34.30
39.35
14.46
19.39
30.71
35.38
41.09
22.04
45.18
47.35
58.34
1.97
2.44
3.56
11.28
12.71
11.82
9.78
4.73
5.58
61.62
61.07
69.78
65.90
62.37
69.13
58.34
64.01
69.11
42.09
70.40
65.02
75.94
75.95
82.22
77.30
52.56
66.93
39.05
49.24
54.60
49.14
66.85
83.29
82.02
80.87
1>
Si -3 M
Sri kakulam
Vizi anagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prak asam
Ne11ore
U ui
1n
o
3.
4.
5.
6.
7.
8.
9.
Rural
Sani
tation
64.38
70.90
78.72
80.68
87.06
90.38
87.48
S3.44
41.15
0
54.20
39.91
26.21
40.11
41.43
31.40
58.97
31.28
(SB « 36
0
54.45
57.65
71.83
57.51
37.19
46.87
24.72
31.98
10.95
0
5.28
6.94
4.71
5.28
5.56
5.94
5.76
5
80.70
90.43
75.70
83.53
72.06
78.20
80.97
69.99
84.78
70.82
72.46
86.48
70.15
66.28
85.23
61.92
59.46
63.08
41.16
56.31
63.76
87.71
56.43
60.56
48.45
51.50
61 „ 0 1
47.20
53.23
34.45
---- ----36.89
48.89
6.62
73.3
73.82
54.60
30.07
33.58
48.36
54.33
51
63.01
44.79
33.49
45.79
M 01 -0
1
o
. • •
tn m tn w
m
S M
■£=
»
1
i
O! £> Cd Cd
1
1
1
1
Kurnool
Ananthapur
Cuddapah
Ch ittoor
cn Qi
10.
11 .
12.
13.
w
Coastal Andhra
Rayalaseema
14.
15 .
16.
17.
18.
19.
20.
21 .
23 a
Ranga Reddy
Hyderabad
Nizamabad
Medak
M ah ab oobn ag a r
Nalgonda
Warangal
Khammam
Karim Nagar
Ad i1abad
Tel angana
40
ANNEXURE
4
COUPLE PROTECTION RATE - 1907
SI Mo.
1.
*7 >1
to .
4.
5.
to n
7.
8.
9.
District
Sr ikaku1 am
Vizianaqaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Me 1 lore
Couple Protection Rate
'A
41.80
41.20
38.80
46.10
47.10
43.30
45.70
35.80
36.30
Female age (Mean)
at Marriage-1991
17.10
17.40
16.50
15.80
16.10
16.10
15.80
16.20
17
Coastal Andhra
__ _____________ -________
10.
11 .
12.
13.
Kurnoo1
Ananthapur
Cuddapah
Ch it toor
29.70
33.90
35.7
16.50
17
17
17.10
28.60
43.80
30.60
25
24.20
30.20
32.30
38
29.20
21.40
15.20
17.70
14.50
14.50
14.80
14.60
14.50
15.90
14.30
15.20
Rayalaseema
14.
15.
16.
17.
18.
19.
20.
21 .
a
Ranga Reddy
Hyderabad
Ni zamabad
Medak
Mahaboobnagar
Nalgonda
Warangal
Khammam
Karim Nagar
Ad i1abad
Telangana
41
ANNEXURE
5
REVERSE-SURVIVAL ESTIMATES OF CRUDE BIRTH RATES AND TOTAL
FERTILITY RATES DERIVED FROM 1981 & 1991 CENSUSES FOR
DISTRICTS IN MAJOR STATES OF INDIA.
Crude Birth Rate
per
1,000
Total Fertility
Rate
Dis tricts
1984-90
1984-90
Andhra Pradesh
28.2
3.2
1.
s*
Ci *
4.
5.
6.
7.
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
18.
19.
20.
21 .
Srikakulam
Viz ianagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne 1 lore
Chi ttoor
Cuddapah
Ananthapur
Kurnoo1
Mahaboobnaaar
Ranga Reddy
Hyderabad
Medak
Ni zamabad
Adilabad
Karim Nagar
Warangal
Khammam
Nalgonda
29.2
28.0
76.8
27.5
26.4
25.8
24.9
26.7
25.0
25.0
25.5
30.3
32.6
33.7
33.4
26.5
31.2
28.3
32 n 2
26.5
29.3
29.7
30.5
Source : Health Monitor 1995
3.5
3
'r'
2.9
3.2
2.9
2n9
2.7
3.0
2.6
C' ~7
2.8
3. 6
4.1
4.2
4.0
2.9
3.9
3
4.0
3.2
3.4
3.5
3.6
ANNEXURE
6
SCHEDULED CASTES AND SCHEDULED TRIBES POPULATION DISTRICT-WISE, 1991
SI . No.
<1)
1.
*7
3.
4.
5.
6.
~7
8.
9.
Scheduled Castes
District
(3)
(2)
1.34
1.90
4.69
1.76
0.85
0.92
1.81
0.99
2. 14
44.11
16.40
5.18
4.52
3.38
6.00
0.57
1.11
0.47
1.05
19.08
3.20
4.39
2.79
3.08
4.06
5.42
5.04
4.85
3.60
5.64
3.86
1.09
0.29
1 .21
0.95
2.27
2.76
3.85
5.59
0.83
3.55
Telangan a
42.73
22.39
Andhra Pradesh
105.92
41.99
Kurnoo1
Ananthapur
Cuddapah
Ch ittoor
Rayalaseema
14.
15.
16.
17.
IS.
19.
20.
21 .
'7'7
2dr
(4)
2.17
2.20
2.57
8.26
6.29
6.13
5.73
5.53
5.23
Srikakulam
Vizi ananaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne1 lore
Coastal Andhra
10.
11.
12.
13.
Scheduled Tribes
Rangareddy
Hyd e rah ad
N i zamabad
Medak
Mahbubnagar
Nalgonda
Warangal
Khammam
Karimnagar
Adi labad
Source : AP Statistical Abstract, Directorate of Statistics
ANNEXURE
DISTRICT-WISE
1981 CENSUS
S.No .
^71 .
C/ «
4.
5.
6.
7.
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
IB.
19.
20.
21 .
23.
SHARE
District
Mahbubnagar
Karimnagar
Guntur
Kurnool
Anantapur
West Godavari
East Godavari
Nalgonda
Warangal
Chittoor
Kr i shna
Prakasam
Ni zatnabad
Visakhapatnam
Khammam
Sr ikakulam
Medak
Adi 1abad
Vi z i anagaram
Cuddapah
Ranga Reddy
Ne1 lore
Hyderabad
OF CHILD WORKERS IN
7. Share of
all Rural
Child Labour
Rank
6.67
6.37
6.14
5.91
5.16
4.97
4.91
4.9£5
4.87
4.55
4.34
4.29
4.17
4.12
4.01
3.93
3 ■ 93
3.7B
3.40
3.37
3 22
2.97
—
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Source : Child Labour in AP - A Profile
44
77
—
ANDHRA
7
PRADESH,
7. Share of
all Ru ra1
Child Labour
Rank
3.75
3.00
8.88
7.74
4.49
5.91
7.87
2.24
2.86
3.65
9.06
3.74
3.59
3.24
1.61
1.76
1.8
2.15
2.14
3.89
1.95
3.77
10.82
10
15
o
5
7
6
4
17
16
12
11
13
14
23
22
21
18
19
8
20
9
1
ANNEXURE - 8
NUMBER AND PERCENTAGE OF CHILD WORKERS BY TYPE
CATEGORY IN ANDHRA PRADESH, 1981 CENSUS
S.No .
Category
Total
AND
INDUSTRIAL
7> of total
main workers
404540
23 ■>
labourers
947134
54.00
3.
Livestock, Forestry etc
143874
8.20
4.
Mining & Quarrying
4,397
0.25
5.
Manufac turinci,
Processing etc
1148845
8.57
1.
Cultivators
2>
Agricultural
6.
Construct ion
11084
0.63
7>
Transportation
4514
0.26
s.
Trade %r. Commerce
38,041
2.19
9.
Other Services
51760
2.95
1754189
100.00
Total
45
Some of the questions to be answered and resolved
the strategies for A.P.
4.
technical
while
developing
*
What
level of
project holders.
*
How do our partners perceive our roles in the
support and guidance.
*
What are the possible barriers for CHAI to be an effective partner.
*
How long should we associate with a group.
*
How can CHAI fulfil its responsibility as a membership organisation
and at the same time make its presence felt in the mainstream.
*
As a national organisation, how does CHAI perceive its role in A.P.
*
In
terms of promoting community health, what other roles CHAI
play in A.P.
can
*
What should be the partnership between NGOs and NGOs; and NGOs
people.
and
support
CHAI
should
to
the
process
of
provide
whole
The vision of CHAI
Health
is the total well-being of
individuals,
families
and
communities
as a whole and not merely the absence to sickness.
This
demands an environment in which the basic needs are fulfilled,
social
well-being is ensured and psychological as well as spiritual needs are
met.
Accordingly, a new set of parameters will have to be considered
for measuring
the health of
a community such
as the peoples'
participation
in decision making, absence of social
evils
in the
community,
organising capacity of the people, the role of women and
youth
in
the field of health and development etc.,
other
than the
traditional ones like infant mortality rate, life expectancy etc.
The concept of the community health here should be understood
as a
process
of
enabling
people to
exercise
collectively
their
responsibiities to maintain their health and to demand health as their
right
Regarding our option s In the light of this vision and philosophy,
we
identify the
exploited
and the unorganised massess,
the
rural
in
particular as our target group. We intend
to reach
these groups
through
the existing health institutions in the country,
especially
through
the member institutions of CHAI and other
individuals and
groups engaged in the field of people-oriented programes, so that our
motto of "HEALTH FOR MANY MORE" would be realised. In this process,
possibilities of collaboration with other valunatry organisations
which uphold similar philosophy and objectives will be explored to the
maximum extent possible.
30
4.1
Our Mandate
The CHAI
Bolden Jubilee evaluation study and the subsequent
action
plan have re-affirmed that promotion of community health should be our
first priority in the decades to come. Other priorities
identified,
namely health, healing and wholeness, preferential option far the poor
are in the ultimate analysis comp 1ementory to the aver riding priority
of community health.
As a strategy to promote community health in India, the Projects and
Evaluations Cell of CHAI has been established. The overall goal is
to
promote community health
in
India through supporting,
guiding,
associating and assisting member institutions and other NGO groups
in
various parts of the country.
With regard to project studies,
5.
the CHAI would be willing to take up
which contain larger components of
1.
Projects/programmes
heal th.
2.
Projects/programmes which offer flexibility and
receptivity
incorporate and modify to the large extent of community health
community
to
STAKE HOLDER - ANALYSIS
The following
individual organisations
and others who are
in
a
position
to
influence our work or place demands on us,
who are
effected by or who can affect our work, who have an interest
in our
work or who can lay claim to our work.
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Disadvantaged and vulnerable people of AP.
CHAAP - Regional Unit of CHAI in AP.
Peoples Movements.
Similar and Donor Agencies in AP.
Member institutions.
Board of CHAI.
Regional Units of CHAI.
Field Partners of CHAI.
Non-Governmental Organisations.
The Catholic Church in AP.
CHAI's Funding Partners, Bilance, Memisa, Misereor b. Simavi.
National Health Organisations (CMAI and VHAI )
State Government of AP.
District Administrations
Peop1e of AP.
National Government.
Development Support Institutions in AP.
National Network Organisations (AIDAN and MFC).
GGiv\ H T-o- 8
PROMOTION OF COMMUNITY HEALTH PROGRAMMES IN ANDHRA PRADESH
AN APPROACH PAPER
THE CATHOLIC HEALTH ASSOCIATION OF INDIA
P B NO. 2126, 157/6
STAFF ROAD, BUNROCK ENCLAVE
SECUNDERABAD 500 003
Prepared by
ALOYSIUS JAMES
Department of Community Health
1
PROMOTION OF COMMUNITY HEALTH PROGRAMMES IN ANDHRA PRADESH
AN APPROACH PAPER
1.
INTRODUCTION
This paper attempts to a present strategic approach for promotion of
Community Health in Andhra Pradesh. It consists of :
An
analysis of External
Environment covering
the
socio
economic
and
health profile of AP,
NGO
scenario
and
government responses.
An internal analysis of CHAI.
The mission and mandate of CHAI.
The strategic issues and
Strategic plans
*
*
*
*
*
2.
EXTERNAL ENVIRONMENT ANALYSIS
2.1
Andhra Pradesh - A Profile
2.1.1
Physical Features :
Andhra Pradesh
is the fifth largest state in India, in
area and
population.
It
is bounded by Madhya Pradesh and Orissa
in
the
north,
the Bay of Bengal in the east, Tamil Nadu and Karnataka in
the south
and Maharashtra in the west. Andhra Pradesh forms the
major link between the north and the south of India. Aridhra Pradesh
consists of three distinct regions
Coastal region made up of 9 districts generally called Andhra.
This is fertile and agriculturally advanced regions.
(ii) The
interior region cansits of 4 districts collectively known
as Rayalaseema which is a drought prone area and hence very
backward and
(iii) Telangana region comprising Hyderabad and 9 adjoining districts
is industrially advanced.
(i)
Table
1 : ANDHRA PRADESH AT A GLANCE
Part iculars
Area - 1991 (Census)
Districts
Mandals
Village Panchayats
Inhabited Villages
1991
Towns
1991
1991
Population
Males
1991
Females
1991
Rural Papulation
1991
Urban Population
1991
Scheduled Castes
1991
Populat ion
Scheduled Tribes
1991
1991
Population
1991
L i teracy
Un i t
'000 sq. kms
No.
II
II
(Census)
<1
II
’1
II
(Lakhs)
•1
11
u
It
II
II
<i
II
II
Source : Handbook of Statistics
275.0
23
1110
19497
26613
264
665.08
337.25
327.83
486.21
178.87
It
105.92
II
41.99
44.09
(Percentage)
AP 1992-93
1-2 Demography
The population of Andhra Pradesh is 66304854 with 33623738 males and
32681116 females
(1991 census) decadal growth rate
<1981.-91)
is
23.82. The percentage of urban population is 26.79% as against 23.32
in
1981. The scheduled caste and scheduled tribe account for
15.9%
and 8% respectively.
Rural
households can be broadly classified into three categories
classes. Agricultural labour is the major group accounting for 36.8%
followed by cultivators <32.7%) and self-employed <30.85%).
1.3 Economy
Andhra Pradesh has a widely diversified farming base with
a rich
variety of cash crops. 74% of the states population live in villages
where people
live on agriculture. Nearly 40% of state domestic
product comes from agriculture. Andhra Pradesh can rightly claim to
be
the granary of the south. The crops extensively cultivated are
paddy,
bajra,
jawar, ragi, maize,
groundnut,
chillies,
tobacco,
cotton, sugarcane etc.
Irrigated
area constitutes 34.5% <94% lakhs acres)
of cultivated
land,
and
188
lakh
acres
is under-rainfed cultivation.
The
benifits
of irrigation are confined to a small segment
1/5
rural
population
resulting in regional disparities. Despite
the massive
investments in agriculture and irrigation the growth of this sector
is sluggish at 2% per annum.
There
are 825 medium and large scale industries with
a capital
investment of Rs.11763 crore providing employment for more than 4.96
lakh persons. There are 918868 small units with investment of
1245
crore providing employment to 8.6 lakh persons.
The
industries are concentrated in Telangana area like Hyderabad,
Ranga
Reddy,
Medak
and Mahabubnagar.
Of
late,
after
the
liberalisation of economy, the state and central govt.,
is wooing
the multinationals,
NRIs and other industrialists
to Andhra to
establish
industries. Though there is positive response, the power
scarcity in the state is a major stumbling block in the process.
With a 970 kms coastline, AP is the largest maritime state in India.
Fishing brings employment to the traditional fisherfolk and the
to
the groups using employees mechanised boats.
Aqua-culture
on
brackish waters is slowly picking momentum in the coastal belt.
30%
of the local shrimp production in the country comes from the state.
The
forests
account
for 23% of the total
geographical
area and
contributes 1% to the state domestic product. The forests are under
tremendous pressure both for its produce and the land.
1.4 Literacy
Andhra Pradesh is one of the educationally backward states in India.
The literacy rate among the population age 7 and above is 44% in the
state compared with 52% in India. The literacy rates 55% for males
and 33%
for
females in AP compared to 64 and 39% for males
and
females respt. for the whole of India.
Based on
the overall literacy rating 11 districts
category 12 under C category
come
under
Table 1A : Ranking of Districts According to GDLR Scores
1.
o
O*
4.
5.
6.
7.
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
IB.
19.
20.
21 .
97
23»
Srikakulam
Vizianagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne1 lore
Kuriiool
Ananthapur
Cuddapah
Ch i ttoor
Rangareddy
Hyderabad
Nizamabad
Medak
Mahbubnagar
Na1gooda
Warangal
Khammam
Karimnagar
Ad i 1 ab ad
Total Lit
rate (7.)
Male Lit.
Rate (7.)
Female Lit
Rate (7.)
□venal1
Lit. Rating
31.13
29.37
39.40
41 .37
45.66
45.81
40.70
35.10
41.29
33.60
35.69
41.52
43.11
41 .95
55.03
29. 13
27.51
24.95
32.14
33.99
34.10
33.02
27.79
41.59
39.14
48.57
46.78
50.93
52.19
49.11
45.71
50.02
44.47
47.23
54.22
53.75
50.91
6i.es
39.77
37.79
33.71
43.39
44.50
42.06
44.32
37.57
20.82
19.60
30.00
35.95
40.37
39.22
32.04
24.19
32.38
22.22
23.50
28.. 27
32.11
32.40
47.58
18.69
16.94
15.94
21.48
23.08
25.81
21.56
17.80
C2
C2
B2
B2
Bl
Bl
B2
C2
Bl
C2
C2
Bl
Bl
Bl
El
C2
C2
C2
C2
C2
B2
C2
C2
Source : Demographic Diversity of Indian 1991 Census. State and
District level data. A reference book - Ashish Book
4
the
B
Table IB
s
Category
Summary table for literacy rating
No at
Districts
Total Pop.
of Districts
Percentage
to Pop. of
State
Name of the
Districts
A (A1+A2+A3)
B (B1+B2)
11
34 025 609
52.5
West Godavari, Hyderabad
Krishna, Chittoor, East
Godavari,Cuddapah, Guntur,
Rangareddi, Nellore,
Visakhapatnam, Khammam.
C(C1+C2+C3)
12
31 479 165
47,48
Anantapur, Nizamabad,
Adilabad, Mahtiubnagar,
Karimnagar, Prakasam,
Warangal, Kurnool, Medak,
Srikakulam, Vizianagaram,
& Nalongda.
66 304 854
100,00
TOTAL
C=C1+C2+C3
MB : Code for Literacy Rating A=A1+A2+A3, B=B1+B2+B3
Al
A2
A3
75 +
'
75 +
50-75
75 +
50-75
50-75
OLR
OLR
OLR
Male
Female
Bl
B2
Male
Female
50-75
25-50
25-50
25-50
Male
Cl
C2
C3
50+
25-50
<25
Female
<25
<25
<25
OLR : Overall Literacy Rate
2.1.5 Health Status of Andhra Pradesh
The health status of a population is determined by a large number of
factors such as nutritional status, availability and accessibility
of health services, sanitation, source of drinking water,
supplies
of essential goods, work pattern, incomes, housing etc.
In the case
of women
and children, socio-cultural factors may also play a
significant
role.
Certain
indices which speak
about
the health
status are given in the following pages.
Source s Demographic Diversity of Indian 1991 Census. State and
District level data. A reference book - Ashish Book
Table 2 : Basic demographic indicators for Andhra Pradesh and India,
1981-92
Index
Andhra Pradesh
Ind i a
Population (1991)
66, 5078,008
Percent population increase
24.2
<1981-91)
242
Density (popu1 ation/Km2) (1991)
26.9
Percent urban <1991)
972.
Sex ratio (1991)
38.6
Percent 0—14 years old (1981)
34.2
(1991)
3.6
Percent 65+ years old (1981)
4.0
(1991)
15.9
Percent scheduled caste (1991)
6.3
Percent scheduled tribe (1991)
Percent literate (1991)'
55.1
Male
32.7
Female
44.1
Total
846,302,688
24.1
9.1
2. 17
3.0
71
29.0
10.0
2.14
3.6
79
59.1
62.2
45.3
58. 1
59.1
43.5
Crude birth rate (1992)2
Crude death rate (1992)2
Exponential growth rate (1981-91)
Total fertility rate (1991)
Infant mortality rate (1992)2
Life expectancy (1986-91)
Male
Female
Couple protection rate (1992)
2.1.5.1
23.9
273
26.1
927
39.6
36.3
3.8
3.8
16.7
8.0
64.1
39.3
52.2
Health priorities and programmes
Delivery of Health services
in AP. is mainly governed by the
National
Health Policy. It identified certain areas which needed
special attention
Nutrition for all segments of the population.
The immunisation programmes.
Maternal and child health care.
Prevention of food adulteration and maintenance of quality
drugs
Water supply and sanitation.
Environmental protection.
School health programmes.
Occupational health services.
Prevention and control of locally endemic diseases.
Sources National Family Health Survey (1992)
6
After the Alma Alta declaration in 1978, the government started
to
concentrate on
the development of
the
rural
health
infrastructure. This was done to provide health care services to
the rural population which had by and large remained neglected.
As of March
1994, AP has
the
following
infrastructure and
facilities.
Table 3
: BASIC RURAL HEALTH INFRASTURCTURE AND SOME DERIVATIONS
(As on 31.03.1994)
No. of Functioning
SubCentres
P.H.C.s
C.H.C.s
SubCentres
P.H.C.s
C.H.C.s
(in 1akh)
7894
1342
46
6159
36230
10.05
131471
21214
2321
4782
296335
2.71
Andhra Pradesh
India
Table 4
:
Average Rural
Population Served
RATIO OF PHC/SCs, CHC/PHCs AND AVERAGE NUMBER OF VILLAGES
SERVED BY SC, PHC AND CHC
(AS ON MARCH 1994)
Average No. of Villages
Served
---- — — —----- —-~— — — —
—
PHC
CHC
PHC/'Sub-Cent re CHC/PHCs Sub-Centre
Ratio of
Andhra Pradesh
1: 5.8
1:29.2
3.47
20.40
575.20
India
1:6.2
1: 9.1
4.48
27.74
253.62
Table 5 s STATEWISE AVERAGE RURAL AREAS COVERED AND MAXIMUM RADIAL
DISTANCE COVERED BY SUB-CENTRE, PHC, CHC
As on 31 March 1994)
Average Rural Area
covered by
Sub-Centre
PHC
(sq.km)
(Sq.km)
Andhra
Ind i a
Pradesh
Maximum Radial Distance
covered
CHC
Sub-Centre
(km)
(sq.km)
PHC
(k m)
CHC
(km)
34.33
211.95
5891.78
3.31
8.01
43.30
23.91
148.17
1354.26
2.76
6.87
20.75
Source : Health Monitor 1995
7
2.1.5.2
Infant and Child Mortality
Table 6 : Infant and child mortality by background characteristics
Background
characteristics
Infant
mortality
Child
mortali ty
Under-five
mortali ty
Residence
Urban
Rural
61.9
77.0
11.8
29.0
73.0
103.8
79.6
66.4
(62.3)
(36.4)
28.5
25.1
( 6.1)
(2.8)
105.8
89.8
(8.0 )
(39.1)
76.9
15.4
25.6
22.9
100.5
59.4
94.4
(85.4)
68.0
22.5
(53.5)
22.7
114.8
(134.4)
89.1
No antenatal or
deli very care
98.8
(52.7)
146.3
Either Antenatal or
delivery care
69.8
(5.5)
75.0
Both antenatal and
delivery care
51.1
(6.6)
57.3
73.2
24.6
96.0
Mother's education
Ill iterate
Literate,<midd1e complete
Middle school complete
High school and above
Religion
Hindu
Mus1i m
Caste/tribe
Scheduled caste
Scheduled tribe
Others
Medical maternity care
Total
The
above table shows infant and child mortality statistics of AP
and
table shows the district-wise details. The IMR of Andhra Pradesh 73 per
1000 live births. The infant mortality rate is 1.2 times higher in
rural
areas than in urban areas ie 77 per 1000 live births compared to 62 per
1000 live births. The child mortality is two and half times more in rural
areas than in urban areas. Children in rural, areas of AP experience a 42%
higher risk of dying before their fifth birthday than urban children.
Infant mortality declines sharply with increasing education of woman,
ranging from a high of 30 per 1000 live births for illiterate women to a
low of 36 per 1000 live births for women with alteast
a high school
eduat ion.
8
In infant and under-five mortality rates (ie 99.8 per 1000 and 114.8
thousand are higher for scheduled castes than for non SC/ST groups.
child
and under-five mortality lie 53.5 and
134.4 respectively.)
scheduled tribes are higher than for scheduled castes and others.
per
The
for
The presence of medical maternity care for mothers
(ante-natal
and/or
delivery care by a trained health personnel) is associated substantially
lower mortality risks. The IMR drops from 99 per 1000 for births with no
care
to 70 per 1000 for births with either ante-natal or delivery care
and
to 51 per 1000 for births with both ante-natal
and delivery care
(NFHS - 1992)
Table 7 s INFANT MORTALITY RATES AND CHILD MORTALITY IN DISTRICTS
OF ANDHRA PRADESH
SI No.
3.
4.
5.
6.
7.
8.
9.
District
Srikakulam
Vizianaqaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
P rakasam
Ne 1 lore
Infant Mortality Rate
Child Mortality Rate
98
109
78
62
67
74
64
71
62
142
157
106
93
97
101
93
105
91
77
97
84
92
124
145
114
119
66
N.A
56
66
79
70
79
70
65
73
97
N.A
84
104
124
118
115
99
87
108
73
105
Coastal Andhra
10.
T2.
il3>
Kurnool
Ananthapur
Cuddapah
Ch i ttoor
Rayalaseema
14.
15.
16.
17.
18.
19.
20.
21 .
S'Q
Ranga Reddy
Hyderabad
Ni zamab ad
Medak
Mahabub Nagar
Nalgonda
Warangal
Khammam
Karim Nagar
Adi labad
Telangana
Andhra Pradesh
2.1 .5.3
Immunisation of children
As per the National Family Health Survey (NFHS) 1992 in AP, only 457.
of children aged 12-23 months are fully vaccinated and 187. have not
received
any vaccinations and 377. only partly vaccinated.
Andhra
Pradesh
thus has a long way to go to achieve the goal of Universal
9
Immunisation of children. Interestingly the service status published
by the government claims that the state has achieved 100% coverage
of child immunisation. (Ministry of Health & Family Welfare 1992 and
Directorate of Health Services AP 1993).
The proportion of children fully immunised is 58% in urban areas and
40% in rural areas. The percentage of children of illiterate mothers
36.4% to 80 percent for children of mothers who have competed high
school. Scheduled caste and scheduled tribe children are less likely
to be fully vaccinated than children of non SC/ST mothers.
.1.5.4 Treatment of Diarrhoea
Diarrhoea is a major killer of children, especially children underfive years of age. Deaths from acute diarrhoea are most often due to
dehydration
resulting
from loss of water and
electrolytes
(Black
1984).
Deaths due
to dehydration can be prevented
by
the
administration of ORS solution or by RHS (Recommend Home Solution).
The govt., has been creating awareness among the public for this.
NHFS - 1992 tells that ORS is known to only 31% of mothers (52%
in
urban and 24% in rural areas). Knowledge is lowest in rural
areas,
among
teenage mothers,
illiterate women,
scheduled caste
and
scheduled tribe mothers and mothers not regularly exposed to either
radios,
TV and cinema. ORS and RHS was not used extensively by any
population subgroup
and such treatment was even
less common
far
rural children and children with illiterate mothers.
10
Table 8 : Knowledge and use of ORS packets
Know about
ORS packets
Background
Characteristics
Have used
ORS packets
No. of
mothers
Mother's age
15 20 25 30 35+
19
24
29
34
24.2
32.2
34.4
33.1
27.0
12.3
15.3
19.3
18.8
18.9
285
593
398
133
74
51.5
24.4
28.2
12.4
369
1117
22.8
11.7
1057
37.4
51.0
66.0
17.2
31.7
35.2
163
104
162
30.2
39.9
(30.0)
15.5
25.4
(10.0)
1303
138
40
24.6
26.4
32.8
12.7
13.2
17.3
228
106
1152
36.0
47.7
39.4
18.1
23.9
19.5
1092
511
870
36.6
17.1
754
17.5
11.2
394
31.1
16.3
I486
Residence
Urban
Rural
Mother's education
Illi terate
Liteate < middle
school complete
Middle school complete
High school and above
Religion
Hindu
Mus1i m
Christi an
Caste/tribe
Scheduled Caste
Scheduled tribe
Others
Mather's exposure to media
Exposed to media
Watches T.V. weekly
Listens to radio weekly
Visits cinema/theatre
weekly
Not exposed to any of
the media
Total
2.1.5.4.1. Availability
Health
of
Facilities
and
other services
Almost
two-fifths of the villages in AP have some form of health
facility within the village and 367. of villages have some form fo
health facility within 5 km from the village. Almost one half of the
villages have a village health guide and 587. have a
trained birth
attendant.
Table below gives the availability of other
facilities
in the villages.
Source : National Family Health Survey 1992
11
Table
9
: Availability of Health Facilities and other services
villages of AP
Anganwad i
Adult education classes
Jana Shikshana Nil ayam
30.5
35.2
6.4
Village health guide
Trained birth attendant
Mobile health unit
49.0
58.4
10.5
ElectricityBank
Cooperative SocietyPost office
Market/shop
Fair price shop
Mahila mandal
Youth club
76.6
12.5
■4
7
Integrated Rural Development
Programme (IRDP)
National Rural Employment
Programme (NREP)
Training the Youth for
Self-employment (TRYSEM)
the
O' 61 CD (7
Percentage
kJ kJ (7 U CD kJ
kJ C-J
kJ
C
J1
Fac i1i ty/Services
in
41.8
12.3
11.8
2.1.5.5 Partial and complete blindness
The overall prevalence of partial blindness is 51 per 1000 with a
higher prevalence in rural <56/1000) than in urban
areas 39/1000.
Partial
blindness increases with age. The reported extremely high
prevalence among older persons in rural areas (351/1000) is striking
ie
in AP every third person aged 60 is suffering
from partial
blindness.
Urban people are more prone to complete blindness
(12/1000)
than
rural (7/1000) while the reverse is the case with regard to partial
blindness.
The prevalence is much higher in the
age groups 0.14
(15/1000)
and 60 and over (12/1000) than in the
age group
15-59
(4/1000) The complete blindness in the younger and older persons are
strikingly higher in urban areas.
2.1.5.6 Malaria
The ovrall
occurance of malaria was 19/1000. Rural
residents are
twice as likely to have malaria 1’3/1000 as urban residents
11/1000
(NFHS Survey 1992). Though there are no statistics to support,
the
occurence of malaria is on the increase in AP.
Source : NFHS 1992
12
Table 10 : No. of Malaria cases detected and reparted
S.No.
District
No. of Malaria cases detected
Month of May 1995
1.
*7
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15 .
16.
17.
18.
19.
20.
21 .
O'?
23.
Srikakulam
Vizianagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne1 lore
Kurnool
Ananthapur
Cuddapah
Ch i t toor
Rangareddy
Hyderabad
Ni zamabad
Medak
Mahbubnagar
Nalgonda
Warangal
Khammam
Karimnagar
Adi labad
411
255
2489
835
7
1157
304
433
26
95
64
78
o
9
129
97
0
21
o
111
124
68
451
1995-96
reported
Month of May 1996
795
515
3721
590
10
2167
108
32
385
204
299
4
IB
136
19
1
38
0
128
100
158
652
2.1.5.7 Tuberculosis
The overall occurance of TB is 4/laoo with almost the same rate
in
rural
areas. In urban areas, the prevalence is 3/1000. TB
is more
prevalent
among persons above age 60 and over (14/1000) than
among
those aged 15-59 (4/1000) and those aged 0—4 (1/1000).
(NFHS Survey 1992)
Source t Directorate of Health Services
Table 10A : No. of TB cases detected and reported
S.No.
1.
o
o.
4.
5
6.
7
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
18.
19.
20.
2.1 .
22.
23.
District
No. of T.B. cases detected
1995
1996
reported
4925
3528
4749
4056
2056
3541
3144
2185
3899
2042
2427
2896
2648
1838
6131
1792
1940
2215
2250
4069
3618
2981
1445
Srikakulam
Vizi anagaram
V isakh ap a tn am
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne 1 lore
Kurnool
Ananthapur
Cuddapah
Chi ttoor
Rang areddy
Hyderabad
Nizamabad
Medak
Mahbubnagar
Nalgonda
Warangal
Khammam
Karimnagar
Ad i1abad
2.1.5.8 HIV/AIDS
ni
HIV/AIDS virus has already made its way to Andhra Pradesh.
Various
cases have been identified and reported in variours parts of Andhr
Pradesh.
The
total no. Elisa positives are 1233,
the
total
AID
cases reported is 7. The seropositivity rate is 1.9*/. for the groups
tested,
47.2% of HIV infection is from the high risk, behaviour
and
15.17.
is
through blood transmission.
The
incidences of cases
reported and its prevalence asked for an organised intervention
for
al 1.
tn
Table 11 : Profile of HIV/AIDS Status (AP Scenario) as on 1-9-94
1.
*7
3.
4.
5.
6.
7.
8.
9,
10.
11 .
Total Blood samples screened
Total established Elisa Positives
Total Western Blot positive
Total AIDS cases as reported
Seropositivity rate for all groups
tested (1993)
Seropositivity rate in STD attenders
(1993)
Seropositivity rate in Blood donors
(1993)
Probable sources of HIV infection
through high risk behaviour contributed
Transmission through blood
From foreigners
□thers-students, hospital patients,
antenatal mothers etc. contributed
Source : Director of Health Services, AP
14
1,44,110
1,233
195
7
1.97.
5.27.
1 .27.
47.27.
15.17.
4.57.
33.27.
Table 12 : Progression of Seropostivity in all groups tested
Year
Total samples
screened
No. of HIV
Positive
14,967
17,848
28,511
34,150
24,865
23,769
25
29
214
249
475
241
1,44,110
1233
1986 - 89
1990
1991
1992
1993
1994
Total
Seropositivity
rate %
0.16
0.16
0.75
0.73
1.90
1.01
The data is as per the reported statistics on date
Table 13 : HIV Surveillance in blood donors and STD attenders in AP
1
1
1
1
1
1
1
1
1
1
1
1
1
1
i
1
1
M
1
1
O'
1
1
r
j
1
1
i
1
1
1
i
1
1
1
1
1
1
!
1
1
1
1
1
0.01
0.20
0.24
1.2
3
51
65
143
-•
O'
U1
1
1
1
-
Q
1
1
M
M
I
I
I
1
1
1
03
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
01
1
1
15,315
23,742
29,279
11,829
1.02
3.4
3.7
5.2
1
1
1
1
1
W
Q
1
:
1
1
1
1
1
1
1
1
i
1
1
I
1
1
1
I
1
1
1
1
1
1
1
i
c
n
tS
1
1
Table 13 A
1
i
1
1
1
26
163
184
149
!
Q
r
l(
N rt
O' 0- O' O'
0
- O' 0- O'
2533
4769
4871
2847
Total
Blood donors
No. of HIV
Screened
Positive 7.
No. of HIV
Positive 7.
STD attenders
Screened
1
Year
Sentinel Surveillance
Period of study
No. tested
M
F
T
No. of positive 7, psotive
M
F
T
M
F
T
STD
l-12-93to31-l-94
Clinic
Attenders
324
76 400
8
STD
1-1—94to31-5-94
Clin ics
Attenders
387
117
Sentinel
Site
Target
group
Andhra
Medical
College,
Visakh—
apatnam
S.V.
Medical
Col lege,
T i rupat i
504
2
20
9
10
27,
0.57, 2.57,
29
3.9
1.7
5.75
2.1.5.9 Disabilities
Andhra Pradesh is one of the states with a very high prevalence of
disabilities.
The state
accounts
for
10.57, of
the
physicially
disabled.
It stands only next to Punjab
in
rural
prevalence
and
Haryana and Tamil Nadu in urban prevalence.
15
Table 12 s Progression of Seropostivity in all groups tested
Year
Total samples
screened
No. of HIV
Pos i t i v e
14,967
17,848
28,511
34,150
24,865
23,769
25
29
214
249
475
241
0.16
0.16
0.75
0.73
1.90
1.01
1,44,110
1233
-
1986 - 89
1990
1991
1992
1993
1994
Total
Seroposi t i v i ty
rate 7.
The data is as per the reported statistics on date
Table 13 : HIV Surveillance in blood donors and STD attenders in AP
Year
STD attenders
Screened
No. of HIV
1990
1991
1992
1993
2533
4769
4871
2847
26
163
184
149
Total
15020
522
Table 13 A
Eload donors
No. of HIV
Screened
Positive 7.
1.02
3.4
3.7
S o
15,315
23,742
29,279
11,829
51
65
143
80,165
262
0.01
0.20
0.24
1 .2
•2/
Sentinel Surveillance
No.
M
tested
F
T
No. of positive 7. psotive
T
M
F
T
M
F
STD
l--12-93to31 —1-94
Clinic
Attenders
324
76 400
8
STD
l-l-94to31--5-94
Cl inics
Attenders
387
117
Sent ine1
Site
Target
group
Andhra
Medical
College,
Visakhapatnam
S.V.
Med ical
Col lege ,
T i rupat i
Period of study
504
2
20
S>
10
27.
0.57. 2.57.
29
3.9
1.7
5.75
2.1.5.9 Disabilities
Andhra Pradesh is one of the states with a very high prevalence of
disabilities.
The state
accounts
for
10.57. of
the
physicially
disabled.
It stands only next to Punjab
in
rural
prevalence
and
Haryana and Tamil Nadu in urban prevalence.
15
1
The prevalence rate's of ftp are higher than for all India, not only for
the overall but also for each type of disability ie locomotor, visual,
hearing and speech.
The reasons for high prevalence of disabilities can be understood only
by examining the food habits and social and
institutional,
factors.
The high flou.ride content in drinking water in many areas of AP has
resulted in a high incidence of dental and skeletal flourosis in some
districts.
District
wise
estimates of prevalence rate per
lakh population
is
presented
in the table. It is found that Mahabubnagar,
Vizianagaram,
Ananthapur and Prakasam are
the
top
four district
with
high
prevalence of disabilities. Both central and stat
governments and
the
voluntary agencies work towards th
development of disabled.
But still the coverage is not adequate.
Table 14 ;: Prevalence of Disability according to Self Reporting Surveysl986
Orthopaedic
District
Blind
Deaf/
Dumb
Mentally
Retarted
Total
Disabled
28
35
35
18
18
31
24
26
48
19
20
20
52
29
34
■33
28
36
32
18
18
6
19
646
932
613
514
613
612
445
668
824
553
662
517
907
705
712
688
659
939
731
733
439
155
504
27
634
Sri kaku1 am
Vizi anagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Ne1 lore
Prakasam
Ch i ttoor
Cuddapah
Kurnool
Ananthapur
Karimnagar
Warangal
Khammam
Mi zamabad
Mahbubnagar
Medak
Na1gooda
Ad i1abad
Hyderabad
Rangareddy
338
481
362
341
429
380
271
398
506
326
384
299
527
435
438
442
400
543
430
404
223
110
311
161
254
105
72
66
84
60
118
112
94
122
102
172
135
114
94
142
209
157
161
114
99
120
162
122
83
100
117
90
125
157
94
136
94
157
106
126
120
88
151
112
136
84
16
76
Andhra Pradesh
380
116
111
Source
:
23
Status of women and children in AP 1990
16
2.1.6 Water and Sanitation
The source of water and availability of sanitary facilities are
important determinants of the health status of household members,
particularly of children.
367 of households get piped water for
drinking,
277 water from a hand pump and 327. from wells.
There are
large urban rural differences in the source of drinking water.
Almost
three
fourths of households
in urban areas get piped water
for
drinking.
The sources of water used for bathing/washing and drinking are similar
in rural areas but a higher proportion of urban house holds use piped
water for drinking and bathing.
Availability of sanitary facilities is poor in Andhra Pradesh.
Only
177 of
the households have a flush toilet, 87 have pit
toilets or
latrines and the substantial majority (76*4) have no facility at
all.
Half of the house holds in urban areas and 57 in rural areas have
a
flush toilet.
Source - NFHS 1992
2.1.7 Vulnerable and Disadvantaged Groups
2.1.7.1 Children
The
magnitude
of child
labour
in AP standout
and
is
very
discouraging.
Nearly 8.57 of all its children are workers and
the
state accounts for 137 of all child labourers in India.
Andhra Pradesh stands out having the highest number of child
among,
a.
Total population
b.
Total
workers and
c.
Total child population.
workers
In
all
the categories the average for AP far
average as shown in the following table.
national
exceeds
the
Table 15 : DISTRIBUTION OF CHILD WORKERS BY STATE
Region
7 of child workers
to total population
7 of child workers
to total population
7 of child
to total
population
AllIndia
1.68
5.03
4.26
Andhra Pradesh
3.28
7.75
8.50
927 of child labour in AP are mostly found in the rural areas. Very often,
the children supplement family income. More than 807 of children primarily
work as agricultural labourers and cultivators.
17
child workers are boys and 42% are girls.
The
incidence of
587. of
all
labour is the highest in Andhra radesh. 7.29% of
the
total
female child
all over
female child population in AP are workers. While the comparable
India average is 2.95% only.
Nearly 60% of all children in the 5-14 years age group do not
attend
school., 86% of all children ie. 5-14 years age do not attend school are in
the rural areas.
Aclilabad
and Mahbubnagar districts stand first for children not
the schools.
Table 16 : Children not attending school by District,
8. No .
o
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15 .
16.
17.
18.
19.
20.
21 .
97
-73 *
24.
Percentage*
District
Andhra Pradesh
Ad i1ab ad
Hahbubnagar
Ni zamabad
Karimnaqar
Medak
Nalgonda
Warangal
Kurnool
Viz i anagaram
Khammam
Srikakulam
Anan tapur
Visakhapatnam
Ranga Reddy
Cudd ap ah
East Godavari
Prakasam
Ne1 lore
Guntur
Ch ittoor
West Godavari
Krishna
Hyderabad
59.18
73.21
72.64
68.36
67.76
67.28
64.84
64.68
64.15
63 = 60
63.59
63.30
61.83
61.66
58.96
57.93
56.22
56.62
53.82
53.16
52.47
51.69
47.17
29.26
Source : Child labour in AP - A profile
18
1981 Census
attending
Table 17 s PERCENTAGE SHARE OF CHILD WORKERS TO TOTAL WORKERS BY DISTRICT,
RURAL/URBAN, 1981 CENSUS
District
Male
Rural
Female
Srikakulam
Vi z i ananaram
V i s a kh ap a t n am
East Godavari
Krishna
Guntur
Prakasam
Ne1 lore
Ch i t toor
Cudd ap ah
Anantapur
Kurnool
Mahbubnagar
Ranga Reddy
Hyderabad
Me dak
Nizamabad
Ad i1ab ad
Karimnagar
Warangal
Kh ammam
Nalgonda
7.09
6.79
7.31
7.60
6.40
6.59
5.76
5.74
6.01
6.28
7.68
9.39
10.02
9.43
—
8.61
8.33
8.99
8.15
8.05
8.26
7.94
10.01
9.98
11.07
9.30
10.54
11,46
10.66
8.49
10.14
12.15
11.40
13.32
10.43
9.16
—
9.29
11.4
11.71
12.69
10.93
13.36
9.55
All
Male
chiIdren
8.12
7.88
8.48
8.12
7.70
8.35
7.56
6.65
7.30
8.11
8.99
10.92
10. 18
9.33
—
8.57
9.6
9.98
9.97
9.05
9.97
8.49
2.83
2.85
1.65
3.70
C, n
3.10
2.89
3.19
3.02
3.45
3.04
4.38
4.72
1.97
2.13
2.95
2.95
2.30
0.30
1 .76
3.10
3.24
Urban
Female
5.56
5.07
3.81
5.51
6.70
6.46
8.35
5.34
5.42
7.92
7.68
9.10
8.94
3.35
3.28
7.07
8.06
7.11
11.99
9.67
5.95
6.73
All
Ch iIdren
3.43
3-33
1.91
4.03
3.85
3.76
4.15
3.59
3.39
4.22
3.74
5.40
5.73
2.19
2.26
3.79
4.31
3.00
5.18
3.37
2.57
3.84
risks
The
in
their occupation.
Child
labour
face h e a 1th
and safety
a result
consumption
and quality of diet among them is inadequate and as
nearly 45’Z of pre-school childr en are unde r—nauri shed with merely 8.9*Z
suffering from severe malnutrition.
AP has high prevalence (2.37.) of d isab i1i t i es among children and
more than 807. are concentrated in rural areas. (NSS 1981)
of
this
2.1.7.2 Fisherfolk
The AP coast
line
is 974 kms with 407 fishing
villages and a
population of half a million. Marine fishing is their main source of
livelihood.
The men catch fish whereas the women process and market
it.
The marine
fish production
is 99,135
tonnes
(1990-91)
and
contributes to 0.97< of SDP (Commissioner of Fisheries, AP)
Fishing is a high risk activity. This is compounded by lack of
access
to
institutional
credit which deprives them from owning boats and
nets.
Exploitation by money lenders, at the
time of selling
the
produce
and
legislations that encourage the operation of
trawlers
lower their income.
Source : Child labour in AP - a profile
19
As part of the liberalisation policy of India,
the government has
allowed 40% of marine farming (prawn farms) to be operated by the
private sector.
This has resulted in proliferation of prawn
farms,
causing
economic hardships
to the
fishermen and
environmental
degradat ion.
The
increasing shrimp aquaculture activities by commercial companies
in coastal AP is causing serious land degradation and health problems.
The aquaculture
farms require sea water which
is pumped
in and
chemcicals and pesticides are added which after use is pumped back
into the sea and
the neighbouring
lands.
This has resulted
in
salinating
the ground water which has led to the reductions
in
the
availability of drinking water. A number of small farmers have sold
their productive lands to private companies and have turned daily wage
earners.
A number of them have become unemployed because
the
labour
requirement for prawn cultivation is very limited.
Fishing communities are gradually loosing access to the sea from their
villages and marine
life is being depleted due
to pollution and
capture of young shrimps.
.1.7.3 Tribals
The
tribal population in the state is 42 lakhs and
this constitutes
6.3% of
the state and the seventh largest tribal population
in
the
country.
The decadal
growth rate is 32%
(1981-91).
There
are 33
communities
listed as scheduled tribes.
According
to
ITDA,
of
the
total
85.87
lakh hectares of
the
geographical area, 53.3
(62%) lakh hectares are under forests and the
actual
cultivated
area
is 15 (18%) lakh hectares.
The per capita
availability of land is 1.17 hectares. Thus the livelihood system of
tribals is dependent on agriculture arid minor forest produce. This
is
subjected to various forms of exploitation.
Land
alienation
is a serious problem in the scheduled
areas of AP
inspite of the existence of land transfer regulations which clearly
prohibits
the nori-tribals from acquiring immovable property
in
the
scheduled
area. In AP approximately 50% of agricultural land in such
areas has passed on to non-tribals.
Maternal mortality among the tribals is estimated at 4.4 per 1000. The
infant mortality rate is very high ie 85.4 per 1000 live births. About
25% of
these deaths occur due to diarrhoea. The sex
ratio
is also
lower
(962) than the state's average (972) and there is a decline
in
this ratio from 977 in 1981 to 962 in 1991.
Literacy
is much lower (7.8%) than the all-India average for
(16.4%). Female literacy is at a dismal level of 3.4%.
tribals
Nutritional
deficiencies are more severe
among
tribal
children.
Calcium deficiency is common to all tribes.
89-90% of pre-school
children are found to be anaemic.
The most common health disorders of tribals are enlargement of
liver,
soreness
and
the
angles of mouth,
opthalmic
diseases,
hair
discoloration,
moon face and dental cavities. They also suffer from
many nutritional disorders.
20
Goitre
is prevalent in tribal areas. Yaws, a tropical disease marked
by skin sores which may develop into ulcers has re-occured in certain
tribal
areas.
Measles and meningitis are other diseases
prevalent
among the tribals.
.1.7.4
Dali ts
Dalits are the worst victims of the scourge of castism. This
is the
community which faces the worst combination of economic
exploitation
and social oppression. They are mostly landless, alienated
from all
other productive assets, lacking skills and education and often forced
to
live
in segregated conditions at the fringes of
the mainstream
society.
The situation in AP also doesn't make any difference from
other parts of
the country. The population
of Dalits
(scheduled
caste) in AP is 105.92 lakhs ie 15.97. of the total population.
The
literacy among the scheduled caste and scheduled tribes are very
low as per 1981 census report. The 1iteacy rate us 17.65 percent SC
and 7.82 among STs. The females literacy among SC's and ST's are worse
ie 10.3 and 3.5 respt. the tables are give below.
Table 18 : District-wise and Sex-wise Literacy Rates of Scheduled Castes &
Scheduled Tribes Literate Population - Population Census, 1981
i
1
1
1
1
1
i
Male
Female
Total
Male
Female
(2)
(3)
<4>
(5)
<6)
(7)
15.6
15.2
24.8
24.3
23.9
28.8
27.4
21 .3
17.9
24.0
23.0
33 a 2
30.0
28.9
35.5
36.7
31.7
24.9
7.4
7.2
16.1
18.5
18.8
21.8
17.6
11 .2
10.7
9.6
8.0
6.3
12.6
11.4
14.5
13.6
14.7
8.2
14.6
11.9
10.4
16.5
14.3
20.0
19.5
20.6
11.0
4.6
4.0
2.0
8.6
8.5
8.9
7.5
8.4
5.2
21.1
18.9
17.6
13.2
6.5
5.2
3.9
3.9
11.4
38.1
8.4
9.7
7u3
7.8
8.5
10.0
8.7
12.0
2.5
20.0
0.7
1.3
1.2
1.0
1.4
2.5
1.6
1.6
12.0
3.5
Kurnool
Anantapur
Cuddapah
Chittoor
17.1
14.2
16.3
16.6
Rayalaseema
15.83
Rangareddy
Hyde rab ad
Nizamabad
Medak
Mahbubnagar
Nalgonda
Warangal
Kh ammam
Kar imnagar
Ad i1ab ad
15.5
42.3
8.9
9.8
7.4
11 .5
12.7
16.5
10. 1
9.8
Telangana
13.2
Andhra Pradesh
17.6
14.
15.
16.
17.
18.
19.
20.
21.
'7'7
23.
Percentage of S.T.
Liter ates to S.T.
Popul a t i on
Total
Coastal Andhra 23.02
10.
11 .
12.
13.
1
.
tn
4.
5.
6.
7.
8.
9.
I
M-
Srkakulam
Vizianagaram
Visakhapatnam
East Godavari
West Godavari
Krishna
Guntur
Prakasam
Ne1 lore
1.
■7
1I O- 0-
i
1
(1)
i tn
Perce nt age
Liter ates
Popul at ion
1 0 4=0
i
District
9.73
*75
S'
20.0
26.3
25.3
8.5
5.9
5.8
7.6
14.0
12.2
11.1
8.5
11.16
23.0
52.5
15.1
15.4
12.2
18.4
19.4
23.4
16.5
16.2
7.9
31.8
3.0
4.0
2.4
4.4
5.7
9.2
3.8
3m2
7.1
29.5
4.6
5»
4.3
4.5
5.1
6.3
5.2
6.8
5.86
24.8
10.3
7.8
They form the major work farce in the state. 68.27. of the
agriculture
labourers
are from the Dalit background. The dalits are prone
to all
kinds of exploitation and health hazards. They are exposed to all kinds
of atrocities from the higher castes.
With education,
political
awareness and a growing sense of self
empowerment building up amongst this community, they have begun
to
stake their claims for their basic human rights and far the benefits of
the development process. They are always at serious risk of facing from
the dominant culture.
2.1.7.5 Women
(1991).
The sex ratio in Andhra Pradesh is 972 per 1000 males
maternal mortality is 4 per 1000 and female literacy is 33.77.
The
The women,
due to the cultural and social
discrimination have
less
access to health facilities. The girl-child has less opportunities to
health, education and nutrition compared to the male child.
f i rst
In AP,
257. the girls within age of
13-15 year's have
the
18.1
pregnancy.
The singulate mean age at marriage of women in AP is
years overall. In Telangana region child marriage is still common
The dalit women are always the target of victims by the dominant
to settle the scores with the dalits in general.
group
Despite
an
increase
in the number of primary schools,
girl-child
enrolment in classes 1-5 increased only from 37 (1956-57) to 717, (199091). The girls enrolled in primary schools are four times more than the
boys not
enrolled 77. The dropout rate among SC/ST girls
is higher
being about 757.
The economic domain is another source for gender discrimination.
The
inequity
is manifested in the unequal wage rates
and
in
inadequate
access
to the government subsidies, technologies which
enhance
their
economic level and independence.
The attitude among the parents to have a male child still continues.
The broader problems of women are same throughout AP, though they are
differences between urban and rural women.
In AP, the women are capable of setting a political agenda.
With
the
efforts of women, government has declared prohibition in the state. The
state govt., has established a commission for women.
There
is a reduction
in the percentage
organised sectors.
Women
are
targetted
Programmes.
of women working
in
the
for
the Family
Planning
The
joggin system is very much prevalent in AP.
Approximately,
30000
women
from various districts ie. Karimnagar,
Warangal,
Mahbubnagar,
Nizamabad, Chittor are forced to enter this profession.
The major health problems of a large number of pregnant women in AP are
low birth
anemia and nutritional deficiencies which in turn lead to
weight. Mortality and infections are also common among pregnant women.
Inspite of
all these problems 54.27. (1991 census) of deliveries are
conducted by the persons in the rural areas.
Data on prevalence of morbidity among poor women reveal that 497 of
pregnant women
in
rural
areas and 377
in urban
areas have some
illnesses during pregnancy.
.1.7.6 Agricultural Labourers
A study conducted by Radhakrishna et
al
(1988)
states that the
agricultural
labour households are subjected to the highest
incidence
of poverty
ie.
657.. the very poor households agricultural
labours
account for 277 in the developed region and 677. in the backward region.
The agricultural
labourers -form 36.87 (ie 83.25 lakhs) of
total
the
working population with regard to employment opportunities, the
labour
force do not find employment opportunities throughout the year.
The
busiest periods are at the time of sowing and at the time of harvest.
They are given
low wages with the women being differentiated and
underpaid
as compared
to the men. These
labourers are uneducated,
unorganised
and unskilled, have almost no employment opportunities
elsewhere and as a result have to borrow heavily. Heavy borrowing leads
them into debt traps.
The scheduled caste and scheduled tribe forms the major group among the
agricultural labourers (approximately 407). All the problems of SC/STs
would also reflect among the agricultural labourers.Table 19 ; Working Population - By Occupational Divisions, 1981 Census
in lakhs
Working Population
among
Total
Work ing
Population
Scheduled
Castes
Scheduled
Tribes
Cultivators
74.08
(32.7)
6.98
(17.4)
6.78
(43.20)
o
Agricultural
Labourers
83.25
(36.8)
27.35
(68.2)
6.86
(43.7)
3.
Household Industry
Manufacturing,
Processing, Servicing
and Repairs
10.64
(4.7)
0.56
(1.4)
0.60
(3.8)
81 .
No.
Occupational
Divison
A.
Main Workers:
1.
4.
Other Workers
58.32
(25.8)
5.19
(13.0)
1.45
(9.3)
5.
Total Main Workers
226.29
(100.00)
40.08
(100.00)
15.69
(100.00)
B.
Marginal Workers
18.77
3.12
1.45
2.1.7.7
Urban Slum Dwellers
The urban population has grown to 277 (1991) from 247. (1981).
Nearly
one-quarter of the urban population resides in slums. AP has 848 slums
with about 9 lakh population and of it 267 constitute SC/ST.
Though urban areas show better performance in health than rural areas,
urban slums have substandard conditions. Civic amenities and housing
conditions
are very poor. Only 5.37. of the slum population in AP
is
convened by the basic amenities against 20.67 at the national
level.
More than half of the slums in AP are undeclared as a result they are
not entitled for civic amenities.
24
Employment opportunities are less, since most of them are unskilled
labourers.
Small
cities
are subjected to a greater
incidence of
poverty which may be due to lack of employment opportunities.
Though
medical facilities are available in close vicinity, their utilisation
is not up to the mark.
The urban child labour consitutes 6.5’/< of workforce. The majority of
their children
are over eight years of age and have never attended
school.
e
The NGO sector in Andhra Pradesh
The origin of the organised voluntary sector of Andhra Pradesh is due
For
to
influence of Christian Missionaries and Gandhian groups.
decades,
the church has been engaged in
two main
areas,
namely
Education and Health. In both, the church has played significant
role
but confined insitutional
to services. While welfare and relief have
been the main activities of the church till the early seventies, adult
education programmes,
awareness programmes and community
health
programmes
(in
its elementary forms)
started
receiving
attention,
since mid-seventies. The Gandhian groups have been drawing inspiration
from the Sarvudaya movement and getting involved in activities aimed
at promoting that. There have been also sporadic upsurges among
the
people in certain areas, inspired by certain radical ideologies.
The NGO activities in the state has got expanded in the seventies. The
the coastal
region.
1977 cyclone saw mushrooming of many NGOs in
very often
as
Various NGOs came up in various parts of the state,
splinter groups and sometimes as off-shoots of a few major NGOs.
Gome
of
these major NGOs are Village Reconstruction Organisation
(VRO).
Guntur, Rayalaseema Development Trust (RDT), Ananthapur, Comprehensive
Rural
Organisation Society, Hyderabad, Association for Welfare
and
Awakening of Rural Organisations, Hyderabad.
All
parts of
the state
is covered by the NGO.
But there
is a
concentration of NGOs in certain pockets of AP ie in districts
like
Ananthapur, Cuddapah, Chittoor, Mahabubnagar and the coastal districts
NGOs are
less
in Adilabad, Warangal,
Khammam,
Karimnagar,
Medak,
Nizamabad
etc.
The NGOs are
involved
in
all
the health
and
developmental activities.
2.2.1
NGOs - Various categories
The NGOs in AR can be categorised into 5 types, on the basis of
origin, these are -
their
->
The first type are NGOs started by socially concerned people, who
migrated
from other places and established
themselves
in
the
state over a period of time.
->
The 2nd
type NGOs are initiated by those who worked with
the
first
type of
for a long period. They established
themselves
with
the support of the parent organisations and has
a good
credibility among the public.
->
The 3rd
type belongs to the native,
with a
rural background.
These groups are concerned about fellow brethren suffering from
social discrimination and social injustice. Some of
them would
have also experienced the social inequalities in their life also.
25
The Christian missionaries working in various parts of AP
forms
another brand.
Their approach
vary according to
the personal
convictions and ideologies.
The
Sth category of NGOs are formed with varied
interests.
The
first
two types of NGOs have urban sophistication and
professionalised or gets the services of professionals whereas
groups 3 and 4 are not managed or supported by professionals. In
present
development scenario,
the son-professional
groups
sidelined.
Presently our team
supports groups belonging to
3rd and 4th types and some selected NGOs from group 5.
are
the
the
get
the
Another c .1 ass i f ic at ion of NGOs can be done based on
the coverage,
competency,
availability of funds, no. of staff, their role etc.
The
groups are
The corporate and mega NGOs : The NGO bases in one place
and
operates
in different districts/or one district
itself.
Their
normal coverage will be more than 100 villages. They have various
projects and programmes and handle mul11i-mi11 ion projects.
eg.
VRO, RBT, AWARE, RAGS etc.
Big NGOs
:
Operating in 50-100 villages of
various mandala.
Multiple programmes exists. Professionals work with the group.
They
Medium size NGOs : Mostly they operate in 30-50 villages.
employ professionals and are involved in multifarious activities.
Very often they have the recognition and financial assistance from
government.
Small NGOs : Small NGOs having a coverage of upto 30 villages with
micro
involvement
and
limited perspectives.
Most
of
then
including
the leadership are from local areas and managed by non
professionals.
Management skills
and systems
lack
in
the
organisation. But the group is committed and has good rapport with
the people. Some of them represent the disadvantaged group also.
Peoples organistions : These are all small organisations
emerging
at the community by the involvement of intermediary organisations.
These organisations come together and form a network/federation
for the specific geographical area. Obviously, the leadership
is
from the disadvantaged,
partially exposed
to the development
trends.
CHAI has been mostly associating and supporting the medium and small
size
organisations
and
network of peoples organisation.
CHAI's
Member
Institutions also come under this category since most of our
institutions
are small dispensaries with a bed capacity of 0-6 and working
in
limited
geographical area and managed by a sister-nurse.
2.2.3. The trends among NGOs
In all
the districts, NGOs come together and form a federation of
NGOs.
Some of
the district federations are quite active
and
its
membership
limited and is based on quality commitment etc. The
inter
and
intra rivarly among the NGOs affect the functioning of district
federations.
26
AP has witnessed the mushrooming of NGOs in certain pockets due
to
various reasons. Districts like Ananthapur, Cuddapah, Chittoor, Guntur
etc.
has got more than 500 NGOs in each district. Most of
these
are
on paper and inactive organisations.
In
the recent past, the NGO sector is witnessing a new development.
Many NGOs get registered with the blessings of government beauracrats
and other vested interest groups to mobilise
the government
funds
especially for watershed programmes, Joint Forest Management,
CAPART
programme, housing, sanitation etc. These NGOs gradually get co-opted
into the government network.
A silent revolution is taking place with regard to the leadership of
the NGOs. Good many dal it and tribal NGOs who work exclusively for
their own groups are slowly emerging. Some of the
funding agencies
support such a collective movement. Though such efforts has got ups
and downs, the results are encouraging.
Various
issue based network organisations are becoming more and more
active
and make their presence felt in the state. Networking of NGOs
on
environment, watershed, credit unions etc has made its
impact
in
the
field. These network organisations are effective in highlighting
various aspects and issues related to it with the government,
funding
agencies etc. We can also find that the same NGO is part of several
ne tworks.
As
funds availability
for NGOs has increased the number of
funds
seeking NGOs have also mushroomed. The easy availability of funds for
certain
programmes eg.
HIV/AIDS,
watershed,
child
labour
has
accelerated
this
trend. Funds from govt, sources eg CAPART,
social
welfare dept.
has become easy.
Such a supply
induced
increase
in
demand has occasionally led to substandard quality, diversion of funds
to
fulfill
political and personal aspirations and corruption among
NGOs.
Major donors operating in AP
AIDS, EZE, Memisa Bi lance, Mi
Action Aid
eor, HIVOS
OXFAM
TDK, i
CRY
Christian
Ind i a.
INTERNAL ENVIRONMENT ANALYSIS
At
the moment a three member team as part of CHD co-ordinates and
looks
after the projects and evaluation activities.
The
team gets
support from the rest of the department and the Delhi Zonal office
to
complete
its
tasks. The team also makes use of the services of
the
extended
team members and the regional
units whenever necessary.
However,
CHAI
is on the look-out for competent personnel
as full
timers in the team.
1 Our strengths
*
CHAI has been promoting community health in the region for the past
15 years through orientation and trainings. The team was set up
in
1991 exclusively to support projects and programmes.
*
The present CHAI team have a good understanding about the
the needs and the NEG sector.
*
Team
is committed, experienced and competent to support small
medium sized NGDs.
region,
and
*
Regional
team is slowly developing good rapport with
agencies and the donors in the region.
*
Very positive relation with the field partners.
*
Expertise
on
organisation.
community
health
are
available
the
similar
within
the
Our Weaknesses
*
Absence of a proper reporting system.
*
Heavy workload and personnel constraints.
*
Broader understanding with the regional team to be developed
regard to support and guidance to the project holders.
*
Absence of gender balance in the team.
*
Absence of a proper gender perspective within the team.
*
Less opportunity exists for institutional learning.
*
lack of expertise in advocacy and lobbying.
with
CHAAP - The Regional Unit of CHAI
As part of decentralisation, CHAI is in the process of strengthening
regional
units and gradually a resource team will be formed
in
each
region. Along with that several of the responsibilities which CHAI now
discharges
for promotion of community health will be
transferred
to
the
regional units. Thus, over a period of time, regional units will
play a significant role in appraisal, monitoring and
evaluation of
community health programmes.
4
CHAI - Member Institutions in AP
CHAI membership, all the health care institutions are located in
all
parts of the state. The total membership is 270. Most of the members
are small
dispensaries
located
in the
remote
areas of AP.
The
following table shows its strengths in each district.
Most of
the member institutions are involved
activities at varying degrees.
in
community
health
The regional unit of CHAI has been in existence since 1990.
With the
assistance of MEMISA, CHAAP has been promoting community health
in
Andhra Pradesh mainly through its member institutions. The head office
is in Vijayawada and has two full time staff and an active Board.
Distribution of CHAI Member Institutions in AP — District—wise
Total Members
10
Ad i1ab ad
Karimnagar
Ni zamabad
Warangal
Medak
Ranga ReddyHyderabad
Nalgonda
Khammam
Krishna
Gun tur
Sri kakulam
East Godavari
West Godavari
Mahbubnagar
Kurnool
Prak asam
An an thapur
Cuddapah
Ne1 lore
Ch i ttoor
Vi j ayanagaram
Viskhapatnam
3.5
CHAI and Field Partners
W M
h
M tj
® M O' W
•
* HM M I - i3 ..J J
Xi fl-
U lj! f,|
. . . . . . fj
f-J M
Districts
12
5
5
11
21
16
31
2?
12
5
10
12
7
S
4
6
13
Since
1992,
CHAI started associating with project partners at
the
request of our funding partners and through a policy decision.
At
present,
CHAT
associates with 23 projects in AP of which
16 are
supported by MEMISA. Most of these are small and medium size NGOs
involved in community health programmes.
Partnership
The
involvement of CHAI in the project studies and evaluations
is
a
recent phenomenon.
CHAI,
after having a lot of deliberations and
discussions have decided to study, support and guide community health
programmes
and projects in the country. As we get involved,
it was
realised that a lot more interactions and involvements is needed with
the field partners to translate the community health vision of CHAI in
the
field. Hence it became imperative to look at the role of CHAI
on
the process and the relations with the funding partners and
field
partners.
From our experiences with many projects in the past,
CHAI
believes
that a long term association with the project holders is necessary
ie
to play7 an
accompaniment role and to evolve
a true partnership.
However, CHAI has to address a number of questions around partnership
with project holders and the funding partners and its meaning.
29
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