COMMUNITY HEALTH WORKER'S PAPERS
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- COMMUNITY HEALTH WORKER'S PAPERS
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Special Report
HINDU, 6th September 1978•
What art the ways by which the millions
of poor in developing and under -develop
ed countries can be provided with a good
health care system? An international
meet is to discuss this question*
OOlilREK■'.SIW CARE VTIE PEOPLE'S ?7\BTIGIHTICN
iBHealth for all by t^c year 2000. This call, given
Dr. Halfclan
biahler, Piro ol or -0 o: '■ oral. of the World health CrganisaticTj a'.-.the
world Health Asseifbly in '.'ay 1977, map sound to pany ao utopian
dream or wishful thirtong- But WHO and the United Nations Gllldren^ s
Fund are well set to make it a realistic goal. As part of the efforts
these'two• hgve aountc-d,- nc-rt/p 700 delegates from all oyer the world
are ncc tirw for a week f:. on tet-day at Alm- Ata, the capital of soviet
i^shakhstan.
The Conference, claimed to bo the first ever to be convened on a
world-scale to discuss ways--and moans of providing better health
' care for all people in the world,’ is a follow-up of the resolution
adopted by the World Health Assembly in hay 1975» TDo Assembly
called for exchange of experience among member-countries on the
development of primary health care, as part . of the national health
services •
The unsatisfactory’ state of public health services was first high
lighted by W0 in 1973. "There appears to be widespread dissatisfaction
among populations about their health services. Such dissatisfaction
occurs in the developed as well as in the thid worlds” the repor
■had said.
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Er ora then, on. WHO had been periOdiocally driving , home the need
for correcting the situation. In May 1973, the World Health
Assembly passed a resolution advocating special emphasis on meeting
the needs of those populations which have clearly insufficient
health service a. A year later the WHO Dira ctor-Gcncral frankly
admitted that the most signal failure of WHO and its Member-states
w?s the inability to promote development of basic health scrvj.cos
and. to improve their . coverage and utilisation.
Dr. Pb-hLcr had oven advocated resort to "unorthodox ways, like
increased use of auxiliary health personnel to correct the situa
tion even though this might be disagreeable to sone policy makers.
In January 1975, the WHO executive board underlined the plight
of the rural, population and recommended ;priority attention to primary
health care at the community level... Closely following tins, tlic
World Bank came out for the first 'tine with a study specifically a
addressed to health issues. Its significant feature was the lank
it sought to establish between health and economic development.
It formed,, the basis of World B nk lending for projects to control
ma.jor diseases.
According to WHO, about two-thirds of humanity does not have access
to the simplest of health care sys ' cus. A joint report oy Dr. Mahler
and the UNICEF Kxecutivo Director, Mr, Henry R. Labourssc, which
forms the basis working document for the Alma Ata conference,
condemns the widening global gap between the "health haves and
the "health have-nots". The gap is evident not only as between
a ffl went countries and the developing world, but also within
individual countries, vhatever nay be their level of development.
Discussing the reasons for this situation, the report says:
"Better health could bo achieved wrth the technical knowledge
available.. Unfortunately in most countries this.knowledge is not
being put to the best advantage of the greatest number . Health
resources are allocated mainly to sophistiermed medical institu-
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tions in urban areas. Quite apart fron the dubious social preuiso
-orL.which this..is based, the concentration of complex and costly
technology on licit <-2 scgiaents of tho population doos ne t even
have tho advantage of inpreving health.
\
bIndeed, t?::- teprc-Voixnt cf .-e- 1th is b-.irr oquotc-d. u-’t1- th;,•• provision
of nodical care dispensed,^ growing numbers cf specialists, using
narrow medical tochndc^zics for the benefit cf the prviloged- few.
PoopLe Imvc bo cone cases without porsonaliti; s end contact has boon
• lost between those providing r.odicrl- care and those receiving it
<F At tlie same tine, disadvantaged groups throughout the world liavo no
/• access to any pcrY2anont form of health caron.
health systems arc all tco often being devised evtsido tho rainstroari of social end ocor.c ic dovclopcont. nThese sy.3tov.s frequently
restrict thonselves tc nodical care, although industrialisation a-d
deliberate alteration of the on’dronricnt ai*o crcatinf health prcblcns
whose proper control lies f-r beyond tho sccpo of nodiccl care
Tims,
most conventional health co.r.? systems are boconinr increasingly ccnplcx rir*. c< stly and hdvc doubtful s cicl relevance*
11 They, h? vo been disterte - by dictates of nodical tcchnolo'y and by
tl'io rdsgutded efforts of a helical industry providing r.iodicol ccnsunor
goods to society# Ahron seno cf the nest affluent countries have cere to
roaliso the disparity between tho high ca.ro costs and lew health
benefits of those systors. Obviously, it is cut of - he question for
the developing countries tc continue inporting then15 . Tho report
rcccniionds in tide context the alternative approach of "priirry
health. care” •
This approach does not envisage acre oxpc.hsion cf ncdical services
to cover the hitherto neglected sections. It is senothi- g rcoro tian
tlat and has social and dovclcpuontal dimensions with goals like
improvei'ents of the qurlity of life and raxirmLi health benefits to
the greatest number* The basic promise is tliat in level oping countries
in particular, occ.ncr?ic develop' ont, enti-pcvor'cy measures, feed
production, water, sanitation, heusing, environu-cntal protection ,
and.education-all these contribute tc bcuclth. For the success of
pi: aTy health cere prcgrayia, thurohos to bo de— or di:'a ted effort
in all these sectors*
According tc VJHO, the seven hr. 31c principles of pri-r^ry health care
ere:
It sb vid be shaped around the life patterns of the peculation it is
to pervo and s /.ovld nc- .t tho needs -of tie cc’xunity.
It should be an integral part- cf iJic natio nal health syston, end. other
echelons of service s’1 erId be designed tc svnport it*
I
It should bo f lly irtograt-c/t with th; activ tics cf t->o other
scoters inV'Ivod in ecru unity-o vol op isnt (agri culture, oducatton,
public works, housing r-r' co- rmnicati ns) *
.
Tho local population diculd be actively involved in the fcrimlotion
and iupLonentation. Decisions as tc- th<j ecu unity’s needs should
be based on r. continuing dialogue be;tween people and the services.
Health euro efferq ’ should place urjeiimu rolia co on availablo cenn*
unityro s vrcc's, o spacial'1 y those that have ronhinod untapped, and
should rennin uiibiu the strictest cost liuitations*
Primry health care should use an integrated ar -roach cf pevontivo,
proactive, curative, and rehr In ttr.ti'vo services. The balance between
those services should vary accordin'; tc. co rmnity needs.
Tho mjerity of health interventions shcnld bo undertaken at -the iioct
poriphornl level possible by suitably trained werkor^
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Tho most l»port»t stoylo ftotor 1, . strop,. poHtld pin
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STO„ort
at both national and comumty
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lewis, rm'nyorcc-’ by a firm national '
strategy in favoui? of not only an incroaa-d hoal+h budspi but also
allocation of the increased1 resources to -institutions providing direct
support to primary health co
care. The report also calls for action
to support national policies
-J and strategies.
Apart from this strong political
^commitment and increased resources
the report suggests specific
.
antidotes to some of the obstacles likely
to be encountered. ~ or finstance, health professions, from, whom resistance can be eypected, should be
ing medioal ftmctdons W gaining her 1th responsihil 'tb^.'^i^th^same"
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way, resistance anonr the general public can be defused by discussions
^communities and m mass media, which should rim to make n-ople 'ann
reeiate that primary health care is realist-in -ince i+ orrnHd^o ' +PP~
cost that can be afforded, essential health do "for all rather thV
sophisticated medical care for the few.
Opposition from the nodical industries, ^ccordirt to the report, can
be net by making them interested in nrodUcti or
eqmnmont for use in
primary health care. Any losses from reduced sale o expensive- equipment could bo more than counterbalinc.ed by the rale to lr’r?lurt™d
markets of frreator amounts of loss oyn-msive oqv-nnent and supplies.
The report cautions ayalnst Ihm assumption that primary health care
implies the cheapest form
medical core for the poor, with the bare
minimum of financial and technical surnort.
The health care and medical care servk -s that
■
up should bo
made accessible-geogrankically, f--: ai.vi■-’’..rp culturally, and function
ally. Geographical adcessibilltv pears that t!r distance, travel time
and means of transnortati on are acc^^k- to the people financial
accessibility means that the services must be-wHt the community can
afford. Cultural accessibility refers to the technical and managerial
aethods used, which should be in boenin- with tie cultural patterns
of the cconunity. TFunctional accessiHTity ensures that the right kind
of care is available on a continuing basis to those who need it
_■<, wherever they need it.
Then ccnies the question of appropriate technolo
Dealing with this
the report points out that fewer c-rurs than thoeo row in the narbet
are necessary and a list of 200 essential drugs has been prepared by
WO. The report feels that it will be an advantage if the equipment
and drugs selected por prirary health care are manufactures locally
at low cost.
The maintenance of equipment shou3.d. pre drably be within the capacitv of
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in^ human, should be made full use of. In other words, the surwstion
thpF'l 12T10 sklld
active interest and participate in solving
Sr 1 °t hh^S- Py thiS involvonr!nt, individuals become Ml meneers of the health team.
According to the renort, the nost realistic sedition for attaining total
population coverage is to ermlov connurity health workers who can be
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trained to perform specific jobs, in shiort. tine. They Rave to bo
trained.and retrained, based on a clear .dof.Lnition of the probions
involved, the tasks to be performed and the uotbods to bo used.
The organisational set-up at the ccrmnity level and at the referral
levels, to provide support, will involve ir-.oroased rosp.or sibilitios
for the highly trained staff at the referral'levels. They will < Iso
be required, to guide, to.-.bh, '-nd sufjerad-co sohrunity he-1th workers
and educetc connunitios on all natters per' oining to health.
The report Cells for r-uturl co-operation a' onr; dcvelopii'::: cevntrios
by way of exchange of informtion and experience -.nd urges affluent
countries to increase substantially ironsf. a of funds tc the develop
ing countries for. prir-ry health care.
The’ oxpoctr.tion is.thr.t the Hm Ate conf : once will- prove tc bo a
turning point in i •toraaticnal efforts and provido concrete rocoDBondations for action by U..1I. agencies and . ' bcr-.3t^tos
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CofvA h Txr . 3
JRIlteY HEALTH CARE
Primary Health Care is essential health care made
universally accessible to individuals and families
in the community by means acceptable to them, through
their full participation and at a cost that the
Comiumity and country can afford. It forms an
integral part both of the country^ health system
of which it is the nucleus and of the overall
social and economic development of the community.
Primary Health Care addresses the main health pre'.lons in
the community, providing promotive, preventive, curative and rehabili
tative services accordingly. Since these services reflect and evolve
from the economic conditions and social values of the country and its
communities, they will vary by country and community, but vd.ll include
at least: promotion of proper nutrition and an adecuate supply of
safe water; basic sanitation; maternal and child care, including family
planning; immunization against the major infectious dise<ases; prevention
and control of locally endemic diseases; education concerning prevailing
health problems and the methods of preventing and %c ontrolling them;
and appropriate treatment for common diseases and injuries.
In order to make Primary Health Care universally - cccssible
in the community as quickly as possible, maximum community and individual
self-reliance for heth development are essential. To attaii.. such selfreliance requires full community participation in the plannii ■, organi
zation and management of Primary Health Care^ Such parti cipation is
best mobilized through appropriate education which cna7les communities
to deal with their real health problems in the most suitable ways.
They will thus be in a better posticn to take rational decisions
concerning Prir.ia.ry Health Care and to make sure th.-.t the right kind
of support is provided by the other levels of the national health
system. These other levels have to be organized and strengthened
so as to support Primarj^ Health Care with technical knowledge,training, guidance and supervision, logistic support, supplies,
information, financing and referral facilities including insti
tutions to which unsolved problems and individual patients can be
referred.
Prir.Tary Health Caxe is likely to be nest effective if it
employs means that are -understood and accepted by the comr.-unity and
applied by community health workers at a cost the community and the
country can afford* Those community health workers, including tradi
tional practitioners whore applicable, will function best if they
reside in the community they servo and are properly trained socially
and technically to respond to its expressed Health needs.
Since Primary Health Care is an integral part both of
the country1 s health system and of overall economic and social
development, without which it is bound to fail, it lias to be
coordinated on a national basis with the other levels of the health
system as well as with the other sectors that contribute to a
country* s total development strategy.
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(S) All Govcrnr'.cnt.s should forixila'te national policies? stra
tegics and plans of action to launch and sustain priuary hoafith caro as part
of a couprchcnsivc national health system end in co-ordinal3.on '.'ith
other sectors*
(9) -AH countries should co-operate in a spirit of parti.-rshi]
and service to ensure prinary health care for all people, since the
attainnont of health by people in any one country directly concerns
and benefits every other country.
(1O) An acceptable level of health can be attained for all the,
people of the world by 2000 A.D. through a fuller and bettor use of the
world1 s resources, a considerable part of which are now spent on
arnauents and military conflicts .-PH.
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10 - point declaration on health,
NEW
NEW DELHI,
DELHI, Sept.
Sept. 20.
20. - The declaration of Alma Ata approved by the
world conference on primary health care early this month says that an
acceptable level of health can be attained for all the people by
2000 A.D. through a fuller use of tho world’s resources part of which
are now spent on armaments.
According to a press release by the World Health Organisation,
tho declaration approve^, unanimously by delegates from 140 nations and
numerous non—governmental organisations !5ca.lls for urgent an... effective
international and national action to develop and inplomont pr_. . ary
health care throughout the world and particularly in developing
countries
The 10 points of the Alm Ata declaration arc:
(l) Health, which is a state of'complete physical, mental
and social well-being and not merely the absence of •'.escam or infir
mity, is a fundamental human right.
(2) Tho existing gross inequality in tho health status of two
people, particularly between developed and developing countries is
economically unacceptable and is. therefore^ of common concern to all
countries.
(3) Economic and social development, based on a now international
economic order, is of basic importance to the fullest attainment of health
for all and to the reduction of the gap between the health status of the
developing and developed countries.
(4) The people have the right and duty to participate individually
and collectively in the planning and inplericntation of their health care.
(5) Governnonts have a responsibility for the her 1th of their
people which can be fulfilled only by the provision, of adequate health
and social neasures. A min social target of Governtients, inter
national organisations and the whole world connunity in the coning
decades should bo the attainnont by all peoples of the worlf. by 2000 A .D .
of a level of health that vjill permit then to load a. socially and
economically productive life.
INTEGRAL
PART
(6) Primary health care is essential health care based on
practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals and fa: Hies in
tho community through their full, participation and at a cost, that tho
community and country can afford to maintain at every stage of their
development in tho spirit of aclf-roliancc and self-do termination. It
forms an integral part both of the country’s health system, of which
it is the central function and main focus, and of tho over-all social
and economic development of the co: munity.
(?) Rrimry hcclth care reflects and evolves from the cconomc
conditions and socio-cultural and politial char a tori sties of the
country and includes at least education concerning prevailing health
problens and the nethods of preventing and controlling then.
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Health Pare Polley an& Delivefy Methode*
by
Major General B MAKIDEVAN PVSI4 AVfM
Director of Rural Health Services
and Training Programmes
St John1s Medical College, Bangalore 560054
Introduction
Public Health in British India mainly concentrated on
legislation and measures for the prevention of epidemics in the
civil population to safeguard the health of the British Army. In
1945, a rapid stride was however made by the British India Government
in the wake of the constitution of the famous Beveridge Committee
in Great Britain, by the appointment of ’The Health Survey and
Development Committee (Bhore Committee)’ to survey the existing
position in regard to health conditions and health organisations in
the country and to make recommendations for the future development.
The Bhore Committee Report, as it is popularly known, came out in
1946, which recommended a short term and long term programme for
the attainment of reasonable health services based on the concept
of modem health practice.
India became independent in 1947* A democratic regime
was set up with its economy geared to a new concept, the establishment
of a ’’Welfare State”. The burden of improving the health of the
people arid widening the scope of health measures fell upon the
National Government.
The Constitution of India came into force in 1950 and
India became a Republic in the Commonwealth. Article 246 of the
Constitution covers all the health subjects and these have been
enumerated in the Seventh Schedule under three lists - Union List,
Concurrent List and State List. Article 47 of the Constitution
under the Directive principles of State Policy states "that the
State shall regard the raising of the level of nutrition andstandard of living of its people and the improvement of public
health as among its primary duties’. The planning Conjmission was
set up in the same year by the Government of India which set to
work immediately for drafting the First Five Year Plan and subsequent
plans. Paradoxically, the policy frame for health services of Independent
India was to be the blue print of health services drawn up by the
Bhore Committee for post war British India.
The Shore Committee formulated its recommendations on
the basis of certain remarkably progressive guiding principles listed
below:
1.
Medical Services should be free to all without distinction
2.
The Heal th programme must from the very beginning lay special
emphasis on preventive work
Suitable housing, sanitary surroundings and1 a safe drinking
water supply and adequate nutrition are pre-requisites of
a health life
- 3.
4.
5.
6.
Health services should be placed as close as possible
Health education should be provided on a wide basis
Doctor of the future should be a social physician
*Paper read at the Plantation Medical Officers’ Conference
organized by UPAST during 21-22 December 1978 at Coonoor.
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7.
The training of the basic doctor should be designed to equip
him for playing an effective role as a social physician
It is significant that even at such an early period
when the country was still under colonial domination and the
members of the Committee were British and native health administrators
and public men of that period, they could develop such profound
insights into the issues involved in the formulation of a national
heilth policy.
.
'
The Bhore Committee had categorically stated that it
is ’’fundamental that development of the future health programme
should be entrusted to Ministries of Health at Centre and in the
Provinces which will be responsible for the people and sensitive
to public opinion. The need for developing the. programme in the
closest possible cooperation with the people has already been
stressed”. The Committee had also emphasised that in drawing
up a health plan, certain primary conditions essential for healthful
living must in the first place, bo ensured. Suitable housing, sanitary
surroundings and safe drinking water supply are pre-requisites
of a healthy life. The Committee enjoined that ’’the provision of
adequate protection to all, covering both its curitive and preventive
aspects, irrespective of their ability to -pay for it, the improveoeut
of nutritional standards qualitatively and quantitatively, the
elimination of unemployment, the provision of a living wage for
all workers and improvement in agricultural and industrial production
and in means of communication, particularly in the rural areas,
are all facts of a single problem and call for urgent attention.
Nor can a man live by bread alone. A vigorous and heilthy community
life in its many aspects must be suitably catered for. Recreation,
mentxl md physical, plays an important part in building up the
conditions favourable to sound individual and community health
and must receive serious consideration. Further, no lasting
improvement of the public health can be'achieved without arousing
the living interest and enlisting the public cooperation of the
people themselves.
The Prime Minister Jawaharlal Nehru in enunciating
the health policy of Independent India to the first Conference of
the provincial Health Ministers held in 1946, endorsed the views
expressed by the Bhore Committee and stated that in the past,
little attention was paid to health which was ’’the foundation of
all things". He asserted that economy in this sphere might mean
greater expense, in the long run and that "the health of the
villagers required special attention as the country derived its
vitality from that and hence benefits of health must be extended
to the whole country side”. The aim according to Shri Nehru was
to develop a "National Hexlth Scheme which would supply free
treatment and advice to all those who require it".
Five Year Plans and the Health Status of the Indian People
Although policy decisions have been taken from time
to time to evolve a sound National Health Policy over the last
28 ’planned’ years, we seem to have drifted further ancLfurther
away from the goal of ’’total he .1th for all” envisaged by the
Bhore Committee. Every five year Plan document contains a brilliant
rhetoric for expanding health programmes for more and better
equipped Primary Health Centres and for better implementation of
programmes. The recommendations of the Chadha Committee and Kartar
Singh Committee were aimed towards this end. Even more recently
in 1975, the Shrivastav Committee, brought out a blue print for
major policy changes giving a social orientation to the entire
system of medical education and in rural health programmes of India.
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As stated by the Shrivastava Committee on development
of a national programme of health services for the country based
on the Bhore Committee Report-"During the last
years, su?taine
efforts have been made to implement its recommendations as
as those of other important Committees in this fie . n spi e
substantial investments made and the impressive results
narticularlv in the production of medic.nl manpower, the health
status of the Indian people is far from satisfactory. The sheer
magnitude of the tasks that still remain !S so great and
additional
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be
so
limited
that
one one
resources available for the purpose appear to be soJhat
*•
’ health needs or realising our
almost despairs of meeting
our
basis
of
the broad models we seem to have accepted.
aspirations on the 1.—
come
when
the entire programme of providing
A time has, therefore,
efficient
and effective health services
a nation wide net work of
„1
LIa
needs to be reviewed de novo with a view to evolving an' alternative
for our conditions, limitations
strategy of development more suitable
s---.and potentialities”.
There is no doubt that all the while manpower, material
and economic resources drained inexorably away from the country's
real needs. They flowed towards establishing a sophisticated,^
individualistic, expensive, illness service for the privilege ,
rather than towards a simple community based and inexpensive Primary
service for the deprived who form the bulk of the population. The
W.H.O. Regional Director, Dr V T H Gunaratne has termed as Disease
Palaces" the present day hospitals. According.
to hfp»;P*Lat we now
have in India and other developing countries is .an incredibly
expensive health ’industry’ not for the promotion of health but
for the unlimited application of "disease technology" to the affluent
section of society.
He further adds that consequence of the present high
technological pitch of therapeutics is that the very treatment of
one illness may produce another, either through side effects or
iatrogenesis. He goes on to say that "this distortion of health
work is self-perpetuating. The whole un-healthy system finds its
most grandiose expression in buildings, in disease palaces, with
their overgrowing need for staff and sophisticated equipment. In
medical research t00j the main thrust is towards pursuits of disease
oriented establishment. Even in the less developed countries probably
more than 90% of the research now going on concerns problems, the
solution of which would benefit less than 10% of their populations".
Dr Gunaratne made these observations to highlight the
need for a shift in favour of the ’primary Health Care’ concept,
which envisaged integration, at the community level, of all the
elements required to make an impact on peoples’ health. This concept
was explained by him thus ’It is an expression of what a person
should do in order not to fall ill -and what he should do when he
falls ill’.
A Revised National Health Policy and Health Care Delivery System
The Bhore Committee had visualised that health services
would percolate down from the teaching hospitals to the taluq hospitals
and then to the Primary Health Centres, Sub-Centres and ultimately
to the villages. But it never worked like that. The health services
got clustered around the apex institutions — hospitals — instead
of percolating to the peripherals. In the new national health
policy of our government, this trend is sought to be reversed and
a deliberate decision taken to spend 75 per cent of the planned
allocation for health in the rural areas.
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I find that in your plantations (a primary rural industry)
too, the trend of expenditure has a similar pattern. With the
introduction of the Plantation Labour Act, the Government placed the
responsibility of providing medical care in the Planters while
stipulating the minimum requirements. This was based on the concept
of the Western model. Garden Hospitals and dispensaries with personnel
were prescribed on the basis of the labour force. On some estates
these hospitals developed to provide sophisticated medical care.
In an analysis of the morbidity and mortality undertaken by
Dr (Mrs) V Rahmathullah, Medical Adviser, UP.iSI, we find that
only 3% of out-patient require admission into the Garden Hospital.
The es.tate budget runs to about Rs.75/- per worker per annum and
85% of this budget is spent on the Garden Hospital which looks after
only 3% of the out patients. This lopsided expenditure and inadequacy
of health care system in plantations need to be given serious conside
ration. In conformity with the national health policy, it is desirable
'that 75% of budget is allocated for expenditure on peripheral health
services ie., a shift in favour of the primary health concept is
necessary. The change is imperative.
If the Infant Mortality Rate is accepted as a good index
of the socio-economic progress of a country, then we have one of the
highest rates in the world as far as rural areas are concerned,
ranging from 90 to 138 per thousand. In some rural areas 80% of the
children are undernourished and only 3% have normal body weight. Fifty
per cent of the deaths in our country are of children under four.
Nearly 60% of our people who live below the poverty line,
lack the purchasing power to secure health services. They constitute
about 378 million people whose health care is being neglected. Let
us consider this matter in terms of ’health economics’ ie., the loss
to the national economy due to the ill health of the poorer rural
and urban people. If 40% is taken roughly.as the number of able
bodied people in our population, then the lowest 60 per cent of our
population (approximately 378 millions) provide a work force of 151.2
million. If even 10 per cent of them are ill at a time, then 15*12
millions are away from work every day for the whole year. At the
current per capita income rate of Rs.1400/- ( I am quoting the lowest
rate ) we are losing at least Rs.2006 crores a year in Gross National
Product alone due to ill health. If there are epidemics of any sort,
we lose much more. This huge national loss occurs because we do not
have a clear cut .and firm national policy.
«
3
A major shift in the emphasis in the health services was
necessary from a curative to a curative-preventive approach, from
urban to rural population, from the privileged to the under-privileged
and from vertical mass campaigns to a system of integrated health
services forming a component of overall social and economic
development. Health had to be given a high priority in the Government’s
general development programme.
Health services are only one factor contributing to the
health of the people. Economic and social development activities
often have a positive influence on a communityf,s health status.
Sanitation, housing, nutrition, education and.coEmunications are all
important factors contributing to good health by improving the
quality of life. In other absence, the gains obtainable with the
disease—centred machinery of health services cannot go beyond a
certain point. Two kinds of integration are, therefore, necessary.
The first is the integration of various aspects of health policy
into economic and social development. The second is the welding
of the different parts of the health services into a national whole.
A firm national policy of providing total health care
for all will involve a virtual revolution in the health care
delivery system. It will bring about changes in the distribution
:5:
p Pow^r, in the pattern of political decision making, in the
attitude and commitment of the health professionals and administrators
P00Ple's awareness of what they are entitled to. To achieve
sue
ar reaching changes, political leaders will have to shoulder
the responsibility of overcoming the present inertia as well as
e well entrenched vested interests. Though the framing of health
po icy belongs to the domain of politicians, the medical profession
oil a responsibility that goes beyond protecting its own interests
n-p 4-2° ynter“st of individual patients, to protecting the health
oi the whole community. Plantations will no doubt have to adopt
?011cy of health care delivery. In a captive population
. °rco) ln plantations, greater advances are possible, with
an enlightened management and an effective medical service.
Managements must accept this new philosophy and make greater
investments towards providing comprehensive medical care to its
labour force, with a sound peripheral health delivery system. Through
your Comprehensive Labour Welfare and Link Workers Schemes, some
advances have been made but a great deal is still to be done.
■
The new rural health programme launched in October last
ie present Government, has in my view provided the
thTOUgh- "Instead of waiting and waiting indefinitely
for the he ilth services to percolate down from the teaching
7
hospitals and district hospitals and getting obstructed and lost
somewhere on the way, it is a bold attempt to build from the
Jhe Health^i U2ng
the base", as stated by
the
Health Secretary
Secretary to
to the
the Health
the Government of India.
year
y
+v, k • ThA fyral heilth and development programmes launched on
2d pI2h
+ p Bh0K3 Comitts® ReP0I,t and subsequent Community
and Panchayati Raj Development Programmes,, may not have made the
impact expected of them to bring about an all round development of
6 mural aroas’ but tb0 necessary infrastructure has been built
up* There are now 5400 Primary Health Centres (with an equivalent
number of Blocks) and 38,115 sub-centres with i largo number of
para medical staff (now Multipurpose Workers) trained in the
delivery of the different components of the package of services
required.
^h° °nd °f thS Slxth plan> there would be °ne sub-centre
for a population of 5000 compared to one for 10,000 now. Each
Thl~rn
h3Ve °ne malQ
one female Multipurpose Worker.
The day to day health care at the village level will bl provide!
WorkXs^CW/S17 °f.1C0mmUnity Health Workers/Village Level
by voS
U similar in a way to the Link Workers introduced
of 1000
e WU1 bS °ne CHW for a P°Pnlation
Organization 2+ f
lnforElatlon Siven by the World Health
ReSn7221 J
S1X
countries in South East Asian
ReSaon (Bangladesh, Burma, Tailand, Indonesia, Nepal and the
Maldives) have adopted this scheme.
of CM. th°r?han
°thQr Part °f this scheme, it is the deployment
of CHWs that has met wxth opposition from the medical profession
embayed ^non thV^^
qUackery- Befor3 thG Government ’
arked upon this on a national scale, several nroiects wat-a
undertaken by hospitals and voluntary bodies. The Sfi Ind ^SSH
reviewed these projects and the consensus was thlt Z action
i
I
shouii brieXeritthth?s:Mrinree’ !?o^ine heaith worke-
oJfmStJ2eI?sWeuiCs?TPlated forP*kem’
scheme^'within-nin^months^of
main nine months of its launching was undertaken by the
i
•H
.
■
:6_:
Th^re^s^n'1^1 Healt^.an<ifManasrOTe»t Institutions in the country.
seXS oJ f
fn!ra1’ maSSiVe SUpport for the sche“e
all
Zilla PaXaSPe?c.
“ C™ity Lead6rs’
omc^.
.
The Government of Karnataka has now accepted the '
Community Health Workers Scheme.
Health Delivery through Auxilliary Health Personnel
Our Government hopes that in due course of time, when
recommendations of the Shrivastava
Cornrri ttee} on Health Services and
,
Medical .Sducation are ffully implemented and internship training in
ruraltr areas
to two
two years, adequate number of doctors may
Ho
*i kt is increased to
n™le for
ln rural areas on the basis of one doctor
per 10,000 population. There is a great reluctance on the part of
doctor to serve in rural areas. For many years Governments and Health
Administrators have been attempting to coerce; induce, persuade or
even compel young doctors to go to the rural areas and we are '
astonished that they evince signs of reluctance. May be we should
instead, be astonished that we succeed in getting, any physicians ’
to go to these areas. One school of thought is that we are training
a Person in the science of Clinical Medicine and the academic pursuit
of knowledge to attain excellence and then attempt to place him in
a position where his whole eduCation is negated. In short, we are
attempting to place the physician, an elegantly trained professional
in a somewhat inelegant position. The obvious end is dissatisfaction
and frustration of the young doctor. To a large extent this may be
due to defects in our medical education system or more correctly,
lack of implementation of accepted educational, policies by Medical
Colleges, to produce the type of Social Physicians, envisaged by'the
Shore Committee.
All countries want a physician-manned health service
and this no doubt will ultimately be achieved in the under-privileged
areas. Under-developed countries cannot immediately attain this
objective, for they cannot afford to pay for a health service that
gives satisfaction to its personnel, which means providing the
buildings, equipment, operational funds, .and supporting staff that
comprise the physician’s working environment. There is also a need
to provide such as educational facilities for the physiciaris children,
adequate remuneration and housing, and means to overcome intellectual
isolation.- AH these are very expensive, which an under-developed
country can ill afford.
But perhaps a physician is not needed to the extent
that we imagine in rural areas and many of his functions can be
undertaken by the lesser trained and much less costly personnel. What
we need to do is to apply the concepts of big business-market
research, job analysis or the breakdown of the job into components
that require a lesser degree of skill than demanded for the whole,
and organisation and m.anagement. It is partly the image of medicine
that is wrong. The emphasis has been -all along on clinical aspects and
0
? management, to-day medicine demands competent management
and this applies.particularly to Plantation Medicine.
I
!
£ ProSr™s.
also higher incomes, more education,
agricultural
reform,
Ttere^s
UthLo?ore
m’ 1
husband^> and proved sanitation,
view pein? ChfnZ! a
3 need to /PP^oach
approach health from a broad ecological
; a certain rate. 7
a total outreach to all the
small privileged urban minority,
on progress.
vr1-- "s
7
1
Underdeveloped countries have several common factors*
These are limited economic resources, a paucity of educdb^d man power,
rapidly expanding populations, conservative traditional cultures,
a prevalence of communicable diseases and undemutrition. The use of
auxiliary health workers offers a means of achieving a balanced
programme of curative, preventive and promotional medicine.
Three essential distinctions have to be borne in mind
in the delivery of health services•
First is the distinction between human medical wants and
scientific health needs* Human medical wants are very simple* They
are for relief when hurt, care when sick, and reassurance ahd help
during maternity. The majority of people in the underprivileged
countries have not yet reached the stage of interest in health as
such, but only want an absence of sickness* The scientific health
needs are equally clear. They are control of the common cummunicable
diseases including those of childhood, the parasitic diseases, and
the vector borne diseases; the need for. planned fertility patterns,
for, as Enke said, ’’the equivalent sum used to reduce births can
be 100 times more effective in raising per capita incomes in
underdeveloped countries than if invested in traditional development
projects”,and the relief of protein calorie malnutrition, which
could be furthered by the marriage of agriculture and medicine.
The second distinction in the delivery of health services
is that between the minor and major ills with the implication of minor
and major solutions. I classify diseases into five categories for
the purpose of distinguishing between minor and major ills. The
symptomatic illnesses are the headaches, sore throats, bronchitis,
flatulences, dyspepsias, colds, neuralgias, rheumatisms, aches and
diarrhoeas. A second classification is the visible ailments, including
wounds, snakebites, tropical ulcers, scabies, eczemas, impetigos, burns,
conjunctivitis, caries, and goitres. A third group are those commonly
known to the local population, the local entity diseases tapeworm,
roundworm, anemia, malaria, and gonorrhea. A fourth group are the
infant and toddler diseases, such as marasmus, kwashiorkor, whooping
; cough, measles, and chickenpox. The final group are the suspect and
referral diseases—those which must be referred to more highly triined
\ persons for diagnosis and treatment.
The third- essential distinction in delivering health
Services is in the training and use of auxiliaries in the assistant
role, when they are working directly subordinate to a more highly
tained person and in the substitute role with supervision remote
at best and completely absent at worst.
There are broadly speaking, two methods of delivering rural
health services and achieving total outreach. Ono is to develop
an absolute standard for medical and health personnel. As time goes by,
the .number of persons'meeting these standards increases and their
reach spreads from the center to the periphery, to cover the whole
population. The other is to commence at the economic and educational
level which the country can afford, train personnel on a less rigid
standard, begin with total outreach, and over a period of time raise
the standard of education until professional quality is reached.
At a distant end point, both those methods will achieve the s<ame
result^bf quality care to all the people all the time. It is what
happendi\to the people during the interim until this objective is
reached’ that matters.
....8
:T5:
A combination of these two methods offers much better prospects
for this interim period. Experience dictates that the demand for physicians
and other high level manpower always exceeds supply. The use of
auxiliaries, working through a few dedicated physicians and para-medical
personnel, offers a much greater prospect for improving the health of
the populations in the underprivileged territories, than either of the
two alternative methods.
’Primary Health Care*and 'Health by the People’
He .al th for all by the year 2000 A.D. This is the pall, given
by Dr Half dan Mahler, Director General of the World Health Organization
at the World Health Assembly in May 1977. Dr Mahler has advocated resort
to ’Unortfiodex way like increased use of auxiliary health personnel to
correct the situation even through this might be disagreeable to some
policy makers”. Botji the developed and developing countries have
expressed dissatisfaction about their health service. This was highlighted
by W.H.O. as early as 1973* The Director General had frankly admitted that
the most signal failure of W.H.O. and its Member States has been the
inability to promote development of basic health services and to improve
their coverage and utilisation.
In January 1975, the W.H.O. Executive Board underlined the
plight of rural populations and recommended priority attention to
’’Primary Health Care” at the community level.
Over 700 delegates from all over the world met for a week in
September at alma Ata, the capital of Soviet Kozhakhstan, to discuss ways
and means of providing health care for all peoples in the world. There
was an exchange of experience among member countries on the development
of ’’Primary Health Care” as part of the National Health Services. India
was one of the nine countries whose experience with community involvement
in the health sector had triggered international action in fivour of the
’Primary Health Care’ approach. Besides India, the other countries whose
experience has been drawn upon by W.H.O. in advocating ’’health by the
people”, were China, Cuba, Guatemala, Indonesia, Iran, 'Niger, Tanzania
and Venezula. Based on the experience of these countries, W.H.O. brought
out a book in April 1975, ’’Health by' the People” and following that, the
Executive Boards of UNICfip. and W.H.O. adopted a now health policy which
underscored the need for combined curitive, preventive, educational and
social approach and for simplified technology.
As India has accepted in principle the ’primary health care’
approach as a national policy, it is worthwhile clearly defining this
approach.
According to the WHO, the seven basic principles of
’primary health care’ are:
a) it should be shaped around the life patterns of the population it
is to serve and should meet the needs of the community;
part of the national health system, and
b) it should be an integral
:
other echelons of service should be designed to support it;
c) it should be fully integrated with the activities of the other
sectors involved in community development (agriculture, educition,
public works, housing and communications)
d) the local population should be actively involved in the formulation
and implementation. Decisions as to the community’s nee^s should
be based on a continuing dialogue between people and the services;
9
»
:9s
e ) health care offered should place maximum reliance on available
community resources, especially those that have remained untapped,
and should remain within the strictest cost limitations;
f) primary health care should use an. integrated approach of preventive,
promotive, curative, and rehabilitative services. The balance
between these services should vary according to community needs; and
g) the majority of health interventions should be undertaken at the
most peripheral level possible, by suitably trined workers”.
We may briefly state that Primary Health Care is essential
health care made universally accessible to individuals and families in
the community by means acceptable to them, through their full participation
and at a cost that the community and country can afford. It forms an
integral part both of the country’s health system of which it is the
nucleus and of the overall social and economic development of the
community. In short, medicine has rediscovered the community at large.
It is rxther amazing and ironical that a profession which began, in the
community should suddenly need to rediscover it!
Since primary health car ? is a component of integrated
rural development, participation in community development activities
must remain one of the concerns of the- ho .al th team in addition to
other ’management1 tasks such as registration, notification, health
reports, or referrals, depending on local circumstances. These
activities call upon many disciplines: nursing, obstetrics, health
education and especially education in healthy and balanced nutrition,
elementary medical diagnosis, therapeutics, environmental sanitation,
dental health, mental health, community development, health management
etc.
In the frequently presented diagram of the pyramid of health
services, the organisation of Primary Health Care can be organised
through a three tier system - Health Centre, Sub-Centre ind Community
Health Worker. At the base of the pyramid arc- the CHWs/VLWs, with their
emergency kit boxes, a CHW/VLW is selected and supported by the local
community and looks after a population of about 1000. They are given
adequate training to carry out a limited number of specific curative,
preventive and health promotional activities with the aid of the
emergency kit and elementary sources. Those workers, however, will not
be able to solve the more complex but at the same time less frequent
problems.
At the sub-centre level are the two Multipurpose Workers
(male and female) looking after a Community of 5000, who are more
experienced and have h.ad sound training in maternity, child health
and welfare progr names, national health programmes and other aspects
of community health work. They will supervise and assist the community
health workers, improve their skills and supplement their activities.
The work of Multipurpose Workers will be supervised by the Multipurpose
Worker Supervisors from the Primary Health Centre.
At the apex of the primary health care pyramid, will be
the Primary Health Centre with 6 beds. A Primary Health Centre will,
therefore, lock after a population of about 80,000 through 16 sub-centres
each with a population of 5,000 and 80 CHWs at the village level, each
CHW looking after a population of 1000. The staffing p ittern and functions
of a Primary Health Centre are well known to you. Three medical officers
will now be available at each Primary Health Centre for preventive,
promotive and curative work. From the Primary He ilth Centro, ref errals
will go to the Taluq or District Hospitals.
10
'f
:10:
I± will be observed the pr. sent concept of Primary Health Care
delivoay System is almost tho same as advocated by the Shore Committee
in 1W46. Let us hope that now with the strong backing of WHO, UNICEF
.and National Governments, tho call of Dr Mahler, Director General,
WHO, ’’He.alth for all by the year 2000 A.D.° will come true'a'nd not
sound to many as an utopian dream or wishful thinking.
In your own plantations with dispersal of labour, distance and
terrain, the three tier system of prin-iy health care .could be organised
through Garden Hospit als, Dispensaries (Mini He alth Centre) and Link
Workers, but adequately supervised by medical officers. I know that
your Medical Adviser is already planning on the basis of one Garden
Hospital for 10,000 population with four mini he ilth centres, each
looking after 2500 population and Link Workers (each Link Worker looking
after 20-40 families)
10 point Declaration on Health (’THO/UNICEF)
I x/ould like to conclude with the- 10-polnt declaration on health
taken at the Aina Ata Conference of WHO, which calls for urgent
and effective international and national action to develop and
implement primary health care, throughout the world ind particularly
in developing countries.
(1) Health, which is a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity, is a
fundamental human right.
(2) The existing gross inequality in the hejlth status of the people,
particularly between developed tand developing countries is
economically unacceptable and is, therefore, of com-on concern to
all countries.
(5) Economic -and social development, based on a new international
economic order, is.of basic importance to the fullest attainment
of health for all and to the reduction of the gap between the
health status of the developing and developed countries.
(4) The people have the right and duty to participate individually
and collectively in the planning and implementation of their health
care
(5) Governments have a responsibility for the health of their people
which cm be fulfilled only by tho provision of adequate health
and social measures. A main social target of Governments, international
organisations -md the whole world community in tho coming decades,
should be the attainment by .all peoples of the world by 2000 A.D.
of a level of health that will permit them to lead a socially and
economically productive life.
INTSGR.IL PART
(6) Priniry
is essential
health
- Health Caro
-—
--- care based
on practical,
scientifically sound and socially acceptable methods and technology
made universally accessible to individuals and families in the
community through their full participation and at a cost that
the community and country can afford to maintain at every stage
of their development in the spirit of self-reliance and selfdetermination. It forms an integral part both of the country’s
health system, of which it is tho central function and'main focus,
and of the over all social and economic development of the
community.
♦
11
I
■
<■-
r
:11:
(7) Primary Health Care reflects and evolves from the economic conditions
and socio-cultural and political characteristics of the country and
includes at least education concoming prevailing health problems
and the methods of. preventing and controlling them
(8) All Governments should formulate national policies, strategies
and plans of action to launch and sustain primary health care as
part of a comprehensive, national health system in coordination
with other sectors
(9) All countries should cooperate in a spirit of partnership and
service to ensure primaiy health care for all people, since the
attainment of health hy people in any one country directly
concerns and benefits every other country.
(10) An acceptable level of health can be attained for all the
peoples of the world by 2000 AD through a fuller and better
use of world’s resources, a considerable part of which are spent
on armaments and military conflicts.
/////////////
♦i
L o >y\ H
D R A F T
WIOffiL HEALTH FOLICY
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
NEW DELHI
WAMBLE
^eonnJS^hil-c P°sitive attribute of life. It is characterised by a state
of SsSse ^Sin^ raeSal
S0Cial wcll-be“g
not nerdy the absence
•
peonle is out
attainable and acceptable levels of health for all
teXh Lg X X17 CTtlzen should be enabled to attain a level of
Stic potentS HeeTti°P W-S, “®ntal
physical faculties to their full
goals J-J XX
X J ™Ot be TTewed “ isolation fron the overall
iXvX? XtheS ifXXX1 X610^- De-10P-nt inplies progrXive
aXshSed byXXnSS and XT X
°f 11 ° eWd
Thus hcAli^ 4« hA+k”
s and the central focus of such development is ’rianX
end-Jrofa»<of dXdo^eSX
pathway to development as well as a desirable
facilities av^il hl
4+d aspirations of the lomon man and where the
availabie are equitable accessible to the population in rhvsical
t«w. Th. .aophion ZU nShS o? mAiadaptation to our cultural ethos has only brought in dependency
u2
t0 COpe
Own XblensXfZsI
in
!•
f b. d latest resources of the connunity can play a kev role
levelZZhZltZX13^ healbh serviccs- A connunity achieves the highest 1'
Served Zdreaches a stage of least dependence on wofessionaly
intervention and maxLwn reliance on its own rescues and action.
XcureXrtXZX"1
•?
13fs equipped man with increased ability
health of the ZZvidZlsTweZZXf
XT °?? “
PRIMARY HEALTH CARE
for at-taining th^XXof ^d^ForZS*
sine
non
on Primary Health Care hold +^1
?+ X- '
the International Conference
world haw Xn unio tXL^v Xh
n “ SePtenbcr
the Jfations of the
level of health fcr all the JZiXZX“X?,°f
an acceptable
toiy to theTZa X
by th<3 year 2000a sign.-,we have to take active stonq th*1
spirit of service to cur own people,
objective.
a
PS thr°Ugh
}3ealth
to attain this
universally acc^essiblo Srindfv?H'Pr?C^iCaJ’-paPrr°aCh in nakinS essential care
acceptable aS
xndlvldUa}s
famlies in the .ornnity in an
sationaid self-reliance fr^theS^
their
rartiGi-mtion. Decentmli
of JMxiarv Heal+ro^
the corner-stones of this approach. The gcals
inc^S/Sater
S°Cial “ OTch aS acceptancf
and their active particion ’
scale trmsfS of^SS^ft^ “
-
for health by connunities and individuals
This aPPrGach involves large
Tpd
3 Xnd kncwlGdS° to people sleeted b-the cotheir confidence and willing to CO^VP ~J_ —L -
: 2 :
compassion and spirit of service. The translation of much of medical and
health knowledge into practical action involves use of
of simple
sample and
and inexpensive
anexpensir..
inventions which can be readily implemented b ordinary peop .e wi i amnama
training leading to the greatest benefit to the society.
x
2.3.
Prirary Health Care can only succeed if the organised health services
povide full logistic and professional support to the voluntary workers resid
ing within the community. Such astern would result in optimal utilisation
of the knowledge and expertise at higher levels and in the.long run, it can
be expected to relieve the overburdened curative services in the urban and
semi-urban areas. The develops nt of an effective primary health care syste .i
both for rural and urban areas would ensure would ensure the following.i. A greater awareness among the community and p-rpulation of the
health problems and ways to tackle them at their own levels;
ii • Intervention at the lowest practicable levels by a worker more
suitably trained;
.
Optimal
utilisation of khowledge and expertise by. higher level .
iii
technical experts, be they health workers, physicians or specialist.
iv. Increasingly less dependence on hospitals and thus optimal
uti 1 i sain on bf such facilities for cases where they arc actually
peeded.
PR.EW.T~TTVEA.HD FUBLIC HEALTH SERVICES
3 .1 •
The emphasis on public health services has slowly decreased in the
last 30 years, ’yielding its own rightful place to curative services. The.
trend has to be arrested to reversed. The coverage of public.health services
and provision of preventive services are now spatially very limited. Munici
pal and local authorities responsible for such services generally suffer from
a lack of will and resources to implement them effectively. It is rational
and economical to deal with a cluster of causes for poor health conditions
on a broad front in the form of integrated package of services which are
■more than a mere collection of health interventions. There is, therefore,
an urgent need to set up a chain of sanitary-cum-epidemiological stations
throughout the length and breadth of the country, manned by suitably trained
and equipped staff. Such stations can conveniently take- care of environment.?^
health problems, detection and control of epidemics, handle checks on quality
of food, water, etc. Investments on such stations now will have a relatively
high pay-off in the long run.
3.2.
The pattern of diseases in developed countries lias changed radically
in the last $0 years. Their.ngo of vaccines, sera, etc., is ever increasing^
Our aim on the preventive front should, be achieve l00/£ coverage of the totau
population by the year 2000 in terms of inoculation, vaccination, etc. The
wherewithal is within cur technical competence.
WATER SUPPLY AM) SANITATION
3«3«
Provision of safe water supply to the population and improvement in
sanitation is basic for improving the health status of the people* This no
to be done at a cost and with a technology which the nation can afford, .ho
should, therefore, aim at providing safe drinking water and improved sanitr.■tion to all population within a given time-frame.
PROMOTIVE SERVICES,
4*
For a meaningful involvement of the community in the health care
systemj education about the advantages both immediate and long-term are
necessary. It is, thezefore, in-fee interest of the health system, itself
to take on the responsibility for explaining, advising and providing clear
information about the favourable and adverse consequences of interventions
available or proposed as well as their relative cost. As part of.promote
cl service#,, it world be necessary to erlucate jeopl n cbout fo d habits.
: 3 :
nutrition, breast-feeding, etc., which are themselves not costly if
properly adopted and which could lead to substantial savings in terns
of human misery* In view of the large-scale widely prevalent malnutrition,
the question of proper nutrition assumes special importance and requires
concerted action. There wuld also be a difficult but pressing need to
overcome religious and social taboos which often-tines prevent people from
adopting healthy habits.
FAMILY WELFARE AID fOJULATION POLICY
5>
A reducticniin birth rate is part of the Rational Family Welfare
Policy, a Statement on which was adopted in June 1977» Health and family
welfare are; so intimately intertwined that, without an active and vigorous
implementation of the Family Welfare Policy, the National Policy on Health
or, for that matter, any policy of national development,, cannot even be
conceived of.
I
MATERIAL AID CHILD HEALTH SERVICES
.
6.'!
The future of-any nation is the future of its children. If the
limited reso rces in the health s ector are to be preferentially applied to ax
segment of population, it should logically flow to children apd mothers.
Infant mortality, child mortality and maternal mortality in this country
are. stark figures signifying our inability to achievd a break-through in tlrL.
field. Bold attempts need to be made to ensure 100$ health coverage in the
next 10 to 15 years for all children in ..the age group 0-5 and by the year
2000 of all children up to the age of 15.
6^
Maternal services are sparsely distributed. Our dependence on
professional birth attendants will continue for a long tine. While there
nay be an addition in. the institutional facilities for deliveries - particul
arly to provide for complicated cases - wd should ensure that all deliveries
are handled by competently trained persons • This would reduce ‘ signficantly
the maternal mortality and morbidity.
6.3
Along with vigorous steps needed to a chieve deduction in the birth
rate, we need to improve the facilities availabeltto mothers and children to
assure the families of the safety of their progeny. This, by itself, will
have a psychological impact and would over the period favour a reduction in
the birth rate.
CURATIVE SERVICES AID HOSPITALS
7*1
We have inherited a system of health services and medical education
from the colonial days which has a large emphasis on treatment in hospitals
and cure of diseases. With increasing sophistication, wo are now devoting
S0% financial and manpower resources in the health sector to this segment of
health services which is more or less concentrated in urban areas. With the
public secitn^ private sector and voluntary sector operating jointoly and
sometimes at cross-purposes, there is avoidable disorganisation in the pro
vision of curative services • Even the general hospitals run by Government do
not provide equality of access to the poor. There is often^times duplicate
and triplicate utilisation of facilities in an effort to get second and third
medical opinions. A method should bo developed to avoid this wastage of
scarce resources. The urge of the common man to got quick and effective
medical treatment, particularly when he is at the physical and psychological
nadir is understandable* The pace of investment in hospitals and curative
services has to be slowed down, linking it rationally to a national policy on
'urbanisation.
' --- . One can,( however, hope that extensive provision of preventive
pronotivcj public health services would go a long way to relieve the burden
promotivo,
curative health system to a largo extent.
: 4 •
I-
I
£
7.2.
Even so, there would be a need to provide an increasing number of
hospital beds; firstly to take care of some of the under.served) semi-urban
and rural population and secondly, as part of the referral system. Construc
tion of hospitals on traditional methods is a costly proposition, mostof
the money going into brick, mortar and equipment. We need to explore ideas
on new type of hospitals in which modern construction is restricted only to
essential areas such as theatres, wards, etc.; the rest being of simple
structures using local materials with provision for members of the family to
stay and provide basic nursing services*
7.3 •
We have, in addition to themodern system of medicine, indigenous
systems like ayurveds, unani,’ siddha, naturopathy and homoeopathy in wide
use. There has so far been no coordination among all these systems, either
in terns of education or in terns of services, not to speak tf integration.
We should now begin an attempt on .a co-ordination of the services offered
by all these systems so as to obtain optimal economic utilisation.
The trend is towards increased application of sophisticated modern
technology, be it auto-analysers, linear accelerators, EMI scanners or inten
sive care equipment arid the like. Very often these provide a cultural shock rci
for the average Indian. In any case, they tend to increase competition amongstorofessionals to acquire more of these sopjhisticated techniques at great
W
cost and thereby increase the distance between the patient and the doctor
We must learn to use increasingly appropriate health technology replicable
with scientific, technical and managerial resources available within the
country.
7.4.
MEDICAL EDUCATION ALL HEALTH lANPOWER
Sil.
Medical Education has suffered as a result of cultural dichotomy
coupled with parallel development • The modern medical s ystom has kept pace
with developments in the rest of the world but the typo of education imparted
particularly at the under-gradUp.te level is heavily hospital-oriented with
little relevance to Indian situations. This makes a fresh graduate unsuitable
to handly situations in the community and unable to appreciate the problems and
dilemmas of the community. The indiogenous (traditional) Systems of medicine
have, after years of neglect) started coming into their own. The earlier
attempts to integrate the modern medicine with the traditional systems have
failed. While no attempt to forcibly integrate any system of medicine should
be made, all the systems should realise, in the Indian conditions) $bo limits .
and potentials of other systems and draw inspiration from them and should
support each other mutually^
This can to done only tor a concern for other
systems and understanding of their functioning.
The training of agents of health care in sufficient numbers at appro
priate levels, with right altitudes, cutlooks and functioning in an orchaestrated manner, holds the key to success of any health system. The hierarchical
structure of the preset day health i.anpowcr and the roles allocated to each
evel in the hierarchy arc the outcome of a historical process. A dynamic
process of change and innovation is needed. The concept of health team is
important in this context. The national medical education policy aims at
cpualitative and quantitative develojxe nt of adequately trained health personnel
o all. categories in a reorganised structure keeping in view the training of a
composite health team. To.help in innovative development of medical education
31 Presses and ensure a continuous input of properly trained manpower, it
would be necessary to set up a Medical ard Health Education Commission embrac
ing all systems of medicine and all Categories of medical and para-medical
personnel.
HEALTH PLANMUG AND HEALTFnB II-FORWION SYSTEM "
9*
The need for an effective infcniiation system.in the Health field at
all .Levels providing for. collection, processing, storage, and retrieval as a
■ oc S'C' ' Vu‘/.y actively aiding appropriate decision making and programme plarr• lold of Health is well roco^-iiscd'. Vo have to a?er
f
: 5 :
set up a dynamic inforaa'tion system to support the Health HLaming and
decision-i^ahing machinery.
MENTAL HMLTH
10.
Mental well-being is an essential component of the state of good
health. With increasing industrialisation and greater strains in the
community, mental health problems are on the inrease. Here again, a primary
health care approach would enable isolation of the problem at an early stage.
and hand Id n.g of the same in an appropriate manner. Traditional Indian practice
such as yoga, sadhana, etc., need to be strengthened and made universally
available to attempt non-medical methods of handling mental health problems.
REHABILTmSKB
11.
Rehabi 1 i tation forms the fourth side of the health square, the other
sides being prevention, promotion and cure. Medical rehabilitation services
are not fully available to those in need of the same. Here again appropriate
technology should be increasingly used. Medical rehabilitation also needs
to be coupled with social rehabilitation in certain circumstances like Tburnt
out leprosy cases1, etc.
BIO-MEDICAL ENGINEERING
Developments in this field are occurring every day and at a rapid
12.
pace. However, particularly due to miniaturisation occurring in electronics
it should be possible to take advantage of the electronic industry in the
This
country to make available such advances to a multitude of istitutions. T.
branch of medical science has so far not been adequately attended to • The
Indus trial capability of this country is of a high order and it should be
possible, with some attention, to keep pace xd.th developments in this field ;
and transfer them in an appropriate manner to Indian conditions.
PHARMGEUTICAI&
It would not be far wrong .to say that the pharmaceuticals industry
13.1
dominates the health s ector and the doctors are deeply influenced by the drug
industry. Instead of being able to dictate tc the drug industry, the medical
profession is in fact dependent on the drug industry of whatever continuing
education it receives in the form of literature. Over-utilisation of drugs
so as to increase the profits of the drug industry, has become the end and
hospital and the medical profession are used as a means towards this dnd.
This problem has been deliberated upon by various committees, essentially
to ensure that the drug industry plays a subordinate and not a dominant role,
without, however, minimising the plenitude of go cd that it brings to millions
of people. The medical profession should have a greater say in determining
the direction of growth of the drug industry.
13.2
Reliance on synthetic chemicals and antibiotics is a growing world
wide phenomenon. Greater utilisation of drugs tends to increase the cost of
tho health system, ©n the other hand, vaccirxs and sera w hich arc used in
preventive medicine need to be encouraged and now vaccines need to bo deve
loped •
In so far as the medicines belonging to the traditional systems
are concerned, the age-old practices of local preparation of such drugs have
slowly vanished loading to greater commercial preparation cf such such drugs.
It might be worthwhile and necessary to encourage local manufacture of such
durgs in small corrunities wherever such treatments arc in vogue. Further
use of herbs and meicinal plants, particularly for common ailments wherccver practicable, needs to be encouraged. It is expected that the local
growing of such herbs and plants, harvesting, storing and preparation of
medicines out of the,, at the community level, would go a long way towards
self-reliance•
13.3
• '! |
il!’ 1
• 11 fi
:6:
13 •4*
In keeping with the concept of corxiunity participation and selfreliance it is also necessary to reduce dependence of the population on the
formalised nodical, syston for the use of medicines. While on the one hand
it would be necessary to guide the population in the uso of medicines particu
larly those which arc toxic or have reactions, it is also necessary to d epend
on the people, thorns elves for knowledge of their own conditions and use of
appropriate remedies* Thus, consistent with our concern for overuse of drugs
and professional supervision on tho uso of drugs having toxic or side-effects,
we should liberalise the idea of self-medication. This will imply strict
control on the quality of medicines available in the market.
RESEARCH
14.
No nation can afford to neglect the support of fundamental and basic
research, for without it there can be no proper teaching of science and no
national capability for solving unresolved problems, meeting changing situa
tions and for adopting, in certain instances, known technology to suit local
conditions • And yet, highest priority should bo given to applied research, in
particular health services research, if the technological achievements of
medicine arc to be placed within the reach of those who need them most. Health
services research is holistic, multi-disciplinary in character involving the
I tho joint participc.tion of bio—medical sciences and social sciences. Such
(
research should bo carried out within tho health service system and research
priorities determined as a result of joint discussion between researchers,
administrative decision—makers and the public^ The whole ethos of such re
search should be based on discoverer of simple, low cost, appropriate health
technology, the results of which are replicable under routinised settings. Wo
■, also need to devote ourselves to basic research, particularly with a view to
Ji
solutions to problems plaguing our country. We are yet to develop
cfioctivc cures or vaccines.
vaccines, for such diseases as malaria, leprosy, etc.
.there^is immense scope for research in matters relating to Human
Reproduction. Research in the field of medicine should be relevant to the
needs of the community.
LEGISLATION, INSURANCE AID coordination
Eeelth being a State subject, the approaches to legislation in the
*
Health
Health field, would necessarily vary frem State to State* A variety of legis
lation s already on the statute book, bo it on tho national level or State
,cvc *
k y^lcl be necessary to review these items of legislation and work
towards a single comprehensive legislation applicable to the health field,
inc services provided by government are generally free. This leads to a
si ua ion where there is not enough appreciation that the services do cost
money o ohe nation and, therefore, should be utilised only where it is essen—
^avoidable• A realisation of the utility of such services can be
roug t about by educating people as also by levying nominal charges for all
services •
he possibility of introducing some form of national health insur
ance, at least in the future, to provide for guaranteed health s ervices to all
segmon s of population needs to be pursued. In the present system since' there
is
is a co-existence of the private sector, voluntary sector as also the public
sec or, 1 is essential to coordinate tho services by these sectors. The
■pos??'.
\ of Getting up coordination committees to regulate the services
available in each of .these sectors needs tobe explored. Secondly, in the
C Sc? or anc^
a United extent in tho voluntary sector, sometimes
Gj_^Q<3° ? argod are rather high. While this drawback will continue as long
as o pnva o sector exists, an attempt needs to be made to ascertain whether
J~
bc
SG’^’“regulation. As part of this exorcise bold attempts
need to be made to end the system of private practice by doctors in Government
service and in Medical Colleges.
INPUTS IN HEALTH-RELATED FIELDS
. ^Gvelopnents in health come not merely as a result of inputs and
JtJTt ^GS-k:Ln "khehealth field, but also due to developments in health related
sue. as agriculture, water supply and drainage, communi cation
: 7 :
At the comunity level, all health activities must be coordinated with and in
fact, fora part of, total rural d evolopnont* To the extent decentralisation
of resources, planning and inpleDontation can be achieved, there will be
greater efforts and development in all field and thus in health also • Such
decentralisation should, therefor , be actively pursued and supported. Even
at State and national levels, health activities and inputs should benefit
from investments in health—related fields and to that extent, coordination with
other sectors of development have tote volunatrily sought for and achieved.
CONCLUSION
17.
’ The following should, there fore, be the short-tern and long-tern
goals of the national health policy:17.1.
| Short-tern ffoals
i. to eradicate/control corziunicable diseases in the country;
ii. to provide adequate infrastructure for prim^ health care
in the rurol areas and in urban slums;
z
iii. to utilise all availabrlmethcds for health education and
spread the me-ssage of Health and Family Welfare;
iv. to utlise knoledge from different systems of medicine for
p? ofiding quick and safe relief fron sickness and debility
at the cheapest possible cost;
v. to reorient nodical education to be in tune with the needs
of the commit y>
vi* to provide increasing internal and child health coverage.
17.2*
Long^tOti, goals
i. to inprove public health services by setting up a chain of
sanitary-cun-epideniological s tations ;
ii. to ensure 100$ coverage of all segnents of population with
preventive services;
iii. to create a self-sustaining systen of health security so that
earnings of the individual are not affected adversely during
periods of -illness;
iv. to inpart nedical education in a nediun which is an integral
jart of our culture and life-style and thus reneve the foreign
concepts associated with foreign languages which are najor
factors inhibiting people fron understanding the true and
proper role which nedidne plays in the developnent of a healthy
connunity;
v. to utilise available knowledge fron the ancient and nodem
systons of nodi cine in an effort to develop of CDnposito systen
of nedicine, t) us obliterating the caste systen prevailing in
the Held of nedicine;
vi. to inciklcato a sense of self-reliance and discipline in all
segnents of population so that all four sides of the health
square, nanely, prevention, prenotion, cure and rehabilitation
are effectively handled at the local level ccnsistcnt with
the developments in the field of nedicine.
•Ostt'c-K-K -:h<
-raHHHHHt -:s$-
C-O »v\ Vi Q—- t
CHW
BC
WORKING KITH THE COftUKOT
3.1
DSF'INITION
A conmiunity is a social group
grcnip determined by geograpliical
goograpliical
boundaries and/or common values and interests.
Hie meUbers of a community, particularly in a rural area, know
and interact with each other and create certain norms, values, and
social institutions•
COPMJNIIY HEALTH REFERS TO THE HEALTH STATUS OF THE MEM
BERS CF THE COM UNITY, TO THE PROBLEMS AFFECTING THEIR
HEALTH, AND TO THE TOTALITY OF HEALTH CARE PROVIDED FCRTHE COMMUNITY.
The assessment of the health status of the community requires
an understanding of the general populations to be sensed. Refer to
sections 4.3.1 and 4.3.2 for the methodology for collecting general
information and conducting a, base-line survey.
4 HEALTH CARE PROVIDES A WIDE SPECTRUM OF SERVICES INCLUK NG
PRIMARY HEALTH CARE. THE INTEGRATION OF PREVENTIVE AND
CURATIVE SERVICES? HEALTH EDUCATION, THE H OTECTION OF
MOTHERS AM) CHILDREN? FAMILY PLANNING AND THE CONTROL OF
ENVERONF.ENTAL M\ZAJDS AND CO1 i .UNIC/iBLE DISEASES.
The system of health care delivery, if it is to be effective
and serve the needs of the community, must have the following
characteristics:
i. It must bo accessible to all tie population.
ii. It must be available when needed*
iii. It must be free of economic barriers, i.o. it should bo
available to all economic groups.
iv. It must not be limited by social or cultural distinctions,
v. It must reflect certain inherent characteristics of the
community.
vi. It must be fLcxl-blc in its approaches.
vii. It must recognize that the primary avenues to health may
bo through education, economic progress, legislation or
other aspects of society rather than through organised
health structures.
3.2. YOUR ROLE IN COrdMUNITY HEALTH ACTIVITIES
As a health worker in a rural community you arc also a community
worker aud you must, therefore, work very closely with the community
and other workers, e.g., agricultural, educational, public works,
housing and communications, working within the same community.
3.3 WORKING WITH THE COMMUNITY LE/DERS
If your services to the community are to achieve their objectives
you must create a demand for those services within the community, This
demand can be created in the following ways:
i. Involving the comi unity in all aspects of health services
delivery, i.e. in the planning, delivery, utilization and
evaluation of health care.
ii. Inter-relating the services with other operating social systems
within the community.
iii. Shaping the services around the life patterns of the community,
iv. Relying on the community to provide the mobilize its own
resources to assist in the provision of health caro.
: 2 :
Your success will depend on how fare you will bo able to
got the support of the community to help you with your work* A very
cruedal part in this respect is played by the community loaders.
TYPES CF LEADENS
In every rural community there arc formal and informal
leaders who can either promote or obstruct any health programme.
i. Formal leaders (Official/Functional): These individuals
arc often employed by the’ Government and include the
sarpanch, school teachers, tax collectors, etc. Some
nay bo elected or appointed to bd the loaders of non
governmental organizations.
ii. Informal. Loaders (Na.tural/Status) : These indivicLals
ray be any influential non or women in the community
such as midwives, shopkeepers, furors, housewives or
other persons who h^vc the r spcct and confidence of
the people. They ray hold a pc si tic n of leadership on ,
account of their age, caste, rclig5.cn, wealth or education.
3*4
SUPFOFT FROM BOiF TIFFS OF LWERS IS WFSSARY SO TlIA’p
THEY GUI POSITIVELY INFLUENCE PERSONS WHO BELONG TO THEIR
FES FESTIVE GT. PUPS.______________________________________ L_
3-5
IDENIIFICLTION OF LENDERS
Much care needs to be given to the identification of comunity
sc
that they arc well—accepted by the people. Trusted local
leaders
can
be expected to exert considerable influence on their
leaders
conmunity#
Tiicro arc various methods you can use for identifying
leaders in any community. Those. methods are:
1. Interview Method: You may interview formal leaders to
obtain the names of men and women whom they consider
to bo influential in the community and who represent
Various com unity groups*
ii. Observation Method: You may observe which.persons in
the community are consulted frequently by the people who
arc in need of advice and assistance*
iii. Sociomctric Method: You may ask several recognised leaders
to name throe or four persons whom they consider as
leaders. Those whoso names are mentioned frequently
are identified as community leaders.
iv. Sampling Method: In tills Method you. nay interview the
head of every third, fifth, tenth, etc., family to get
his opinion a . to whom his family would like as a leader*
The. persons whoso names are mentioned me st frequently
arc approached to act as leaders.
3.6.
*
ORIENTATION OF LEADERS
.
Orientation sessions for community Ica.dcrs and. their expected
roles with regard to health programmes should be planned byyou along with
with your supervisor. The participation cf the Medical- Officer and the
Block Health Assistant from the Primary Health. Centre often adds
importance and prestige to such meetings and arrangements should be
made for this, if the situation requires it.
The subjects which could bo discussed at those sessions
include the following:
1. The health services available to the community and the
role and limitations of the health workers in the
community.
••.Ccntd/3-
: 3 :
2. Tlie varicus health problens existing in the
connu.nity and thu role of tho loaders in helping
to solve those problens.
3. Specific infer at ion related to various health
probions and pro;granncs, o.g.,
1. Cause and control of connunicable diseases
ii. i 'atornal and child health
iii. Fauily planning
iv. Nutrition
v. Envir oni. icntal sanitati on.
Identif^nng and utilizing the resources in the
connunity to inprovc the health status of the
corirunity.
Ebthods
of educating and r otivating tho connunity
5to improve tho^j? health status and clriange their health
behaviour.
6. Tho need for coordinating tho various developmental
activities of tho cor.nxmity sc achieve improvement
in the total well being of tho community.
UTILIZING THE COMi.UNITY LEADERS
4*
3.7
When you work with the community leaders, you should
remember that you arc working; through then, with oorhunity you arc
{serving. They can promote or destroy your programme, so you should
ensure that your relationship with thou remains cordial, friendly,
cooperative and promotes team work. Utilize the connunity leaders
as follows:
i. Enquire what the current needs of the connunity are.
ii. Relate these needs to the objectives of the health
services ani ensure that your activities will satisfy
their needs. If you are unable to satisfy these needs
explain to the leaders why you cannot do so, and what
they could cb to meet thoir requirenonts.. ' n o'
iii. Han with'the loaders the delivery of health services,
their timing and what motivational steps arc necessary
to pronetc health programmes•
iv. Request the help of the loader': in the delivery of
tho health progrannes.
v. Enquire Aron the leaders whether tho connunity is
satisfied with, tha services being delivered. If not,
ask why and try to find ways, in con suitcation with
the loaders, fr inproving the progranno.
'• KEF®BER TW BECAUSE OF FIN/MI/i 03 NSTFAINTS ONLY THE
ESSENTIAL NEEDS OF THE COMiUNITY CAN BE SATISFIED . HOWEVER,
YOU CAN HELP THE COIL UNITY TO SELECT HEALTH PRIORITIES AND
MOBILIZE THE 001 a UNITY RESOURCES IN ORDER TO 0WC01E THESE
. CONSTRAINTS.______________________ _________ _________________ _
vi. S-tinulato tho loaders to relate health programmess
with other develop lent al progranincs in tho coununity
RcLioEiber that uajor inprovononts in tho health of the
cominity can roswlt from ninor cl'^ngcs in the cultural
behaviour and oeononic standards of tho people or in
the existing conrcunity organizations.
vii. Use the loaders to activate aonbers of tho connunity
who arc resistant to health programes. This can bo
done throiigh the organization of health c omit toes,
which would encourage tho connunity to take an active
part in the running of the subcentro which servos then.
•. • .Contcl/4-
: 4 :
viii. Influence the lenders tc assist you in your
xvork tlwogh community participation in health
activities.
; REI-ffiMBER THAT IF A FOGR/iil-E IS lALIRRSD AID 0WATER) WITH
GOMIOTETY PARTICIPATION, TT.EIR INTEREST WILL BE MAINTAINED
../xID THE HiOGEA-LE FILL BE MORE EFFECTIVE.
ix. You should plan for nestings with the loaders
fron.tine to tine either individually or in
groups- At these sessions, the following
topics could be disciajsed:
a. Information about to achievenont of the
• • health prograrinc in the area.
b. Specific prob? o: is or doubts raised by the
connunity rionbcrs.
c. Hew developments in the health progranno.
d. Planning for involvement of the. corxiunity
in the education and sorvd.ee program-re.
c. Orientation of new loaders in.- the community.
3.S.
WOPKING WITH OTHER COMMUNITY WORKERS
Besides workers from the health dopant; lent, bi orc are workers
from other departments such as teachers, agricultural workers, community
development workers, brlsovikas, etc., all of whom have specific responsi
bilities but with the some overall goal of improving tiro welfare of the
community. It is necessary for you to work closely with all .these
workers in order tc benefit the community to th maximum extent possible
The following are some of the ways in which you can get assistance fron
your colleagues, or help in their wo rk :
i. Jhrticipatt in tb-e activities of the team.
ii. Exchange inforrat ion with the other community
workers tc identify areas of - work whore you can
cooperate with each other.
iii. Lc<. k for opportunities where you con contribute
to improving the welfare of too cow- unity, o»g.,
by giving health talks to schorl children,
coop .rating with tie panchayat loaders etc.
iv. Request the assistance, of ether workers in your
programme, e-g., the coL.nunity dovolopnont
officer can liolp w'-th water supply schemes, the
nrTici’ltr>ral officer with advising the cornunity
on kitchen gardens, etc.
v. Request the panch<ayat leaders for assistance
with manpower to support health rrcgr ammos, e-g.,
in spraying operation.
3.9.
TKE-COIWNITY LEVEL WOP'KER
The idea of utilizing corxiunity level workers to deliver
health services of an oloriontary nnt'urc lias now boon accepted as
part of the health delivery systea in India. These workers will
net bo govern; ent eurloycos but will be selected by the ccanunity
and, after training, will werk within the coni unity. These community
level workers will be draivn fron ano ng teachers and educated and
willing housewives.
* • • * •Contcl/5-
: 5 :
Your help ray bo requested by the village leaders or
coi/nunity in selecting a proper person who can bo trained in oleuontary
health work* In giving this advice you will need to use your judgenent
and to keep in rand that you will be working closely withtais worker.
REMEMBEF TH/_T THE COMMUNITY LEVEL WOFJCEI. IS NOT IN COMPETITION
WITH YOU, BUT THAT HE IS YCOT HELPER /jD IS TH UE TO EXTEND
HEALTH CARE IN YOUR ABSENCE .
CHW
BC
WOPJQMj WITH THE COIWNITY
3>1
DEFINITION
A community is a social group determined by geographical
boundaries and/or common values and interests.
and inSn
°f ?
sooiS SSfartt™?
Particularly in a rural area, know
r “d °r"to °ert°“
COWUNITI HEALTH FEFERS TO THE HEALTH STATUS OF THE MEMDHFS Q THE COMMUNITY, TO THE JROHLEHS AFFECTING THEIR
HEALTH, aw to the totality of health CARE FROVI-DED FCR-.
THE COMMUNITY.
The assessment of the health status of the community requires
an understanding of the general populations to be served. Refer to
sections 4.3.1 and 4*3.2 for the methodology for collecting general
information and conducting a base-line survey*
' HEALTH CARE PROVIDES A WIDE SPECTRUM OF SERVICES INCLUIZ NG
PRIl.ARY HEALTH CARE. THE INTEGRATION OF PREVENTIVE AID
CURATIVE SERVICES? HEALTH EDUCATION THE PROTECTION OF
MOTHERS AND CHILDREN? FAMILY PLANNING AND THE CONTROL OF
E NVIRONi<ENTAiL HAZARDS AND C01 i UNIC/iBLE DISEASES.
■
The system of health care delivery, if it is to be effective
and serve the needs of the conxinnity, must have the following
characteristics:
i. It must bo accessible to all tie ppopulation.
be available when needed.
iii
iii* It must be Rree of economic barriers, i.c. it should bo
available to all economic groups
groups.
iv.
It
must
not
bo
limited
by
social
Tr T+
,
- -v--— or cultural distinctions.
v. it must reflect certain inherent characteristics of the
community*
yi. It must be flexible in its approaches*
V + Vb rGCOSnize ■that the primary avenues to health nay
bo through education, econoraic progress, legislation or
other aspects of s ocicty rathor than through organised
health structures.
3.2.
YOUR ROLE IN COWNITY HEALTH ACTIVTTTRS
f health ^or^er in a
comnunity you arc also a community
orkor ano you must, therefore, work very closely with the community
and other workers, e.g., agricultural, educational, public works,
housing and comumcations, working within the same community.
3-3
WOliKING WITH THE COMWNITY LEADERS
If your services to the community are to achieve their objectives
you must create a demand for those services within the community, This
demand can bo created in the following ways:
i. Involving the com unity in all aspects of health services
delivery, i.e. in the planning, delivery, utilization and
evaluation of health care.
11. Intcr-rclating the services with other operating social systems
within the community.
the services around the life patterns of the communitv.
iv. Relying on the community to provide the mobilize its own
resources to assist in the provision of health care.
..Contd/2-
.
-J!------
•
......
: 2 :
Your success will depend on Jhow fare
~
v -- will
— be
— able
—
you
to
gei ihe support of* the comnunity
you- with
v to help
x- </------ your work. A very
crucial part in this respect is played by the community leaders.
3.4
TYPES GF LEADENS
_In every rural community there arc formal and informal
leaders who can either jDroniotei or obstruct any health programme.
i. Formal leaders (Official/Functional): These individuals
are often employed by the Government and include the
sarpanch, school teachers, tax collectors, etc. Some
may be elected or appointed to bd the loaders of non
governmental organizations.
ii. Informal Loaders (Natural/Status) : These indivickals
may oe any influential mon or women in the community
such as midwives, shopkeepers, farmers, housewives or
other persons who h?vo the r .spoct and confidence of
the people. They way hold a positicn of leadership on
account of their age, caste, religi on, wealth or education.
SUPFOF'T FROM BOTH TYPES OF LEADERS IS NECESSARY SO THAt
ir,C!TTTTr!7'TV TT.TTnr TTT-n<T/-vm -i-h-.t-. n
_________ _____
1.
THEY PAM
CAN POSITIVELY
INFLUENCE JEFSONS TWHO _BELONG
TO ____
THEIR
I RESPECTIVE GROUPS.
THTTV
3-5
IDENTIFICATION OF LE/DERS
Much <care needs to be given to the identification of community
leaders1 sc that they
+K^y are well-accepted by the people. Trusted local
loaders> can be expected tc exert considerable influence on their
conmunity.
There arc various methods you can use for identifying
leaders in any community. These methods are:
1. Interview Method: Yen may interview formal loaders to
obtain the names of men and women whom they consider
to be influential in the community and who represent
various community groups.
ii. Observation Method: You may observe which persons in
the comiTunity are consulted frequently by the people who
are in need of advice and assista.ncc.
Sociometric Method: You may ask several recognised loaders
to name three or four persons whom they consider as
leaders. Those whose names are mentioned frequently
are identified as community leaders.
iv. Sampling Method: In this Method you may interview the
head of every third, fifth, tenth, etc., family to get
his opinion a- to whom his family would like as a leader.
The. persons whoso names afe mentioned most frequently
are approached to act as leaders.
3.6.
ORIENTATION OF LEADERS
Orientation sessions for community leaders and their expected
roles with regard to health programmes should be. planned by you along with
with your supervisor. The participation of the Medical Officer and the
block Health Assistant from the Frit-pry Health Centro often adds
importance and prestige to such meetings and arrangements should bo
made for tats, if the situation requires it.
The subjects which could bo discussed at these sessions
include the following:
1 • The health services available to the community and the
role and limitations of the health workers in the
community.
• • •Ccntd/3-
: 3 :
2. Bio vancus health probions existing in the
conuumty and the role of the loaders in helping
to solvo these problens.
P
* rroblo^ Xnfor ation related"to ■various health
problems and p^ogranmesj e.g.,
1. Cause and control of connunicable diseases
.11. internal and child health
iii. Fauily
Fanily planning
iv. Nutrition
v. Environmental sc'.nitation.
4 Idontiljcing and utilizing tile resources in the
connunity to inprove tbc- health status of the
community.
5• . Methods of educating
i
... . ■—°
motivating the connunitv
botviour? : e3* health Dtetl-S
change their health
0
6.
3rtiSic"OrfCH>rdinnt '‘'ttliC'
rl''^lopncnta.l
..cuivitiCo of the connunity so achieve jnluvw,., >,1;
m the total well being of the conr-nmity.
WEIZING the COIit.unity leaders
■3.7
When you work id th the community l eaders von shrmlH ’
remomber that you are working, throurh then ‘
-y .fhcnld
serving. They can pronoto or’destroy yo4 pr^tTT^
ensure tha.t ycur relationship with then ronAns cASl £
cooperative and prftotes teau work. Utilize the comunit-^1 o f
uic community loaders
cis follows:
^l^rrcnt needs of the conmnity are.
thGS° neGds te thc objectives of the health
thlir needs ‘"l?11’0
y0Ur activities wiH satisfy
exnLain to t1--^ 1 y?U arG un£’-ble to satisfy these needs
S- could
leadGrsgby you cannot do so, and what
iid Finn AHA A I1OCt ;,hoir requirenents.
' ,A ; w-blrtae leaders the delivery of health
sorviccs,
tneir tiding and what motivational sters arc
necessary
to promote health programmes.
IV. Bequest the help of the loader- in the delivery of
the health programmes.
V‘
F0!
lcfldcra gather
whether tin
tlio cennunity i 3
A f 1 Wlt’ the scrvicos being delivered. ^If no-b
the leader
7 to find way^ in consultation with ’
1-c Icadcro, fir inprovmg the programme.
ii*
.
TEAT BECAUSE OF FINANCIAL ODNS'hVTTJT0 n\rrv tttv----
s;™™ St™
YOU CAN HELP THE COMUI'JITY TO SELECT S?SmF?ST’
essential needs of we com unity can
Emf C0I'™Tr resources in wdep. to owcoie weIe
vi. Stirralato the leaders to relate health propramness
tVoonSty
he.ioLiber that major improvements in the health of the
connunity can result from minor clia.ngos in the cultural
WMxoff rarf ooouonlo St„„aartS of io ^o oTS
A Gg3tln&' connunity organizations.
vii. Use the loaders to motivate nombers of t)io cornnunitv
cornmnity
wio are resistant to health programmes. This can bo
done through the organization of health comnittoes
■ ■
pe
cnccvraSC the community to take an active
m the running of the subcentre which servos them.
•.. •Contu/4--
: 4 :
viii. Influence the leaders tc assist you in your
work thraigli connunity participation in health
activities.
REI4EMBLR THAT IF A. R)(Z?AlylI’E IS F7J113W) AI-D OIETATFD IOTH
COMOTm PARTICIPATION, TI.EIR INTEREST WILL BE IRINTAIbiED
ARID THE FROGEAMl E KILL BE MORE EFFECTIVE.
ix. You should plan for ncetings with the loaders
iron tine to t ine either individually or in
groups. Ait these sessions, the following
topics could bo discussed:
3.8.
a. Information about te achievement of the
health progranno in the area.
b. Specific problems or doubts raised by the
connunity nonbers.
•
c. Now dcvclopnonts in the hcplth programme.
d. Planning for involvement of the community
in tlio education and scrvi.co programme.
o. Orientation of now loaders in the community.
WORKING WITH OTHER COMMUNITY WORKERS
j--osidos workers from, the health department, there are workers
from otner departments such as teachers, agricultural workers, covmunitv
dc^lopmnt'Workers, brlsovikas, etc., all of whon have specific rgponsiili acs but with the sene overall goal of inpwving the welfare of the
connurnty. It is necessary for you to work closely with all those
T?rkSrf ■Ln.orr'lcr to benefit the community to th, maximum extent possible
o oilowing arc sone of the ways in which you can get assistance from
your colleagues, or help in their wo ik :
i. Jhrticipatc in the activities of the team.
ii• Exchange information with the other community
workers to idont?.fy areas of rwerk whore you can
cooperate with each otter.
iii. Lo> k for opportunities whore you con contribute
to improving the welfare of bi o community, o4g.,
by giving health talks to schorl children,
cooperating w?th the panchayat Icod^rs etc.
iv. loquost tlx assistance of other workers in your
programme, e.g., the cormunity development
°£ficor can help w;th water supply schemes, the
■ ■' ^icultural officer with advising the community
on kitchen gardens, etc.
v. Request the panchayat leaders for assistance
with manpower to support health nrogr ammos, e.g.,
in spraying operation.
3.9.
THE COLWNITY LEVEL WORKER
T1.IC :Ldoa of utilizing community level workers to deliver
health services of an elementary nature has now boon accepted as
part of the health delivery system in India. These workers will
not bo government onployoos but will bo selected by the community
and, after training, w£Ll work witbin the com unity. These connunity
tcvcl werkors will be drawn frou anong teachers and. educated end
willing housewives.
......... Contd/5-
: 5 :
Your help my be requested by the village leaders or
he“Xkn S£C
°PCI ?CrS°n Wh° Cr-n b° trained ±n d^ntaiy
nearw work._ In giving this advice you will need to use vour ludapnent
and to keep in mnd that you will be working closely with ibis worker!
REMEMBEF TRET THE COWHNITY LEVEL WORKEIi IS NOT IN COMPETITION
WITH YOU, EOT THAT HE IS YOUK HELIER
Al<D IS THERE TO EXTEW
health care in your mw.
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Go
HEALTH
VOLUNTARY
>
■ r
bi
Z7*/
C-14,
Community
Centre.
Phone : 652007, 652008
Safdarjung
ASSOCIATION
Development
Area,
\ H X h- %
OF INDIA
New
Delhi-110016
Telegrams : VOLHEALTH New Delhi-110016
Director of Rural Health Service*
And Training Programmes
Code No» $2
RroTD -."HEAT/PH CAKE AND HUMAN DIGNITY”
by David B. Werner.
I would like to summarize a few of the steps that economy being
taken, or might be taken, to implement a regional or country-wide
approach to rural (or periurban) health care which is more genuinely
community supportive.
Decentralization. T£is means relative autonomy at every level.
Advice and coordination from the top.- Planning and self-direction
from the bottom.
,2.
Greater self-sufficiency at the community level. This is, of
course, impJJxit in decentralization. The more a community .Itself
can carry the weight of its own health activities, both in cost and
■ personnel, the less paralyzed it will be by break-downs in supply and
communications from the parent agency.
5,
Open-ended planning. For all the talk about "primary-decisionmaking by the community,” too -often a program’s objectives and plans.
have been meticulously formulated long before the recipient communities,
have been consulted. If the people’s felt needs are truly to be taken
into account, program plans must be open-ended and flexible. It is
essential that field workers and representatives from the communities not just top officials - attend and actively participate in policy
planning and policy changing sessions.
4.
Allowance for variation and growth, If a program is to evolve,
alternatives must be tried and compared, Substantial arrangements for
conceiving and testing new approaches, methods and points of view should
be built into the ongoing program., Also, private or non-govemment
projects should be observed and learned from, not forced to conform
or stamped out.
5.
Planned obsolescence of outside input
input.. If self-sufficiency at
the community level is indeed to be considered a goal, it is advisable
that a cut-off date for external help be set from the first. All input
of funds, the earliest possible date when such assistance is no longer
needed. Thus the outsider’s or agent-of-change’s first job, whether
he be a medic or an agronomist, should be to teach local persons to
take his place and, in so doing, make himself dispensible. Outside
funding, likewise, should not underwrite ongoing activity, but should
be in the form of !seed^ money or loans to help launch undertakings
which will subsequently carry their own ongoing costs.
6,
Deprofessionalization and deinstitutionalization.
V/e have got
to get away from the idea that health care is something to be
delivered. Primarily, it should not be delivered, but encouraged.
Obviously, there are some aspects of medicine which will always
require professional help - but these could be
be —
:2:
be far fewer than is usually supposed. Most of the common health pro bions
could be handled earlier and often better by informed people in their own
homes. Health care will only become truly equitable to the extent that
there is less dependency on professional or institutionalized help and
more mutual s elf^*0 are. Ihis means more training, invol venent and respon
sibility for and by the people themselves* It should include continuing
education opportunities for villagers which reinforce their staying in
and serving their communities.
7More curative medicine. For a long time, health care experts have
been pushing for more preventive medicine at the village level — and
with gpod reason. But too often this has been used as a convClient
excuse to keep curative medicine completely — or almost completely in professional hands. Clearly, preventive measures are basic. However,
the villagers’ felt needs have consistently been for curative measures
\to heal the sick child, for instance). If primary health workers are
to gain the respect and confidence of their people, they must be trained
and permitted to dia@iose and treat more of the common problems, especi
ally those when referral without initial treatmsit increases the danger
to the sick.
I should point out that when I say •toore curative medicine,» I
don’t mean ^nore use of medicines.h Ovemedication, by both physicians
and villagers, is already flagranti. I mean more infoimed use, which in
many cases will mean far more limited use, of medications. But this
will require a major grass roots demystification of Western medicine which
can only happen vdien the people themselves leam more about how to prevent
and manage their own illnesses* To promote such a change, the village
health worker must have a solid grasp of sensible medicine and, in turn,
help reeducate his people.
------------------- —
9
9
7^ CourseJ doubtful whether such a metamorphic awakening to
sensible medicine can ever happen outside the medical institution mtil
there has been some radical rethinking within it.
8*
MpHe. feedbyk between doctor? and health workers. When health
workers refer patients to a doctor, the doctor should always provide feed
back to the health worker, explaining in full clear detail and simpie
language about the case. This can end should be an important part of the
nealth worker’s and the doctor’s continuing education.
, l&rli er old ent at3,on of medic al student g. From the very beginning
of their training, medical students, should be involved in conmunity
health, and be encouraged to leam from experienced village health workers
and paramedics.
JP*.
feaater appreciation and respect for vilj agers* their traditions.
thffl.r skills, their intelligence, and their potential. Villagers, and
especially village health workers, are often treated like children or
ignoramuses by their more higily educated trainers and supervisors. Ihis
3his
is a great mistake. People with very little fomal education often have
their ovn special visdom, skills and powers of observation which acade
micians have never acquired and therefore fail to pexceLve. If this native
toioTl edge and skill is appreciated, and integrated into the health care
process, ttu.s will not only make it more truly community oriented tfid
u ilu*
i willJhelP preserve the individual stmegths and dignity of the
his P60?16* 1 cannot enphasize enough how import&it it
is that health program planners, instructors and sipervisors be ’’tuned in "
to the capabilities and special strengths of the people they work with.
11.
the d^reptor§ gnd key personnel in a program be people who are
hangn. ihis is the last, most subjective and perhaps most important point
I want to make.
Tn?.
Let me illustrate it with an example :
3.
:3'.
In Costa Rica there is a regional program of rural health care
under the auspices of the Health Ministry which differs in important ways
irom the rural health system in the country as a whole. It has enthu
siastic community participation and a remarkable impact on overall health.
It may well have the lowest incidence of child and maternal mortality
in rural Latin America. Its director is a pediatrician and a I©et, as
well as one of the wannest and hardest-working people I have met. Ihe
day I accompanied him on his trip to a half-dozen village health posts
we didn t even stop for lunch, because he was so eager to get to the
last post before nigit fell. He assumed I was just as eager. And I wasnis enthusiasm was that contagious !
I will never forget our arrival at one of the posts. It was the
day of
tmdei>fives "clinic. Mothers and patients were gathered on
the porch of the modest building. As we approached, the doctor began to
introduce me, explaining that I worked with rural health in Mexico and
was the author of ^nde No Hay Doctor. Frantically, I looked this way and
hat lor the health worker or nurse to whom I was being introduced
As
persons began to move forward to greet me, I suddenly realized he was
introducing me to all the people, as he would to his own fanily. Obvi
ously he cared for the villagers, respected than, and felt on the sane
level with than.
Ihis, I must confess, was a new experience for me. I was used
to being marched past the waiting lines of patients and being introduJed
to the health vorker, who was instructed to show me around and answer my
questions, while the patient, whose consultation we had interrupted,
silently waited.
4.1,
u'^T3 T?1 ■ys
excePti°n!" I thought to myself. In our visits
throughout Latin America, we found almost invariably that the trulyoutstanding programs have at least one or two key people who are excep
tional human beings. Ihese people attract others like thansoLves. And
e genuine concern of people for people, of joy in doing a job wail, of
a sense of service, and the sharing of knowledge permeates the entire
program clear down to the village worker and members of the community
People are what make health care work.
4.
RECJjNT TRENDS OF RURAL .HEALTH CARE PJDGRAMS
from this
TREND
V
to this
4^
I
liho are served?
few most
privileged
majority in
^accessible areas
■>.
all the
people
»
Uho provides the
key services ?
prof ess ion al s
(a few outsiefers at hi$i
cost with long
inappropriate
training)
sub-professionals
local persons,
traditional healers
(many insiders at
low cost with short,
practical training)
health •tean*
w
TAhere are training
and services provided ?
large
hospitals’
modest
small post
health centre^^or dispmsary
home
Priniary concern:
sickness (of
individuals)
individuals)
health (ofhealth, well-being and
future of the community
Focus of action:
Curative
> Preventive
_
(water sanitation
hygiene, vac c in ar
tion, nutrition
mother/child care
family planning
early Dx-Rx)
Integrate Development
(he al th educ ation, .
leadership, agriculture
communications)
Intermediate technology
| (conscientizacion
| ^and reform social
Teform)
Geographic coverage
of outreach programs:
small, arbitrarily defined
areas of great need (or beauty)
entire regions
o^ countries
Sponsoring agencies:
many
small
pilot
proj ects
C private j
Z foreign (-^national
1 religious
international
c ent rali zed
dec or trail zed
r
:5:
RURAL HEALTH PROGRAMS IN LATIH AMERICA
TWO APPROACHES
COMMUNITY SUPPORTIVE
1
I
COMMUNITY OPPRESSIVE
(CRIPPLING)
1
Initial objectives
Open-anded. Flexible.
Consider community’s
felt needs. Include
non-m easur abl e
(human) factors.
Closed. Pre-defined
before community is
consulted* Designed
for hard-data evalua
tion only
Size of progress
Snail, or if large,
effectively decentra
lized so that sub
programs in each area i
have the authority to
run their own affairs,
make major decisions,
and adjust to local
needs.
Large. Often of state
or national dimension.
Top-heavy with bureau
cracy, red tape, fill
ing out forms. Super
structure overpowers
infrastructure. Fre^
quent break down in
communic ation.
—
Planning,
prioriti es, and
decision
making
Strong community
participation. Out
side agents-ofchange inspire,
advi se, dcmonst rate
but do not make
unilateral decisions
Theoretically, community
participation is great.
In fact, activities
and decisions are
dominated or manipular
j ted extensively by
outsiders, ofter ex' Patriate consultant s'"
4—------------------------------------------------ ----I
Financing and
supplies
Largely fron the
community. Self
help is oicouraged.
Outside input is
minimal or on the
basis of ’’seed
funds", matching
funds or loans.
Agricultural ex
tol sion and other
activities which
lead to financial
self suf ficienc y
are promoted.
Low cost sources
of medicine are
arranged.
:
Many giveaways and
handouts: free food
supplements, free
medicines, villagers
Paid for working on
"community projects"
Village health worker
(VHW) salaried from
outside Indefinite
dependency on
external sources.
:6:
'
COMMUNITY SUPPORTIVE
COMMUNITY OPPRESSIVE
(CRIPPLING)
I
T Jay in which com
munity participation
is achieved
With time, patience,
and genuine concern.
Agent-of-change lives
with the people at
their level, gets to
know than, and esta
blishes close relation
ships, mutual confi
dence and trust.
I
!
Data acid evaluation
■
Care is taken not to
start with free ser
vices or giveaways
that cannot be con
tinued.
i Many programs start with
; free medicines and hand; outs to "get off to a
; good start”, and later
begin to charge. This
i causes great resentment
! on the part of the people.
Underemphasized. Data
gathering kept simple
and minimal, collected
by members of the com
munity. Includes
questions about the
people1 s felt needs
and concerns.
Overanphasized. Data
gathered by outsiders.
Members of the community
may re salt the inquisi
tion, or feel they are
guinea pigs or
"statistics".
Simple scheme for
self-evaluation of
workers and programs
at all levels. Eva
luation includes
subjective human
factors as well as
"hard data".
Experience and
background of
outside agents-of-change
Income, standard of
living, and charac
ter of outside
agent s-of-change.
(MD’s, nurses,
social workers,
consultants, etc.)
Much practical field
experience. Often not
highly "qualified"
( dogroesL
Often volun
i Modest.
teers who live and
dress simply, at the
level of the people.
Obviously they work
throu^i dedication,
and inspire village
wrkors to do like
wise.
j
With money and giveaways.
Agents-of-change visit
briefly and intemittently,
and later on discover that,
in spite of their idealis
tic plans, they have to
"buy" community partici
pation.
-—&
Evaluation based mainly
on "hard data” in
reference to initial
objecti ves.
Much desk and conference
room experience. Often
highly "qualified"
(cdogroo^.
Often high, at least in
comparison with the
villagers and VHtf (^ho,
observing this, oftai
finds ways to ”i&d” his
income, and may become
corrupt). The health
professionals have often
been drafted into "social
service" and are resentful.
:7:
(IMMUNITY OPPRESSIVE
(CRIPPLING)
OOMMOJITY SUPfORTIVE
At each levej, from
doctor to VHW to mother,
a person's first res
ponsibility is to
■ teach - to share as
( much of his knowledge
as he can vdth those
who know less and
want to learn more.
At each level of the
preordained medical
hierarchy (health tean)
a body of specific
knowledge is jealously
guarded and is consi
dered dangerous for
those at "lower" levels.
Regard for the
people's customs
and traditional
folk healing, use
of folk healers
Respect for local tra
dition. Attempt to
integrate traditional
and lAfestem healing.
Folk healers incor
porated into the
program.
Much talk of int eg rarting traditional and
Wstem healing, but
little attanpt. LaPk
of respect for local
tradition. Folk healers
not used or respected.
Scope of clinical
activities (Dk. Rx)
Determined, realisti
cally, in response to
community n^eds, dis
tance from health
center, etc.
Delimited ty outsiders who
reduce the curative role
of the VHW to a bare mini
mum, and permit his use
of only a small nwiber of
'hamless” (and often
useless) medicines.
VHW is from and is
chosen by community.
Care is taken that the
entire community is
not only consulted,
but is informed suffi
ciently so as to se
lect wisely, liduca, tional prerequisites
are flexible.
VHW ostensibly chosen by
the community. In fadt,
often chosen by a vil
lage power group, preacher,
or outader. Oftoi the
primary health worker is
himself an outsider.
Educational prerequisites
fixed and often unrealis
tic ally. high.
Sharing of
knowledge
and skills
• perfoimed by VHW
Selection of VHW
and health
committee
1
Training of VHW
Ebes the program
include "conscientization” (conscious
ness raising) with
respect to him an
rights, land and
social reform ?
Includes the scienti
fic approach to prob
lem solving. Initia
tive and thinking are
encouraged.
Yes (if it dares).
VHW taught to mechani
cally follow inflexible.,
restrictive 'norms" and
instruction. Ihc our aged
not to think and not to
question the "syston"
Issues of social inequi
ties, and especially
land refoim are often
avoided or glossed over.
f
:8:
(IMMUNITY SUPPORTIVE
COMMUNITY OPPRESSIVE
(CRIPPLING)
Simple and informative
in language, illustra
tions, and content.
Geared to the user’s
interest. Clear index
and vocabulary inclurded. All common prob
lems covered. Folk
beliefs and common use
and misuse of medi
cines discussed.
Abundant illustrations
incorporated into the
text. Ihe same time
and care was taken in
preparing illustra
tions and layout as
villagers take in
their artwork and
handicraft.
Cookbook-style, unattrac- |
tive. Pure instructions.
No index or vocabulary.
Language either unnessarily complex or childish, or both. Hlustra^
tion are few, inappropri
ate (cartoons), or care- I
; lessly done. Not integ
rated with the text.
! Useful information is
; very limited, and sane of
it inaccurate. Many com
mon problems not dealt
with. May use misleading and/or incomp rehensible flow charts.
1
I
I
Manual or guidebook
for VHW
Manual contains a
balance of curative,
preventive, and pro
motive information.
I
•
!
I
I
i
i
'
Manual often strong on
preventive and weak on
curative information;
overloaded with how to
fill out endless forms.
I
Limits defining
what a VHW can do
Supervision
j
Ihcouraganent of
self-learning
outside of norms
Intrinsic. Determined
by the demonstrable
knowledge and skills
of each VHW, and modi
fied to allow for new
knowledge and skill
which is continually
fostered and encouraged.
Extrinsic. Rigidly and
immutably delimited by
outside authorities.
Often these imposed
limits fall far short
of the VHW’s interest
and potential. Little
opportunity for growth.
Supportive. Depend
able. Includes fur
ther training. Super
visor stays in the
background and never
"takes over". Rein
forces community’s
confidence in its
local workers.
Restrictive, nitpicking,
authoritarian, or pater
nalistic. Often indepen
dable. If supervisor is
a doctor or nurse he/she
often "take over", sees
patients, and lowers
community’s confidence
in its local worker.
Yes. VHWs are pro
vided with informar
tion and books to
increase knowledge
on their own.
F
No! VHWs are not per
mitted to have books
providing information
outside their ’^norms’’.
i
i
t
:9:
4-----------------------------------
OOMMUNITT SUPPORTIVE
COMMUNIK OPPRESSIVE
(CRIPPLING)
Feedback on
referred patients
(count er-ref er ence)
When patients are re
ferred by the VHW or
auxiliary, the M. D. or
other staff at the re
ferral center giv«s
ample feedback to fur
ther the health -wor
ker’s training.
Eb ctor at the referral
center gives no feed
back other than ins
tructions for injec
ting a medicine he
has prescribed.
Plow of supplies
Dependable
Uhd spendable.
Profit from
medicines
(in progrws
that charge)
VHW sells medicines at
his cost which is pos
ted in public. (He
may charge a small fee
for services rendered).
Use of medicines is
kept at a minimum.
VHW mdc es a modest
(or not so modest)
profit on sale of
medicines. Ibis
may be his only
income for services,
inviting gross
overprescribing of
medicines.
Evolution toward
greater community
invol venent
As VHWs and community
menbers gain experi
ence and receive addi
tional training, they
move into roles ini
tially filled by out
siders - training,
supervision, manage
ment, conducting of
under-fives clinics,
etc. More and more of
the skill pyramid is
progressively filled
by mBribers of the
community.
Little allowance is
made for gio wth of
individual members
of the community to
fill more and more
responsible posi
tions (unless they
graduate to jobs
outside the commu
nity)?^ 0 ut a. ders
perpetually per
form activities
that villagers
could learn.
Openness to
growth and change
in program structure
New appro aches and
possible improvanents
are sought and encour
aged. Allowance is
made for trying out
alternatives in a part
of the program area^
with the prospects of
wider application if
it works.
Ehtire program is - ,
standardized with
little allowance for
growth or trial of
ways for possibly
doing things better.
Hence there is no
built-in way to
evolve toward better
meeting the commu
nity’ sneeds. It
is static.
1
9
:10:
I
OOMMUNIIY SUPPORTIVE
COMMUNITY OPPRESSIVE
(CRIPPLING)
4-------- —---------------------- —-------------
RESULTS:
j Health wr^cer continues
to learn and to grow.
i Takes pride in his work.
j Has initiative^ Serves
the community’s felt
I needs.
Siows villagers
what one of their own
can leam and do, sti
mulating initiative and
responsibility in
others.
Health worker plods
along obediently or quits* He/she
fulfills few of the
community’s felt
needs. Is subser
vient and perhaps
mercenary. Rein
forces the role of
dependency and
unquestioning ser
vility.
Community becomes more
self-sufficient and
s elf—con fid ©it.
Community becomes
more dependent on
paternal! satic out
side charity and
control.
Human dignity and
responsibility grow.
Hunan dignity fades.
Traditions are lost.
Values and responsi
bility degenerate.
- -------------------------- ______
If outside support
fails or is
discontinued ....
Health program conti
nues because it has
become the commu
nity’ s.
Health program flops.
TACIT OBJECTIVE
Social reform - health
and equal opportunity
for all.
"Ibn’t rock the boat,”
Put a patch on the
underlying social
problems - don’t
resolve than !
SPONSORING AGENCIES
(Ihere are notable
exceptions)
Often small private,
religious, or volun
teer groups. SomeI times sponsored by
foreign non-govemment organizations.
Often large regional
or national programs
co-sponsored by
foreign national or
multi-national
corporate or govemment organizations.
ST- JOHN'S MEDICAL COLLEGE, BANGALORE
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G
THE DEVELOPMENT WORKER AND THE PEOPLE
1- THE MEANING OF HELPS
One can safely assume that a voluntary organisation is primarily •
in the field to help the beneficiary,
a person who‘is helped.
The word beneficiary itself speaks of
Therefore, the relationship between the voluntary
organisation and the beneficiary will be one of helper and helped,
relationship two different parties which
are brought together by a magic words
In this
often have very little in common
"help”,
When this word is understood
in exactly the same way at both the conscious and the unconscious level, by
both the giver and the receiver the likelihood of misunderstanding bdtween
the voluntary organisations and the beneficiaries are minimal.
But,
unfortuna
tely, this is not always the case.
For the beneficiary help was a very narrow meaning.
of poor people,
there is always one thing which needs urgent
pay back a debt, to find employment, a well in the fields.
Help means to
take care of that need.
words, words,
words 1
For
In the lives
solution? to
This is his need.
Any talk on something else is just
the voluntary organisation on the other hand, help is very
ways
likely to be understood in a very different manner, and in different
depending on the main aim of the organisation#
Thus, if the main aim of the
VO is education, then the help which the beneficiary needs will be understood
to be education; but his main need will
change to curative medicine, housing,
agriculture, lift irrigation, control of rodents or road building depending
oh what is the voluntary organisation^ main area of activity.
In short,
help myy mean one thing to the voluntary
organisation and a very different one to the beneficiary, giving rise to a
misunderstanding.
Indeed, the very first question, that a voluntary
organisation should ask itself is thisS "If help has to be given in answer
to a naeri. .whQao nefcd Goo® it answer the help which I give?"
Sometimes our
needs meets the patient needs the doctor as much as the doctor needs the
patient 1
But sometimes the doctor may need the patient more than the
patient needs hirt; in which case, the doctor may feel tempted to protract
the illness uf the patient.
In other and clearer words, the need of the
voluntary organisation or its personnel is made to be the need of the
people.
Or, in other words. the former project their needs on the latter#
This projection can be of either institutional or personal needs,
Let us
explain each separately.
...2/-
2
2. PROJECTION OF PERSONAL NEEDS
s
The distinction between personal and institutional needs takes
cognizance of the fact that the personnel manning the voluntary organisation
may have needs different from those of the institution he serves,
these personal needs may work against the beneficiary.
point, let us take a
Now
To clarify this
hypothetical example where the voluntary organisation
aims to help the beneficiary precisely where he wants to be helped.
The
example* A voluntary organisation well aware that there is lot of unemployment
and eager to solve the problem sets out to help the beneficiary by setting up
a milk-producers’ Cooperative on the understanding that the scheme will provide
additional employment and income.
provides the initial
The organisation
loan, the managerial apd animal husbandry knoitj-how and even helps in buying
the buffaloes*
The result is a magnificicnt cooperative.
The cooperative
is so successful that people from all over the country come to see it? even
internet ional
organisations take interest in it.
T he cooperative helps so many
feel nice.
begin to court its managers.
people that the local politicians
The voluntary worker feels powerful,
cooperative now becomes an end in itself.
of the beneficiary.
The voluntary workers
The
It did satisfy the first need
But the cooperative is subsequently made to serve the
The cooperative which
personal needs of the so-called people’s helpers.
could have helped the beneficiary first to achieve economic independence,
then
competence in animal husbandry and finally managerial skills to run the
cooperative himself, stops short of these lofty goals.
All this, of course,
Because, it is agreed,
in the name of the people and their true welfare,
if the management is given over to •’ cneficiary , the cooperative will soon end
up in corruption and mismanagement.
Those who so speak might not have
been able to answer an entirely different question? ”If I give power to
the people where am I?”
Hero the personal needs of the voluntary worker' starTd in the
way to the true development of the beneficiary.
The need -for power, tho
people arc all examples
need "to feel needed", the need to father or mother
of such personal needs.
‘
From the above some may draw tho conclusion that development work
demands so much detachment, as to be beyond the possibility of ordinary
human beings.
or saints;
This is not true.
Development work does not ask for mahatmas
All that it asks for is enlightened self-interest.
how? To begin with, it is important to stress that no
personal need is bad
in itself? therefore, nobody should be ashamed of having
motives.
Secondly, it is very important that
the person in question and by his organisation.
us have their way of hitting back at us.
these
Let us see
such needs are
needs be accepted by
Needs which are denied by
Finally, the person in question
...3/-
3
out
and his organisation must find/creative ways of dealing with those needs.
A creative way is that which satisfies the personal needs without harming
the client4
Thus, in the above mentioned example withdrawing in time will
not decrease but increase the prestige of the voluntary organisation and
its personnel. . And, by replicating the model somowhoro olso, personal power,
far
from being lessoned, is greatly enhanced.
The only difficulty in the whole exercise is that the person in
/
question requires personal courage to accept one’s own needs to oneself and
to others.
Or’3
requires self-confidence to believe that what has been
done here can be replicated somewhere else.
are not these great
Personal courage, self—confidences
individual?
individual?
Here is the
’’The more wo give, the more we receive”.
’’Acceptance
’’developmental” needs of evdry
great paradox of life?
of the developmental needs of our clianted loads to our own personal growth”.
A person need nbt be a great man to do development work; but he may very
For, if
well end up by being one if he does it in a professional manner.
development work demands from us self discipline and detachment so does
personal growth and emotional maturity.
This may not be perceived by
voluntary workers because they, like the beneficiaries at another level, are
so blinded by their immediate needs that they forget their long-term interests.
Development work may bring about this awareness.
3. INSTITUTIONAL NEEDS PROJECTED ON THE BENEFICIARY
The above example has taken for
granted that sometimes, the
professed need of the organisation and the felt need of the beneficiary
can
meet.
But
unfortunately that is not always that case.
Sometimes they
differ, in which case the" likelihood is that the voluntary organisation may
project its needs on the beneficiary.
/
Here again is
a hypothetical example of a'n organisation which
specialises in slum clearance,
Food,
be three of the basic needs of man.
clothing and housing are understood to
In a city lack of decent house is seen
by the affluent society as a crying need which
demands urgent solution.
And so an organisation has been set up to take care of this need,
of rich and well-meaning citizens offer their money,
A number
Government and inter—
national agencies see it as their duty to help in the venture,
new organisation- goes to a slum.
And so the
What is the help the slum dwellers need?
Fob one set of persons atleast there is no doubt - what these people needs is
a good housing sefheme.
Now the chances are that
the slum dwellers’
housing is a need which is very low in
list of priorities.
In which case help (the satisfaction of
their needs) will be understood differently by the beneficiary and the
organisation and this, of course,
r
give rise to a misunderstanding.
4/_
f
4
Let us now examine the possible situations which this misunderstanding
may give rise to.
A voluntary worker goes to a slum to meet the people.
There they are? he and they,
misunderstandings they
help them”.
rich and poor.
After the first initial
wants to
”He
begin to receive a clear message?
But they need money or employment and he offers them housing.
want anything to do with him”.
Others cleverer
say? "He is rich, he has influence. We do not want a house.
But it may very
well be that if we accept it we shall secure what we want”,
The others see
Some of them say?
”UJc don’t
reason in this and now all agree to go along'with him.
This situation has all the elements of a bargain. Briefly? there is
a party(a voluntary organisation) which has a need to set up a housing scheme.
There is another party(the beneficiary)
which needs,
let us say
money.
In
this situation how ddies the latter sec the former and its project?
1. The beneficiary may look at the organisation as something he
needs.
In which case the project will be seen as something to be done in
order to preserve the organisation’s services.
t
The project then becomes the tribute
the voluntary organisation.
if the project
A
A
the beneficiary has to pay to
tribute is always paid reluctantly,
is sabotaged in more or less subtle ways.
No wonder
For example, the
houses may be sublet or sold and the people may revert to the slums.
2. The beneficiaries may not see the voluntary organisation as
indispensable; but they may see the project as
means to achieve their aims
In this case, the project becomes the handle which can be used to manipulate
"them”.
project.
"They have plenty of resources.
Wg give it to them.
Wg need money.
Let them now give us money".
project must be giving plenty of money to "them".
in it.
The need a housing
OR
"This
Now we also cooper’ate
Therefore, we shouldl also share in the spoils".
In this situation, the beneficiary feels that a tough bargaining
is shead; and , therefore, he is likely to adopt the usual bargaining
t a ct i cs •
Secrecy will be one of them "One does not show one’s cards”.
Indeed he may even try to mislead the voluntary organisation,
And, of
course, in every bargain the stakes must always be kept high.
4
In ths process the slum dwellers keep on looking at the voluntary
organisation as the other bargaining party,
interpreted in this lights
All its moves will be
"How do the voluntary workers play their cards?”
1. They may be very soft towards the beneficiary, in which case
the letter is likely to interpret this' attitude in three possible ways?
(i) That the former are stupid, and there-forc, have no credibility,
(ii) That they have a lot of money in which case the beneficiary will try
to get as much as
possible from them or (iii) That they need the project
very badly in which case ho will harden his bargaining position.
5
5
2.
If the voluntary organisation is seen as a very hard
bargainer he is likely to see it as> an improved replica of
the local money-lender Zamindar. 'This means that the
relations between him and the voluntary organi'sation will be
patterned very much along the well known relationship of
money-lender and the poor.
There is9 of course, a third possibility i.e. when
the voluntary workers turn the whole situation into a learning
3,
one.
More will be said about this later.
This attitude of the people may trigger off similar
reactions among the voluntary workers. Thus, they may brand
the beneficiary as a cheater, as a lazy person or ignorant,
or any other adjective to describe a situation which they see
as unreasonable. If that be the case, the relationship between
them and the beneficiary becomes vitiated.
4.
THE NEED OF DIALOGUEs
The important thing in all the possible situation
described so far is that the relationship established between
the people and the voluntary organisation is not a sound
one, simply because it is based on either a misunderstanding
(in the case of help being understood differently) or in
attitudes which are not authentic when the voluntary worker’s
avowed aim is one and his real motivation is another.
relationship exists, it is evident that
When such a
real communication has been
no dialogue is possible because no
established. Therefore, growth does not take place. And
required sometimes by the
who can deny that growth may be
voluntary organisations and
beneficiaries, sometimes by the
sometimes by both? In development work it is first the duty
that they
of the voluntary workers to grow by making sure
institutional needs
are not acting out their personal or
on the people. One way to do it may be self examination and
another way is to start a dialogue with the people in order
to understand them better and also to make themselves
better understood by the Ipeople. Whatever may be our
shortcomings the people have a way of teaching us and
correcting us which is wonderful, if we only listen to them
and understand them. There is also a need of dialogue when
the people are so overwhelmed by immediate needs that they
are ready to take steps contrary to their own long-term interests.
6
6
The beneficiary in this case must be made aware that his need
is only part of a bigger reality, and that no affective means
can be taken to solve their felt needs unless the totality of
the situation is taken into consideration. An example will
help to illustrate this point.
A Voluntary organisation working in a village, studies
the situation and comes to this conclusion- the expenditure
of the beneficiaries is higher than their income and conse-OLuently the people are indebted. A .study of their expenditure
reveals that not enough is spent on the necessaries of life,
food, clothing, housing and agriculture, while too much is
spent on social customs, medical bills and uneconomic
borrowing. Since they are so hard for money they are forced
to accept loans on adverse terms. Again, since they don’t
have money to bi$ they must take on credit paying double,
is higher than the
The amount of money paid on interest
--4
original amont of money b orrowed.
A study of their income reveals that their income
from agriculture
is too low because their methods of cultivation art too primitive and because not enough is invested
in their fields.
The beneficiaries are haunted by the money lenders
unavoidable need of cash. If the organisation
and have an
it knows too well that it is helping to
gives them money,
perpetuate a system, If the voluntary worker, ignoring the
beneficiary’s needs, tries to push, say an agricultural
improvement programme, than he is facing a sure
failure, since the beneficiaries are not likely to give their
full-hearted cooperation to something which they consider
irrelevant to their present needs.
There is only one way out and that is a true dialogue
where the voluntary organisation keeps on relating the beneficiaries1 need to the totality of the situation, Education
is anotherword for this dialogue.
On the other hand, this dialogue is not as easy as it
may appear. It requires from the organisation's personnel
professional skills; (i) The ability to listen to the people
□nd understand not only their words but the real meaning
behind them, (ii) knowledge of the situation. This demands
deep involvement in the lives of the people and a serious study.
7
7
(iii) Knowledge of the wider reality viz., that of the whole
country (and of the world at large) of which situation is only
a part.
It requires also certain inner attitude without which
those skills will not be put to good uses
elf-confidence; to face the seduction, opposition
and indifference of the beneficiaries without either being
trapped or feeling personally threatened.
2. Authenticity and courage to ownup one’s needs and
motivation.
3. Faith in the people: If voluntary workers lack
this faith no meaningful dialogue is possible with the benefi
ciaries and no real education will take place. Indeed the
chances are that the voluntary organisation will eventually
work against the long term interest of the beneficiary. If
the social workers believe that the beneficiary cannot take
care of himself, evidently they will never work towards an
eventual stage where he becomes self-reliant. If they do
not believe that he can learn they will not even try educating
him, or, if they do they will unconsciously undo what they
are professedly doing Let, on the other hand, the voluntary
organisation have on the people and that faith will be
communicated to them. If the voluntary workers fail they will
attribute the failure not to the beneficiary but to their
approach or methodology their imperfect understanding of the
situation and the people. In other words, when there is
faith, failure makes the voluntary organisation search. When
there is no faith failure makes the voluntary organisation
blame the beneficiary.
Faith in the people can be said, without fear or
exaggerting, to be most important virtue of all those required
by development workers.
Much is being said in development literature about
dependence and often it is assumed that social or developmental
work leads unavoidably to a state of dependence. That this
happen often is evidently true. Taht this is in the nature
of things is not so clear. Faith in the people and courage to
live upto that faith will help the development workers to
make themselves dispensable at the right moment and will
8
10
One of the objectives of thss National Work-shop
on Rural Development is to evolve a more effective strategy
for the mobilization of people and the resources in the
struggle against poverty and injustice". The above consider
ation have been submitted having this objective in mind.
6.
THE NEED OF PROFESSIONAL TRAINING:
One often hears complaints about the shortcomings of
the people working for development, To point out defects is
the first step to remedy a situation; but it is not enough.
One must study the causes leading to such a situation, This
paper has already suggested the first step towards better
development work — the professionalisation of its services
by creating those conditions which will makd it possible to
recruit people who are both competent and comitted.
There remains one question to be answered? are there
such people available in •the country. The answer, unfortunate
ly, is negative. Dr. Kurien of the National Dairy Development
Board has been forced to plan his own training services to
provide his cooperatives with competent personnel.
While much of the theory needed in development work
is given at the various schools of social work, theory alone
is not enough. And indued the same theory may mean one thing
when given within one value system and it may mean something
quite different when the values held are different, In any
case, theory alone docs not bring about committment, The <
latter is the product of’ the values one upholds. And, un
fortunately, the values prevalent in our universities arc
not likely to promote the right attitudes towards development
work. To be more specific: mention can be made of those values
which lead people to believe that teaching is more important
than learning; that city people are better than their rural
c ounterparts °9 that money and power arc the standards of success
of life; that a successful student is one who has made it into
an executive post in industry. When our universities accept
such norms they are not likely to turn out graduates who will
be looking forward to work in the villages, who will think
that they must learn from the poor, who will have faith in
illterate people! Without these fundamental attitudes is
there any chance that these graduates develop those other
skills required in development work, like the, ability to
o11
11
understand others and to communicate with them which is the
basis of a meaningful dialogue and true education? Therefore,
development work cannot rely entirely on the training given
by our universities.
May be that this work shop could explore the possi
bility of using the existing voluntary organisation to develop
our own training facilities.
If the voluntary organisations could set a model of
unity and cooperation; if the aid-giving agencies could also
do the sameand if, as a result, permanance of service and
professional salaries could be offered to prospective candi
dates, then the system could be rounded off by a number of
volunatary organisations joining together to offer training
services as well.
Let this paper end by stating in clear words the
assumption on which the whole paper has been based’ True
development means, in the last analysis, personal growth
the ability to cope every time more effectively with difficult
situations; the ability to make history,meaningfully. May be
if voluntary organisations spent a little more time in
’’developing” their staff they would be in a better position
to help in the development of others.
Ms*/14/3
@
.. .
l-■r
1
H ,•'7-■»'
<10
•i'
ST , JOWS MEDICAL COLLEGE & HOSPITAL, BAMGALORE
TRAILING PROGRAMME FCR COMMUNITY HEALTH WORKERS
COMMUNITY
■ 6^
DEVELOJMENT
J <M • Herectcrd'’
Definition of Corx'ium.ty:
A sense developed Ly people of their local comon good.
a) Sense
: To the extent to which a group of people
develop a sense of their common good, to
that extent, wo say, there is a community.
b) Coiauon good
: It embraces various aspects:
1« Political: (Political is taken hero in the
sense of sharing power).
Ains:
a) to avoid a position of dependonce which nay load to exploitation. The connunity
w (through united
organisation) .acquires sufficient
power to defend the rights of its
nenbers* In other voids, the
connunity asserts its rights.
b) The individual whether in a tradi
tional or in a nodem society has
very little control ever his life.
Most of the decisions which affect
his life are taken by others. In
the western consuner society this
has led to non-confornist novenent
like the hippies. In India, the
caste controls the majority of
individuals through the manipulations
of a few traditional leaders. In
either traditional or modern society
the net result is the loss of indivi
dual autonomy.
The community where each member is
aware of those facts and willing
to do something about them is the
only means to restore the a’utonomy
of the individual •
2. Social
^Behavioural Scioncr 1'
-
-74.
Man is a social animal* There are
certain things which can only be
satisfied in a society. Thus, for
example, the need cf mutual support,
of friendship, the need of celebrations,
are needs which arc best taken care
of by the community. More in parti
cular, man is communicative. The
community provides a forum whore its
members can exchange their ideas.
Again, man needs recreation. The
Coomunity helps each member, accord
ing to his age etc., to fulfill this
need •
I
♦
3. Religion: a) Religion has always been a social
phenononon. The community helps ft®
•‘ ■
members to worship in commonb) Society imposes on nan values wh'ichrun counter...to..his religious convic
tions • One ran can individually re*"_
jcct these values, Ixit it is in and tJt
through the community that ran can have
:his religious values accepted^in a
manner which is relevant to him and
his neighbours at a particular tine
.in a particular place* Tc extent to
which'the true fundamental values of
religion are accepted in the community
to that extent religion has neaningfu-L
relevance in society. This is aIrvinprocess who^e mon discern in their ow
religion/ the difference between funda
mental3 and accidentals, between imor
attitudes and external rituals and, ‘ .
thenr daily lives, mon are allo tc sec
the difference between real needs and
addictions or compulsions»
Gomiunity work should be an anticio >0
against institutionalised religion
lihorc the institution bo cones noro
inportant than the nossage and, ospe^"
the peopled) The eorxiunity is important to relign j.
/and vice versa) because it is in the
forwr that the ideas of the latter arinplcnentod- '’pcciflcaniy, it is
through the connunity that the fi^ht
against social evils and in jus 1 co can
best be waged0)
1 ■
4. Educationi
The community helps its members to
teach and to learn.
a) The community helps its members to
learn:
i) to be more ethically sensitive
in solving problems by taking
cognisance not only of one!s ovn
interests but also of his neighbor.:nr
ii) re-assess one’s own attitudes and
habits vis-a-vis their impact or.
one’s own neighbours;
some very specific skills whicn
an individual learns in the commur ’
aro communi cationsand loader simp f
skills;
ly) in short, tlio ‘ fndividwlsvlearn
how test to liolp-tho bbrii^init^^
to achicvolthd'oo-arion Joed. ’ ?.
' 7 ""'s:
b) The conriunity helps, its noribors to
teach•
3
of the aocio-aeononic strictures
which inOaonoo or r.nnipulato it;
id; the community may crganisc other
ninor schemes wiicr:. individual menbors
sHTLs to others.
o-ttiors.
’ will impart specific skills
5? Ecrnmiic;
3----------- 2
H.
Anong -the weaker sections of society the
^orEUXli.b7 ,..ny p.2 th0 oniy moans to solve h^i
economic difficulties. CoopeKrtitvcs of all
tyres'mybe ti e orily^swpr to solve problems
lilce indebtedness, iiaikcting difficulties and
even uneujd.oynent *
’
Types of ConvivMty: Thoir
jidynt
The Caste as Cowwiity
ctiste Hcuber his own set of rights and du-ics.
■■'This soon al stricture provides for a.clear sense, of identity and'
belongingness, which is found tissing in the s<? culled -atoaised socie
of the West.
Another characteristic of the caste is that.it is not nerely an
effective group, or a group organised for action ouu a ..so n ax.,.
group or a group bound together by links of oomon fellowship.
Religion as a Co-ai.iunit.Yi
In India religion creates a conr.nmity clearly anong the Parsees.
gives rise to a corwriity•
Territorial Group as a Cony amity:
Gdrornnent have consistently taken the view that caste and religion
lead to casteisi.1 arid connunalisri and consequently, lhey cannot
- Jr
basis of a comuiW. Therefore, govpmnent and "’any°^litv.
claim that the territorial groups should xorm the basis o
-v o *
y
In rural areas, it is the village/,and in an uroan set up it should
the neighbourhood.
v- While there is no doubt that tjpftain daste fevils oust be rooted
out it is an open question whether the whole systet must be eradicated.
In which case the caste would serve as an obvious basis for corxiuni y
traditional end modern societies.
Characteristics, of a Traditional Society:
%
Without attempting to define it, cortaiA cRir^cteristixjs nre given
here below which can identify it.
i) The sense of 1 clonging to t?,.$.cni?cru.;
<nt in
tBiditi-m-■’
: L. :
ii)
iix)
iv)
i
■
■
... v
Jr
v)
'. This sense of belonging binds the
net questioned.
nenbers of the cconiiiiity together •
This co; mon meml?crship .defined their identity ?» Tradisense
tionally groups are characterised by a strong
to
of identity..
A traditional group tends to possess distinctive
to itself,
qualities of social life which .are peculiar to*itself.
like all groups it has its own culture but unlike
other groups this culture is more
norc rigid. There are
throe conponertto of this culture*, First, the normative
normative
system that tells people how they should behave.
Secondly, the action system which includes the actual
— the custom, folk
folic
ways in wlxi.sii things are done —
ways, etc. Thirdly, the things which are produced,
the s^rnibols .and water al products, must also be included.
As for pho acceptance of fundamentally perceptual and
normative values, it is above all the community which
largely determines the individuals ’ perception of
possible questions and their answers.
Characteristics of Modern Sociotjo^
n0vnr the last" contruios, it is clear that the Western societies
have moved from an emphasis upon social organisation based upon kinship,
fealty and status to one based upon contract and rational co-ordination.
This novenent is characterized by increasing specialization,, of function
and increasing rationality in the lives of the members of the society.
Specialization has led to thq growing division of labour*' There
has been a powerful process of social differentiation which has operated
in the separation of function of the major institutions in sod qty and in
the growth of associations aimed at furthering specific interests •
Rationality has helped the Western Society to move away from un
critical acceptance of the established order. There has been a trend towards
secularism and pragmatism. Ways of doing things are measured in terms of
effectiveness in achieving sone i atorial end. This has been sui-imrised oy
Talcott Parsons in the notion that the dotdnanf value theme in advanced
society is mastexyr of the world around. This emphasis upon secularisn
and rationality is believed to go hand in hand with impersonality in human
relations - an emphasis on heads not hearts. This societ;/, according to
Tonnes, produces the ’mass society’ of rootless individuals bound together,
not by unquestioned perceptions of reality and an undisputed normative order, o
but by personal choice. Thus, the bond is still, there, but it is a much less*
secure one. It is dependent upon- fads ..and fashions of individual choice and is
more prone therefore to violent chauge and to ’sickness* or ’nornlessness ’ •
Advantages of Traditiona..lovor
1« Greater sense of belongingness
£* Greater sense of identity
3» More emphasis pLa-cod on affective links
Therefore, a traditional society lends itself better to community development.
Disa^yantages ?
1. It may give undue prominence to its leaders •
(This my be counteracted, by greater awareness
of all its nenbers).
j. It plays undue emphasis on tradition with its
•or espcnding lack of stress on rationality.
(This |an be counteracted by better education
of the •orr/u.nity).
3- The
caste s... •
' -■’a n. .. . r
C: 1- -
: 5 :
IH. COfrMJNITY DEVELQH4E1CT *
11 Definition:
Community Development is a social process by which human beings can
become more competent to live with, and gain some control over, local
aspects of a frustrating a nd changing world.
ExTfLajia^ion^
i) It is a group nethod for expediting personality growth, which
can occur when gce-grephic neighbours work together to serve
their growing concept of the good of all*
ii).It involves cooperative study, group discussions, collective
action, and joint evaluation that loads to continuing action.
iii) It calls for the utilization of all helping professions and
agencies (fron local to international), that can assijrt in problen
solving.
iv) But personality growth through group responsibility for the
local connon good is the focus-
Fr.cn the abov^ it is clear that in recent tines there has been a
change of ompha-si-s- -ff’cn improvement of facilities, qnd even of public
opinion to inprovonont in people. But this personal betternent is brought
about in the midst of social action that serves a growing awareness of
community need •
3 • Community Development is a Process:
.....
shall use the- •woitL, process refers to; a progression -of events
that- is planned by the participants to serve goals they progressively
. choose. The events point to changes in a group and in individuals that
can be termed growth in social sensitivity and competence • The essence
of process docs not consist in any fixed ■succession of events (these may
vary widely from group to group and fron one tine to another) but in the
growth that occurs within individuals, within groups, and within the
communities they serve.
__ I£__
* Extracts fron: Biddle & Biddle: The Connunity Dcvelopnont Process.
** The Connunity developnont process is, in essence, a planned and organized
effort to assist individuals to acquire the attitudes, skills and concepts
required for their dcnocratic participation in the effective solution of
as w ide a range of coixrunity inprcycuent problens as pssiblo in an order
of priority detemined by their increasing levels of conpotence1’ •
J .D • Ifezirow, "Connunity Development as an Educational lYocess",
Connunity Development, Nati nal Training Laboratories Selected Reading
Series N0.4, (1%1), p.16.
: 6 :
TV.
THE CCWNITY PEVEIQEEB
I*. His Ain:
Connimity devolopuent is, essentially, hunan dovolppuicnt • In
the field of cornjunity dovolopnont, the goal is to .create an ctuospherc
in which non and wonon can express their inherent right to "Life, liberty
and the pursuit “of happiness”, unfettered by the chains of hunger, poverty
and ignorance. The attainnont of that goal oust start with the'basic nood
of tho hunan soul to express, to grow, to build a life that will fulfill
its drcans. Ho needs nly the stinulus of understanding* the knowledge that
others recognize his individuality and respect it* and tho guidance that
evokes his latent ability to achieve his goals *
2 < His Dole i
a) A nucleus level worker is tho central figure in the draua of
ccnLymty dovolopnont • Ho is tho instigator of process. His responsibility
is Significant, but difficult, for ho has a role f paradoxes • Ho is cal 1 od
upon
take actions that soon to bo contradictory in thonselvos or to run
counter to ruch conventional widdori. Ho is a contra! figure who seeks
pronlnenoQ for others.
b) Is a nucleus-level encourager an innovator? .Most people use
the word ttinnovator
?
” to describe the inventor, the introducer, or the ponoter
of a now idea* A ^^^WQ-ty developer is none of those; hens rather an
upon-------others
innovators • He takes
4-v, • -Sator
• 4.• 4.of
• processes
~
. that■call
----- -1'--- to
— bocono
——
the initiative so that others will kike tho initiative.
■ c) Neither is tho comunity developer aa change agent in the
sense of a n advocate of (to hiu) favourable Changes.• He is rather
_ the
expediter of tho favourable changes that people have chosen. ■
thp process riay begin and continue without him, ho is
contralto any pJAnnefl. and organized utilization of it. Profossionaly
nucleus-level workers of sone sort becone indispons-able, and sone institu
tional responsibility for onploying and training then is called for, if
coununity devclopnent is to have any inpact upon tho history that is lived,
nut i± the professional workers de their job adequately, they can expect
poop e o learn how tq develop with less and less oncouragononts fron thenselves. An encourager instigates a growth of initiative that should run
away fron hin.
of the CoiXTunjiy Developer:
a) .The Institutional Dilcijia.:
.
helping prqfbqsions face, a lilenna posed by their institutionali
zations Hlixch sfell cone.first -- service tc.-hunan beings or loyaltv to
ODpq.oying organization?
c
v •
‘
;
*
/
that is required to serve the people’s needs is
restricted by the pressure upon the connunity developer to support the
sponsoring institution and to follow its prograsnno proscriptions.
•4.?1?, ^HS^-^tion makes its own demands, nany of which arc incompatible
with the processes of coraTunity development. For example, an institu
tion nay demand to bo aggrandized, "played up”, given credit; and. usually.
PrGssurG ’t’° follow traditional rituals. But the community may
go off in pursuit of activities of its own choc sing — Indeed, the
coni.unity developer seeks such displays of independence as evidence of
the growfei;-: initiative of the citizens. ut sub: - - .y a-*-tu-r1
the institution,
" ‘
: 7 :
In working with people through the oommuntiy development process,
it is easier for a community developer to l e self*-effacinr than it is for
him to red‘ ce the prominence of his institution, But then, institutions,
too, can change - in aspiration,, :,d in the nature
re of their pro;
programmes.
Sometimes they do this as a result of pressure f(■ ontly applied; from
employees. There are sone that arc beginning to set up programmes which
call for the flexibility to meet people where they are and which will free
employers to foLlow the stumblin g yet hopeful development of ordinary people
h)
The proMen of financial support:
The employed community development worker wants to keep his institu
tion solvent, if only t o preserve his salary. But if the work with commuhity
nuclei is so little heralded that the donors to the institution do not hear
of it, this particular work nay fall on evil days, or the institution itself
be ’in jeopardy.
c)
Identic, cation with_bour.c;eoise values :
Most institutions, once they have received public recognition for
their work, tend to identic with the ’’establishment”. In practice this may
mean lining up vdth middle-class morality and values, with the ethic of
”success”, and so on. Indeed, most community developers must wrench themselvo
away from their accepted beliefs to accept the patterns of valve that may grow
in the nuclei. Uncomfortable as the community developer may be, an institu
tion is even more uncomfortable when it discovers that its employees have
«
identified with people other than those who accept middle-class values. The
community developer who does come close to people’s needs and thinking may be
condemned for lowering Ms standards of excellence or for being disloyal to
middle-class ethics.
d)
Fbrsonal pileTnmas:
• Personal Relationships:
There are uniquenesses of personal relationship that seem to effect
outcomes favcurably or unfavourably. The success of process seems to depend
upon a mutual trust bet'woon the community developer and the community develop
ed. Unless the community developer trusts and is trusted, unless he* is
acceptant" of people, the process cannot be expected to work.
The relationship (rapport) is one of warmth toward people, one
in which they •coiie to trust him because he obviously believes in them.
He is acceptant of then, as they are, lout with the expectation that they
will become .better in a process that develops from friendship, He likes
then as individuals and believes in their favourable potentials. His belief,
expressed in manner, tone of voice, and activity, more than in words, tends
to create an atmosphere of confidence —— confidence in thonselves and in the
growing competence of other members of the group and in the group as a whole*
Tlie community developer contributes to this social atmosphere by
being the kind,of person he is. He is inperturb-bio, non-shockable, quietly
confident, patient, nonpartisan but devoted to people.
The people thus encouraged tend to discover that they are creative
in ways that they had not earlier expected. This leads then to act increasing]_y
bettor. In other words, to the extent to w3 ich the community developer is
successful to that extend his services will gradually become less and less
necessary. This is the shokc of diminishing dependence - when he real 1 ses
bhat he is no longer necessary to the on-going process. Will ho be satisfied
with sue ■< self-effacing r'ble? ’ 'This will depend on his s elf-c once pt' •
*The worft ’’acceptant0 is used in this ccnncctiun by ps7/cr».othGr<u:ist
Carl P.. Rogers - Soo c o-ooioT • • n " - '?•.? "■ ■ •
Sclf~concopts:
■Expectation of Proninoncc z
thn
gained workers-w th-pcoplo feel obligc.ted to exhibit
wortaSVX1? t
? arG e*Pert- Th0 teacher must instmet; the social
somicesVhrV
.of,peopAc^ the religious worker must conduct worship
liV ThoiXV010:11 wst
community surveys; and so on down a long
the iob tW'is
Pcrsoa'a concept of his own dignity rests upon his doing
stanH
V
+ ab®°ciated Wit) his own sense of importance. Merely to underSmXnS th 1°
W°rrieS> t0 teKeTC “ them> and tc create cS
eumstc.nces that will enlp them to solve their problems, may not give a
h“^X0P°r ”»* °f a
of £ conthtutta,,
OI
tivitv to
±^rG i
perfonal P^^nence tends to interfere with sensiS^consoSnT P
+° are ° deVel°P' HopeS for ^“o^i-tion (conscious
It is better to
^+7
Probability of learning along with the particip. nts
develop
Th t
the tnuaphs of success in ihe lives of those who
not 1-iM + £ 13 ‘sa’fc:Lsfac’t:Lon ln discovering such triumphs. But this is
fSly abandoned! appar9nt W±il the potation of prominence has been cheerDo-Gooder ImyudLsos:
SUV
°r ba^y ^SdSUt
lUb^eaS^Ss00
Tho emPhcsis upon predetermined imporvements and the reliance
Few co
GS! r°prcnscnt
Poles of a scale of operational
“r W «»«po do-eoolor
The S£“"
x.to .y eood ldcas is GVGr a temptation. But some developers
of probl^sd^1^
clearor a mG^hod that seeks the strengthening’
pro lem-solving initiative among the beneficiaries of development.
iii) Hoy much influcnco?
..
A final paradox needs to be mentioned. It has to do with a
bXSXS XV ,
GoncePt °P his ^fluence. He may be instrumental in
mWh-iW
fundamental, changes in people's lives that rake them
his voice
?oXo
CTtlzcn+s; At thG same time ho must recognize that
modem life
cacophony of influences that exist in
mi(i<5+ c-p
A community developer wields one ve^ small influenco in the
m a 0OnfPslnS complex of forces. The process he hopes for may never
no^\VVe S'boppod attor starting, or may be diverted to undesirable pur
poses by extraneous events and circumstances. While almost miraculous
hoW V OreUr Tn peOpLe (w0 13ave scen ■them occur time and time again)
he must also be prepared for the disappointment of poor response.
’
s._<
: '9 :
sU M MARI
1 . The
camwity developer attaches more importance to man,
than to
institutions/ideologies.
2. His mp.in aim is to make the
3 . His method is to develop in
individual-n n-tho-coynrruTn +-y*
the people critieal_awaronpss■>
faith in the people.
4. His most effective weapon is
longer needed
5< His greatest jox is to sec that he is no
■because the community has talcen ever.
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i
SHAPE POSITIVE HEALTH WORKBOOK
Inside this workbook:
i
Module: 1
■ ■■ I
■
I
I.
What is Shape -Vision & Mission
3
POSTIVE HEALTH -INTRODUCTION
Module-1 Positive health. Disease & dis-ease
4
PHYSICAL HEALTH-DIET NUTRITION
do you eat the right food?
7
PHYSICAL HEALTH-EXERCISE
' How fit are you?
10
MENTAL HEALTH
Do you know how to handle stress?
13
INTELLECTUAL HEALTH
Reading & remembering for exams—the easy way!
17
SOCIAL HEALTH
What is the basis of Value based living?
19
ANSWERS
21
Module-2
i
Module-3
Module-4
i
■ 1
Module-5
Module-6
J
I
J
■
Dedication:
This workbook is dedicated to our Pujya Gurudev Swami Chinmayananda
.. ... '
S?-'
2
■ 1
d
i
l
r
What is SHAPE?
•
IV
SHAPE is a acronym for School Health Awareness
ProrammE.
I
2
i
I
•
SHAPE is an unique student centred, activity-based
learning programme
The programme consists of six 40-minute modules that will be presented to students of
classes VIII to XII
The topics include:
I KSHEMAM Positive health concept
2. Diet & nutrition
3 Tips for everyday fitness
4 Mind mechanics & Stress reduction strategies,
5. Study reading techniques,
6 Value-based and principle-centred living
SHAPE
?
VISION:
Shape aims to impart the knowledge of positive health and its maintenance to the younger
generation so that they can integrate positive health practices into their everyday life
AIMS OF THE PROGRAMME
1
2.
lo introduce the concept of positive health in an interactive manner with the aid of
games and activities.
I
I o emphasize that health is made up of the physical, mental, intellectual social and
spiritual components
3.
To highlight exercises in each of the above components to practice everyday
4.
I he reinforce overall personality development is based on values and principles
and that it is a life-long process
3
Module: 1
POSITIVE HEALTH
<
'
‘
________________________________________
Ypu will learn .
1.
2.
3.
4.
5.
View of life and widening it
Definition of positive health
Components of health
Health spectrum
Health interdependence
Activity I
Puzzle I
Join the following 9 dots by
• Using 5 straight lines,
•
Without overwriting.
• You should start and end without lifting your pcncil/pcn from the paper
Puzzle II
By drawing a single line change the Roman numeral 9 to 6
IX
IVAYTO VIEW LIFE
Imagine a horse with a shield by the side of its ey es. The owner of the horse
puts it there so that the horse can sec only the road ahead of it and it is easy to steer
such a horse But as human beings we should keep our sights wide and should be
able to view the world around as fully as we can. The way we view life is calleclour
perspective. We learn new things by keeping an open mind and thereby widening
our perspective.
4
c
We invite you to widen your perspective
and learn about positive health!
m
5
Definition of Health
WHO has defined health as “a positive state of
physical, mental and social well being, not merely
absence of diseases and infirmity. ”
i
•
•
Health is a positive state of well being
Being free from disease will not make you healthy
Health Spectrum
Activity II
Fill the boxes with the correct colors of the rainbow
B
G
Y
I
J
R
O
The rainbow is an example of color spectrum.
The metamorphosis of a butterfly is another example of a spectrum
Spectrum Entire wide range of
anything arranged by degree or quality
As you can see above each color of rainbow gradually merges with the next
color. In the same way health is a spectrum with positive health on one side and
disease on the other
Positive Health
Disease
Dis-case
The term dis-ease means “out-of-balance”
Many of us are in this state of health, called dis-case We do not suffer from any illness or disease but at the
same time we are not in positive health. This lack or deficiency in positive health can be in any one of the
components of health
5
□
I
Components of Health
Health is a dynamic and composite entity We call it dynamic because it changes from minute to
minute Wc generally think that being healthy means physical In reality health is made up of the following
5 components:
____________
2. Emotional
4. Social
1. Physical
3. Intellectual
5. Spiritual
Not only should we be free from disease but also we should be strong in all four components of health to be
in a positive state of health
Health Interdependence
Story of Devas and Asuras
Once there was a fight between the Devas (the good) and the Asuras (the bad) One day they' went to lx)rd
Vishnu asking for justice Vishnu decided to give a grand banquet to teach them a lesson Though the
Asuras and the Devas did not think it was going to solve their problem they agreed to it was after all a
grand meal they were going to enjoy. They had dinner served in two different halls. In one hall, sumptuous
vegetarian mouth watering food was served for the Dc\ as and in another hall spicy hot non-vegetarian food
was served for the Asuras
The Asuras could not wait to enter the room as the nice aroma of the non-vegetanan food of C hinesc.
Mexican Tandoori varieties made their mouth water But to their surprise both the hands got locked al the
elbow disabling them as soon as they entered the room The hungry Asuras became even angrier when they
could not get the food to the mouth They were spilling the food all over the place but not being able io eat
They went straight to Vishnu to tell about the injustice done to them serving a grand dinner and not being
able to eat it. As they talking to Him they saw the D^ as coming out of their hall very happy belching away
after a nice meal This made the Asuras even angner Vishnu calmly told them to go and look into the room
where the Devas were eating
Can you guess what the Asuras saw? They found to their surprise that the Devas hands were also jammed
at their elbows; but they were enjoy ing their meal by feeding each other They returned to with their heads
dow n ashamed of themselves that they never thought of sharing and helping each they were too selfish.
The above story highlights the fact that as individuals we need to share and ne are interdependent on
each other, Sirnilarly tfiefive components of hyMf^rTdtSD^riterdependent.
Envotjonal
""Health^
Spiritual
Health
eal
InteHecttfa
Health
6
Social
Health
Module: 2
PHYSICAL HEALTH-DIET & NUTRITION
i
i
You will learn
1. Food groups and their role in our diet
2. To categorize everyday food items
under these food groups
3. Importance of well balance and
healthy diet
4. Healthy eating habits
6
A
Food Groups
The food that we eat everyday can be grouped under one of the following five groups:
Go foods- arc rich in energy and provides the fuel for vyork and play.
E g: Rice, Roti, Bread
2. Grow foods- give as protein, which arc the building blocks pf our body
(E g : Milk, Cheese, Curd (preferable from low fat milk), meat. fish. dal. rajma etc)
'■
.7.-
■g
wS
1
3.Glow Food- Provide vitamins, mincralsiand fiber, which arc essential
for our body Taking adequate quantities of these foods gives a healthy
S^n and hcncc ’ B*ow"
: fruils and vegetables)
4. Jlink foods- These food items give us instant energy and are tasty but not
good for heal th and nutrition (eg: Chips Chocolates, soft drinks etc) Fatty food
items arc tasty but excessive eating of these this kind of food items arc responsible
for heart diseases when we grow older
7
I
c
I
Did you know?
Fat deposits in our blood vessels, which block the
arteries of our heart leading to sudden heart attacks, are
found as early as 16 years of age!
Activity I
k.
Categorise the following food herns in the box under the four food groups.
Go foods
Grow foods
Glow foods
Junk goods
J
I1
al
Fruit salad
Ice cream
Paneer
Chocolates
Mysore pak
chips
Curd
orange
Bread
Idli
Rice
Brinjal
Carrot
Meat
Spinach
Milk
Egg
Well-balanced & healthy diet
WhaihAYsllzbalanc^Jki?
Weil balanced diet contains the proper proportion of the various food items. A healthy and well-balanced
diet contains all the food items belonging to the four groups; but the proportion of each varies
Look at the pyramid below. If you should plan your meals like the pyramid, you arc eating a well-balanced
diet.
Eat plenty of grow and glow foods which forms the base of the py ramid We should also have go foods to
provide us energy for work and play. Junk food and fried food items should be kept to a minimum.
8
<
Food pyramid
A
./ Fats,
\
Me
Junk food
oils,
cheese
/ Milk products, meat;
poultry, fish, eggs, huts
Grow food
Glow food
evetahles A fruits
Vr
" ;-‘4
•
XWW'* Bread, cereal, rice, oasta
Go food
c
T
1
2
3
Healthy eating Habits
I
2.
3
4
Eat like a king at breakfast, like a common man at lunch and like a pauper at supper.
Try' not to eat junk food in between meals
Sit in the Dining table and enjoy your food Do not watch TV and munch your food.
Keep yourself busy - boredom leads to over eating.
9
Module: 3
PHYSICAL HEALTH - EXERCISES
You will learn
1. Categories of exercise
2.Benefits of exercise
d
I
3.Components of exercise
J
4. .Goals setting & practical tips
Categ-Qrks
There are 3 mam categories of exercise:
1. Aerobics
2. Calisthenics
3. Weight Training
^T> Aerobic exercises are done bv moving large groups of muscles vigorously enough10
T increase the supS” of oxygen from the lungs to the heart and other parts of the body
When done regularly it improves heart and lung fitness
E g swimming, fast walking, jogging, cycling and skipping
w
r
Av
it'
Calisthenics arc stretch exercises It improves the flexibility. They are done
by moving the large and small joints of our body They are
good as warm up and cool down routines. They do little to
improve heart and lung fitness.
E g Touching toes, leg lifts, knee bends
3 Weight training helps to build muscle strength These exercises do not
directly improve the heart and lung fitness.
Eg. Lifting weights
10
Though all the above 3 categories of exercise are beneficial, aerobic exercise are very useful for overall
fitness and it has be proven to prevent lifestyle related diseases like heart attacks, diabetes etc.
Activity I
. .
Write down your previous day routines and calculate how many times you did an aerobic activity
Name of Activity
Number of Times
Place
No of Minutes
i
2.
3.
4.
Benefits of Exercise
Regular physical exercise gives one a healthy body and a healthy mind.
Through regular exercise you can
• Make heart and lungs strong
• Reduce risk of heart disease, high blood pressure and high blood sugar
• Burn body fat
• Become stronger and more flexible in body moxements
• Have strong bones
• Ixjok better with good shape bright eyes and healthy skin
• De more alert with better concentration
• Sleep better at night
• Reduce the effects of mental stress
In short you can gain
Stamina, which is the endurance to do, sustained physical activity'
Strength which is the ability to have power to move or lift things
Flexibility is the ability to be agile and fit
Components of exercise
Choose an exercise that conveniently fits your daily routine.
An exercise routine should be preferably done all days of the week - at least 3 times a week
It should last for 30 -45 minutes
Always warm up-do your routine - and cool dow n
GoaLsetting & practi(?al tips
Easy tips to be healthy
• Walk or cycle to the market instead of going by car
•
Climbs stairs instead of going in lifts
• Dust and mop your rooms yourself instead of asking someone to do it
• Go for a walk with friends instead of playing video games
• Play outdoors instead of watching TV
Give no excuses like “no time", “no facilities”, too tired”, “too difficult” and so on
Like any activity in life that you need to succeed, you need to set goals for yourself and make sure you
stick to your plan. The activity pyramid in the next page gives you guidelines for the goals and plan for
every week
11
1
I
Cut down on
FROM THE PRESIDENT'S
COUNCIL ON PHYSICAL
FITNESS SPORTS
•Watching TV
•Playing computer games
•Sitting for mcxe than
30 minutes at a time
2- 3 tim«> a weak
• Stretch/strengthen
•Cud-ups; sit-up
•Weight training
a week
Leisure activities
•Golf
• Bowling
• Softbcjll
•Yardwork
2"3
3-5 timei
a week
'Recreational
3-3 tinsoK
q wook______
Aerobic exercise
•Swimming
• Bicycling
•Brisk
walking
jporh
• Basketball
♦Tennis
♦ Hiking
•Soccer
Everydayj
• Wol ITriwiTdpgW
• Tak? the^itaits]
• Ma ke^jjraw^T; i n^your^day
12
it
TV
ID
I
1.
Module :4
2
MENTAL HEALTH
You will learn
i
6.
i
1. What is mind
If1
sc
2.flow do thoughts arise
3.What is stress
4. How to cope with stress
Mechanics of Mind
What-js Mjnd?
Mind is flow of thoughts
Mind can be compared to a river.
Stagnant water is not a river so also when there is no thought flow (as in deep sleep) there is no
mind.
The nature of a river depends on its quality and quantity of water and the direction of flow.
Quality of water in the river depends on whether it is clean or dirty. How the river flows depends on the
quantity of water When there is a flood, water overflows the banks and water gushes all over Ihc
direction of flow depends on the banks that direct the water in the right direction so that the water will flow'
into the sea
So too the nature of mind at any given time depends on quality, quantity and direction of thoughts as shown
in the picture.
QUALITY
Quantity
Direction of flow
clean
floods
stream
13
■
i
i
I
Our mind emotions and thoughts keep on changing every' second is it neural? What is this due to/
The rapidly changing character of mind is it’s natural state of acth ity The nature of mind at any given
moment is dependent on three factors of thought flou quality> quantity and direction of flow
The state of our mind will depend upon:
1. Quality of thoughts - noble and selfless thoughts make the mind pure Low passions and criminal
thoughts make it dirty
2. Quantity of thoughts - more the thoughts, the mind is agitated; reducing the number of thoughts
make it peaceful
3. Direction of flow- the directions of flow of a river is determined by its banks and to the ocean into
w hich it ultimately drains into, the direction of thought flow arc guided by the values and principles
that arc important to us (These arc the banks) Our life time ambitions is the ocean into which our
thoughts flow ultimately
How does thoughts arise?
An object or action from the world outside stimulates thought (It can be an ice cream van or an unkind
word ) This is perceived by our sense organs This information reaches the mind. Till now it is purely a
physical process like any physics experiment Once the stimulus has reached the mind thoughts arise
J
STIMULI
I
2.
.3
4
5
sight
sound
smell
taste
touch
PERCEPTION
iHNSli
ORGANS
I eye
2 ears
3. nose
4 tongue
5 skin
INPUT
MIND
THOUGHTS
If we react to the stimulus then these thoughts take the form of a desire (’7 want strawberry ice cream' or
‘7 want to bash the person who insulted me") these desires activate the action organs and they carry out he
appropriate actions This last event is also purely mechanical
DESIRES
¥
B
THOUGHTS
(•
ACTION
ORGANS
mouth
hands
legs
4. vital organs
5. sex organs
ACTIONS
|r|| OUTPUT
I.
2
3
4.
5.
speech
hand actions
locomotion
vital functions*
reproduction
Thus wc can sec the only place we can intervene or make any change between the stimulus and response is
in the arena of the mind. Thus the mind has the abiUty to choose our response. This is called responsibility
(response -ability) This is a unique gift to fnankind. Animals and plants are programmed by nature and do
not have this response -ability. Hence we should take pride and use this response-ability to the maximum
extent.
14
!•
Response - ability
find P
respo
How
Wca
STIMULUS
1. L
Prcsc
2. v
Weh
can i
contr
RESPONSE
MIND
What is stress?
3.
Wha
i
7 ///< STRESS RKSPONSF
1.
Imagine the following situation.. You haye rented a small cottage in a
remote port of kodaikannl and one night after dinner you arc standing nt the
sink washing the dishes II s been raining all day. and now a strong wind is
blowing the rain against the windows. Although it’s pilch dark outside, the
collage itself is warm, and you are looking forward lo relaxing with a book
prior to going to bed As you turn away from lhe sink, you suddenly see a an
ugly face pressed up against lhe windows and grinning at you!
Al the momcnl this happens, striking physical changes are set in motion in your
body Because you had just finished eating dinner, and relaxed, blood was being diyerted to your gut to aid
digestion (therefore less blood is being sent to your brain) Your breathing was relatively slow, your heart
rate was quite slow and regular, and your skin was dry and warm
Now, digestion has stopped Blood is being shunted rapidly away from your
gut to your brain, which is now highly aroused, and particularly to your muscles,
which arc preparing for action. Your heart rate and blood pressure have increased
dramatically, and your skin (as the blood is diverted away from it feed the brain and
A
muscles) becomes cool and clammy The palms of your hands are becoming moist and
your pupils dilate From your nervous system a message has been sent to the adrenal
glands to secrete the stress hormones, i e. adrenaline and noradrcnalin. These hormones
increase the force and speed of contraction of the heart and they also enlarge the airways so that more air
can reach the lungs more quickly. Blood sugar (glucose) is released from storage in the liver into that can
be burned rapidly. Your blood has also become ‘stickier’ and more likely to clot should you be injured
The perceived threat (the essential component in all stresses), has produced a highly
complex scries of biochemical and psychological reactions, which Walter Cannon of
Harvard described as the
or flight9 reaction*. This sequence of bodily changes is
genetically programmed into each of us and links us to our prehistoric ancestors Of
course, you don’t need to go to a remote cottage in Kodai to experience all this. A
r near miss on the chcnnai roads can produce exactly the same pattern of changes.
A
Today , most of the stress wc face are not solved physically by either fighting or fleeing, so the
body's stress response has no way to dissipate Modem man has retained his primitive hormonal and
chemical defense mechanisms, but a twentieth century lifestyle docs nol allow a physical reaction to lhe
stress agents wc face.
Physically attacking people Mhom we hate, or running from w hat we find to be an acutely stressful
event(like exams-however much we may relish the thought), are not socially acceptable reactions.
f
15
2.
3.
4
1
I
at4.
Our
imp
MC
■
!
J
Our long evoked and ancient defense mechanisms prepare us for dramatic and rapid aclioq. Ipit
find little outlet. Wc have to repress them It is the inappropriateness of the normal biological stress
response in the context of modem living, which is potentially harmful.
How can we reduce stress in our lives?
Wc can reduce your stress levels by following these three simple strategies
1. Live in the present.
Present is the only time wc can act and do and achieve
2. work within your area of influence
Wc have to be practical and do small little things which is within the area of our life that we
can influence. Sitting and broodihg about the slate of the world over which we have no
control is a sheer waste of time and mental energy
jc in a
at th'
ind is
the
book
: a an
your
o aid
heart
3. Be practical - expect all eventualities
Whatever action wc do, only four kinds of results arc possible:
1. equal to w hat w e expected
2. more than what we expected
3. less than what we expected
4. opposite of w hat we expected
It is impossible for us to do any action without expecting results. If we expect all the
above eventualities our disappointment is much less and it goes along way in reducing
1
our stress levels.
4. Acceptance - accept that we cannot call all the shots
Our performance is usually not consistent. Wc have little say regarding external factors. Jt is impossible to predict unforeseen factors that may modify the results So we should learn to
accept things as they are
Lord! Give me the courage:
A
i
: air
can
□ To change things that can & ought to be changed
□ Accept the things that cannot be changed and
□ The wisdom to know the difTerence!
k
“A
the
md
the
■fill
i
16
1
StepJ
Module: 5
’-Read i
INTELLECTUAL HEALTH
Step 4
You will learn
Read
Step.5
1. What is reading
-Read
Slept
2 Principles of study reading
-Look
Step:
- -Rea;
3 Revision - the proper way
Step:
-Rcvi
Reading for exams & enjoying it!
Step:
What is reading?
-Rea
Recognition
Step
Reading starts with recognition of written words
Make
Revic
Physical transmission
You also need a good eyesight and lighting for the transmission
Comprehension
You should next understand w hat you are reading If w hat you are reading is ABCs,
there is no problem! But if it is nuclear physics, you will not understand a
thing!
RE
First
you
But
And
you
Anc
with
'/yKnowledge bridging
If you do not understand a certain area of w hat you arc reading, you get a
doubt. You can either ask your teacher or refer other books to bridge the gap in your
knowledge
Retention & Recall
This is the most important aspect of reading for exams you want to
remember what you have read and write it clearly in the examinations
i
i
Principles of study reading
Step: |
Read the title and think about it: how much do you know the topic
StejrJ
' ook at the Table Of Contents
17
I
Step: 3
-Read introduction and summary of Chapter (or) first and last paragraph
Step 4
Read review or discussion questions
Step:5
^-Read all major headings and subheadings
Step: 6
-Look at all pictures and tables
Step: 7
-Read first and last lines of the each paragraph
Step: 8
-Review and write down the major points of the chapter as fast as you can ( 2minutes)
Step: 9
-Read the chapter in depth
Step: 10
Make notes
Review & revise
Cs,
REVISION ■ THE PROPER ITA Y
First revision should be done 10 minutes after one hour of learning This will enable you to remember what
you have learnt for day only I
But if you revise the sonic topic the next day also, you will remember what you learnt for a week
And if you revise the same topic the next week and c\ cry week for 3 weeks, the learning is permanent and
you will be able to recall a| will
Another advantage of regular revision is that the time you spend in revising the same topic becomes lesser
with each revision
L
REVISION
TIMING
RECALL
24 hrs
II
10 mins. After
1 hour learning
1 day after
III
7 days after
15 -30 days
IV
Every week x 3
Long term
I
Vi
.
7 days
•
i
18
e>
c:
Module: 6
E
SOCIAL HEALTH
A
ft
V
v
Yqu will learn
1. What is Value
I
F
i
t
2.What is happiness
J.Living a life of values
VALUE BASED LIVING
value9
What is value?
A ,
Value literally means worth or desirability In our context, it stands for one’s judgement of what is valuable
or important in life
>.
/!•
I,
What is important in life?
What is the most important thing in our lives ? Money ? Power? Home? Parents7 Friends? These may look
important; but when we analyze why we think any of the above is important, it boils down to a very selfish
reason - our happiness! Don't kid yourself It is a universal need Our happiness is most important in our
ll'cs
What has values to do with cnir happifiifes?
Remember that value is one's judgement of w hat is valuable in life The most important thing in life is our
happiness. Naturally wc arc going to pick our values for our living which will give us happiness.
§
How_do__we_de< erni i ne_avalu e9
First a knowledge of standard codes of living in our society is necessary - you can call this ethics, morals,
principles, it docs not nutter.
At birth, wc have no knowledge of values When the baby throws tantrums, it gets a strong message from
the mother that it is not right In order to please the mother, it stops tlic tantrums- the first step towards
value based living’
All through our lives we continue nuking this value judgment- is this important in my life? Will this give
me happiness? Will I be comfortable doing this9 If we arc convinced, then wt internalize this value After
this internalization, our actions and interaction with the society is in line with the value set we earn
Let us hike an example - Truth Wc all know 7 ruth is a good value and telling lies is not right But how
much wc adhere to this principle depends on how much wc have internalized this knowledge At one
19
I
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♦
4
i
i
extreme, when we have zero internalization we have absolutely no qualms about it. Mahatma Gandhi is
example of 100% internalization of the value of Truth
I
X
J
Free will- the human prerogative
At every turn of our lives we are faced with a choice Man is the only being in this universe that has this
free will. Though it is beneficial, this choice makes us afraid w hether we will make wrong judgments
What looks like a perfectly ideal solution at one time looms as a large mistake in die future. In choose
values to guide our lies this freedom of choice plays a very important role
How to distinguish between right and wrong?
Right and wiong are relative and depend upon the society in which wc live in What we consider as wrong
in India may be viewed as right in another country' In a society of cannibals, eating human flesh may not
be considered wrong!
These arc the two ways of finding out w hat is right or w rong
Step 1. Look at the collective wisdom of our society that has laid down certain codes of conduct w hich will
lead to universal happiness Examples of such values arc honesty, chanty. love, generosity, and
unselfishness. Wc should read and acquire knowledge about these values
Step 2 This is a very personal one Just w atch your minds’ reaction to any action you do If the mind is
agitated and keeps on thinking, "I should not have done it” then that action is wrong You should attempt to
clarify' your values on that subject and avoid doing it again Right actions on the other hand, bring
happiness and your mind is at peace with itself
Respect for eiders is one value many teenagers ha\ e problems with Especially in India this is an important
value. If wc arc and brought up in India this value will be ingrained in us Naturally if we act against this
value it creates mental disturbances and unhappiness It is important we accept this value and internalize itfor our happiness!
i
valuable
1 T’'
'
. i
I •*
pay look
y sclfiih
in oir
‘e is our
morals.
2 from
rds
s give
After
tow
c
20
$
'-■J
ANSWERS
Kb
Module: 1
Puzzle: 1
.• u;.:.
■'
Module: 1
Puzzle 2
SIX
Module: 2
Activity: I
Categorize tlw foJlQwing.fp_Qd jtemsjn theb_Qx under £he _^
Go foods
Grow foods
Bread
Egg______
IdljL____
Rice
Milk_____
a
Paneer
Curd
Meat
Glow foods
Junk goods
Fruit salad
Ice cream
orange
Brinjal
Chocolates
C ai rot
Spinach
chips
k
B K,
Bio
Mysore pak
I
21
b
r
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' u- ■
4
mom t.
KSHEMAM TEEN HEALTH CAMP WORKBOOK
*
SERVE .CO**'
M H
VALUE BASED LIVING
What is a value?
Value literally means worth or desirability. In our context, it stands for one s judgement of what is
valuable or important in life.
What is important in life?
What is the most important thing in our lives? Money? Power? Home ? Parents? Fnends? These may
look important; but when we analyse why we think tliat any of the above is important, it boils down to
a very selfish reason - our happiness! Don't kid yourself. It is a universal need. Our happiness is most
important in our lives.
]I
!
I
What has values to do with our happiness?
Remember that value is one's judgement of what is valuable or important in life. The most important m
our life is our happiness. Naturally we arc going Io pick values for our living which will give us
happiness.
Values start with llrst with liic knowledge ol standard crxlcs of living in our society- you can cull this
ethics morals principles, it docs not matter.
Al birth we have no knowledge of values. When the baby throws tantrums, it gets a strong message
from mom that it is not right. In order to please the mother, the baby makes a judgement that not
throwing tantrums is important or valuable-thc first step towards value based living!
All through our lives w e continue making this value judgement - is this important in my life ? Will this
give me happiness? Will I comfortable doing Ibis? If we arc convinced, then we internalise this value.
After this internalisation, our actions and interaction with the society is in line with the value set we
carry.
Let us lake an example - Truth. We all know I ruth is a good value and telling lies in not right. But
how much we adhere Io this principle depends on how much we have internalised this knowledge. Al
one extreme, when we have zero internalisation we have absolutely no qualms about it. Maliatma
Gandhi is an example of 100% internalisation of the value of Truth
t
Free will - the Im man prerogative
At every turn of our lives we arc faced with a choice. Man is the only being in this universe that has
this free will. Though it is beneficial, this choice makes us aftaid whether we will make wrong
judgements. What looks like a perfectly ideal solution al onetime looms large as mistake in the future.
In choosing values to guide our lives this freedom of choice plays a very important role.
do distinguish between right and wrong? ,
Right and wrong arc relative and depend upon the society in which we live in. What we consider as
wrong in India may be viewed as right in another country. In a society of cannibals eating human flesh
may not be considered w rong!
There arc two ways of finding out what's right or wrong
Step: I Look at the collective wisdom of our society who lias e laid down certain codes of conduct
which will lead Io universal happiness. Examples of such values are honesty, charity, love, generosity,
and unselfishness. We should read and acquire knowledge about these values.
Step: 2 This is a very personal one. Just watch your mind’s reaction Io any action you do. If the mind
agitates and keeps on remembering the action- you keep on thinking, “ I should not liave done it then
that action is wrong. You should attempt Io clarify your values on that subject and avoid doing that
action again Right actions on the other hand, brings happiness and you mind is al peace with itself
Respect for elders is one value many teenagers have problems with. Especially in India this is an
important value. If we arc born and brought up in India this value w ill be ingrained in us. Naturally if
we act against this value it creates mental disturbances and unhappiness. 11 is important that we accept
this value and internalise it - for our own happiness!
25
(J
/ 1
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1
Summary table of card-game for CHWs: Diagnosis of fever in adults
No.
1.
Age/sex
35, male
Duration
of fever
5 days
Periodicity
Cold?
Cough?
Fever
on No
alternate days
No
Any pain?
Diarrhea/
urinary
complaint
Other features/Supplementary questions
Some
headache,
bodyache
No
Chills?
6,
female
2 days
Intermittent,
no regularity
Yes
Yes
Some
headache,
bodyache
No
3.
14, male
1 day
Continuous
No
No
Severe
headache
No
4.
70, male
2 days
Intermittent,
no regularity
No
Yes
Pain in
chest
the No
8,
female
3 days
Intermittent,
no regularity
No
No
Abdominal
pain
Treatment
v
Malaria
Para, Chloro
Common
cold
Home
remedies, Para
Meningitis
Immediate
referral
Pneumonia
Immediate
referral
Dysentery
with fever
ORS,
Cotrim
Yes
2.
5.
Diagnosis
Diarrhea
Neck
rigidity?
Yes
Semi
conscious,
not speaking
Cough since Breathless
when?
ness?
Expectora
tion?
2 days
Yes
No
Diarrhea
since when?
Blood
stools?
3 days
Yes
m
Para,
o
3
t3
No.
Age/sex
Duration
of fever
Periodicity
Cold?
Cough?
Any pain?
6.
25,
female
5 days
Intermittent,
no regularity
No
No
Pain in the Burning
loin, lower urination
back
7.
10,
male
4 days
Intermittent,
no regularity
No
No
Pain in the No
arm pit
Diarrhea/
urinary
complaint
Other features/Supplementary questions
Examine armpitBoil, pus
Diagnosis
Treatment
Urinary
tract
infection
Plenty
fluids.
Cotrim
of
Para,
Abscess
with fever
Remove
Para
pus.
If fever and
swelling
continueCotrim
8.
16,
female
4 days
Intermittent,
no regularity
No
Yes
Sore throat
No
9.
45,
female
3 days
Intermittent,
no regularity
No
No
Aching
entire body
10.
12,
male
8 days
Continuous
No
No
Some
bodyache
Examine throat - purulent spots in throat,
tender nodes in neck
Bacterial
Pharyngitis
Gargles, Para,
Cotrim
No
Viral fever
Rest, Para
No
? Typhoid
Referral
f '
Con f I
ST. JOHN'S MEDICAL COLLEGE, BANGALORE
£
Class
Roll No.
Semester
Subject
Examination
Date
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.1
INSTRUCTIONS
FOR
COMMUNITY HEALTH WORKERS
CHUC— 1
CHAPTER 7
Maternal and Child Caro
The care of mothers and children is an important part :f family welfare
services. Some of your tasks which relate to tho health care of mothers and
children have been described elsewhere in this Course e.g. in the chapters
on Nutrition,
Immunization and Family Planning.
i t .) consult the Health Worker (Fenale) ar the
7.1
Advise pregnant w<P'.
trained’ dai for prenatal, natal and postnatal care
It is important that a mother maintains good health during her pregnancy
in order that she ri|ay deliver a
Tt is also important that she
a healthy
healthy baby.
baby.
should receive competent care during her labour and that after delivery she
and her baby should be followd up to ensure that they progress normally.
Therefore, during your homo visits whenever you find a pregnant woman,
you should emphasize the'following points about the need for prenatal, natal
and postnatal care?
’■*3 Health Worker(Female) or trained
1. Regular prenatal care given by the
important
for
the
health
of both the mother and her unborn
dai is :
baby.
2. Prenatal care ensures the followings
(a) Tho health problems of the woman are treated or she is referred
as early as possible
(b) Tetanus tr xoid is given well before the expected date ■. i delivery
(c) Iron and folic acid tablets are given to th 'se who are anaemic
(d) The woman receives the necessary information about how to look
aft er herself during pregnancy end how to prepare for delivery
3. Proper care during labour ensures the following?
(a) Prevention o-f infection
(b) Prevention of complications caused by improper handling during
delivery
(c) Early referral when complications arise
4. During the first week after delivery the mother and baby should be seen
by the Health Worker(Female) or the trained dai, anc^subsequently,
both mother and child should attend regularly the MCH clinic at the
Subcentre
5. Regular postnatal care ensures the following?
(a) Health problems in the mother can be identifier.! and treated early
(b) Health problems in the baby can bo identified and treated early
(c) If necessary the mother or baby can be referred in good time
(d) Iron and folic acid can be given if necessary
(e) The baby edn bo given the necessary immunization
(f) The mother can be given family planning advice
(g) The mother can bo advised about infant ca»e and proper feeding
7 >2
Advise pregnant ujamon to got immunized against tetanus
Tetanus germs are commonly found in rural areas because> of the close
The use of unclean
association between animal manure and human habitation,
instruments during home delivery and the improper care of the cord stump after
This
is usually fatal.
it has been cut can cause tetanus in the newborn.
?
2 °
Fol
The diseaso can h*j av<.firlod t>y
‘*9 nirjrtf?.' n- • '•*-**
in two doses at an
interval of 2 to 3 weeks
(b) If, for some
medicating the baby1s cord.
7.3
■
j availability of maternal and child care
Educate the community about the
them to utilize the facilities
services and encourage
ln tho
-—"S
You should inform the people
which are available for mothers and children
/ to encourage the
and at the Primary Health Centre,t Take every opportunity
to
promote maternal
of these facilities so as 1
community members to make use c. -----and child health.
These facilities are as follows?
(a) The trained dai is always3 available
for giving prenatal^i natal and
She
accompany
postnatal care*
F,._ will
—
the mother to the Subcentro for
NCH care.
1. In the village?
(b) The Health Worker(Female) will be
available on the specified days
when she is scheduled-t □ visit the
village in her intensive area.
During these visits she will do the
foliowin g?
(i) Examine prJghant and nursing women
(ii) Conduct homo deliveries.
(iii) Immunize mothers and children
below one year
(iv) Distribute iron and folic acid
tab-l-ots topregnant and nursing
wtrneru
(v) ui-.ribute vitamin A to children
1 to 5 years of ago
(vi) Treat mothers and children for
minor ailments and refer them to
tbe pHC if necessary
(vii) Civo health teaching about the
care of mothers and children
(c) The Health Worker(Male) will be
available on the specified days when
he is scheduled to visit the villages
—i and those in
in his intensive area
- • • area.
- , He will carry
his twilight
out the following activities?
‘t
(j$ Immunize children over one year
in the intensive area and all
mothers and children in the
twilight area
(ii) Distribute iron and folic acid
and vitamin A in coordination
with the. Health Worker (Female)
(iii) Treat minor ailments in mothers
and children and refer them to
the PHC if Hecrscorv
I
t
o
O
ZZ
vJ
o
o
(d) The Health Assistant(Male) will be
available on specified days each
month for carrying out the immunization
of school-going children
2. At the Subcentres
(a) The daily general clinic will be
attended 'either by the Health Worker
(Fema1 e) or the Health Worker(Hale)
The services for mothers and children
will be as follows?
(1)
(ii)
(iii)
(iv)
Prenatal and postnatal care
Child health care
Immunization
Distribution if iron and folic
acid, and vit .oiin A
(v) Treatment a minor ailments
(vi) Health teaching
(b) The weekly HCH' clinic will be attended
by the. Medical Officer, Primary Hea]_th
Centre, and/or the Health Assistant
(Female)
3. At the PRC 2
The following
services will bo available^
(a) Daily general clinics attended by
one of the Nodical Officers
(b) Weekly out-patient NOH clinics 9
attended by one of the Medical Officers
(c) In-patiffiiat care
(d) Fofcrral to the District Hospital
7.4
Educate the community about how to keep mothers and children healthy
Some of the topics about which you should t Ik to poople^in’the community
are as follows?
1. The value of pregnant women attending NOH clinics regularly and the
need for postnatal examination of the mother and her baby
2. The need for delivery to po conducted by the Health Worker(Female) ior a
trained dai and f. r precautions to be taken to prevent infection
3. The importance of having children examined and weigred at regular
intervals to check that they are developing /ind gr ;wing normally
4. The importance of g >jd nutrition for the mother and baby
5. TpQ need to protect pregnant women an;- children against communicable
diseases by immunization
6. The importance of personal hygiene and of hand-washing before handling
the baby and especially before preparing food for the baby
7• The need to make the environment in and around the home clean and
safe.so as to prevent children from getting diarrhoeal diseases,
worms and sore eyes
8. The need for every child to be a wanted child am! to receive love
an d affection
9. The need to seek early treatment if either the mother or the child
is ill
If any of the following signs; and symptoms are present the mother or
child should be taken immediately to the Health Worker or to the SubcentreS
(a) In pregnant women
(i) Headache
(ii) Swelling of feet, fingers, face or vulva
(iii) Blurring of vision
s 4 s
(iv) Pallor
(v) General feeling of weakness
(vi) Yellow eyes and highly coloured urine
(vii) Swelling and pain in legs
(viii) Vaginal bleeding
(ix) Vaginal discharge
(x) Fever
(xi) Cough
(b) In newborn infan'.o (within one week of birth)
(i) Inability t o suck
(ii) Difficulty in passing urine
(iii) Stools not passed
(iv) Daiindicc
(v) Diarrhoea.
• (vi) Fever
(vii) Dischargo from cord stump
(c) In infants(up to one year)
(i) Inability to suck or refusal of feeds
(ii) High fever
(iii) Severe or persistent diarrhoea
(iv) Vomiting-'
(v) Excessive crying or irritability and drawing up legs on abdomen
•.(vi) Convulsions
(vii) List le.ssness or drowsiness
(viii) Difficulty in breathing
(ix) Skin rash
(x) White patches on tongue
(xi) Discharne fr -m eyes
(xii) Discharge from ears
\
(d) In- children (one to Five years)
(i) High fever
(ii) Severs or ^persist ent diarrt ea
(iii) Vug^ting
• ; (iv) Passin g worms in st Is
(v) Skin ra.S'jn(vi) Con . ul iir/13 ’
(vii) Paralysis r weakness of muscles
(viii) Stift’nesh c.f neck
(ix) 'ljallor
(.x). Drynes.; jf eyes
(xi.) Shinys dry o_d scaly skin or wrinkled skin
for his/her age
(xii) N a ••‘gaining.weight one' rnot developing
,
(?<iii) Po t a.pnetitc
(xiv) Bowing • f lens
(xv) Rubbing,eyes tr discharge from eyas
(xvi) Pulling on ear or discharge from ear
/
i
pc
/////////
i
CHAPTER 9
M ..TERRAL AND" CHILD HEALTH
Health services for mothers and. children, more
more commonly
commonly
a31
Hild health' are - 'Package of sowicesthat has been developed to meet the needs of pregnant women
before, .during, and after delivery, and of infants from birth
to five years.
The package o: maternal and.child health 30rvices is
concerned with the ■ ■. ..lowing:
i. Ensuring V-.e birth of a, healthy infant to every
exptctant. nother.
iio Providing services to promote the healthy growth and
development of dhiipren up to he age of five years.
iii. Idertifyi Lg health problems in mothers and children
at an early stage and initiating prompt treatment,
iv rreventin-j malnutrition in mot?)ers and children.
v . Preventing communicable -diseas -.s in mothers and
children.
vi. Improving she health of mothers and children by providing family planning services.
vii. Educating mothers on how to- improve or maintain
their own health ano that of their children.
9.1
THE NEED FOR HCH SERVICES
1. Human Resources : If children are to be born strong
and healthy, their mothers will need to receive good
prenatal and natal care. After they are bom, they
need. specially designed health services ’so that their
survival and healthy growth are ensured through proper
nutrition and protection against communicable diseases
and poor environmental conditions.
SERVICES FOR IMPROVING THE HEALTH OF MOT'ERS AND -CHILDREN IN
THE VILLAGES ARE IMPORTANT FOF THE CONTINUED PROGRESS OF THE
NATION.
2. Numbers Affected: Sixty per cent of the total popu
lation in the country consists of women of child
bearing age and children under 15 years. Twenty per
cent of this group are children under five years of
age. This means that maternal and child health
services would reach almost two thirds of the copu
lation.
3. Special Health Needs: Women and children have the
highest risks in terms of number of illness and
deaths. They also have special health needs which
are not met b^ other services.
4. Investment in Health: The early identification of
health problems and prompt treatment of disease among
mothers and children can yield life-long benefits
for the individuals, their families and communities
in which they live.
c
°EIiVERHG2CURA^IVE AND PREVENTIVE HEALTH SERVICES AT THE
SAME TIME TO
MOTHERS ANT CHILDREN IN THE VILLAGES IS A PROFIT'
ABLE INVESTMENT IN THEIR HEALTH.
contd./
Ikr:
2
2
:MOST WOMEN IN THE CtM4UNITY WILL SEEK
IE CARE OF THE LOCAL
DAI WHErj. THEi BECOii.I PilEGNANT AND ARE R-IADY TO ‘‘'El. TVER,, YOU
WILL HAVE TO CONVINCE THS WOMEN ABOUT THE VALUE ON ALSO ATTEN
DING THE MCH CLINIC F01-- THE HEALTH OF THE UNBOR CH TTP 0
The advantages of attending the MCH clinic are as
follows:
•leneral h
which can
-Tth assessment can reveal abnormalities
e corrected or tre ed early,
ii. Further (e. -nation and treat;../t can be carried out •
when there are irregv. lari ties related to the pregnancy.
iii. Health ec-rcation can be given regarding care during
preg .-.anc ? preparation for home•delivery or hospital
delivery. md care of the infant.
'-tdle .motivating women to
attend
MANY OF THE HEALTH PROBLEMS RELATED -TO PREGNANCY . ilD CHILDBEARING CAN BE PREVENTED OR REDUCED BY <EGULAR EXAMINATION
DURING PREGNANCY A'f PROMPT TREATMENT »
9.2
WHAT YOU SHOE ID KNOW ABOUT THE HETLTH CARE
OF PiIEGNANT WOMEN.
In the twilight area, among pregnant women, you will have
to concentrate on those who are more likely to develop compli
cations and assist them to obtain the necessary health care
At present, in the twilight area, in the absence of the Health
Worker (Female), pregnant women without complications■will be
cared for by the local dais.
Maternal health problems that are commonly seen are
as follows:
1. Malnutrition with anaemia.
2. Poor or no weight gain during pregnancy.
3. Poor gene-.1 health due to the burden of too frequent, unplanned pregnancies.
4. Infection from induced abortion.
5. Toxaemia of pregnancy.
6. Vaginal discharge.
7. Parasitic infestation.
THE MOST COMMON CAUS £S OF DEATH RELATED TO CHILDBEARINC ARE:
i. INFECTION FOLLOWING INDUCED Al. ?• ..PION.
ii. ANTEPARTUM ^ND POSTPARTUM HAE1 ?R CIAGE □
iii. TOXAEMIA OF PREGNANCY.
iv. ANAEMIA.
Women who are_
<
likely
to develop complications during
pregnancy and child-birth include the followina:
Those under 15 or above 45 years of age.
ii..Those who lave had four or more pregnancies.
iii. A woman 35 years or older who :.s pregnant for the
first time.
iv. Thoswho h ve h-v previous abortio s,
r• -
•
ieduced
-2 3
v. Those whose last child is under one year.
vi. Those who have had previous premature births
vii. Those who have had complications during ■previou s'
pregnancies or deliveries.
viii. A woman of small build.
ix. A woman with twin pregnancy.
x. Those who are malnourished.
xi. Those who have a chronic dise-Lse such
culosis or malaria.
■ : tuber
After identifying a woman who is Likely to. pavelon conplications during pregnancy or childbirtl , proceed 3 follows-
i. Do a Tallquist haemoglobin estimation an ■. administer
iron and folic 'acid tablets if indicated.
iie
Advise her to attend .the MCH clinic at tie subcentre
for exami intion and treatment.
iii. Find out what she is eating dally and-...advise "mr as
to how to improve her diet.
iv. Persuade her and her husband to allow you to immunize
her against tetanus in order to protect her unborn
child.
IF YOU COME ACROSS .A WOitkN WHO....IS LIKELY TO DEVELOP COMPLICz
TIONS DURING PREGNANCY OR CHILDBIRTH, INFORM THS HEALTH
WORKER (FEI-4ALE).
Prenatal-complications that are commonlv found include
the following:
i. Threatened abortion.
ii.
Incomplete abortion or expulsion of the contents of
the pregnant uterus early in pregnancy usually
beofore 20 weeks.
iii. Septic abortion or infection of the uterus. This
develops after abortion when unsterile methods or
equipment have, been used to in'uce expulsion of the
f odtus.
iv. Haemorrhage after the seventh month of pregnancy.
v. Toxaemia if pregnancy is characterized by two sets of
signs and symptoms. Pre-eclamosia is the earlier
stage of the condition and is characterized by
swelling oi the legs and fingers which may be accom
panied by headache. • Eclampsia is the more severe
form of the condition in which the woman has generalised
swelling of the body, severe headache and convulsions.
Abortion or premature delivery often occur when a
pregnant woman develops eclampsia.
contd./
Ikr:
4
-: 4
If a pregnant woman has any of '.■•a follow’’, ig con :.i bions.
proceed as follows:
I
T
.—r
| Threatened • Incomplete!
Septic !
I Abortion I Abortion j
Abortion
History of vaginal
bleeding
Ye s
Amount of bleedin-
Slight
He >vy
y ciable
No
Yes
I lay be
No
Yes
Products of conce
passed
on
Yos
L
Purulent, foul disc.large
No
Abdominal pain or
tenderness
Yes
Yes
Yes
Fever
No
No
Yes
I
_____
Ergot tablets
Triple
Sulpha
Tablets
______
Instruct
woman to
stay in
bed.
ii. Inform
HW(F) o
IF YOU COME z-.CROSS .
™ FA mi
HE/lL
_________
i. Refer to PHC
ii. Inform HW (F )
WOMuiN WHO HzlS VAGIT .L BLEEDING TZF^ER THE
ARRANGE for her IMMEDIATE iXiSGER
1 CENTRE. HER HUS3./D SHOULD .ACCOMPANY HER
ihform
If a pregnant.woman has any of th.
proceed as follows: ■
raE
fallowing conditions
■ Pre-Ecla. 'nsia
Eclampsia
Swelling:
Feet and legs
Hands and fingers
Face
Puffiness of eyes
Convulsions
Headche
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Occasional,
severe
Frequent or
continuous,
severe
Blurring of vision
No
Yes
Dizziness
May be
Yes
use
_______ V
• It i’i
i.
i
J
-: 5
I
9* 3.
in the diet.
ii. Refer to PHC
iiio Inform HW (F)
guiet, dark
ened room
iio .attendant cons
tantly with
patient.
iii. During convul
sions :
(a) Turn head
to one
side.
(b)Pl ace pad
ded piece
of wood bet
ween the te
eth to pre
vent biting
of tongue.
iv. Inform PHC or
arrange to tra
nsfer patient
to PHC.
Vo
Inform W(F)b
WHAT YOU SHOULD KNOW .ABOUT THE HEALTH CARE OF WOMEN
AFTER DELIVERY
When you visit the home shortly after a woman has delivered,
you should ascertain whether the mother and
-- infant
--- -- are progressing
normally. The dai who has delivered the woman
-- may or may not
refer her patient for medical care even when
-- - is necessary,
--- this"
Delay in referring either the mother or ithe
'
'
infant
with complications to the Primary Health Centre or hospital may result in
unnecessary suffering or even death.
Postnatal complic'ations which may commonly occur in the
mother include the following:
io
Puerperal sepsis (infection of the genital tract).
iio Mastitis (infection of the breasts).
iiio
Severe or nrolonged bleeding following delivery or
abortion.
iv. Thromboohlebitis (infection of the veins of the legs)
Signs and Symptoms:
If a woman who has recently had a baby has any of the
following conditions, proceed as follows:
Puerperal
Sepsis
Mastitis
Severe or
prolonged
bleeding
Thrombo
phlebitis
May be
No
Yes
May be
Purulent
discharge
Yes
No
No
No
Pain and tender
ness:
Lower abdomen
Breasts
Yes
No
No
May be
No
No
No
History of:
Excessive
vaginal
bleeding
I
Yes
i
- : 6
Puerperal
Ser si s
Mastitis
Severe or
prolonged
... bleeding
i Thrombo
phlebitis
History of:
Swelling of
legs
No
No
No
Yes
Headache
. as
Ye s
No
May be
F e ve r
' es
Yes
NO
Yes
Rigors (s i • ivering)
Y. i s
Yes
No
May be
r
T ripla-suIpha
tablets
ii. Refer
iiio Inform HW(F)
• 9.4
Re fI
er
I
In
ii.
form |
HW(F)j
i. Triple
sulpha
tablets
iio Bed rest
iii. Refer
iv. Inform
HW (F)
WHAT YOU SHOULD KNOW ABOUT THE HiblLTH C RE OF NEWBORN
INFANTS
Whenever you enc'rater a newborn infant (within a week
after birth), you should make sure that the baby:
is able to suck.
ii. is urinating freely.,
iiio is passinc stools within 24 Lxirs after birth,
iv. does not have fever.
io
does not i a ve j c tu nd i c e.
vi. does not lave diarrhoea.
vii. does not have any birth injury or malformation
which carl be coserved.
Vo
WEEK OLD HAVE YELLOW
MOST NEWBORlxf INFANTS WHO A:tE LESS THAN
IF'THIS PERSISTS BEYOND TEN
COLOURING OF THE SKI T AND EYES
DAYS, THE INFtNT S' ■- ULD BE REFERRED TO ?HE PRIM/ARY HEALTH CENTRE
REMEMBER THAT INFANTS ARE SOMETIMES BOR*7 WITH SERIOUS PHYSICAL
DEFECTS WHICH NEED PROMPT MEDICAL CARE. DELAY IN REFERRAL FLAY
RESULT IN DEATH.
YOU WILL HAVE TO WORK -CLOSELY WITH THE LOCAL DAIS SO THAT THEY
UNDERSTAND ' THE NEED FOR REFERRztL TO THS PRIMARY HEALTH CENTRE
OF EITHER THE WOI‘4EN THEY DELIVER OR THE INFANTS WHO DEVELOP
COMPLICATIONS FOLLOWING DELIVERY.
G- nt
7
7
Complications whic.
the following:
io
i< o
Prumatur.
nay u' mmonly occur in the infant include
y (birth --eight qf . , 500 grams or less)
infec .ions are -haracte .
by inf lammatiorTand
t >c/aL K fr 'm th= ©ye vary! j from sticky, watery
drscnar,.r to chick... purulent matef-ial. The
The infant's
infant1s
eyes c.\.
i.-y in ectea during thd■ 'passage through
the birci) -.1 -or later by hhe dirby ' bonds’ of the
birth a/ andant or moth
... Lb ■ r or by flies. With'the.
cor.trol
dually tran smitt ed "disee s-rs and the
use of s.. Iyer nitrate drops at birth,
the incidence.
of opthaJmia neonatorum has become minimal in the
country
iiio
Umbilica. infections are characterized by inflammation and Aisclj..i._ge from the umbilicus. Unclean hands
and ute
.Isysed by the birth attendant in handling the cord,/ or the^ application of cow dung, dirty
coverings or other
substances
>
----- to the eord or umbilicus
ar. sources of infection. Tetanus infection is the
mo;b f!y
serious
infection
iOUS type of infec
tion of the umbilicus.
•7ont .rues to occur in
-- rural
------areas because most
women h ,.ve inot been immunized against the disease
du ri ng pre gnancy.. The disease is characterized by
muscular spasms.
~' stiffness of the jaw and foul,
turulenl discharge from the umbilicus. The disease
is usually fatal in infants.
iv.
Thrush-ic a disease which is characterized by the
, appearanc e of white curd-li:
□atches in the mouth
and on th. tongue, A woman ’ho has the same fungal
infect! >n of the vagina can pass it. on to her baby
" if she ^.s careless about washing here hands or breasts
before feeding her
baby.> The
r~
\
condition should be
suspectr. when the baby who) seems to be hungry is
put to breast- for feeding and pulls; aw-y and
screams. In order to cure tt ; infant, simultaneous
treatment of mother and baby as. necess- jy.
v.
Gastroer - critis in newborn i1 o.ants is c. .aracterized
by sudde.1 onset of water, ye. low stools. 1 +• time^
there is vomiting, and the in.' :nt looks ill.
Because
inj_ants
ive lictle physical reserve for resisting
infect! y s and can become critically ill wit' , in a"
short 'time./ prompt medical cain is needed.
If a newborn infant has any of <■ e conditions already
mentioned,
proc ee as follows:
rt-
Contd./.o.o.
Ikr:
■
■
8
-; 8 :
Pre
matu
rity
Eye
Infec
tion
Yes
No
I
r
Umbili
i Gastrocal In-s- Thrush Ienterifection
i tis
i
Unable to suck
| No
■'/
; Mav be
■
i------------- |
Body tempe nature
.Unstable
Raised! Rais< „ ' 1
Yes
No
I No
No-
No
No
Refusing feeds
M<..z be
No
i No
Crying and Irritable
No
No
! May bo j res
Weight under 2,5OOgrns|
I
Vomiting
4-
i
White patches on
tongue
I
:
No
o-al
Raised
No
■•To
;
-ty b
' May be
fas ’
i --lay be
, Yes
I
No
No
Yes •
No
No
N
; No
from the umbilicus
No
No
Yes
No
f No
Watery stool
N.
No
No
' No
! Yes
i. Clear
eyes.
;
Purulent discharge:
from the eye
i----------------------
I
I
Hand t as
litt e as
pos;-- ’ ble
I
; iiu Kec: - baby
warm
.
I
i
;
ii- Apply
|
tetra'
cycline
ointment
I
,
J
es
1 No
U lean
mouth
ii. Apply
I
gentian
violet
!
to
mouth
j liii. Teach
parent i
to
aoply
gentian i
violet I
I
iv. Revisit'
next
i
day
_ I i-----
r
vrit/'
spasma
Without spa
-sms
Clean umbili
cus.
ii. Apply warm
compr ss
iii. Triple sulpha
tablets.
No Vomit
ing
Vomit
l
I
/
I
!
/
-------------------------------
io Continue breast
feeding.
ii. Roh yd r-' ti^-; ix.tu re
I
I
¥
In-
—: 9
9.5
WHAT YOU SHOULD KNOW zABOUT THE HEALTH CARE OF
AND PRE-SCHOOL CHILDREN
INFANTS
Almost one ..it of every six inf' ts born dies before
reaching five years of ace because of ii proper child care/ poor
environmental conditions and malnutritic i. Therefore/ this'
group needs to be given high priority in health c-are.
YOUR ACTIVITIES II’ . .E COMMUNITY FOR FEIA’ ENT ING DISEASE ARE
VERY IMPORTzEKT FOR E SURING THE SURVIVE? ANY CIEILD.E.EN.
These activities include the following:
■
'
$
i..Health teaching (educating the parents -nd relatives),
ii. improving the environment around the homes,
iii. .administering immunizations.
iv. Early detection of illness.
v. Giving simple medical treatment and early/ prompt re
ferral for more specialized care when indicated.
vi. Promoting child spacing (family planning) and preventing
unwanted pregnancies.
You must/ th. refore/ be very observant as you go about in
the villages and use every opportunity to examine young children
who are not growing like other children or who have signs of
illness. Administering treatment for minor ailments/ referring
those who need special care to the Primary Health Centre/ and
teaching parents about child care are all important ways of
promoting and maintaining the health of young children.
HEALTH EDUCATION IS ESPECIALLY IMPORTANT FOR PREVENTING MALNU
TRITION ACCIDENTS i-ND DISEASE AMONG YOUNG CHILDREN. MID SHOULD
BE GIVEN AS 1\ PART CF E^CH CONTACT WITH PARENTS.
"4
Health probl ms that are commonly seen among infants and
young children are as follows s
1.
2.
3.
4.
Lovz b i rth ./e i ght.
Ma 1 nu t r i t i, o n.
Infecti 1- > diseases.
..Ec ci dene • „
THE YOUNGER THS CHILD/ THE HIGHER ARE THE RISKS OF DEATH OR DIS
EASE WHEN PROPER DIET/ CHILD CARE AND IMMUNISATIONS ARE NOT GIVEN.
9.51
HEALTH NEEDS OF CHILDREN
It is necessary that you should know the health needs
of children and how their needs can be met by their parents and
others who care for them. The following points should be kept
in mind:
1. Careful observation and health assessment of infants
and young children is necessary because the younger the ••
child/ the higher the risk of his dying for lack of
proper child care.
2. It is very important that infants and young children,
are seen regularly at the clinics in order to check
their growth and development .^nd to keep them well
and heal' ’?y. The child should be seen once every
month fthe first year/ every three months during
1
!
- : -10
the secon.. year, and once a year thereafter.
3.
to th.ir very rapid growth, children have special
food requirements.
4. The weaning period, i.e., from six months to about
three years, when
1 '
the transition is made from diet of
only breast milk to the full family diet,-- is-- a very
important time for •young children because improper
feeding re ults in severe malnutrition with grave
c msoquenc -s.
-5. Young children are ,susceptible to communicable diseases and should be protected by timelyTmmRization.
6<, Health education of the parents, grandparents and other
rel" lives is’ necessary so as to ensure proper child
care. r
Particularly useful topics for discussion are
as f How 3 :
i. The early signs and symptoms of illness,
ii. The selection and preparatien of weaning foods.
iii.•How to - ecognize malnutrition and how to prevent
it.
iv. The need for a s<?fe -and hucionic environment.
v. The dangers -of using.water from unprotected ponds
and rivers for drinking and washing utensils.
vi. How t ■ look after a child with symptoms such as
fever, disrrboea, constipation, vomiting or cough.
vii. The need for immunizations.
7. There is a
a need
need to
to^ assist older
older children
children who care'
care' for
for
their younger brothers and
sisters
while
their
-- - ------J while their mothers
mothers
work outside the home, to learn about proper child care.
i
REMEMBER, HEALTHY CHILDREN ARE THE
PARENTS, GRANDPARENTO, THE DOCTOR, RESULT GF TEAM .WORK BETWEEN
THE INDIGENOUS PRACTITIONERS
AND DAIS, THE COMMUN ?TY MEMBERS,
THE HEALTH WORKER J?EMALE) END
YOURSELF .
8. The smaller the family and the longer the birth
interval (at least three years)) between children, the
more likely is the child to receive the care he needs.
9. Children need 1,ve and affecti .•a in order to become
healthy adults vho are capable cY giving and receiving
love.
10. Efforts t help parents and th community to ^ake the
environment around homes safe
d hygienic will pay
high diver, s :in
‘
terms of redu> tim of illness in
children (see Chapter 6,/ 'Environmental Sanitation',
for details)
INCREASING THE HE;. -Tn AWARENE8S OF PARENTS. THROUGH HEALTH EDUCATION CARRIED OUT CNDIVLDUALLY AND IN GROUPS IS THE MOST EFFECTIVE METHOD OF BRINGING
ABOUT
-- --J IMPROVEMENT IN CHILD T. ..RE
PRACTICES.
Ikr:
Contd/
11
11
A healthy er Id (see fig.9.1):
is 1 vopy ..id alert to
the oeoplo and things
in his environment.
ii. has an abundance of
/,
to
V
’
a
energy and is active
almost Cf~ '.stantly.
iii. developsrate.
a e
rmal
d j
i.vo grovs in t iight and
gains we -t at a
regular pace.
■
v
has a good appetite.
vio has moist and clear
eyes.
vii. has abundvit, shiny
hair which, is springy
in texture.
Vo
viii., has. a firn abdomen
which is not enlarged,
ix. has a clear skin, and
pink nails and con
Fig. 9.1 :
junctiva, o
x„
1
/'
v. -
M\J
healthy child
is able ■/ run and
jump as v.'ll as other
normal children of
the s ame age.
►
xi. enjoys receiving and
giving affection.
xiio
recovers from illness
rapidly.
9.5.2. ILLNESS IN C/fLDREN
I
Illness of . \
kind in an infant t young child can
quickly becom. very -erious.
therefore, parents and others who
care for children imu ;t^bo familiar with the early signs and
symptoms of illness :.no t <e I 'rompt mea.. ured to avoid deterioration
of the condition.
Some of the,-?
signs and symptoms are as follows:
io Fever wit'
or without other symptoms.
iio
Twitching of the muscles or c avulsions.
iiio Excessive crying and irritability.
iv. Poor aonetite or refusal to eat as usual.
V. Loss of weight or stationary weight over a period
ot time.
vi. Change in colour or consistency of stools.
vii. Vomiting or passing worms in stools.
viii. Drawing up the legs on to the abdomen.
ix. Dry, wrinkled skin that keeps a fold when pinched
(see fig,, 22.2)
x. Dry mouth and dry red tongue .
xi. Less uri
than- usual.
xii. Running ’
' us'
the nose and breathing that is more rapid
i<? noisv, or becoming difficult. (Nostrils
- : 12
xiii* Pallor and lack of interest in play.
xiv. Dryness of eyes and inability to see well in the dark,
xv. Rubbing the eyes or .discharge from the eyes.
xvi. Pulling on the ears or discharge from the ears.
9.6
HEALTH EDUCATION
Some of the topica about which y m should talk to indi
viduals or to grov 3 in the community are as follows:
lo
The valv.c of pregnant women ttending MCH clinics
regularly and the need for pc stpartum examination
of the r.7 ther and her baby.
he importance of having
children examined regularly in order to keep them
healthy and well.
2n The importance* of good nutrition for mother and baby.
What and when to feed young children (see Chapter 11/
'Nutrition').
3. Personal hygiene of both mother and child. The importan
ce of hand washing before handling the baby and especially before preparing food or eating.*
4. The need to protect pregnant women and children against
common communicable diseases by immunization (See
Chapter 12, 1 Immunization’).
5. The value of spacing children for the improved health
of both mother and child (See Chapter 10, 'Family
Planning’).
6. The need to make the environment clean and safe to
protect children from contracting gastrointestinal
infections and from accidents (See chapter 6,
’Environmental Sanitation’).
4
7. The early recognition of signs and symptoms of illness.
The reasons for seeking prompt medical care or advice
when either the mother or the infant is ill (see
Part IV/ 'Primary Medical Care in Accidents and
Diseases' for specific ailments).
I
1
8. Simple measure which parents can take in caring for the
sick child at home until it is seen by the doctor or
health worker/ e.g.,
i. Applying cold compresses to bring down fever (see
section 27.1).
ii. Keeping the child warm.
iii. Giving it plenty of fluids including rehydration
fluid (see section 30.10).
iv. Giving it a light non-spicy diet.
9. The importance of love and affection for the healthy
growth and development of children/ the need for
constant mothering and the need for the provision of
a substitute where the mother is away at work.
9.7
SERVICES PROVIDED FOR MOTHERS AND CHILDREN
At the Primary Health
Centre:
i. Out-patient MCH
clinics (usually
•held once a week)
Health services/ curative and pre
ventive/ are provided by a team
of doctor/ nurse and other health
workers.
Contdo/o. o .a-
13
13
/
In-patients care
(available 2or 24 hrs.
a day)
iii. Domiciliary Zisits
(made periodically)
iv. School Health
At the Subcentre:
i. Clinics
Clinics for sick and well children
are often tie Id on the same day as
those for women who are pregnant or
delivered. Health education is
provided by all the members of the
health t am is part of their work.
This may include demonstrations
of prep '■Ing we; ii i} f ads, snacks
for you.’ j ch i Id e an t, e t c.
Medical nursing and bstetric
core is ''■rovid.ee. in th . wards of
the PHC
Dr those ■-ho reed it.
Patient.-> requiring more specialized
care ar; referred to the district
hospita is
Periodic1 visits are made to homes
for follow-up of pregnant women
or those who have recently delivered
to condict a home delivery or
to supervise the 'are of children
who hav health problems. Visits
are usu ILy made bp members of
the he a .1 th te am.
Health services for children in
schools are limited to what can
be done on periodic visits to the
sch ol oy the*MO, PHC and other
members of the health team.
Health education of both teachers
and children is done mostly in
groups.
Immunizations are given
to children oy the health team.
Teachers are helped to learn- to '
identify children who require
referral.
These are conducted daily by the
Health Worker (Female) and Health
Worker (Male).
In these Clinics:
Immunizations are administered
on scheduled days.
ii. Minor ailments are treated and
those who require further
treatment are referred.
iii • Dietary supplements, e.g.,
calcium lactate tablets, vita
min B-complex tablets. Liver
extract for pregnant and nur
sing mothers and vitamin A
and D capsules for mothers and
children.
iv. Distribution of vitamin A
solution (2 lakh dose) "to"
children aged one to five
years every six months as a
special programme.
v. Health education is included
in all these activities.
14
lb —
I
-: 1 4
Mothe..
and chil-Jnon w o require
special examine a.'. ?n Dr treatment
are seen by ,he lector on a regu
larly scheduled lay iach week*
ii. Domicili
?■/ Visits
The services or 'voided are similar
to those J.escrib>, ■' abo”e f or the
PHC.
•wever,
the roilight
ar a,
n_^lth Worker (Female)
along ith she o-i will visit on
reques . the ' -r;
f /smen who are
pregnant or .v io sue rjcently
delivered, Following ' maternal
death or infant death the Health
Worker (Female) will visit the
home t investigate the cause of
death.
k
i
iii. School Health
Immuni: ations ar.- given -to suscep
tible children by the Health Assis
tant (Male) assisted by the Health
Worker (Male).
ivo Health Ecucation
(May also be held in
places other than
sub-centre)
Both the Health Worker (Female)
and the Health Worker (Male) are
expected to utilise the various
groups which exist in the villages
or organize fresh groups and
conduct health education on topics
that pertain to preserving and
improving the health of mothers
and children.
v. Referral
Referral of patients for more
specific treatment can be done
either by the Health Worker(Female)
or the Health Worker (Male) . De
pending on the situation and cir
cumstances, such referrals may be
made t their respective health
assist nts or dir ctly to the
PHC.
vi. He a 1 th Re c o rd s
Several kinds of registers and
records of services delivered to
mothers and children are kept
by the -lea 1th Worker (Female)
at the subcentre. These are
suppler.' jnted by those that are
maintained, by the Health Worker
(Male) so that together they
reflect the health -status of the
family. These records are used
by the health workers to give
Continuity of care based on needs
and enable them to evaluate their
work or have their work evaluated
by their respective superiors.
REMEMBER, THE 2\IM OF MCH SERVICES IS TO HELP MOTHERS TO LE/xRN
WHAT THEY SHOULD DO TO miNToIN THEIR HEALTH AND THAT OF THEIR
CHILDREN.
* -k k -k -k
k k -k k -k
kkk
k
Ikr:
CHAPTER 9
. l -TERNAI, and child hf-^lth
Health ser\ ...c s for mothers and c. ild-cen, more commonlv
known as maternal and child health, an/ a. '.package of S3OTicesr
that has been develo ed to meet the needs of pregnant women
beiore, during, and atter delivery, anc of infants from birth
to five years.
The package of ma - ?.rnal and child health senzices is
concerned with the
?llo- . ing:
Ensuring t v.e birth of a healthy infant to every
expectant /other.
iio Providing -ervices to pro iota the healthy growth and
development of children un to the age of five years.
iiio
Identifyi.r , health problems in mothers and children
at an early stage and initiating prompt treatment.
ivo Preventing malnutrition in mothers and children.
v. Preventing communicable diseas:.s in mothers and
children.
vi.
Improving the health of mothers and children by providing family -Tanning services.
vii. Educating mother-s- on how to improve or maintain
their own nealth and that of their children.
9.1
THE NEED FOR 4CH SERVICES
1. Human Resources : If children are to be born strong
and healthy, their mothers will need to receive good
prenatal and natal care. After they are born, they
need specially designed health services so that their
survival and healthy growth are ensured through proper
nutrition and protection against communicable diseases
and poor environmental conditions.
SERVICES FOR IMPROVING THE HEALTH OF . 'iTHERS AND CHILDREN IN
THE VILLAGES ARE IMPORTANT FOR THE CONTINUED PROGRESS OF THE
NATION.
2. Numbers Affected: Sixty per cent of the total popu
lation in the country consists of women of child
bearing age and children under 15 years. Twenty per
cent of this group ?.re children under five years of
age. This mea-_s that maternal and child health
services would reach almost two thirds of the popu
lation.
3. Special Health Needs: Women and children have the
highest rx>ks in terms of number of illness and
deaths. They also have specie 1 health needs which
are not met by other services.
4. Investment in Health: The early identification•of
health problems and prompt treatment of disease among
mothers and children can yield life-long benefits
for the individuals, their families and communities
in which they live.
DELIVERING' CURATIVE AND PREVENTIVE HEALTH SERVICES AT THE
SAME TIME TO MOTHERS AND CHILDREN IN THE VILLAGES IS A PROFIT
ABLE INVESTMENT IN 'THEIR HEALTH.
contd./.o..
Ikr:
2
-: 2 :
I
MOST WOMEN IN THE COMMUNITY WILL SEEK
DAI WHEN THEY BECOi-L PREGNANT AND ARE
WILL HAVE TO CONVINCE THE WOMEN ABOUT
DING THE MCH CLINIC FOR THE HEALTH OF
THE CARE OF ’lHE I QCAL
REALV TO Wl.IVEIn
YOU
THE V..LUE OE AIZJO ATIENTHE tj-.-sor' CHILDo
The advantages of attending the JfcH clinic are as
follows:
General hsalth assessment can reveal abnormalities
which car ae corrected or treat >d earl'o
ii. Further •: luation and treatme. t can be carried out
when there
ther_ are irregularities related to the pregnancy.
iii. He a.'-th edui at ion (can be given regarding care during
pregnancy, preparation for hohe j delivery or hospital
delivery, and care of the infant.
Emphasize these advantages while motivating; women to
attend the MCH cli \ico
MANY OF THE HEALTH PROBLEMS RELATED TO PREGNANCY
CITTlDBEARING CAW BE PREVENTED OR REDUCED BY REGULAR EXAMINATION
DURING PREGNANCY i\ND PROMPT TREATMENT.
9.2
WHAT YOU SHOULD KNOW ABOUT THE HEALTH CARE
OF PREGNiJSIT WOMEN.
t^ie twilight area, among pregnant women, you will have
to concentrate on those who are more likely to develoo compli
cations and assist them to obtain the necessary health care.
At present, in the twilight area, in the absence of the Health
Worker (Female), pregnant women without complications will be
cared for by the local dais.
Maternal health problems that are commonly seen are
as follows:
1. Malnutrition with anaemia.
2. Poor or no weight gain during pregnancy.
3. Poor genera.1 health due to the .urden of too fre
quent, unplanned pregnancies.
4. Infection rcom induced abortion.
5. Toxaemia of pregnancy.
6O Vaginal cischarge.
7. Parasitic infestation.
THE MOST COMMON CAUSES OF DEATH RELATED TO CHILDBEARING ARE:
i. INFECTION FOLLOWING INDUCED ABORTION.
. ii. ANTEPARTUM AND POSTPARTUM HEMORRHAGE.
ill. TOXAEMIA OF PREGNzANCY.
iv. ANAEMIA.
Women who are ?likely
'"
to develop complications during
pregnancy and child-birth include the following:
Those under 15 or above 45 years of age.
ii. Those who have had four or more pregnancies.
iii. A woman 35 years or older who is pregnant for the
first time.
iv., Those who have ’ -•d previous aba ctions, r '!-he.: induced
-: 3
V.
Those whose last child is undec one year.
vio Those who
ave had previous pr mature births
vii. Those wh ■. have had • ci .iiplicatic i s durin-.
prev.i'O.is
pregnancies or deliveries.
viii. xh woman of small build.
ix. A won]a.n with twin pregnancy.
x. Those vjh.c are
'.Inourished.
xi. Those who ave
chronic disease such
culosis o.. ,mal i ./ia.
38
cube
After identifying a woman who is Likely to .evelcn com
plications during pregnancy or childbir. , proceed as follows:
i. Do a Tallq.’lst haemoglobin estimation an- administer
iron and folic acid tablets if indicated.
to attend the MCH clinic at the subcentre
for exarni tion and treatment.
iii. Find out what she is eating daily and advise her as
to how to improve her diet.
iio Advise her
iv. Persuade her and her husband to allow you to immunize
her against tetanus in order to protect her unborn
child.
IF YOU COME ACROSS A WOlTch WHO IS LIKELY TO DEVELOP COMPLICA
TIONS.DURING PREGN.hNCY '-OR CHILDBIRTH, INFORM THE HEALTH
WORKER (FEMALE).
Prenatal complications that are commonly found include
the following:
Threatened abortion.
ii.
Incomplete abortion or expulsion of the contents of
the pregnr'it uterus early in pregnancy usually
beofore 20 weeks.
iii. Septic abortion or infection of the uterus.
This
develops after abortion when unsterile methods or
equipment lave been used to induce expulsion of the
foetus.
£
iv. Haemorrhac
after the seventh month of.pregnancy.
v. Toxaemia
‘ pregnancy is characterized by uwo sets of
signs ano ymptoms. Pre-eclampsia i-s the earlier
stage of she condition and is characterized by
swelling of the legs and fingers which may be accom
panied’ by headache. Eclampsia is the more severe
form of the condition in which the woman has generalised
swelling of the body, severe h sadache. and convulsions.
Abortion or premature delivery often occur when a
pregnant woman develops eclampsia.
I
contd./
Ikr:
4
-: 4
If a pregn i . woman has any of. t?ij following conditions.
proceed a' follows;
History of vajinal
bleeding
Incomplete]
el
Septic
Abortion | Abortion
Yes
Y.^s
Yes
He c' vy
Variable
Yes
May be
No
Yes
Yes
Yes
Yes
No
No
Yes
4_._
Amount of bleedin>
i
Threatened
Abortion
Slight
Products of conception
passed
~r
4
I
Purulent, f ou. l d iu 1: a rg e
Abdominal pain or
tenderness
Fever
i
T_____
t___
Instruct
woman to
stay in
bed.
ii. Inform
HW (F) o
5vXCSraCSSp;(EG"?S
V __
Ergot tablets) I Triple------- Sulpha
Tablets
_________
io Refer to PHC
iio Inform HW(F)
®tEr the
' -L
IN CASE HIS
HIS PERMISS1Cpermission is required for surgery,
HEALTH WORKER. (FEMALE)
THE DAI CONCERNED.
inform the
If a pregnant woman has any of th: follovdng conditions
proceed as follows.
Pre-Eclcnosia
Eclampsia
Swelling:
Feet and legs
Hands and fingers
Face
Puffiness of eyes
Convulsions
Headche
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
1 Yes
Occasional,
severe
Isiurring of vision
Frequent or
continuous,
severe
No
Yes
J
! Dizziness
May bYes
C? -i. -
_______ _v_____
1S
S’.?.
i.
■■. ' r
. ■t
i o
- : 5
in the diet.
Refer to PHC
i lii. Inform HW (F)
quiet, dark
ened room
? ii
■ttendant cons
tantly with
patient.
iii. During convul
sions :
(a) Turn head
to one
side.
(b) Place pad
ded piece
of wood bet
ween the te
eth to pre
vent biting
of tongue.
Inform PHC or
arrange to tra
nsfer patient
to PHC.
Vo Inform HW(F) 0
■ ii.
9. 3.
WHzxT YOU SHOULD KNOW ABOUT THE HE, LTH CARE OF WOr'IEN
AFTExR DELIVERY
When you visit, the home shortly
ter a woman has delivered/
you-should ascertai i vhether the mother cd infant are progressing
normally. The dai 1ho has delivered the
woman may or may not
refer her patient fo: medical care even ’ten this is re'"----necessary,
Delay in referring either the mother or i,he infant with
complications to the Primary Health Centre or hospital may result in
unnecessary suffering or aven death.
Postnatal comnlicrcions which rnciy commonly occur in the
mother include the f zllov.iag:
epsis (infection of the genital tract)o
iio Mastitis (infection of the breasts).
io Puerperal
iii. Severe or . rolonged bleeding following delivery or
abortion.
2
iv. Thrombophlebitis
Signs and Symptoms:
.infection of the veins of the legs)o
If a woman who has recently had a
■ baby has any of the
following conditions,, proceed as follows:
i
Puerperal
Sepsis
Mastitis
Severe or
prolonged
bleeding
Thrombo
phlebitis
-'ey be
No
Yes
May be
Purulent
discharge
Yes
No
No
No
Pain and tender
ness:
Lowe r abdomen
Breasts
Yes
No
No
May be
No
Yes
No
No
History of :
Excessive
vaginal
bleeding
6
Puerperal
Sepsis
:Severe or
Mastitis ,prolone a
____________ I bleed!ng
Th rombophlebitis
History ot:
Swelling of
legs
’ 'o
Headache
-2 s
No
Yes
No
II
o
May be
■4
Fever
Rigors (si'live-ring)
3S
Yes
No
•r e s
Yes
No
May Ids
1
I
Triple-sulpha
tablets
| iio Ref er
! iiio Inform HW(F)
i_______
9. 4
__ V___
io Ref
er
ii- In
form
HW (F)j
V
i. Triple
sulpha
tablets
Bed rest
iii. Refer
iv. Inform
HW (F)
WHAT YOU SHOULD KNOW ABOUT THE HEALTH C RE OF NEWBORN
INFANTS
Whenever you encounter a newborn infant (within a week
after birth),. you
should
make3 sure that the baby:
..
-- ---io
ii.
is. able to suck.
is urinating freely
iiio is passing stools within 24 hours afcer birth.
iv. does not have fever.
Vo
does not have J aundice.
vi. does not have diarrhoea.
viio does not have any birth injur 7 or malformation
which can be observed.
MOST NEWBORN INF/JT. ,'J. WHO 7,RE LESS THz\N . WEEK OLD HAVE YELLO'4
COLOURING OF THE SKI I AND EYES.
IF THIS PERSISTS ®EYOTH TEN
DAYS, THE INF .NT SHOULD BE REFERRED TO RHE L <IM/-\RY HEALTH CENTRE
REMEMBER TH^T INFANTS A'M SOMETIMES BOM7 WITH SERIOUS PHYSICAL
DEFECTS WHICH NEED PROMPT MEDTCzRL CARE. DELzTY IN i<ENERRAL MUY
RESULT IN DEATH.
YOU WILL HAVE TO WO.:'k CLOSELY WITH THE ADC AL DAIS SO TlLtT THEY
UNDERSTAND THE NEED FOR REFERM.L TO TH'. PRIMARY HEALTH CENT.eE
OF EITHER THE WOMEN THEY DELIVER OR Tr I IbTFANTS WHO DEVELOP
COMPLICATIONS FOLLOWING DELIVjRY.
1
■
ntd/ .
-: 5
i
9*3.
lllo
in the diet.
Refer to PHC
Inform HW (F)
WHzxT YOU SHOULD KNOW ABOUT
AFTExR DELIVERY
J
quiet, dark
ened room
ii Attendant cons
tantly with
patient.
iii. During convul
sions :
(a) Turn head
to one
side*
(b)Flace pad
ded piece
of wood bet
ween the te
eth to pre
vent biting
of tongue.
i.Vc Inform PHC or
arrange to tra
nsfer patient
' to PHC.
V. Inform HW(F) 0
THE HE. LTH CARE OF WOMEN
When you visil-. the home shortly
you-should ascertain whether the mother a: ter a woman has delivered,
normally. The dai ■•';ho has delivered the nd infant are progressing
woman may or may npt
refer her patient for medical care even - ten
this is necessary.
Delay in referring either the mother or ;.he infant
with complications bo the Primary Health Centre or hospital may
result’ in
unnecessary suffering or even death.
Postnatal comnliconions which may commonly occur in the
mother include the f ,Hoving:
i. Puerperal sepsis (infection of the genital tract).
ii. Mastitis (infection of the bre.-.sts),
iii.
aourtion.
' ?°longed bleeding following delivery or
iv. Thrombophlebitis (infection of the veins of the legs).
Signs and Symptoms;
If a twoman
~
who has recently had a baby has any of the
following conditions.z proceed as follows:
IPuerperal
Sepsis
Mastitis
Severe or
prolonged
bleeding
Thrombo
phlebitis
. ty be
No
Yes
May be
Yes
No
No
History of:
Excessive
vaginal
bleeding
Purulent
discharge
Pain and tender
ness:
Lower abdomen
Breasts
No
--
Yes
No
No
Yes
May be
No
No
No
- : 6
Puerperal
Sepsis
:Severe or
Mastitis ; prolong .-K
_________ j bleeding
I Thrombo
phlebitis
History ot:
Swelling of
legs
‘ ■’ o
No
No
--2S
■■ o
May be
Headache
•is
Yes
!
Fever
25
Yes
1.No
.J 3 S
Yes
No
Rigors (si live ring)
Yes
I
May be
/
I
io
I iio
I iiio
9. 4
triple-sulpha
tablets
Refer
Inform HW(F)
__V
i o Ref
er
ii. In
form
HW (F)
i. Triple
sulpha
tablets
iio Bed rest
iii. Refer
iv. Inform
HW (F)
WHAT YOU SHOULD KNOW ABOUT THE HEALTH C RE OF NEWBORN
INFANTS
Whenever you encounter a newborn infant (within a week
after birth), you should make sure that the baby:
io
ii.
is. able to suck.
is urinating freely.
iiio
is passing stools within 24 hours aicer birth.
iv. does not have fever.
Vo
does not have
aundice.
vi. does not have diarrhoea.
vii. does not have any birth injury or malformation
which can be observed.
MOST NEWBORN INFANTS WHO /_RE LESS THAN . WEEK OLD HAVE YELLOW
COLOURING OF THE SKIT AND EYES»
IF THIS PERSISTS BEYOND TEN
DAYS, THE INF .NT SHOULD BE REFERRED TO THE I- ilMARY HEALTH CENTRE
REMEMBER THAT INFANTS ARE SOMETIMES BOM7 WITH STRIONS PHYSICAL
DEFECTS WHICH NEED PROMPT MEDICAL CARE. DELAY IE REFERRAL MAY
RESULT IN DEATH..
YOU WILL HAVE TO WO.’A CLOSELY WITH THE A-JCAL D^MS SO THAT THEY
UNDERSTzAND THE NEED FOR REFERRAL TO THi PRIMARY HEALTH CF.ORE
OF EITHER THE WOMEN THEY' DELIVER OR THE INFANTS
DEVELOP
COMPLICATIONS FOLLOWING DELIVERY.
0'- " atdz/ -
fl
*
e
•
7;
-: 7 .
Complications whici1
the following::
lay commonly occur in ths infant include
Prematurity
-irth weight of 2,500 ■■ •
or less)
ii.
Bye inf v ctrbn. are character: , _:d by rnr Tamr acion ■ and
discharcv- fr - - the eye var^i ; from st laky, watery
di s chares to '-.hick, purulent 1 iterial. ^h-j in-fart’s
eyes car )ecom? infected dur’, g trie oau Dag- ■ through
the birtv canal- or later by / a dirty hands jf the'
bi ?th a • ndant or mother or . . r flies. Wi . - -the
control c sexuall transmit s 1 cj.isesses and ' the
use of si .ver nitrate drops . c birth, the incidence
of op-thalmia neonatorum has become minimal in the
country.
iii.
Umbilical inf actions are characterized by inflamma
tion and discharge from the umbilicus. Unclean hands
and utensils -used-by the birth attendant in hand
ling the cord, or the application of cow dung, dirty
coverings or other substance to the cord or umbilicus
are sources of infection. Tetanus infection is the
most serious type of infecti -n of the umbilicus,
it continues to occur in rur '1 areas because most
women hv\a not been immunized against the disease
during pregnancy, The disease is characterized by
muscular snasms. stiffness of the jaw and foul,
purulent discharge from the umbilicus, The disease
is usually fatal in infants.
iv.
Thrush is a disease which is characterized by the
appearance of white curd-like patches in the mouth
and on the tongue. A woman who
w io has'
has the same fungalfungal •
infection of the vagina can pass it on to her baby
if she is careless about was!Lag here hands or breasts
before, feeding her baby. The condition should be
suspected when the baby who ... 2ms to be hungry is
put to 1
ast for feeding an Dulls away and
screams. In order 00 cure t- .. infant, simultaneous
treatment of mother and baby is necessary.
v.
Gastroent.riti,: in newborn infants is characterized
by suddan on : .-t of water, yellow stools. At times
there is vomi ...ing, and the infant looks ill. Because
infants have '.ittle physical reserve for resisting
infections and can become critically ill within a
short time, prompt medical cp.‘~e is needed.
If a newborn infant has any of the conditions already
mentioned. proc eed js follows:
Contd./
Ikr:
8
-; S :
Pre
matu
Unable to suck
I
I
Ye s
Eye
1 Umbili‘GastroInfec cal In-? Thrush i enterition rity
fection
tis
No
No
' ■•lay be ; May be
j------------------
Body temper-, sure
Weight under 2,.|00gmsi.
U .1 stable
Raised
Raised
N ..^rm-'-'l
Yes
No
No
! No
No
No
No
Refusing feeds
May be
No
i No
May be
May be
White patches on
tongue
No
No
Purulent discharge:
from the eye
No
from the umbilicus
No
Yes
No
Watery stool
No
No
Handle as
little as
possible
I ii. Keep baby
warm
i May be
i--------------
No
i
May be
Ie s
No
.
I
= No
—!---
Vomiting
Crying and Irritable
Raised
Yes
i Yes
No
i Yes
No
No
No
No
Yes
No
i No
No
! No
| Yes
Clean
eyes.
i. Clean
mouth
ii. /tpr-ly
ii. Apply
gentian
violet
to
mouth
iii. Teach
parent
tetra
cycline
ointment
c.i only
gentian
violet
iv. Revis is
next
day
F
with
spasms
r
With :ut spa
-sms
I'o Vomit
ing
i
I
Clean umbili
cus.
?ipply ^nrm
compr .ss
iii. Triple
sulpha
tablets.
I
/
;
/
/
z
Vomit
/ I
I
I
________ _ ____
i. Continue breast
feedirg.
ii. Rehydr '• ti- ■n mixture
■
In- rm
-: 9
9.5
WHAT YOU SHOULD KNOW ABOUT THE HE...LTH CARE OF INFANTS
AND PRE-SCHOOL CHILDREN
Almost one ■. ut of every six infants born dies before
reaching five years of age because of improper child care, poor
environmental conditions and malnutrition. Therefore, this"
group needs to be gi.ven high priority in health care.
YOUR ACTL TTIES IN
IE COMMUNITY FOR PRII'ENTING DISEASE ARE
VERY IMPO.-TzUT FOR . SURING THE SUPVIV.. • OF IANY CHILDREN.
These activities include the following:
Health torching (educating the parents and relatives).
ii. Improving -he environment around the homes.
iii. zldministoring immunizations .
iv. Early detection of illness.
v. Giving simple medical treatment and earlyprompt re
ferral for more specialized care when indicated.
vi. Promoting child spacing (famiJv planning) and preventing
unwanted pregnancies.
. You must, therefore, be very obsoevant as you
about in
the villages and use. every opportunity t ? examine ycur.g children
who are not growin like other children ?.r who have s’ens of
illness. Administering treatment for mir.or ailments, referring
those who need special care to the Prim ty Health Centre, md
teaching parents about child care are cl 1 important ways of
promoting and maintaining the health of young children.
HEALTH EDUCATION IS ESPECIALLY IMPORTANT FOR ’A EVENTING MALNU
TRITION, ACCIDENTS • ID DISEASE AMONG YOUNG CHILDREN AND SHOULD
BE GIVEN AS A PART ? E/.OH CONTACT WITH PARENTS o
Health problems that are commonly seen among* infants and
young children are c.s follows:
1.
2.
3.
4.
Low b i rth .-/e i ght.
Malnutrition.
Infoctiou■ diseases.
Accident' ■.
THE.YOUNGER THE CHILD, THE HIGHER ARE THE RISKS OF DEATH OR DIS
EASE WHEN PROPER DIET, CHILD CARE AND IM-iUNIZATIONS ARE NOT GIVEN.
9.51
HEALTH NEEDS OF CHILDREN
It is necessary that you should know the health needs
of children and hovz their needs can be met by their parents and
others who care for them. The following points should be kept
in mind:
1. Careful observation and health assessment of infants
and young children is necessary because the younger the
child, the higher the risk of his dying for lack of
proper child care.
2. It is very important that infants and young children
are seen regularly at the clinics in order to check
their growth and development and to keep them well
and healthy. The child should be seen once every
month f->r the first year, every three months during
- : 10
the secor. year,
and once a ye r thereafter.
3. Due to their very rapid growt?
food re qu i re me n t s.
children hav., special
4. The weanin- period, i.e., fro a six months to cbout
three years, when the transit’, m is made from diet of
only breas-'* milk to the full omily diet, is a very
'r ’young children because improper
importan' ■.ihj ror
feeding ■ .ul - • in severe malnutrition with grave
consequ’e”:c . s. •
5. Young chi-'cen re susceptible to communicable dis
eases and should be protected oy timely immunization.
6 o Health edu :ation of the paren
grandparents and other
relatives
~s .s' necessary so as
; ensure proper child
care.
Particularly useful topics for discussion are
as follows
ie The ear y signs and symptoms of illness.
ii. The sedation and preparation of weaning foods.
iii. How to recognize malnutrition and how to prevent
it.
iv. The need for a safe and hugienic environment.
v. The dangers of using water from unprotected ponds
and rivers for drinking and washing utensils.
vi. How to look after a child with symptoms such as
fever, disrrboea, constipation, vomiting or cough.
vii. The need for immunizations.
7. There is a need to assist older children who care for
their younger brothers.and sisters while their mothers
work outside the home, to lean about proper child care.
REMEMBER, HEALTHY CHILDREN ARE THE RESULT OF TEAM WORK BETWEEN
PARENTS, SRiiNDPARENfS, THE DOCTOR, THE ' INDIGENOUS PRACTITIONERS
AND DAIS, THE COMMUNITY MEMBERS, THE HEALTH WORKER (FEMALE) AND
YOURSELF .
The smaller the family and the longer the birth
interval ( _t least three years? between children, the
more like!
is the., child to receive the care he needs.
9. Children need love and affection in order to become
healthy acrults who are capable of giving and receiving
love.
/
10. Efforts to help parents and th.? community to make the
environment around homes safe md hygienic will pay
high divends in terms of reduction of illness in
children (see Chapter 6, 'Environmental Sanitation* ,
for details)
INCREz- iSING THE HEzTLTH AWARENESS ’ OF PARENTS THROUGH HEALTH EDU
CATION CARRIED OUT INDIVIDUALLY IUD IN GROUPS IS THE MOST EFFEC
TIVE METHOD OF BRINGING ABOUT IMPROVEMENT ‘IN CHILD CARE
PRACTICES.
Ikr:
Contd/
11
- : 11
A healthy child (see fig.9.1):
(...
i
i. is happy
id alert to
the people ant: things
in his env--.ronaent.
ii. has an abimdance of
energy anc is active
almost corstantly.
iii. develops
i a normal
rate.
ivo grov> in
.light and
i. air's we
t aa
rcg> lar p-' oe.
Vo
has
a go-.x
I
(
appetite.
vio has moist and clear
eyes.
vii. has. abundant, shiny
hair whicl is springy
in textur ,
viii. has a firm abdomen
which is not enlarged.
ix. has a clear skin, and
pink nails and con
Fig. 9.1: A. healthy child
junctivae.
x. is able ’o run and
jump as well us other
normal children of
' the s ame age.
xi. enjoys receiving and
giving affection.
xii. recovers from illness
rapidly.
9.5.2. ILLNESS IN CHILDREN
Illness of „any nkind
’ " in
‘
an infant or young child can
quickly become very serious. Therefore, parents and others who
care for children must be familiar
---- with
.,_i the early signs and
symptoms of illness and take prompt measured to av -id deterioration
of the condition.
Some of these signs and symptoms 'ire as 'oIIjws:
Fever wits, or without other s? /iptoms.
iio Twitching of the muscles or c evulsions.
iiio Excessiv trying and irritabf. ...ty.
iv. Poor acr'ctite or refusal to
t as usual.
V.
Loss of weight or stationary ’ . iqht over a period
of time.
vi. Change in col- ur or consistency of stools,
vii. Vomiting r passing worms in stools-
viii. Drawing uw the legs on to the abdomen.
ix. Dry, wrinkled skin that keeps a fold when pinched
(see fig. 22.2)
x. Dry moutl. and dry red tongue o
xi. Less uriao than usual.
xii. Running ■ ' ■L
’
the
nose and breathing that is more rapid
than usu „ , is noisy,
., or becoming difficult. ^Nostrils
>- -
r-, 1 .
- —1 r
- .
I
- : 12
xxii. Pallor and lack of interest in play.
xiv. Dryness of eyes and inability co see well in the dark,
xv. Rubbing the eyes or discharge from the eyes.
xvi. Pulling on the ears or dischao e from the ears.
9.6
HEALTH EDUC;\ nI0N
Some of tl
:topics atr-ut which you sh uld talk to indi
viduals or to grouo.j in the community are es follows:
I. The.,.valu„ of pregnant women attending MC.'I clinics
regularly and the need for postpartum ..xami/ tion
°C ■
^ vcher and her baby. The importance of having
children examined regularly in order to keep them
hPAlHlV
.tcsI 1
healthy nnrl
and twell.
2O The importance of good nutrition for m
■ her and baby.
What.and vhen to feed young children (s
Chapter 11/
'Nutrition;).
,
)
3. Personal lygiene of both mother and caild. The importa
ce of hani washing before handling the baby and especially before preparing food or eating.4. The need to protect pregnant women and children against
common communicable diseases by immunizatim (See"
Chapter 12/ ‘Immunization’).
5. The value of spacing children for the improved health
of both mother and child (See Chapter 10/ ’Family
Planning*).
6. The need to make the environment clean and safe to
protect children from contrac - ing gastrointestinal
infecti- ns and from accident' (See chapter 6,
1Environm:ntal Sanitation')o
7. The early recognition of
signs and symptoms of illness.
The reasons Cfor seeking prompl medical
-- care
--- 3 or advice
when either the mother
----- ' or the infant is ill (see
Part IV, ’Primary Medical Care in /Accidents
Diseases 1 for specific ailments).
8. Simple measure, which parents can take in co ring for the
sick child at home until it is seen.by the doctor or
health worker, o.g. /
i. Applying cold compresses to bring down fever (see
section 27.1).
ii. Keeping the child warm.
iii. Giving it plenty of fluids including rehydration
fluid (see section 30.10).
iv. Givinc it a light non-spicy diet.
9. The importance of love and affection. for the healthy
growth and development of children/ the need for
constant mothering and the need for the provision of
a substitute where the mother is away at work.
9.7
SERVICES PROVIDED FOR MOTHERS AND CHILDREN
At 'the Primary Health
Centre:
i. Out-patient MCH
clinics (usually,
held once a week)
Health services/ curative and preventiv
are provided by a team
of doctor/ nurse and other health
workers.
Contdo/O..o o 13
(
13
ii. In-patients care
(available•for 24 hrs.
a day)
iii. Domiciliary Visits
(made periodically)
iv. -School Hoclth
Clinics for sick - ''I well children
are often held an che same day as
those for women vl'^o are pregnant or
delivered. Health education is
provided by all the members of the
health team .vs •■v t of th .ir work.
This mog include
^monstrations
of preparing weaning foods, snacks
for young children, jtc.
Medical, nursing and sbstetric
core is provided in the wards of
the PHC for those who need it.
Patients requiring mor; specialized
care are referred to the district
hospitals.
Periodic visits arc made to homes
for follow-up of pregnant women
or those who have recently delivered
to conduct a home delivery or
to supervise the care of children
who have health problems. Visits
are usually made \by members of
the he a 1 th te am.
Health services for children in
schools are limited to what can
be done on periodic visits to the
school by the MO, PHC and other
members of the health team.
Health education of both teachers
and children is done mostly in
groups.
Immunizations are given
to children by the health team.
Teachers are helped to learn to
identify children who require
referral.
At the Subcentre:
io Clinics
These are conducted daily by the
Health Worker (Female) and Health
Worker (Male).
In these Clinics:
Immunizations are administered
on scheduled days.
ii. Minor ailments are treated and
those who require further
treatment are referred.
iii. Dietary supplements^ e.g.,
calcium lactate tablets, vita
min B-complex tablets. Liver
extract for pregnant and nur
sing mothers and vitamin A
and D capsules for mothers and
children.
iv. Distribution of vitamin A
solution (2 lakh dose) to
children aged one to five
years every six months as a
special programme.
v. Health education is included
in all these activities.
14
)
I
'*
-: 1 4
Mothers and children who require
special examination or treatment
are seen by the doctor on a regu
larly scheduled day each week.
ii. Domiciliary Visits
The services provided are similar
to those describe I above f or the
PHC. However, in the twilight
ar a, the Health Worker (Female)
along -■ ith the dai will visit on
request the homes f women who are
pregnant or who H'.ve recently
delivered. Following
maternal
death or infant death -.he Health
Worker (Female) will visit the
home to investigate the cause of
death.
iii. Sch . d1 Health
Immunizations are given to suscep
tible children by the Health Assis
tant (Male) assisted by the Health
'Worker (Male).
iv. Health Education
(May also be hold in
places other than
sub-centre)
Both the Health Worker (Female)
and the Health Worker (Male) are
expectel to utilise the various
groups Vnich exist in the villages
or organize frosh groups and
conduct health education on topics
that pertain to preserving and
improving the health of mothers
and children.
Referral of patients for more
specific treatment can be done
either by the Health Worker(Female)
or the Health Worker (Male). De
pending on the s.'. Tiati an - and cir
cumstances, such referrals may be
made to their respective health
assistants or dir ctly to' the
PHC.
v. Referral
vi. Health Records
Several kinds of registers and
records of services delivered to
mothers and childr n arc kept
by the Health Worker (Female)
at the subcentre. Those are
supplemented by those that are
maintained by the Heal-.h Worker
(Male) so that together they
reflect the health status of the
family. These records are used
by the lea 1th workers to give
continuity of care based on needs
and enable them co e\eluate their
work or liave their w_rk evaluated
by the A: respective superiors.
REMEMBER, THE AIM OF MCH SERVICES IS 10 HELP MOTHERS TO LEARN
WHAT THEY SHOULD DC TO MAINTAIN THEIR HEALTH AND THAT OF THEIR
CHILDREN.
★ -k -k -k ★ ★ -k
kk-kk-k
kkk
*
Ikr:
9
: 21 :
DELIVERS -OF IlTTEGRATEB SERVICES FOR. -MAl-ERhAL AHD CHILD HEALTH,
FAHILY HdllllNGj NUTRI TION AID M U1IIZATIQ1L
Die health of the mother and child are intertwined so that
the services of maternal and child health, family planning, nutrition,
and immunization are closely inter-related and require) .to
to l?c
. z delivered
do_yro^2 as
an integrated package of family health care. This is indicated in gi
fig. 8.1.
Fig1. 8.1 : Integrated fairily health care
DELIVERING INTEGRATED MATERIAL AID CHILD HEALTH, FAMILY PLAHtllHG- AID
OTHER -HEALTH SERVICES IN THE VILLAGES- CAN HELP TO IMJROVE THE HEALTH
OF TIE WHOLE FAMILY .
:--------------
In order to extend integrated naternal and child health services
using the presently available health workers, the area and population
covered by the subccntre has been divided temporarily into intensive and
twilight areas.
i. The intensive area includes an area of approxiiatoly 5.kilo—
pop-ulation of
netros radius surrounding the suT centre with a population
about /- ,000^
s
*
:
v* Investigate! 'any child who is away fro;: school or in the
same household who is sick.
vi. Carry out a health education pregrarne to inform the .
cormunity al. out the protective •.-.ensures against tho disease and to
and to advise then to seek early treatment in case their
children got sick. The Health Worker (Female) must also parti
cipate in this activity.
If the case is confirmed as a case of polia.nyelitis, proceed as follows:
vii. Disinfect tho house and all the articles 1 elonging to the
child* vi id • /Arrange to> iniunizc all- the children with poliomyelitis
vaccine.• This activity is shared with the Health Worker
vaccine
(Female) and tho Health Assistants (Male and Female).
Ensure
that sanitary latrines are in use.
ix.
aITBIEHSIFIED WITH mj-G/.T-IOH -WGR/aM14E •WILL -HELF -TO HRIHG AU EFIDEMLC
UIDER CCUTRCL AID i-JJST BE C-IVEH IPIORITY IU TCUR ACTIVITIES,.
chtiur.ru shcuid- not- hl wolh iutc cm
DUKE 1JG EPIDEMICS . __________
7.5
-FIACES SUCH /aS 1ARKETS ® FAIRS
MLLARI/l
Malaria, has l.oen described in deta.il in section 15.2..In this
clia.ptor tho emergency operations which need to he taken in the
— face of an
epidemic will lie doscrihed, rather than the routine handling of fever
cases•
7.5.1
IDEmiFLCATIOn
The classical signs and syr^ptons of -malaria are as follows:
i. Fever.
ii. Bouts of shivering (rigors).
iii. Profuse sweating.
iy. Severe echos and pains in the 1 ody.
CCIHRCL WaSURES
When ralaria cases, confirmed ly a positive Hood smear, occur in
high proportions, a T.ialaria opidei ic is estal-lishcd • In order o reduce
the num!or of deaths from tho disease, epidemic measures to prevent ralana
-from spreading ere- put into operati-cn.
‘
‘
7.5.2
WHBN MALARIA OCCURS -IU EPIDEMIC FCI^- IlITEIISIW CCWFC'-L OIW^I-C-NS ■ ”
AGAINST THE VECTCR AID THE r/JASITE IDE HJT HCTO OIERATION. ------------
The contain: ent measures include the following:
i. The distribution of radical treatment to all positive
malaria cases.
nn » Tho distribution of prophylactic chloroquine to all icvor
cases in tho area.
.
n nn L Spraying of houses with insecticide to reduce the adul
mosquito population.
iv. larviciding Operations to reduce the m. os quite, larval popula
tion in urban areas, and in rural areas only if feasible.
•
v Destruction of mosquito breeding places in urban areas, and
in rural areas only if feasible.
vi-. Intensive- health education program:- •ffi a W.ATn'H
WTERtlHECT YCU'TOTC iREHDE THE
K IPr
t® DISEASE, Al® LSSOT Y<W SUCT.V3SGR
: £2 :
ii. The twilight area is the periphery beyond the 5 kilonetros
radius surrounding the sub centre and has a population of
about 6,000/(see fig. 8.2).
A
inip i
H.(j(M)
5,000
Population
. . O
.....
C-
y
\
H.7F.?(M)
5,000
Population
hJw'CP)
10,000.
Pcpulaiion
I
I
I
I
I
I
1
I
1
I
1
Fig. 8.2:Intensive and twilight areas
Distribution of area botwo n health workers (kale and Feralo)
Total population covered ly sub centre: 10, OCX)
Population covered by one Health Worker (Fenale)
(Feriale):
<
Population covered 1 y each Health Worker (Lfelo) :
b/ -^o- n ..b-
s. $ ; :^£rt
.
&■. t,.k' .<■<
■>
»;
••■•I'-
■■
J
4,000 Intensive
6,000 Twilight
2,000 Intensive
3,000 Twilight
7xS nore health personnel becone available at the sul 'Centres, the
worker-population ratio will be increased so that this division of areas
will be eliminated.
The Health Worker (For.ialo) lias the major responsibility for the .de
livery of MCH services in the intensive area, but you also have certain
tasks to porfarLi. Those arc as follows:
1. To ii'jiunizc pre-schocl children (one to five years)
against smallpox diphtheria, pertussis and tetanus and,
whore available, poliormyelitis.
2. To administer BCG Vaccine to pre-school children (one to
five years).
" 3\. To identify and refer nalncurished pro-school children
4* To assist the Health Assistant (Male) in the irxiunization
of school children.
5. To participate in hollth education activities pertaining
fariiy planning, nutrition and ii:::
runization.
to MCH, fardiy
iraiunization.
'
■r
: i2> :
In the twilight area, besides the tasks listed for the intensive
area, you **11 also have the following additional tasks:
I •■ To ii.TTunizo infants (zero to one year) a.gainst sijfellpox,
diplitheria, pertussis and tetanus 'and, Aero available,
poliomyelitis •
■
■ '!'h/
x
2. To ad-tnrn-atnr BCG vaccine to infants (zero to one year)*
To dispense prescribed doses of ixon^and folic- acid tablets
to pregnant and nursing women and children’•
4« To administer prescribed doses of vitamin A solution to pre—
.school children (one to five years).
5* To administer tetanus toxoid to pregnant women.
p. ’
6. .To refer women with prollosn associated with pregnancy arid^ childbirth.to the Health Worker (Fonalo). aj
To educate: the ■•ccr.r.itofty about
family planning; nutrition
■
.
■ r-
- \.p.r.
a^ca, you will 'ol&rvo -that ;
wonon
'*
jy^Rid talking to yod wheh-^dti"make hbiise^to—hpnso visit^’bocause of
shW* soci’Sl taiecs. Be'causc of tris, ,yevr woi^^:';relat.ionship with tho
t '
itfi^rtant since this will larg&ly cldteri-inG yovr ahility
to Carry out the tasks relatefl. to the care of''jjregharit kronen.
.
W;.
-W-V- *
- ’■ X
■■
,
"■ r-
...
v>.
'
'■
- ■-W” ' -
. .
GS-^kmiAED iUIKHAlN GOOD WCSRKIITG BELATlOl® '
SINCE TI®Y li’.’ BE VERY EELJFUL IN LISTING YOU
<fUT -YOUR T/iSK- BELAW TO HE/s.LTH GARE OF EREGW3T- -WOMEN -AND
’ BiFAiiTS ._____________________________________ ______________________
During the oriohtation traiiiing session^ for dais that are
usually conducted at the su1-centres by the Health Assistant (Fenalo)
and the Health Worker (Fenale), rake, it -a point to rieet the da'is fron
your area. After such initial contacts, you should arrange to seek
then out on your regular visits to the villages and shw interest in
their work.
tW WOffi- BETVHSl'-i’YOUTSiiF AND -THS LOCAL DAJIS K VERY -IMFORTMT- FOR
DELUDING MfeTEREM. AKD CHILD HEALTH SERVICES IN THE TVilLIGHT AREA.
s
C;;:
I ■■■-. •. ■rV;
i■ "••••..
;j'
dcilferiiig Solc&ed hotiibh services to’ dothors'hnd
children in -the intensive area along'^ith the Health Worker (Female) who
has the major responsibility fop providing maternal and child health services
in this area* In order to avoid dupdicatidil of activities within hhe .
same femily, tine should be set aside for planning ycur activitiesi.iAth''
the Health Worker (Female). During those meetings the following;Say?''be y /
discussed:
-"■'b'
•
i. Women and children who require’ to bo seen l^y'tho Health’:
Worker (Female) should be referred bo her.
, X,
ii. The Health Worker (Female) should refer to;you husbands who •
are reluctant to permit their wives to accept a family?-plannrm
ing method, or families who want their wells .Chlorinate^ < ’
or pre-school children or school-agod children who have not
been immunized.
iiie The Births and Deaths Register and Eligible Couple Register
should be brought up to date.
iv. If djiy special programmes are to bo carried out, e.g., g^oup
meetings, you and the Health Worker (Female) should plan
these together.
------ ------ -----
IT IS TMFORTAHT TO HAVE A BRIEF DAILY COHFEREHCE ffiTfi'Tlfe'HEAffiH WORKER .
(m<AW>- TO-EXCHAHGE- INFORMATION BEGARWIG SNEGIFIC FAbHlIES AND -TO----ELSLTOl THE DELIVERY CF I1TECRATED HEALTH SEBJICgS.
_ • •
£
X.
i
m
'<?•
■
'■
.f
s
■>
f.
.r-4<
■
: 24 :
You idll be working alone in the twilight are at least until
sufficient nunbers of Health Workers (Fenale) arc available. Therefore, »
in addition to your tasks in tho intensive area, you will bo responsible for
referring pregnant wonon with health prcllons which cannot bo hendled by the
dais to tho Health Worker (Fonale) or Prinary Health Centre, or for request
ing the Health Worker (Fonale) to attend dolivorics in the twilight area.
In order to be able to do this effectively you riust know that are
the nost connon probions relating to pro nancy and childbirth. In addition
to care of prognaAt wonon in the twidight area, you will bo responsible for
advising nothers about the catro of children fron zero to five years of age
and for referral of those children who require nodical care.
fwly pumrn
t).1
What is Fai-iily Hanning
Fanily planning services include the following:
1 • Educating tho? cofniinity ’ as ' to ': ..
'«
------------
i. the advantages of a planned fanily;
ii. the selection and use of contraceptive nothods;
iii. nodical tcrimination of unwanted pregnancy;
iv. tho causes and troatnent of infertility (inability to have
children)•
2. Providing facilities for:
i. sterilization;
ii. IUD insertion;
iii. proscription of oral contraceptives J
iv. distribution of convcritlchal contraceptives through clinics,
hone visits and depot holders;
v. nodical tornination of pregnancy;
vi. troatnent-of infertility.
Tho operational goals of the fanily planning progrannos arc, therefore,
as follows:
1. To create the’ concept of a snail fanily as a nern anong all narriod
couples and ..to ensure its acceptance by tho different groups in
every coixTunity b ’
.. ——
2. To dissoiminato infonraticn "to all eligible couples as to the fanily
planning nothods available.
3* To assure an adequate supply of contraceptives within easy reach
of all eligible-couples.
4» To arrange for clinical and surgical services.
10.2 FAMILY FWnm AID FAMILY WELFARE
Frequent pregnancies in nalnctrishod wonon result in nothers who arc •
i. weak and who lack energy to care for their children;
ii. often sick because of poor resistance to infections;
iii. anaonic and subject to conplications during pregnancy and
childbirth, e.g., prona'turo delivery or hacnorrhagc•
Babies born to such wonon tend:
i. to be born early, and to bo snail and weak;
ii • to develop nutritional doficioncy diseases co.rl;z; "
: 25 :
Serious malnutrition usually develops in infants who arc displaced
from breast feeding early duo to tho birth of a new baby within a period
of about two years.
SPACING A PREGNANCY CAN PROTECT EBE HEALTH CF THE MOTHER. AND HER CHUD
BECAUSE:
i. SHE IS LESS LIKELY TO IAVE SERIOUS CGilLICATIOI'S CF JREGNANCY.
ii. SHE IS LESS LIKELY TO JRODUCE A WEAK, LOW BIRTH-WEIGHT INFANT.
iii. SHE WILL HAVE MORE TIME AND ENERGY TO CARE FOR THE INFANT AID
FOR OTHER CHILDREN.
iv. THE THE INTERVAL BETWEEN PREGNANCIES WILL HELP HER BODY TO RE-
GOVER FROM THE BURDEN OF CEIWBEARING.
Limiting popiQation growth in the country can make it possible for
more people to have. ■.
'
'
i. better job opportunitiesj
ii. higher family income;
iii. better facilities for schooling;
iv. bettor health care;
v. bettor housing;
vi. more adequate food supply.
10.3
TARGET GROUPS FOR FAMILY PLANNING
All couples where the woman is in tho reproductive ago group, i.o.
she is between 15 to 44 years old, arc eligible for family planning services.
GIVE PRIORITY TO GUILES WING TWO Gt MdE LIVING CHILDREN AND’ TO NEWLY
MARRIED COURIES. ENCOURAGE THESD COURIES TO IDOPT EITIER A- -PEPliA-IEI'JT- OR
TEIUFORARY METHOD OF CONTROLLING FERTILITY.
10.4 RESROI^ILITILS IF- TIE HEALTH -WCRKER (MALE) IN THE
DELIVERY OF FAMILY PLAIT ■ING SERVICES :
In the intensive area:
1 • To develop, maintain and use tho Eligible Couple Register for
planning and carrying cut family planning activities.
2. To confer regularly with tho Health Worker (Female) and refer
’ to her women who require her assistance.
3. To inform mon about the.^dvantages of a planned family.
4* To motivate mon to adopt a contraceptive method. ■
5* To distribute condoms to acceptors.
6. To provide fcllbw-up services to male family planning acceptors.
?• To rocjfruit, train, supervise and supply male depot holders.
3. To identify, train and involve male leaders in each vilIago in
family planning activities.
9* To utilize satisfied family planning acceptors and other intorostod
individuals in promotional activities for family planning.
10 • To identify and refer any woman with an unwanted pregnancy, for
medical termination of pregnancy to tho Health Worker (Female).
11. To inform couples about medical, termination of pregnancy and -■
infertility services.
12. To maintain and submit tho required records and reports.
13* To confer regularly with the Health Assistant (Malo) regarding
specific aspects of his work.
In tho twilight area:
(in addition to the tasks listed above)
14. To inform women about tho advantages of a planned family and to
motivate them to adopt a contracontivo method.
: 27 :
10.6 WORKING KETH THE
(FMLS.) IN FAKLY mjimilG
In order to achieve the family planning targets that have been set
for the subcentro, it will bo necessary for ,you and the Health Worker
(Female) to plan your promotional activities and follow-up of family planning
accepters togotter as a tear.1.
I
When there is joint planning and implementation of common activities
groups of eligible couples and influential men and women in each village
can be systematically reached and informed according to a planned schedule.
Duplication of efforts can be avoided or minmized and the information that is
conveyed can be designed to reinforce rather than merely repeat what has
already been Said about family paZkwing.
Points to consider in Coordinating your work with the Health Worker
(Female):
1. Share inforoation regarding approaches that have been found useful
in motivating i ale acceptors .
2. Request her assistance in motivating the wife when the husband in
resistant to adopting a contraceptive method.
3. Discuss with her some of the doubts and misconceptions raised by the
women in the twilight area and seek her assistance in clarifying
these doubts.
4* Give her a copy of the Eligible Couple List and keep it up to date
with her assistance*
5* Together with her, plan the educational activities for health and
family planning so that groups in the community can be comliLned
when feasible, e.g*, male and female school teachers, or male and
female depot holders.
<
1C,7
CONTRACEPTIVE METHODS
In this section of the Manual, the various contraceptive methods that
can be used by men or by women arc described and their advantages and dis
advantages listed. The illustrations have been selected for your own clari
fication as well as for their value as teaching aids for you to use in your
educational programmes in the community.
In-some instances a man may wholly reject the use of any contraceptive
method for himself and insist that his wife should use a method. You will
be able to as sit such a family by informing the man about female methods in
general so that he can encourage end support his wife in adopting a method
either for spacing pregnancies or for limiting the size of their family.
There are ttwo types of contraceptive methods:
1.
Temporary Msthods: These can be discontinued easily at any time by
the user when a pregnancy is desired. The methods differ for men
and women.
Teupccery Methods for Women
i. Intra-uterine devices (IUD)
ii. Oral contraceptives (the pill )
iiit Diaphragm (cap)
iv. Foam tablets and jellies
v. Rhythm method (safe period)..
Temporary Pfethods for men
i. Condon (Wirodh)
ii. Withdrawal.
2.
permanent Methods: Those consist of surgical procedures performed
on either the nan or woman which will make oilier individual permanently sterile.
/
: 28 :
Ftermnent Method for Wonen
i. Tubectomy i.e. tubal ligation (severing and tying off the
fallopian tube).
Permanent Method for Men
i. Vasectomy (severing and tying off the vas deferens) •
RE14EMEER, CONCEPTION CAN BE PREVENTED IF:
i< THE MAN’S SPEE14 CANNOT REACH THE OVUM.
ii. THE OVU-M -IS NOT- RELEASED EACH MONTH BY -THE- VOAN. ■ •
iij. THE OVUM CANNOT ATTACH ITSELF TO THE^ALL OF THE UTERUS.
10.7.1 SELECTION OF COUPLES FOR CO^fACEFTIVE METHODS
In advising a couple as to the most suitable method of contrception
to be used by them, the following factors should be taken into considerat
ion:
1. The age of the couple.
2. The health of the couple.
3. The number of pregnancies the woman has had.
4* The number of living children.
5. The health of the children.
6. The sex of the children.
7• The age of the youngest child.
8. The availability of the services, viz. personnel, supplies and
follow-up.
9. 'Whether the couple.wish to space their children or limit the size
of their family.
10. The preference of the couple for a particular method.
11. The facilities available in the homo, e.g., privacy, water supply
and facilities for storage of contraceptives•
12. The cost involved in purchasing, contraceptives or in travel to the
place of free supply.
13. Specific family situations, e.g., either partner refuses to use any
method, irresponsibility of either partner, long absence or chronic
illness of either partner.
14. The presence of medical contraindications to the use of a particular
method. This could bo determined after history taking and medical
examination at the clinic.
10 .7.2 CONTRACEPTIVE METHODS FOR WOMEN:
1. Intra-uterine Device (IUD): The intra-uterine devices currently used
in India include ’the lipr'es loop which is rade of polyethylene and
the Copper T device which is made of polyethylene and copper. The
IUD is inserted into the uterus to prevent coception (see fig.10.1a
& b).
: 29.:
Advantages:
i. The wearer has little responsibility for preventing conception onco
the device is inserted.
ii. The device can be removed when a pregiiancy
v is desired.
iii. The procedure docs not require hospitalization.
iv. It docs not interfere with intercourse.
v. It is a :reliable method for spacing children especially for women
who ano wablo to use other methods.
Limitations:
.i. There may be some bleeding or pain, which is usually temprorary.
ii. The device may come cut spontaneously so the wearer must check the
threads attached to the IUD each month usually after the- menstrual
period•
iii. An examination by the doctor* at least once a year, is necessary*
iv. The device must bo changed at least once every j^hree years.
v. The IUD cannot be used in the presence of certain gynaecological
conditions.
If.this method is preferred by the couple^ refer the woman to the
Prinar^r Health Centre and inform the Health Worker (Female).
2. 0*^1 Contraceptives (Jdll): The oral contraceptives are pills that are
T-axcn daily by a -women to prevent her ovaries from releasing any eggs
so that She cannot become pregnant. The pills must bo taken on a, pre
scribed monthly schedule to be effective since seven of the pi ~I1 s in
each 28-day supply package arc black pills, i.o. they do not contain
the contraceptive drug but contain only iron. Those"pills are usually
packed as shown in fig. 10.2.
5 MlV
y
fc3 *
-^v
Fig. 10.2: Contraceptive tablets - 28 tablets jack (IDHj)
Advantages:
i. It is an effective method.
ii. There is no interference with the sox act.
a
- r
y
: 30 :
*
iv. It, is usef\£L for a newly carried woman who wishes to postpone
having her first child •
LIMITATIONS:
i. A careful history and nodical examination by a doctor are-required before the pill is prescribed#
ii. Side-effects nay occur, i.e. nausea, headache, bleeding between
menstrual periods or increase inieight.
iii. It requires self-discipline, and is likely
v to be -stopped
-x-x__ '• Or
forgotten by women who arc not strongly motivated to control
conception.
iv. There are certain contraindications to the use of oral contra
ceptives so that all women cannot be given the prill .
Instructions for Use of Contraceptive Tablots (one tablet a day without interruption).
tablets pack
NQTE: These instructions arc for the use of Contraceptive
tablets manufactured by the Indian Drugs and Pharmaceuti
cals Limited for the'Ministry of Health and Family PLanning. The instructions are issued with each packet of
Contraceptive tablets.
The first course of tablets should be started on the
fifth day of the menstrual cycle (counting the first day of bl
bleeding as da^7 No.l) by taking the talbet from the pocket
marked as 1 start1 (white tablet). For subsequent days one
tablet a day should be-taken from the pockets in the
other indicated by arrows Cn the pack, till all the
tablets arc consumed. The new pack sho; Id be started
the very next day by taking the first tablet from the
pocket narked as ’ start1. The tablet should be taken
every day at a fixed tine, preferably before going to bed
at night.
•
CAUTION:
:
------------------------ ------------- ------ i. THE FIRST. COURSE SHOULD BE STARTED STRICTLY ON THE EEFTH DAY
OF THE MENSTRUAL RE' IOD, AS ANY DEVIATION IN THIS RESPECT LAY
• .• -NOT KtEVENT EREGMNCY
-J.. -.
ij, OEP ALL TABLETS AWA.Y FROM CHILDREN.
If this method is preferred by the couple, refer the woman to the
Oentre and inform the Health Worker (Female) •
3. PiaThragn (Cap): The diajteagn is a soft, rubber, doneshaped device,
the rim of whicn contains a metal spring.
Diaphragms are made in various sizes and are used for covering
the lower opening
of" the uterus.
- ~
*
• They prevent the spermatozoa ffon
entering the uterus during intercourse and should be used together, with
spermicidal creams or jellies for more effective contraception (see fig.
id!.3).
*
Advantages:
i. It does not interfere with sexual intercourse.
ii. It does not hurt or affect either the woman or the nah.
iii. It is a very effective method of contraception.
iv. It can be placed in the Vagina at any tine by the worian herself
once she learns how to use it.
rt
: 31 :
1
11
z'
?
f'
■
I
'4
Fig •IT).3: Diaphragri and Jolly
Limitations:
i. One size does not fit all women.
ii. Vaginal" examination by a doctor is required for determining
the proper size needed and for excluding conditions where the
diaphragm cannot be used.
iii. It must bo loft in., .place- for at least 6 hours after intercourse
iv. It must be washed, ('dried and stored carefully in between use.
must bo chocked each tine before use to exclude defects.
v. It rust
vi. It should preferably bo used with a speraicidal croan or
jelly which requires- regular replenishment•
vii. Once a year,. examination is needed to sec if tile prescribed
diaphragn is still of the correct size.
. If tliis method is preferred by a <couple, refer then to- the Primary
Health Centre and inform the Health Worker-' (Feriale.)
4* Foam Tablets: These are vaginal tablets which dissolve on contact with
moisture by developing a thick foan which is spermicidal, i.o. it is able
i° kill the spermatozoa in the vagina during intercourse.
Advantages:
/
i. Insertion of the tablet in the vagina is simple,
ii. It does not interfere with sexual intercourse.
iii* No prior medical examination is necessary.
limitations:
i. It is no an effective contraceptive method.
ii. There is a tine limit for inserting the tablet (5 to 10 minutes)
prior to intorc’oursc.
iii. A now taliot is required for each sexual act.
j.-~
---.z’
irc^Trlt-
: •ritp.-r. ’
y.
■:4'.
: 32 :
v« The tablets may not be placed deep enough in the vagina for
effective spermicidal action*
vi* The tablets deteriorate so that they are of no use when they
have lost their foaming property.
Instructions for the User:
i* Inspect the tablets to see that they are of the proper colour,
consistency and form*
ii. Just prior to inserting the tablet in the vagina, moisten it
with water and discard it if it does not foam,
iii* Insert the tablet high up into the vagina behind the cervix
(mouth of the uterus) •
iv* The tablet should be inserted just prior to intercourse. If
more than 10 minutes elapse from the time of inserting the
tablet, moisten a second tai let and place it in the vagina.
-- - ■
Do- not d-cuche- after- -intercourse-.- .......
.
the FOAN TABLETS -MUST- BE INSERTED
INTO THE VAGINA AND NOT TAKEN BY MODTH.
THE TABLETnS MU-ST -BE ST-CRED IN A SAFE PUCE WELCH IS INACCESSIBLE TO
CHILDREN.
5* Creams and JeUios: There are various kinds of spermicidal creams and
jellies which a re use(T for contraception by the woman. They may be used alone
or with a (diaphragm
“’
or condom. When used alone, the ijelly or cream is inserted
in a measured amount into the vagina with a special applicator.
Advantages:
i* It is easy to use*
ii* No prior medical examination is ncccs£££ry.
iii. It csn be used by a newly married woman who wishes to postpone
having her first child«
Limitations;
.i. When used alone it is not a very e ffectivc contraceptive method.
ii. Side-effects may include local irritation or soreness in either
the man or the wman, or vaginal discharge in the woman.
iii. Errors in the amount of jelly or cream used or in the depth of
its application may occur.
Instructions for the User:
- . -
. .
— TJ
-1 - .J..
,
,,
—
,
4
i. Screw the applicator on to the nozzle of the tub. containing the
jelly or cream'N
ii. Press the. tube so that the applicator is filled with jelly or
cream• •
iii. Unscrew the applicator*
iv. Just prior to intercourse the woman should lie on her back and
insert the applicator into the vagina behind the cervix.
v. Inject the jolly by pressing the plunger while gradually with
drawing the applicator.
vi. Do not douche after use.
vii. Wash and dry the applicator,
the reach of children.
Store the jelly or cream out cf
Bhybhm Method (Safe Period): For those who will not adopt any other
methed of familyplanning because of religious or other reasons, the rhythm
method^ (safe period) may be advised* The method is based- on the fact that
ovulation occurs from "IS to 16 days before the onset of menstruation (see
fig. 10 *4) • The days on which conception is liirely to occur are calculated
as follows:
: 33 s
0v u i a r /
\U
37
•• 3
1O
20
8
21
'7
22
Fig. 10.4 Safe period in a 28-day cyclo
The shortest cycle ninus 18 days gives the first day of the fertile period.
The longest cycle ninus 10 days gives the last day of the fertile period.
For exanple, if a wonan’s menstrual cycle varies £rom 26 to 31 days, the
fertile period during which she should not have intercourse would be from
the Sth day to the 21st day of the menstrual cycle, counting day one as the
first day of the menstrual period.
10.4 indicates the fertile period and the safe period in a 28-day cycle.
hOTE: por LIOro exact calculation the temperature method is used, i.c. the
rise in temperature is taken as the time of ovulation. However, this
requires careful daily observation of temperature and is of little
practical use among illiterate groups.
Advantages:
!• No prior nodi cal oxauination is necessary*
ii* No devices arc required to be used*
Lirjitations:
T+. c-.Trir.'1- Io "s®< i:
V7 ■' o’-l ‘who h- v ■
7?
.3 .
: 34 :
5^^ As it is based on the estimated day of menstruation, there
is always a risk of pregnancy occurring.
id5. Sexual intercourse without the use of contraceptive devices
is limited to certain days in the month.
iv. It is only possible for this method to be used by educated
and responsible couples.
7, Tubectomy (tubal ligation): In .pnida the term ’tubectomy1 refers to
7.
the operation in which the fallopian tubes are ligated with or without
cutting. This prevents the sperms from mooting the ovum so that conception
cannot occur ( see gif: 10.5) •
Fig: 10.5: Tubcctony (tubal ligation)
Advantages:
i. After the operation has been performed, no further action is necessary
by either the man or the woman for preventing conception.
ii. The operation can be done immediately after delivery in a' hoppital
or it can be carried out at the time of some other lower -abdominal
or vaginal operation, or at any other time. convenient for the woman.
iii. The operation is done free of charge in a government hospital or
’ Primary Health Centre*
Ljnitations:
i. The -women has to stay in hospital for about a week.
ii. The results of the operation can bo reversed by rooanalization, but
this is not always successful.
If this method is preferred by the couple, refer them to the Primary
Health Centro and inform the Health Worker (Female).
--y-
-
5
: 35 :
10.7.3 CONTBACEETIVE METHODS FOR liEN
1 • Condom (Nirodh): This is a thinlc rubber sheath which is used to
cover the penis just before intercourse so that spermatozoa are prevented
from entering the vagina (see gif .10.6) •
/m
A
F
/J./Ml
*
Fig: 10.6: Condom (Nirodh) *- rolled and wrolled
Advantages:
i. It is available Rree at the subcentro or from the male or female
health workers, or at little cost from local depot holders
3 pieces
for 5 paise).
ii. No examination by a doctor is required before using the condom.
iii. It is relatively simple to use'.
iv. It is a reliable method of contraception.
v. There are usually no complications after use.
vi. It protects against the spread of sexually transmitted dieases.
Limitations;
i. It nay tear or slip off if* not used properlyii» Without self-discipline, it may not be used dvery time.
iii. The supply may be inadequate or irregular.
iv. It nay interrupt intercourse because it has to bo ’put on after
erection.
v. Occasionally a man or a woman may be allergic to the dusting powder
used for packing condoms.
Instructions for the user:
i. It must he fitted on the erect penis before intercourse-•
ii. The condom must be hold carefully as the penis is taken out of the
Vagina in order
-'v id rn a •• ■ :
'T-m ' into 'die
;ina
: 36 :
after intercourse.
iii. A new condom should be used for each sex act.
iv. The used condom should not be thrown, about ’ indiscriminately but
it should bo wrappd in paper and thrown in the dustbin.
DEMONSTPATE THE-APPLICATION OF THE CONDOM EY USING A CHART (KA MODEL OF
TIE MAZE. GENITAL GBGANS PATEGR THAN USING TEE- FINGER OR,- SOME OTHER OBJECT
TO REERESENT THE PENIS.
Zfcking follow~up visits to condom users: Schedule domiciliary visits to
new acceptors of condoms at least once during the first two months and
every six months after they have become rcf:ular users. Advice, information
and reassurance can be given as needed on such visits.
During these visit.3:
i. Elicit any problems related to use and clarify doubts.
ii. Ascertain the adequacy of supplies and inform the individual
whore condoms canto obtained.
iii. Dispense a supply' of condoms if the acceptor is unable or unwilling
to obtain them from d opot holders •
iv. Rc-motivato him to use the condom, if its use lias been di continued.
v. Urge the use of an alternative method for the wife if the use of
the condom is irregular.
vi. Determine the willingness of the acceptor to motivate other or to
be a depot holder.
2. Witlidrawl (Coitus interruptus): In this method the penis is withdravm
from tho vagina grust before ejaculation.
Advantages;
i. No devices arc necessary•
ii. No cost in involved.
iii. No prior nedicil examination*is required.
Limitations:
i. It is unreliable as a contraceptive method.
nothod.
ii. It can cause psychological disturbances in either the man or the
woman.
Lii. The sexual act is interrupted.
3» Vasectomy: This is an operation done on men and consists in cutting and
tying tho two tubes (vas defereos) that carry spermatozoa from tho testes.
. When the operation has been done, fertilization of tho woman1 £ ova is no
longer possible since no spermatozoa can reach tho vagina (see fig.10.7a & b).
Advantages:
i. It docs not require hospitalization.
ii. It does not in any way interfere with sexual desire or intercourse.
iii. It does not reduce the capacity for physical or mental work.
iv. After the initial three months following the operation, no further
action is needed to prevent conception.
Limitations:
i. The results of the operation can usually be reversed by re canalization,
but this is not always successful, Hchcc, careful selection of mon
for this operation is necessary.
ii. Condoles will have to be used during the first throe months after
■ '/■
. ?• r-'-Hl
’ irat'- rg te :t - \firms
'
I
: 37
VA^GT-a-ff- -IS A S-WI£r SAFK AID
FCR THE MAIA#
..
lETH® OF FAMILY- -PUWING
____
* ' i
A.
A ..
I
f;
7
I
\ i
H c
t
1
Fig. 10.7a:Vasectomy (front view)
Fig.7b: Vasectomy (Side view)
Coixion fears, and doubts about VaSdctoLry: Although vasectomy has
been proven to be a safe and simple procedure, many mon have certain fears
and doubts about tho operation. Their main fears are usually related to
tho following:
i. The harmful effects that they think it will have on their soxual
function.
ii. The pain and discomfort connected with the procedure.
iii. Tho effect it will have on their ability to work.
iv. The physical- risk of tho operation.
Yctut; major task is to reduce such fears and doubts by wing every
available occasion and creating opportunities to encourage m-n in the viTlages
A0.
^Icy laa-VG heard about vasectomy and to ask questions •
■ PQints_ for emphasis regarding xrrsectorry-;
i. It is a fsimple procedure that can be done by the doctor in 10
to 15 minutes.
--------> The man can go hone within a short' while after
the operation.
ii. The procedure consists in cutting and
the tubes thats carry
- tying
v
the spermatozoa to tho penis so that tho sperms cannot bo released
during intercourse.
3« Vasectomy is not the same as castration which is done to animals
The testes are not touched or removed so that a man who has had
a vasectomy done will not become obese, and xd-ll not have any
change in his sexual desire or in his ability to carry out sexual
intercourse.
: 38
4. It is the method of choice for men who do not want any more
children since it is a permanent method of contraception.
5. It is always done free of charge by specially trained doctors
at the Primary Health Centre or in a central place or camp
which is tenproarily sot up for this purpose*
6. Foil ow-up services are provided for acceptors. You will visit
the man in Iris homo after vasectomy and medical care from the
doctor at the Primary Health Centre will bo available if
. needed.
.. .
--t
Y• Incontrives for acceptors as well as for motivators are avail
able. These incentives vary from State to State. Find out
what incentives and compensation payments are available in your
State for persons undergoing vasectomy and what incentives arc
available for motivators, so that you can give the community
this information.
Selecting non for vascctony :
The criteria for selecting non for vascctony arc as follows:
1 • The couple should have iwo or noro living children,
2. The agc of fho youngest child should be two years or more•
3. The couple should preferably have at least one son.
4. The ago of the wife should, be between 20 and 45 years.
5 • The nan should not be below 25 years, nor should bo loo over
50 years old.
6. The couple should not w ant any noro children •
In order to prevent the occurrence of serious psychological
problems that occasionally develop in some men who undergo vasectomy, you
will need to use care in selecting the men to bo motiva.tcd to adopt vasectomy.
If a man is found not to bo suitable for vasectomy, his wife may have to be
approached by the Health Worker (Female) to undergo ster-ilization.
In any of the following conditions exact, the men should not bo
motivated for vasectomy because they arc the ones who are most likely to
develop psychological probions related to the operation#
1 • If the narriage is an unstable one and is in the process of
breaking’ up.
2. If thonan has doubts about tipis nasciiiinity or ho has borderline
inpotonce•
3. If he is unduly concerned with his health and fears that ho may
have a serious disease..
4* If his wife is forcing him to undergo the operation.
5. If the couple has the mistaken belief that sterilization is a
temporary measure and that it can easily b e reversed •
If you have any douts as to the suitability of the man fdr under
going Vasectomy, ycu can discuss the problems with your supervisor. The
doctors at the Primary Health Centre or those who conduct camps are also
’ ’ to
’ do
’ the
■' final screening
‘
" menofwho will undergo TOsediomy.
expected
Infornation to be given to acceptors of vascctony:
1. Inforn the nan of the place and tine of the operation and plan
whore and when ho will moot you so that-you can acconpany hin
to the- placo whore the operation will bo carried out.,
2. Ask hin to bring his wife along, if possible.
Explain what ho should oxpoct, i.e. that the site will bo
cleaned with antiseptic, that a local injection will be given
to deaden pain, that the operation wi31_ bo done on both sides.
: 39 :
4.
and that he will bo completely conscious during the operation.
Tell liim to shave tho R>rt? bathe, and wear clean clothes
before coming for tho “lope ration#
Instructions for non who have undergone vasectomy:
• In order to ensure a minimum of discomfort and to ensure normal
healing of tho operation site, you will have to make certain tliat mon who have
had a vasectomy follow those instructions:
1 • Avoid taking a bath for at least 24 hours after tho operation.
2. Koop the drossing in place, keep tho site clean, and wear a
T-bandage or scrotal support (langot) for 3 to 4 weeks.
3# Avoid heavy physical work and cycling for a wook.
4» Return to the Primary Health Centro er subcontro to have the
stitches removed on tho 5th day after tho operation#
5# Intercourse can be resumed after 7 days but condoms (Nirodh) must
bo used for at least 3 months after tho operation, because some ’
spermatozoa are present in the- part- of tho vas beyond the opera
tion site and arc passed during that time.
6 • Return to the Primary Health Centre after 6 weeks and after
3’ months to have the semen examined, and deepending on the
result, tlie use of condoms can then be stopped#
Folldy-up Activities: Visits should be made to the man’s home to make sure
that he is making normal progress, to treat minor problems and refer serious
ones to the doctor at the Primary Health Centre.
’You will have to plan your work so that you can schedule time to do
regular follow-up of the eases from your area who have undergone •vasectomy#
AH vasectomy cases should be visited according to the following
schedule:
1 • Twice during the first week in order to:
i# identify any sid; •effects;
ii# give the necessary rdssuranco;
iii. treat minor symptoms;
iv. refer those cases with complications to the HIC*
v# remind them about having tho stitches removed on the
5th day;
vi. supply condoms and instruct about their use for three
months•
It is important to find cut how tho man is fooling and whether
ho has_ fever, Jpain, or other discomfort.
DO NOT A.SSUm THAT EVERYTHING IS PROGRESSING NORMALLY BECAUSE THE I AN
TELLS Y U SO. -EXAI'IINE-TEE OPERATION SITE TO HAKE SURE THAT HEALING IS
E CGRESSING AS EXPECTED .
REMEMEER- FREQUENT VISITS AND mCMPT REFERRAL A' E’ NECESSARY FORANT 'MAN W H4g StMEWJJIOHS,_________________________________________
2# Once in tho next month in order to:
i# ascertain tho condition of the wound;
ii# give tho necessary reassurance;
iii# distribute condoms and reinforce tho need to continue their
use;
iv.. refer the man to the Primary Health Centro for semen exami
nation at six -weeks .............
• SfflESS -ON THE LAN -TIA.T THE USE OE-CONDfifS FOLLOWING VASECTC^'IY IS
ESSENTIAL UNTIL THE SEHE IS FREE FROM SPERmOZOA.
: 2fi :
3. Once after throe months in order to:
i. ascertain that he has had,,# somon examination before
discontinuing the use of condoms;
ii. encourage him to motivate his friends for vasectomy.
10 .S
Refer to chart on pages 104-105.
-APPROACHES- FOR ASSISTING ELIGIBLE COUPLES
TO COMROL THEIR FERTILITY
You will need tact and understanding in order to motivate people
to accept family planning methods'.
During your home visits, proceeds as follows:
1. Enquire about the health of the memb*ers of the household.
Ha.ndling their health priorities is important for developing
rapport•
2. Identify health problems and give the necessary treatment
or assistance in order to establish your credibility as a
health worker.
3. Find cut if any family planning method is being used.
4. Find out what they already know so that new, additional, or
correct information can bo supplied.
5. Emphasize the health benefits of family planning to gain the
confidence of eligible couples, especially the men.
6. Keep explanations as simple as possible. Use words and examples
that are familiar in the local area.
7• Supplement verbal explanations with pictures, diagrams or the
actural devices, c.g., Nirodh or IUD.
8. Bo tactful when attempting to correct misinformation or rumours.
Strong condemnation may lead to negative results.
9. Avoid exaggerating thb effectiveness of any contraceptive method.
Inaccurate information may lead to disappointment and create re
sentment •
10'. Liston sympathetically to what people have to say about farvHy
planning. Discuss with them and try to remove any antagonism. ‘ ,
towards the programme.
.
.
11. Respect people !s religious beliefs when giviqg advice about
family planning.
12. Several visits may be necessary before a family planning method
is accepted.
13• Persistent rejection of family planning by an eligible couple
may be handled in the following ways:
a
i. Aslc a Satisfied acceptor oriospocted older to speak to the
husband•
ii. Request the Health Worker (Female) to contact the wife.
iii. Dis-cuss the problem with the- Health Assistant -(ibile).
KEEP THE HEALTH ASSISTAM~(MAil) AID MEDICAL OFFICER OF THE-. PRIMARY
HEALTH GEHTRE INFORMED OF ANY ADVERSE COMMENT- OR RUMOURS IN THE CailUNITY
WHICH MAY AFFECT THE SMOOTH RUNNING OF THE FAMILY FLAWING HROGRAl lfE.
10.9
SELECTION, RECRUIT MEM AID SUPERVISION CF DEPOT HOLDERS:
A depot holder is a man or woman who agrees to store and dispense
condoms (Nirodh) regularly to anyone requesting a supply, keeps records
of supplies held, and influences couples to become users •
y
. You are responsible for the soloction/ recruitment and supervision
of community members in servo as depot holders so that any couple who wants
to usg .
».«.Cont^/41
: 41 :
FOLLOW-UP OF MEN WHO HhVE UIDERGQWE VASECTOMY
First visit (3rd day after operation)
V
Complaints
No Conplaints
I
Examine wound
Fhin
Discharge present
No discharge
________________
Remind to get
stitches our
on 5th day
i. Dust wound with
Sulpha’, powder
ii. Re-bandage
1
f
1
I
'z
Without swelling
With swelling
If no discharge
If discharge
prosent
/
J
With fever
AFC tahlots
for 2 days
Without f
Inspect wound
Seo after 2 days
If no better
Refer to PHC
I
R
Discharge
----1
If better
i. Hot fomentation
ii • Triple-sulpha
tablets
Remind ’to get
stitches out
on 5th day
If no better
I
Refer
i. Dust wound with Sulph.
powder
ii< Ro-bahdagc
4
Refer
If no better
If bettor
1
Refer to PHC
Remind to got
stitches out on
5th day
Contd/42
/
: 42 :
Second visit (7th day after operation)
I
Wound healed
I
;—
Stitches out
... 1
Advise use of
condou for
3 months
Wound not healed
—
1
Stitches in
I
♦
Renovo stitches
Refer to HIC
Third visit (6 to 10 weeks after onoration)
5
No complaints
■ -Sonplaints-
Continue use of
condom for up to
3 months
Scar t< idemoss
pain
Impotence
I
i*~ AFC tablets
ii. Reassure
Piofcr for sencn examination
Encourage him to motivate friends
Symptoms persist
Refer
1
No symptoms
4Cured *Refc;
ZOU CAN PROMOTE FAMILY PLANNING IN THE COMMUNITY BY ENLISTING THE ASSIS-. IXNCE OF MEN WHO ARE SATISFIED VASECTOMY’ ACCEPTORS.
.Contd/43-
: 43 :
condons can procure the supplies within the village fron individuals who
are known to then without having to go to a distant place or centre for ■ .
supplies •
Depot holders should preferably bo selected from among connuni'ty
members who:
i. practise faizily planning and have a snail family;
ii. arc at least 30 years old;
condons.
iii» ano able to teach individuals about the proper use ox condoms,
explain about other ncthods, and answer-questions pertaining to
contraception;
iv» arc active in connunity affairs;
v. have sufficient tine to carry out the necessary activities; .
vi. can carry out this work without objections fron their spousofl;
vii* arc willing to assist in&nily planning educational activities
in the local area;
viii. can maintain simple records and reports.
Orientation of depot holders should consist of the following:
1 • An explanation of how family planning can contribute to improving the welfare of families.
2. The various tasks to be carried out by a depot hold®!', naneAy.
i. obtaining supplies and storing condoms;
•ij » dispensing condoms to anyone requesting a supply;
iii. explaining how condoms arc used;
iv. encouraging acceptors to be regular users;
v. maintaining simple records and submitting reports regularly,
vi» referring cases to the Primary Health Centre xor steriliza
tion and'lUD, and for problems following surgical procedures;
vii • reporting problems related to condom distribution, acceptance,
and use, to the male or female health worker for necessary
action.
3. The procurement and use of visual aids to supplement verbal
explanations •
4. An explanation of the Value of distributing condoms to the
users and to the depot holders in their respective villages.
Supoi'vision (support and guidancoO of depot holders should include
the following:
i. Hogular, planned contacts with d opot holders to acknowledge the
work being done by them and to maintain their interest.
•j~i . Discussion and assistance in problems faced by theebpot holders
xvith regard to f amily planning activities •
jii • Giving information. d'cut the achievements of the family planning
programmes in the area.
iv* Scheduling monthly delivery of supplies to depot holders slightly
in excess of needs.
v. Assisting depot holders, especially those who may be illiterate,
in making entries and preparing reports.
vi. Informing neighbourhood groups about the existence of local
depot holders and their activities.
vii. Contacting on a sample basis those mon who have boon r.iotivr.tcd
by depot holders to become users, in order to ascertain 'whether
they arc using the condoms properly and are satisfied with the
method.
viii. Aa*x*anging for official recognition of the depot holder s work
from the kodical Officer at the IYimaiar Health Centre and from
others •
44 :
REGUIAR CONTACTS, BOTH FORMAL AND INFORMAL, BETWEEN THE HEALTH
WORKERS, VILIAGE WDERS AND DEPOT SOLDERS ALE NECESSW FOR KEEPING
INTEREST AT L HIGH LEVEL AND PROMOTING TIE ACCEJTANCE" CF' FAMILY
PLANNING.
10.10
RECORDS AND REPORTS
Generally, there will be several kinds of information relating
•
to family planning that you and the Health Worker (Female) will
be responsible for tabulating, maintaining and using at the subcentre, These
include the following:
1• Registers
2 • Health cards
3« Programme promrtinn activities
4* Reports..
1 • Registers: These are usually of two types, one for eligible
couples and the other which shows how various supplies have been dis
pensed, e.g., pills or condoms.
2. Health Cards: Services delivered to individuals who become
family planning acceptors are recorded in their respective health cards
including:
ii regularity of use;
ii. reasons for discontinuing a method;
iii* side-effects or complications;
iv. treatment for problems related to various methods.
3. Programme promotion activities: Records are kept showing
the kind, number and frequency, of activities for promoting the programme
with various groups in the villages, e.g., depot holders, teachers, and
community leaders•
’
.
. ..
4. Reports: A tabulated report of various activities is usually
required to be sumitted monthly, quarterly or annually to the Primary
Health Centre (s,
\ jee Chapter 4^ ’Record Keeping1, for details).
10.11
MEDICAL TERMINATION OF PREGNANCY (MTP Or Abortion)
Many women living in rural ar as still die needlessly from the
results of illegal abortions performed on them by untrained persons and
often under insanitary conditions. This method of getting rid of an un
wanted pregnancy is no longer necessary because in India the Medical
Termination of Pregnancy Act (1971) lias made abortions done by doctors,
under certain conditions, legal. Information pertaining to this Act
needs to be widely disseminated in the villages so that women need no
longer resort to unsafe, illegal means in order t o terminate an unwanted
pregnancy.
10.11.1
THE MEDICAL TERMINATION OF PREGNANCY ACT (1971) ■
Before the law was passed, several million women, the majority
of them married, had induced abortions done and most of them had to go to
local quacks in desperation. Because such women were desperate, they
usually paim exorbitant fees, which they could HI afford,- to unscrupulous
quacks. . The unskilled efforts of these quacks and ditty equipment used
have been the cause of a .high rate of serious complications and even death
among women undergoing illegal abortions. The Medical Termination of
Pregnancy Act is expected to create conditions that would make it difficult
for quacks to victimize pregnant women and ruin their health.
:45:
10.11.2 THE CONDITIONS UNDER WOE A IUEG1OCT CAN BE TMNTO
UNDER THE MTP ACT
There arc five conditions that have be n identified in the Act:
1 . Medical: Whore the continuance of the pregnancy might endanger
the mother1 s life or cause grave injury to her physical or
mental health.
2. Eugenic: Where there is substantial risk of the child being
born with serious handicaps due to physical or mental abnormali
ties •
3. Humanitarian: Where pregnancy is the result 01 rape*
4« Socio-economic: "Where actual or reasonably foreseeable environ
ments (whether soical or econmic) could load to risk of injury
to the health of the mother.^
5. Failure of contraceptive devices: The anguish caused by an un
wanted pregnancy resulting from a failure of any contraceptive
device or method can bo presumed to constitute a grave mental
injury to the health of the mother«
10.11.3
OTHER PROVISIONS OF THE ACf
Where abortions can be done: They can bo done ab all hospitals
owned or maintained by government and at such
sucn other
otner places
pi-aces (not being
uuxiig..
,) which have the necessary equipment and facilities
government institutions)
for termination under Safe and hygienic conditions and Which have been appro
approved for the purpose by the government.
Who can perform the abortions: Not all doctors .are authorised to
perform the operation. Those who can do so are doctors who have necessary
qualifications
or experience provided under the Rules. •Under the Act,
h
others arc not allowed to perform abortions.
10.11.4 RESPONSIBILITIES OF HEALTH WORKER (MALE) RELATED TO
MEDICAL TERMINATION OF SECNANCY
1 . Informing men and women about the provisions of the MTP Act.
2. Early identification of pregnant women who want abortions.
3 . Referring women who have an unwanted pregnancy for MTP
to an institution or person approved for carrying out termi
nation.
4. Informing the Health,Worker (Female) of the names of MTP
accentors so that she can follow up those cases.
5. Maintaining the records in a confidential manner and submitt
ing the necessary reports.
10.11 .5 WHAT YOU SHOULD KNOW ABOUT i-EDICAL TERMINATION
OF PREGNANCY
1 . Medical termination of pregnancy or abortion refErs to the
various medical procedures that can bo done to empty the
pregnant uterus of the products of conception.
2. The operation for terminating a pregnancy is simple and without
much risk if it is done within the first 12 weeks of pregnancy.
3* Hospitalization is not always necessary and the women can
usually go home after the .procedure’ when it is performed within
the first 12 weeks of pregnancy.
4. Serious complications from the operation are rare, but some
times there may bo bleeding, pain, fever or menstrual irregul
arity Such problems can easily be treated by the doctor‘at the
PHC.
: 46 :
5 , Women who’ want a prdgnaucy terminated after-the-12th
- week'Wy^rneed an- abdomirtal operatibhxhich will require
\
pregnancy aft beyond 12
weeks but not beyond 20 weeks will have to be examined
and the operation approved by two qualified: doctors .-
KIGO
O'.t.
■hospitalization/.
. Gx'l TO d-ffer 6. A-wofnan’desiring MP and whose
'
■
TfiE’
REhEMBER^ THE WW/Thfe ABCRTION IS ,CO ME, TgE‘ SlMilEB
■ LESS. THE RISKS Ett THE W<MN« ~
1 J., hg ——
K h ...
■■■ , 7. To avoid uhc rood-for repegied.MTP,...-it is csscnui.-l that
ip.' each.case undprgpzmg W.P. the.womah or^ter husband _
should bo encouraged to use any one of the contraceptive
methods
or
undergo ,sterilization
if
*oti’gi‘ble”
.
.
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7..
,.v.
fto
10.11,6
IWOMffi MEN AHD WOW, ABOUT .MP. -
'
'■ ^ Although you will ’ ordinarily ;have- ratherMiMied opportunities
-c -for directly informing;:women about the.availability.of services for the
- - medical termination.- of c pregnancy, you- qre- expected to- pse*
usual con
tacts xd-th -the; .men in. the community for this ppr pose, pa-that ^tkqy can inform
their wives, female relatives, and^ptb-pr men who could, bone fit from sue
information.
:
■’..1
•
W
-
EVERY EFFORT SHOULD’ BE TADE- BY'YCU’ T0r- iWOHM MEN Al^ WOWP ABOUT : THE "
SERMOES AVAILABLE- FOR-” M P SO THAI NEEDLES'S DE/iTHS OR . .DISABILITY FROM
ILLEGAL ABORTIONS PAN BE REDUCED .
__
Yon can carry out this task while you are:
i< orienting or training-family planning .depot.-holders or
village leaders;
ii. meeting with individuals and.groups of men;
nin , talking to parents accompanying children for health care*
You may also have opportunities to reach women and older
children with the information when you encounter them while:
i. administering various immunizatipns in house-to-house
visits in both the intensive and twilight areas;
ii. systematically looking for malnourished pre-school
children in homes with four or more children.
i j j > administering- immunizations, to ..children in the upper
grades in schools.
Other activities-would include, the. following:
i. Developing simple posters and displaying them in public
places• ■
, ,1
ii. Distributing literature on MTP in the villages.to those
who can read.
In order to reach women with information on MTP you can seek
the assistance and guidance of other members of the health team such as the
Health Worker .(Female)> Health Assistant (Male), .Health Assistant (Fooale;
and Block Health Assistant. Indigenous health practitioners, dais, as
well as other- village level workers and their supervisors can also assist
ycu in disseminating information about MTP.
Ch h-.+z; A
J
: 47 :
;.y-.
10.11.7
HEALTH EDUCATION
Topics that you should talk about include the following:
1 • Any woman with an unwanted pregnancy can have MTP on request
grounds
on medical, eugenic, humanitarian, or socio-economic
s—lr-or because of failure of family planning methods.
2. There is no charge for having an MT P performed in the germcal
ward of a government hospital.
3. MTP is a simple, safe procedure when it is done by qualified
doctors in government-approved hea.lth institutions *
4« Women need to inform each other about MTP so that they can
refer themselves for the procedures as early as possible,’
e.g., during the first 12 weeks of pregnancy.
The
earlier the stage of pregnancy in which the MTP is done,
5.
the lower the risk.
6. There are provisions for prompt care and treatment if any
complications should arise following IffP.
7. Preferably insertion of an IUD or sterilization should be
done at the time of the MTPEARLY TDENIIFICATION OF HiEGNANT WOMEN WHO WANT MTP
The earlier any woman with an unwanted pregnancy is referred for
MTP, the fewer are tho medical risks for her. In order for you to be able
to do this, you will have to be familiar with ths early signs and symptoms
of pregnancy-.
10.11.8
EARLY SIGNS AND SYMPT0I6 OF EREGMNCY ARE:
i. A' MISSED NENSTRUAL PERIOD
II. TINGLING AND ENLZxRGEl'ENT OF THE BBEATS
iii . VOMITING IN THE MORNING
jy. FREQUENT URINATION WITHOUT PAIN (R BURNING.
Tho above symptoms occur separately, but when they occur together
it usually.means that the woman is pregnant. If die is concerned about this,
refer her to the Primary Health Centre for confirmation of the pregnancy
and medical termination.
Ip your house-to-house visits to deliver health care, you should
encourage early self-referral by women desiring Iff P.
REMEMBER, WOMEN MUST KNCW THE FACTS EEFCFE THEY CAN EENEFIT- FROM
GOVERNl'ELff-APPROVED SERTYCES FOR MTP
You should be familiar with the usual kinds of family circums
tances that influence the desire for I'ffP by pregnant women. Such know
ledge will alert you to the households whore information about MTP would
be welcomed and used by the wessn.
A woman is more likely to seek abortion when
1 • her last child is loss than 12 months old;
2• she has four or more living children;
J. she is unmarried or has been deserted by her husband;
4. her husband is unemployed or drinks heavily;
5. she has been raped;
6* the family planning method used has failed to prevent concept! onj
7» there has been a natural disaster, c.g., drought or floods.
i
BEFIWING WQFEN FOR. 141P
I
Since this is a relatively new programme, there is considerable
variation in the pattern of locally available MTP services* In addition,
various strategics arc being developed in the districts to make such ser
vices more easily available and acces siblo. Therefore, you will have to
keep yourself well-informed of the developments in your block through
your supervisor so that you can make prompt’.effective referrals that are
not hampered by needless delays duo to misinformation.
IN'ORDER TO RAKE EFFECTIVE 14TP REFERRALS AND AVOID UNNECESSARY DELAYS,
YOU HIST KEEP YOURSELF INSTANTLY INFORMED- /ABOUT THE LOCATION AW HOURS
OF OPERATION OF SUCH FACILITIES .
.•
I
For each MOP referral, you should make sure that the woman:
j
14 knows whore to go and how to get there;
2. knows when to go, o.g., the specific hours and days of
the week when the MTP centre is functioning;
3* knows how long she will have to stay at the MTP centre;
I'las a referral chit which lists her name, age, address,
estimated duration of pregnancy, date of referral, your
name and designation, and name of subcontro.
v
In the intensive area, you will assist the Health Worker (Female)
in the identification and referral of women for MTP. However, since she
will not normally be given prenatal care in the twilight area, you will
bo responsible for referral of women for MTP in this area. Since village
women may often be reluctant to discuss their desire for MTP with a male
worker, you will need to seek the assistance of the local dais, the members
of the mahila mandale, women leaders, and elderly women in the community.
10.11 .10
FOLLOW-UP ACTIVITIES
because there is a kind of social stigma attached to abortions,
women usually shun or reject any official follow-up after MTP for fear
that their mothers-in-law or other relatives will come to knar about it
and criticize them. Therefore, it is necessary for you to bo very discreet i
in making such contacts. Those visits should, preferably) be made by the
Health Worker (Female) or the dai as part of her NOH services.
During your regular housc-to-hcuso visits, you can:
i. reinforce the need for prompt self-referral for any symptoms,
such as fever, chills, pain or excessive blooding;
ii. inform women where they should go for relief of symptoms*
REMEMBER, IF THE VJOMEN FEEL THAT THE FACT CF THEIR UNDERGOING MTP IS
NOT KEPT CONFIDENTIAL THEY ®LL RESORT TO OTHER MEANS TO GET RID OF
AN UNWANTED JREGWICY.
10.11.11
/
i
RECORDS AW REFORTS
In the family folder, information related to MTP should bo
recorded in:
1 • Prenatal record: Date of referral, institution or person
to person to whom referred, estimated longht of pregnancy,
and problems following the procedure should bo noted.
2. Family planning record: Information related to contraceptive
method accopted or sterilization in conjunction with MOP should
: 49' :
Each State will develop its. .own MT.P registers and monthly report
ing forms which you will be expected to keep and submit as required.
10.12
IWRTILITY
An infertile couple is one where the woman has not been able to
become pregnant despite intercourse without any contraceptive methods
for at least two years.
Although the bulk of family planning efforts and activities are
aimed at reducing unplanned population growth by regulating fertility,
your tasks also include assisting those couples who are infertile so that
they are able to produce a wanted child. Childlessness can be the cause
of social ridicule and much-distress to "a couple who desire children.
In Indic, it is considered a very, serious problem since such couples wiH
not have anyone to care for them when they are old or no longer able to
work.
Your tasks related to infertility are as follows:
1 • Identifying childless couples w o desire children.
2 • Informing them about what can be done and whore services can be
sought •
3» Referring them for services.
4. hiking follow-up visits.
5. Maintaining records.
10.12 .1 CAUSES OF INFERTILTT Y
Infertility can te either a temporary or permanent condition affect
ing either the man or the woman. The most common causes of infertility
are aS follows:
1 • The semen may contain no spermatozoa, or insufficient numbers of
spermatozoa•
2 • The woman may have a chronic disease affecting her sex organs.
3 4 The technique of intercourse may bo . incorrect •
4« Intercourse may ndt be carried out during the part of the month
when the Woman is most fertile.
IT IS IMPORTAIT TO REIEML'ER THAT EITHER THE MAN CR TEE WOWT LAY BE
RESFOLSIBLE FOR INFERTILITY. ’ ’ ■
10.12.2 IDECTIFICATION OF INFWILE COUPLES
If you keep yourself alert to the existence of this condition,
you may be able to detect infertile couples in the course of .yoir regular '
ho so-to-house visits in the villages. You may also find others when you
discuss the problem with local leaders since they arc often consulted
by childless couples who desire children.
Those who have had positive past .experiences with your health
activities may approach you directly to report infertility as a personal
problem or as a problem of a relative or a close friend who is reluctant
to discuss it with someone outside the family.
Contd/jO-
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