NEW CONCEPTS OF HEALTH COMMUNITY AND QUESTIONING HEALTH SERVICES IN INDIA
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- Title
- NEW CONCEPTS OF HEALTH COMMUNITY AND QUESTIONING HEALTH SERVICES IN INDIA
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CARB AID JUSTICE
Wlien. the Christian Medical Commission was formed in 1968i its
first major activity was to evaluate the existing patterns of
relationship between church medical institutions and the people
they served. We are deeply conscious of the tremendous dedication
and selfless service that have made church-related hospitals
unique symbols of the proclamation of Christian love in action.
Continuing contributions have been made in changing whole systems of
service providing pioneering approaches to new geographical areas9
opening new educational perspectives, and in all of this in
demonstrating a high quality of concern. Problems have now arisen
which require new adjustments to changing conditions, without
derogating in any way the contributions of the past.
One sign ox trouble has been our inability to keep up with the
progressive ezfxort to natch in the overseas setting the qualitative
improvements in ho epi tai care which have characterised the scientific
surge in world medicine#
This has required a rapidly escalating
investment in both facilities and personnel so that increasingly
specialised physicians can work with more elaborate and ejepensive
equipment •
Hospitals are doing more and more for the same
limited numb er of patients.
Tile coiiiLionts which follow are directed to those in all parts of the
world who share our concern.
The CopiM ssion1 s studies of the past
five years have shovm that the traditional hospital-based approaches
have been both inerrective and inoddicient0
, t
Our approach has been ineffective in meeting the total needs of
populations for both physical and spiritual liealing.
Community
surveys show that we reach only a fraction of the people in a
hospital’s orbit.
It is no longer enough to say that our
responsibility is only to provide a facility and then it is up to
the people to come.
Rather, the service personnel must take more
initiative. The fact that the most intolerable health conditions are
perpetuated immediately around our hospitals is scarcely a Christian
witness. Deplorable health conditions cannot bo casually blamed on
prevailing social and political conditions.
When we did not have
eifectual measures for health improvorient o : it may be justifiable
only to practice curative medicine.
How that wo have increasingly
potent tools for both curative and preventive services, wo must
apply a whole new standard of priorities? based on careful amlysis
of those approaches which are most effective in improving health.
Almost all hospitals are doing something about prevention, but no
effort has been made to use a cost/offectiveness approach.in getting
a more appropriate balance between curative and preventive
activities.
A common response is that wo will got around to
prevention after we have taken care of immediate medical needs and
emergencies.
The seen sick patient before us has an emotional
imperative that draws us away from such activities as caring for
the unseen thousands of children around us who need better nutrition.
But a concern for effectiveness will require a bettor balance of
preventive activities.
The hospital-focused health care system is also inefficient.
A
clinical condition that requires massive investments - especially in
the most precious commodity of persormol-time - could mften have
been prevented at a fraction of the cost. This is especially
true of health problems that crowd the wards in poor communities•
Our. inefficiency is also evident in the way vze use time within
the hospital.
Because of archaic nee ical prejudices about clinical
care being the doctor’s preserve, we do not turn routine treatment
over to auxiliary personnel, although it has been abundantly
demonstrated that they can care for 90 per cent of illness as
effectively as physicians.
Patients must invest ordinate amounts
of wasted time in waiting while nothing is done - both as inpatients
and outpatients - while the harajssed doctor is trying to get through
a phenomenal daily burden, most of. which could bo handled just as
well by others.
. .2. .
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The fact is that elaborate hospital facilities are designed ipore to
serve the professional convenience of overly busy physicians than
the well—being of patients.
Most seriously, the people are not
given the education that would permit them to take care of their
own health problems.
They are also not given the compassionate
listening time needed to unburden their psychological problems
and fears.
The Christian Medical Commission has shared with others increasing
attempts to publicise these areas of concern,
The generally
favourable response has been most encouraging.
Our further
deliberations have now brought us to an additional insight, which
we axe planning to explore in more depth©
7Ze c ommunic at e our
thinking at this time with the hope that we will get the widest
possible participation in our exploration,
for Clxistians the most serious indictment of a primarily
hospital—oriented health care system is that it is not only
ineffective and inefficient but that it is also unjust.
In fact,
it is unjust partly because it is ineffective and inefficient.
Txo tecjmical inefficiency and ineffectiveness we must be sensitive
to professipnally, but those with Christian concern must be
especially sensitive to the injustices of the health system.
The definition of injustice here starts witli the conviction that
basic morality requires equitable distribution.
The greatest moral
dilemma of medical care is to find the least unjust vjay to allocate
centripeta.1 and spontaneous inflow of patients.
Our concern must
be centrifugal in reaching out to all those in need.
Accessibility
has three sorts of constraints?
—geographical - and this means that -.re must decentralise services 5
— socio ‘-cultural -and this required the remova.1 ol' real or imagined
barriers, especially those that are culturally
misinterpreted beca’ase the impersonal environment
of the hospital tends to frighten the ordinary
patient 5 we Bust also be prepared to help patients
understand the root causes of their disease so as to
promote prevention^ and to help them adjust to
questions such as, ^Vfliy did this disease happen
to me?ng
—economic
and here we need innovative ways of avoiding the
dehumanizing aspects both of expensive private care
and of ffoe treatmen’ through providing a mix of . .
financial ar ranger: on.;; s for care that is inexpensive
while still being good©
Tne primary requirement then is tinat tnere be no discrimination in
tne way we assume responsibility for total populations around our
instxtutxons.
This does not imply forcing services on anyone
but ratner seeing that their needs’ are recognised and taken into
account^ and then reaching out to maize ' services available toeveryone in the area.
Two steps are involved.
First, instead of
spending ail our precxous resources on those who cane spont«aneov.sTy
we must work out new ways of defining and providing a basic
minimum og services for all.
The definition of this basic minimum
must be xocally derived and strictly 'limited to ensure coverage.
The second part of providing equitable distribution is to set and
x oxlow prior_L.ti es in care.
The purpose is to focus on the measures
that will do the most for particularly vulnerable groups.
This
exercise must combine technical understanding with community
participation in planning.
A major result is that people are
helped to solve their own. problems;
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Another pattern oT differential deprivation of care is built into
the institutional structure of the lar^e modern hospital.
Tradition
al village comunities provided multiple mechanisms for social and
psychological support for the sick and their families.
Modern
institutional organization becomes depersonalized, partly because
size demands routines and these tend to be dehumanizing. As
Christians we can try to compensate of being loving.
However, the
institutional environment itself often discriminates against the
families most in need of support.
The provision of health care,
particularly in a prestigious hospital, may combine technical
excellence with procedures which are destructive of family and social
relationships.
Ill health in itself places great strain on personal
relationships, and the way that problems are handled can be healing
in strengthening bonds of caring, or grossly disruptive in callous
unconcern for subtle relationships which form the fabric of life.
An important element in the effort to reduce injustice through better
health care is to relate health deliberately to the total developAttont.on must be given to the needs of
orient of the irhole person,
This requires real
individuals,-families and communities.
collaboration of health workers with those working in the economic
and political sectors of community life.
It involves especially
an awareness and willingness to do saiiething about such problems as
environment, malnutrition and the balance between population growth
and development. Qn exciting possibility is to learn whether
a simple, auxiliary-based programme of integrated health and family
planning can be an entering wedge in the process of development,
both through changing personal attitudes and expectations about the
future and also by providing a community-basod channel through which
felt needs can bo expressed.f
We speak here mainly of discrimination in the distribution of services
available to the communities surrounding hospitals.
The same
principles apply with oven greater force in the planning of regional
and national health services.
A truly comnrunity—based approach in liealth care offers a whole new
range of involvement and potential renewal for the church.
Showing
love in action through healing can bo a corporate service activity
of Christians.
With professional guidance, many community
activities can be best done by simply trained auxiliaries and
volunteers.
But church involvement must not be exclusive, it must
be inclusive of all who want to serve.
Tn suiLiLiary, injustices arise because oi*•
1.
inequitable distribution of scarce resources. This requires
a basic minimum of services for all and priority arrangements to
provide Special services for vulnerable groups.
2.
communities and individuals do not nave opportunities to
oartici'oat© in health care decision, especially as they relate
to tot al development•
the health care system does not promote the wholeness of
individual, family and community life tInrough its tendency to
depersonalise individual care and distrupt interpersonal relation'
ships, with those who suffer most often being those most in need.
3•
This leads us to prevent three challenges to policy makers and
funding agencies, to health workers and educators, and to all who
share our concern.
Wo reiterate that challenge represent a new
recognition that we hope to explore with many. The Commission
commits itself to respond to these challenges and to the further
insights that wil-1 come out of continuing efforts to improve our
underst ancling and perception.
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1.
We share;, in a call to openness, to ziew vision and insight and
a daring readiness to explore - comples relationships at the
intor-fa.ee between science and human values •
2.
The challenge to individuals is that In our daily working
setting and relationships we must zna-ce our part oT the action
more Just in allocating- nore equitably those resources WG J
control,
But wo have to atari whore we are and use what we have
as we have as we &ove increment ally to Innovation.
3.
The corporate challenge is tha.t we review critically the
Justness of the health system as a whole.
This does not mean
condemning or discarding the moans and under st anding that
have contributed so much in the past.
T7e can now build on
the past with our new insights, just as those in the future
will build more just systems as today’s Justice becomes
tomorrow’s injustice.
We justify this call in the belief
that there is no force as aggressive yet as healing as love.
THZ FORSGOIITG- STATZnZiTT Oh EZhLTH CARS A1TD JUSTICE REPRESENTS
A POSITION PAPER ADOPTER 3Y TEE CHRISTIA1T H3DIGAL COMMISSION AT
ITS 1973 ANNUAL MEETING.
HEALTH - MEDICINE & UNDER DEVELOPMENT
adapted from Le Doyal & Ie Pennell
There is a great disparity between the state of health of
the population of developing countries and that of the industrialis
ed countries.
The tropical climate of most developing countries is only a
minor factor for this disparity.
The health problems of these countries cannot be considered
and tackled only as technical problems. We cannot properly understand
them and try to overcome them without analysing their socio-economic
context - and taking into account the real nature of contemporary
underdevelopment.
UNDER DEVELOPMENT OF HEALTH:
The major diseases in the third world fall into 2 basic
categories :
1. diseases associated with malnutrition.
2. infectious diseases.
Malnutrition and infection are responsible for the majority
of deaths and illnesses in underdeveloped countries, particularly
in children under five, who account for at least half of all deaths.
Malnutrition is a common feature of underdevelopment and has
a crucial influence on patterns of death and disease. In India it is
estimated that 70% of the people i.e. 420 million live below the
subsistence level, that means ’’the minimum required diet for a
moderate activity” (2.250 calories per day).
Malnutrition can constitute a primary cause of death, espe
cially among babies and young children - and there are at present
about 60 million children in India, who are malnutrished.
It is also a major contributing factor in infectious diseaes because it reduces initial immunity and chances of survival.
Infectious diseases can be subdivided into 3 groups, accor
ding to their method of propagation.
1) Faecally - related diseases are transmitted through
contacts with human faeces, the most common being the intestinal
parasitic and infectious diarrhoea diseases. They also include
polio, typhoid and cholera. These diseases are a major cause of
chronic debilitating
conditions.
death, especially among children, or c'
' ‘
Such diseases are a consequence of inadequate sanitation
and contaminated drinking water.
There is little evidence that progress is being made in
providing such fundamental necessities of life for the masses.
Air-borne diseases are largely spread by breathing the
respiratory secretions of infected persons, and include T.B.,
diphteria, whooping cough, meningitis flu, measles, small pox,
chicken pox and others.
The spread of these diseases is greatly facilitated by the
over-crowded and inadequate living conditions, common to expanding
cities.
3) Vector-borne diseases are caused by parasites which ere
transmitted to human beings through disease carriers such as
mosquitoes (Malaria and Filariasis).
.. .2.
2
..
iid •.
■,
Most of the so-called "tropical" diseases fall into this
category. They have extremely debilitating effects on a large
number of patients.
/' - :
These diseases of underdevelopment were wide spread in
Europe in the past. They have been overcome there not so much by
the medical discoveries/ but mainly because of the general amelio
ration of the standard of living as a result of improvements in
sanitation (housing, drainage, refuse-disposal) and in education.
This indicates that the diseases which concern us here are
a direct consequence oftthe wretched condition of material life
for most people in the third world.
As for the infectious diseases many of them have spread
through colonial conquest, slave trade and even by the environ
mental changes, consequence of technology.
At the same time, the socio-economic relations between the
industrialised countries and the developing ones have So far
prevented these last ones from adopting the solutions that were
available to meet similar health problems in last century Europe
provision of public health.measures and better general
living standards): the necessary capital for these measures was
achieved largely at the expense of their underdeveloped satellites,
whose economic wealth was pumped out to finance the development of
the West.
To the extent that such exploitation continues, it is clear
that the mechanisms of imperialism, preventing autonomous economic
development in the third world, are part of the obstacle to the
solution to these problems;
In this context, there has been a widespread export of
"Western Medicine" to* the third. Wria".
It started with medical facilities for the European staff
in the colonies, and with the penetration- of--the Christian missions.
In the context of continuing economic dependence, and consequent
constraints on independent national development, throughout the
capitalist dominated third world there has been a growing acceptance
of the "Western Medical Model" as a way of mediating between man
and disease. This implies a hospital-based high technology cura
tive medicine dispensed oh an individual basis.
Scientific medicines with its associated drugs and technical
equipment tends to be seen as one of many attractive goods on the
international markets.
This has particular appeal for the local bourgeoisie, whose
patronage has contributed greatly to the adoption of private
Western Medical Care.
The expensive of such a system restricts medical services
to the urban areas where the rich are concentrated. The majority
of the people in the developing countries, on the other hand, live
in small scattered rural communities and cannot afford medical
services even where they are accessible. In India 80% of the
doctors and 90% of the nurses work in urban areas where 20% of
the population lives.
■ In addition, the practice of Western medicines, with its
individualistic curative bias, is inadequate to deal with the
problem created by the underdevelopment of health. We are not
underestimating the very substantial benefits of Western medicine
However, few of these benefits can be mobilised for the global
alleviation of suffering and disease when the economic relations
under which they are produced perpetuate conditions which give
rise to the suffering and disease in the first place.
..,.3,
3
The expensiveness of allopatic medicine in the third world/
for example/ has less to do with its real costs than with the
nature of technological dependence/and the profitability to
mulnational firms of maintaining it.
1.
The most important example of this is found in the drug
industry where a small number of powerful corporations basecT in
Europe and the US dominate the international market.
2.
Other profitable areas of medicine are related to hospital
development. Apart from the vast capital outlay required for hos
pital construction/ running costs are very high because of the
technical installations which can only be restocked through imports.
Prestige hospital developments distort the whole balance of health
expenditure while being totally inappropriate to meeting real
needs. Though capitalist medical technology may alter the effects
of some diseases (if the sufferer can afford it) it cannot lessen
their incidence.
3.
One of the consequence of the adoption of the Western medical
model and its technology/ is the expansion of Western model medical
education. The recognition of medical degrees from developing
countries was for long conditional on the approval of curricula and
"standards” by the colonial powers, and this was a major contraint
on innovations necessary to meet local health needs.
Approved curricula demand a long and expensive training, and
the selected candidates come from a small elite with good secondary
school. Morover, the medical socialisation they receive inculcates
’’trained incapacity for rural practice, which is itself the product
of the British system of medical training within large centralised
hospitals”. Instead, they are encouraged to adopt ’professional’
ambitions which can only be satisfied by urban-based private practice
or by emigration, both of which contribute to the distorted pattern
of health care in the third world.
Control over medical education by the internationally orga
nised medical profession, in conjunction with economic command on
the market by capitalist states, had added skilled man-power to the
drain of resources from the third world to subsidise high-cost
health care in the rich countries.
*
HEALTH
MEDICINE & UNDER DEVELOPMENT
adapted from L4 Doyal & I, Pennell
There is a great disparity between the state of health of
the population of developing countries and that of the industrialis
ed countries.
The tropical climate of most developing countries is only a
minor factor for this disparity.
The health problems of these countries cannot be considered
and tacked only as technical problems. We cannot properly understand
them and try to overcome them without analysing their socio-economic
context - and taking into account the real nature of contemporary
unde rdeve1opme nt.
UNDER DEVELOPMENT OF HEALTH:
The major diseases in the third world fall into 2 basic
categories :
1. diseases associated with malnutrition.
2. infectious diseases.
Malnutrition and infection are responsible for the majority
of deaths and illnesses in underdeveloped countries/ particularly
in children under five/ who account for at least half of all deaths.
Malnutrition is a common feature of underdevelopment and has
a crucial influence on patterns of death and disease. In India it is
estimated that 70% of the people i.e. 420 million live below the
subsistence level, that means "the minimum required diet for a
moderate activity" (2.250 calories per day).
Malnutrition can constitute a primary cause of death/ espe
cially among babies and young children - and there are at present
about 60 million children in India, who are malnutrished.
It is also a major contributing factor in infectious diseaes because it reduces initial immunity and chances of survival.
Infectious diseases can be subdivided into 3 groups, accor
ding to their method of propagation.
1) Faecally
related diseases are transmitted through
contacts with human faeces, the most common being the intestinal
parasitic and infectious diarrhoea diseases* They also include
polio^ typhoid and cholera. These diseases are a major cause of
death, especially among children/ or chronic debilitating conditions.
Such diseases are a consequence of inadequate sanitation
and contaminated drinking water.
There is little evidence that progress is being made in
providing such fundamental necessities of life for the masses.
2) Air-borne diseases are largely spread by breathing the
respiratory secretions of infected persons/ and include T.B.Z
diphteria/ whooping cough, meningitis flu, measles, small pox,
chicken pox and others.
The spread of these diseases is greatly facilitated by the
over-crowded and inadequate living conditions, common to expanding
cities.
3) Vector-borne diseases are caused by parasites which are
transmitted to human beings through disease carriers such as
mosquitoes (Malaria and Filariasis).
. . .2.
2
Most of the so-called '’tropical" diseases fall into this
category. They have extremely debilitating effects on a large
number of patients.
These diseases of underdevelopment were wide spread in
Europe in the past. They have been overcome there not so much by
the medical discoveries, but mainly because of the general amelio
ration of the standard of living as a result of improvements in
sanitation (housing, drainage, refuse-disposal) and in education.
This indicates that the diseases which concern us here are
a direct consequence of the ^retc-hed-cohdition of material life
for most people in the third world.
As for the infectious diseases many of them1' have spread
through colonial conquest, slave trade and even by the environ
mental changes, consequence of technology. •
At the same time, the socio-economic relations between the
industrialised countries and the developing ones have so far
prevented these last ones from adopting the solutions that were
available to meet similar health problems in last century Europe j-'-; . i
(the proyi§lpn of public health measures and better general
living standards): the necessary capital for these measures was
achieved largely at the expense of their underdeveloped satellites,
whose economic wealth was pumped out to finance the development of
the West.
To the extent that such exploitation continues, it is clear
that the mechanisms of imperialism, preventing autonomous economic
development in the third world, are part of the obstacle to the
solution to these problems'.
In this context', there has been a widespread export of
"Western Medicine" to the third world.
It started with medical facilities for the European st^ff
in the .colonies, and with the penetration of the Christian missions.
In the context of continuing economic dependence, and consequent
constraints on independent national development, throughout the
capitalist dominated third world there has been a growing acceptance
of the "Western Medical Model" as a way of mediating between man
and disease. This implies a hospital-based high technology cura
tive medicine dispensed on an individual basis.
Scientific medicines with its associated drugs and technical
equipment tends to be seen as one of many attractive goods on the
international markets.
This has particular appeal for the local bourgeoisie, whose
patronage has contributed greatly to the adoption of private
Western Medical Care.
The expensive of such a system restricts medical services
to the urban areas where the rich are'concentrated. The majority
of the people in the developing countries, on the other hand, live
in small scattered rural communities and cannot afford medical
services even where they are accessible. In India 80% of the
doctors and 90% of the nurses work in urban areas where 20% of
the population lives.
In addition, the practice of Western medicines, with its
individualistic curative bias, is inadequate to deal with the
problem created by the underdevelopment of health. We are not
underestimating the very substantial benefits of Western medicine.
However, few of these benefits can be mobilised for the global
alleviation of suffering and disease when the economic relations
under which they are produced perpetuate conditions which give
rise to the .suffering and disease in the first place.
3 The expensiveness of allopatic medicine in the third world,
for example, has less to do .with its real costs than with the
nature of technological dependence,a nd the profitability to
mulnational firms of maintaining it.
1.
The most important example of this is found in the drug
industry where a small number of powerful corporations basecT in
Europe and the US dominate the international market.
2.
Other profitable areas of medicine are related to hospital
development. Apart from the vast capital outlay required for hos
pital construction, running costs are very high because of the
technical installations which can only be restocked through imports.
Prestige hospital developments distort the whole balance of health
expenditure while being totally inappropriate to meeting real
needs. Though capitalist medical technology may alter the effects
of some diseases (if the sufferer can afford it) it cannot lessen
their incidence.
3.
One of the consequence of the adoption of the Western medical
model and its technology, is the expansion of Western model medical
education. The recognition of medical degrees from developing
countries was for long conditional on the approval of curricula and
"standards” by the colonial powers, and this was a major contraint
on innovations necessary to meet local health needs.
Approved curricula demand a long and expensive training, and
the selected candidates come from a small elite with good secondary
school. Morover, the medical socialisation they receive inculcates
’’trained incapacity for rural practice, which is itself the product
of the British system of medical training within large centralised
hospitals”. Instead, they are encouraged to adopt ’professional'
ambitions which can only be satisfied by urban-based private practice
or by emigration, both of which contribute to the distorted pattern
of health care in the third world.
Control over medical education by the internationally orga
nised medical profession, in conjunction with economic command on
the market by capitalist states, had added skilled man-power to the
drain of resources from the third world to subsidise high-cost
health care in the rich countries.
CHANGING CONCEPTS IN COMMUNITY HEALTH CARE
Definition of Health
WHO
Health is a state of complete physical, mental and social well being
not merely the absence of disease and infirmity.
In their 1962 review of the teaching of Preventive Medicine, Shephard and
Roney listed 20 different titles for sucn departments, commencing from Hygiene
to be present concepts of Community Medicine.
’’Hygiene” (named after ’’Hygeia” the Greek Goddess of health) refers to the
body of knowledge relating to the promotion and preservation of health. It is
a very comprehensive term which includes Public Health and Preventive Medicine.
’’Preventive Medicine” is a comprehensive term used to embrace research into
socail factors which affect health or incidence of disease by means of surveys,
case studies and statistical investigationso
Medical Sociology ? Social Psychology and Social Psychiatry are all branches
of Social Medicine®
’’Clinical Social Medicine” applies to the application of social medical
principles in the diagnosis and treatment of industrial patients.
’’Public health” may be considered as a branch of knowledge or as a practice
i*e. its specialised character as an academic subject and its breadth as a
practice. It is essentially a post graduate study of a vocational character
although fundamentals of the same are taught at the undergraduate level. Public
Health includes sanitary and water engineering, housing construction, town and country planning, large scale food production and veterinary control.
It is a practice of environmental and personal hygiene, preventive medicine and
epidemiology and includes also legislations and administrative provisions and
certain organised medical care and social services which are provided by the
executive Public Health Departmentso
With so many terminologies of this particular discipline, one may be
justified in sayii.g that he is ’’the speciality of ?" The struggle to define this
new speciality goes on.
A definition which allows for flexibility and scope in both teaching and
research is, ’’Community Medicine is the academic discipline that deals with the
identification and solution of the health problems of communities or human
population groups”. We also accept the definition of community as ”a group of
individuals or families living together in a defined geographic area, usually
comprising a village, town or city; these may represent only a few families in a
rural area or may include heavily populated cities.
Even Abraham Plexner noted that ’’the physicians” function is fast becoming
social and preventive, rather than individual and curative. Upon him society
relies to ascertain and through measures essentially educational to enforce,
the conditions that prevent disease and make positively for physical and moral
well being”®
Community Medicine (its erstwhile cousing being Preventive and Social
Medicine) is therefore, a science and art of preventing disease, prolonging
life and promoting physical and mental health and efficiency®
The medical and dental practitioners look after individuals and may be
f ami lies, which is the ’’General Practice” of preventive medicine.
The ’’Community Medicine Practitioner” looks after groups and communities.
Both the above mentioned two agencies,9 practice preventive medicine ’’through
intercepting disease processes by community and individual action”. It has
now been accepted generally that Community Medicine may be perceived as a
distinct thirdarea in medical education, producing a triad of laboratory, hospital
ward and community^ Its particular reliance to the stuAy of the community has
been aptly brought out by an expert committee of WHO. ’’The education of •
every physician should . c • ■>«. •. enable him....
to understand how factors
affecting health can be examined and measured and to discern the practical steps
♦ . az
2
that can be taken to counteract hazards? he should know enough about the
economic and priorities of public health programmes at both the local and national
levels, to recognise when the local community must make important decisions and
when the national cost of health services must be balanced against those of
other community services. He should understand how health services operate
and are related to one another, the principles governing the delivery of medical
care, what parts are played by auxiliaries and other health workers, and the
effects of culture on the demands for services and of the use made of them when
they are provided”0
Community Medicine is by no means limited to the activities of physicians
alone. It draws upon a number of disciplines for its tools. The tools include
community diagnosis (which draws on such diverse fields as sociology, political
science, economics, biostatistics and epidemiology) and health services research
( the application of epidemiologic techniques to analysing the effects of medical
care on health).
It is ironic that a profession which began in the Community, should suddenly
need to rediscover it. Several centuries of gradually institutionalised
medicine followed by technological revolution progressively moved medical
science farther from the people to be served and closer to the artificial life
support system of the hospital centre. Sometimes in the last 15 years, medicine
rediscovered the Community at large. The academicians have become aware of the
wide gap that exists between knowledge acquired and the implementation of that
knowledge. War was declared on poverty, ignorance and disease. Medical educator^
have gradually descended from their ivory tower and recognised flaws in the cult
of our socialisation. The era of revelation has git-on way to the era of relevance.
Amidst these rites of passage, a new discipline, community medicine, has emerged.
The most important tools of Community Medicine , which include community
diagnosis, are dpidemiology and biostatistics. Community
C
diagnosis is the attempt
to identify as fully as possible what health problems and the healthi care
resources are, it enables the practitioner of community medicine to implement
solutions, e.g. John Snow’s investigations of cholera in England before the
bacteriological era. This was an example of pure epidemiological research, in
understanding the determinants of diseas ..-agent, host and environment.
The tools of epidemiology have now been gradually turned to newer tasks.
Methods for delivery of care and containment of disease became increasingly
difficult to achieve. Studies of chronic degenerative diseases have led to an
appreciation of the multifactorial determinants of disease. The behavioural
sciences have also emerged as important tools of Community Medicine for predicting
the occurrence of disease through knowledge of phenomena such as social stress,
as vzell as the factors associated with compliance with prolonged medical regimense
Biostatistics, the black bag of Community Medicine has expanded fast beyond
the stage of dry manipulation of complex mathematical procedures. The computer
has opened up exciting areas for medical diagnosis, simulation models of health
situations and rapid processing of large volumes of date. Environmental health
has risen from the privy to world wide ecological concerns with over abundance
of people and their waste products.
The social revolution has produced a philosophy that health care should
be readily accessible and that consumers of health' services should participate
in planning and decision making. It has often been said ’’Health is a right
and not a privilege” and ’’Health by the People”, Medical care which fulfills
the three C’s - continuous, co-ordinated and comprehensive - is being sought
but at a price society can afford. Departments of Community Medicine will in
future have to play an active role in developing effective delivery systems.
While the science of medicine is forging ahead, the social setting of
medicine is caught up in its own revolution. Medical schools have been
challenged to restructure their position in the community. The pressures for
medical schools to get involved are real and powerful. Communities themselves
have indicated in forceful ways that thev expect medical schools to respond
to their demands for service. No longer will people accept charitable crumbs
of medical care? they now accuse the institutions of exploitation and demand a
reckoning. In the USA, 64 medical schools have been forced to restructure
their curriculum.
3
In our own country the recent report of the group on medical education
and support man power has enjoined, that during the last 30 years sustained
efforts have been made to implement the health sector objectives laid down
by important committees like Bhore Committee, Mudalior Committee and so on.
Inspite of substantial investments made and impressive results obtained,
particularly in the production of medical man power, the health status of our
people, be it in rural areas or plantations, is far from satisfactory. The
medical profession itself, which is noted more for its conservatism and
individualism, has to accept its share of blame. They obstinately cling to the
Western models of easy medical practice, based on hospitals. It is therefore,
but natural that medical colleges have noe been challenged to restructure their
position in the community. They are required to accept a major service
responsibility for a segment of the adjacent community. The potential for
meaningful innovation in nodes of delivering and organising health services
exanple9 the
falls withing the ’Community Medicine’, area of competence, for example,
variety of alternatives to the neighbourhood health centre, should be developed
in response to the social forces calling for increased community involvement.
Introduction of regional medical programmes through medical colleges has
provided one potential means by which we can directly influence the health care
delivery systems.
Such changes have great relevance to plantation industries, for questions
of rural health care and primary health care delivery systems, are of the utmost
importance in plantation settings. The plantation doctor has an important role
to play in bringing about his change with the help of the employer and worker.
Within limited resources of money and man power, primary health care in remote
and inaccessible areas, has to be provided by him. He has to be a good
’’Managerial Physician” and ’’Leader of a health team”.
It is essential that in order to appreciate the community its social
must become
systems and their interactions with the medical care system, he
i
part of that community.
Community Medicine represents a bridge between medicine and society, The
ultimate test of this discipline lies not in its ability to consolidate
a multiplicity of theoretical frameworks but in its application to actual problem
solving situations. It is a discipline which requires a precise definition
of health problems and a specific commitment to examine them and treat them in
the full scope of their implications.
Commun-i ty Medicine has a vast umbrella. They start with communities
analysis and" the basic skills of epidemiology as a tool for applying the
scientific method to medical problem - solving, and build to encompass a variety
of different but often overlapping disciplines including medical economics,
behavioural sciences, environmental health and ecology, health services research
and demography. The; synthesis of these multiple techniques and concerns
represents the methodology and body of knowledge that we recognise today as
C ommunity M e di cine.
Sources of infornation :
1.
The challenges of Community Medicine, edited by Roher Lo Kane.
2.
Alternatives in Development Health, Health Services and Medical Education.
A programme for Immediate Action.
3.
Community Medicine in Developing Countries edited by Abdel R. Omran.
4.
WHO Tech-Memoranda.
5.
Preventive Medicine for the doctor in the Comnunity - Leavell and Claike.
CHANGING CONCEPTS IN COMMUNITY HEALTH CARE
Definition of Health
, WHO - Health is a state of complete physical, mental and social
well being not merely the absence of disease and infirmity.
In their 1962 review of the teaching of preventive Medicine,
Shephard and Roney listed 20 different titles for such departments,
commencing from Hygiene to be present concepts of Community Medicine.
"Hygiene" (named after "Hygeia" the Greek Goddess of health)
refers to the body of knowledge relating to the promotion and pres
ervation of health. It is a very comprehensive term which includes
Public Health and Preventive Medicine.
1 T' .
"Preventive Medicine" is a comprehensive term used to embrace research into social factors which affect health or indicence of
disease by means of surveys, case studies and statistical investi
gations .
Medical Sociology, Social Psychology and Social Psychiatry
are all branches of Social Medicine.
"Clinical Social Medicine" applies to the application of
social medical principles in the diagnosis and treatment of indus
trial patients.
"Public health" may be considered as a branch of knowledge
or as a practice i.e. its specialised character as an academic
subject and its bredth as a practice. It is essentially a post
graduate study of a vocational character although fundamentals of
the same are taught at the undergraduate level. Public Health inclu
des sanitary and water engineering, housing construction, town and
country planning, large scale food production and veterinary control.
It is a practice of environmental and personal hygiene, preventive
medicine and epidemiology and includes also legislations and admi
nistrative provisions and certain organised medical care and social
services which are provided by the executive Public Health Depart
ments.
With so many terminologies of this particular discipline,
one may be justified in saying that he is "the speciality of ?" The
struggle to define this new speciality goes on.
A definition which allows for flexibility and scope in both
teaching and research is, "Community Medicine is the academic dis
cipline that deals with the identification and solution of the
health problems of communities or human population groups". We also
accept the definition of community as "a group of individuals or
families living together in a defined geographic area, usually
comprising a village, town or city; these may represent only a few
families in a rural area or may include heavily populated cities.
Even Abraham Flexner noted that "the physicians" function
is fast becoming social and preventive, rather than individual and
curative. Upon him society relies to ascertain and through measures
essentially educational to enforce, the conditions that prevent
disease and make positively for physical and moral well being".
Community Medicine (its erstwhile cousing being preventive
and Social Medicine) is therefore, a science and art of preventing
disease, prolonging life and promoting physical and mental health
and efficiency.
The medical and dental practitioners look after individuals
□nd may be families, which is the "General Practice" of preventive
medicine.
The "Community Medicine Practitioner" looks after groups
and communities.
. .2.
Z
2
Both the above mentioned two agencies, practice preventive
medicine ’’through intercepting disease processes by community and
individual action". It has now been accepted generally that Communi
ty Medicine may be perceived as a distinct third.area' in medical
education, producing a triad of laboratory, hospital ward and comm
unity. Its particular relevance to the study of the community has
been aptly brought out by an expert committee'of WHO. . "The education
of every physician should
. enable him ........ to understand
how factors affecting health can be examined and measured and to
discern the practical steps that can be taken to counteract hazards;
he- should know enough about the economic and priorities of public
health programmes at both the local and national levels, to recog
nise when the local community must make important decisions and
when the national cost of health services must be balanced against
those of other community services. He should understand how health
services operate and are related to one another, the principles
governing the delivery of medical care, what parts are played by
Auxiliaries and other health workers, and the effects of culture on
the demands for services and of the use made of them when they are
provided".
Community Medicine is by no means limited to the activities
of physicians alone. It draws upon a number of disciplines for its
tools. The tools include community diagnosis (which draws on such
diverse fields as sociology, political science, economics, biosta
tistics and epidemiology) and health services research (the appli
cation of epidemiologic techniques to analysing the effects of
medical care on health).
is ironic that a profession which began in the Community
should suddenly need to rediscover it. Several centuries of gradu
ally institutionalised medicine followed by technological revolut
ion progressively moved medical science farther from the people to
be served and closer to the artificial life support system of the
h.ospital centre. Sometimes in the last 15 years, medicine redisco
vered the Community at large. The academicians have become aware
of the wide gap that exists between knowledge acquired and the
implementation of that knowledge. War was declared on poverty, ig
norance and disease. Medical educator have gradually descended from
their ivory tower and recognised flaws in the cult of our sociali
sation. The era, of relelation has given way to the era of relevance.
Amidst these rites of passage, a new discipline, community medici
ne, has emerged.
The most important tools of Community Medicine, which
include community diagnosis, are epidemiology and biostatistics.
Community diagnosis is the attempt to identify as fully as poss
ible what health problems and the health care resources are, it
enables the practitioner of community medicine to implement
solutions, e.g. John Snow’s investigations of cholera in England
before the bacteriological era. This was an example of pure epi
demiological research, in understanding the determinants of
disease-agent, host and environment.
The tools of epidemiology have now been gradually turned
to newer tasks. Methods for delivery of care and containment of
disease became increasingly difficult to achieve. Studies of
chronic degenerative diseases have led to an appreciation of the
multifactorial determinants of disease. The behavioural sciences
have also emerged as important tools of Community Medicine for
predicting ‘the occurrence of disease through knowledge of
phenomena such as social stress, as well as the factors assoc
iated with compliance with prolonged medical regimens.
Biostatisticsz the black bag of Community Medicine has
expanded fast beyond the stage of dry manipulation of complex
mathematical procedures. The computer has opened up exciting
areas for medical diagnosis, simulation models of health situa
tions and rapid processing of large volumes of date. Environ
mental health has risen from the privy to world wide ecological
concerns with over abundance of people and their waste products.
. .3.
1
3
The social revolution has produced a philosophy that health
care should be readily accessible and that consumers of health ser
vices should participate in planning and decision making. It has
often been said "Health is a right and not a privilege" and "Health
by the People". Medical care which fulfills the three C's - conti
nuous, co-ordinated and comprehensive - is being sought but at a
price society can afford. Departments of Community Medicine will in
future have to play an active role in developing effective delivery
systems.
While the science of medicine is forging ahead, the social
setting of medicine is caught up in its own revolution. Medical
schools have been challenged to restructure their position in the
community. The pressures for medical schools to get involved are
real and powerful. Communities themselves have indicated in forceful
ways that they expect medical schools to respond to their demands
for service. No longer will people accept charitable crumbs of
medical care; they now accuse the institutions of exploitation and
demand a reckoning. In the USA, 64 medical schools have been forced
to restructure their curriculum.
In our own country the recent report of the group on mddical
education and support man power has enjoined, that during the last
30-years sustained efforts have been made to implement the health
sector objectives laid down by important committees like Shore
Committee, Mudalior Committee and so on. Inspite of substantial inv
estments made and impressive results obtained, particruierly in t-bo
production of medical man power, the health status of our people, be
it in rural areas or plantations. Is f-ar
satisfactory. The
medical profession itself, which is noted more for its conservatism
and individualism, has to accept its share of blame. They obstinate
ly cling to the Western models of easy medical practice, based on
hospitals. It is therefore, but natural that medical colleges have
r^ot been challenged to restructure their position in the community.
J‘hey are required to accept a major service responsibility for a
segment of the adjacent community. The potential for meaningful
innovation in modes of delivering and organising health services
falls within the 'Community Medicine', area of competence, for
example, the variety of alternatives to the neighbwrhooa. health
centre, should be developed in response to the social forces calling
for increased community involvement. Introduction of regional medical
programmes through medical colleges has provided one potential means
by which we can directly influence the health care delivery systems.
Such changes have great relevance to plantation industries,
for questions of rural health care and primary health care delivery
systems, are of the utmost importance in plantation settings. The
plantation doctor has an important role to play in bringing about
his change with the help of the employer and worker. Within limited
resources of money and man power, primary health care in remote and
inaccessible areas, has to be provided by him. He has to be a good
"Managerial physician" and "(Deader of a health team".
It is essential that in order to appreciate the community,
its social systems and their interactions with the medical care
system, he must become part of that community.
Community Medicine represents a bridge between medicine and
society. The ultimate test of this discipline lies not in its
ability to consolidate a multiplicity of theoretical frameworks but
in its application to actual problem solving situations. It is a
discipline which requires a precise definition of health problems
and a specific commitment to examine them and treat them in the full
scope of their implications.
. ..4.
—H1L
-r 4
Community Medicine has a vast umbrella. They start with com
munities analysis and thd' basic skills-of epidemiology as a tool for
applying the scientific method to medical problem - solving, and
build to encompass a variety of different but often overlapping dis
ciplines including medical economics, behavioural sciences, environ
mental health and ecology, health services research and demography.
The synthesis of these multiple techniques and concerns represents
the methodology and body of knowledge that we recognise today as
Community Medicine,
Sources of information;
1.
The challenges of community Medicine, edited by Roher l. Kane,
2.
Alternatives in Development Health, Health Services and Medical
Education. A programme for Immediate Action.
3.
Community Medicine in Developing Countries edited by Abdel. R.
Omran.
4.
WHO Tech-Memoranda,
5.
Preventive Medicine for the doctor in the Community - Leavell
and Claike.
'k k-kkk k k k k
MEDICAL CARE ACCESSIBLE TO THE MASSES
GUIDELINES, IN PLANNING
Based on awareness of:
effective demand
(minority)
: reflects the ability of powerful groups
in society to influence the allocation of
resources to produce certain types of
goods and services to meet their needs.
voiceless needs
(maj orityj
of the relatively poor and unskilled ru
ral majority, where the index of health
is lower.
>
AKtAS
Of. I>OCTO l<S
Health Services should^be :
1) ACCESSIBLE:
3'elements of accessibility:
within walking distance
-ge ographical:
(maximum 5 to 7 miles)
study the area, its map,
transportation facili
ties, existence of oth
er facilities (avoid
overlapping)
-p s ye hoio^ic al:
low-cos t
(strive for self-suffic
iency)
acceptability,familiarity,
c onfidence.
)
2) COMPRENHENSIVE: integrating - curative
- preventive )
- promotive )
action
The provision of even basic health services is
met with minimum effect unless:
a) the community is motivated for the necessary
changes in the socio-cultural environment.
b) the community is provided with adequate nu
trition, safe drinking water and a reasona
bly sanitary environment.
. .2.
2
J) - COMMUNITY-BASED
we must seek and encourage people/g par
ti cipation in different aspects of the
programme.
new perspective : viewed in the whole
process of human development, we are pa
rtly responsible for
the whole, not wholly
responsible for a parte
many of the health problem of the rural
villages are of a nature which cannot be
solved by individuals but require the
combined effort of many or most of the
inhabitants.
4) ~ accompanied by continous EVALUATION.
and modifications according to the find
ings, (objectives, data and statistics,
records, cost-effectiveness).
DECIDE OBJECTIVES AND PRIORITIES considering :
socio-economic development of the people
identify health conditions in the comm
unity and problems causing them.
patterns of disease ;
what people think of health and disease
local needs, particularly the needs of special groups and areas
■»
degree of support from the community
resources available in money, man-power and materials
need for co-ordinated and joint action of different service
agencies (voluntary and governmental) for a total .and integra
ted community development.
HEALTH PRQGRAIW,
Health services (whether hospital, dispensary, health centre or
community health programme) need be integrated in the overall
effort of human, community and national development.
For too long the interaction between the health services and the
community they serve was ignored or denieda
Hew per spec five :
I
as "health workers
9
we are partly responsible., for the
whole not whoily responsible for
Health planning belongs to society ( not only to specialists )
Health action needs to te linked with the^ .broader community goals.
The socio-economic situation of the patient and the community
must concern the health team.
importance of the health service as. an information service
should be clears informations about the symptoms and signs of
what is going wrong in a society may be njiore important than
treating the symptoms which, in the long run, could conceal
the real trouble.
■z
3 II - Many of the problems of the rural villages cannot be solved
by individuals, but require the combined efforts of the
inhabitants, the health workers and the government services.
ex:
environmental hygiene is the responsibility of the
community.
To make a contribution to the equitable distribution of the health
services to the masses of India, all hospitals should give priority to the planning and development of primary health and communitycare, taking into account government and civic programmes, and
chiefly the people themselves.
B) Basic health education to the people
2) Work on some preventable diseases ( ex: blindness, T.B.,
leprosy, etc. )
- camps
- special clinics (also pro-school childr
en, E.P., etc.)
3) Organisation of ru ral health zones and health centres.
4) Promotion of auxiliary personnel (para-professionals)
0 OTO'ITY-BASED PROGRAlIi-IE
Considering the local needs.
“ sel-ec“t a c-ommunity of a defined and accessible geographical
area.
B - study the community characteristics. :
- demographic dynamics : birth rate - death rate - age pyramid
causes of death, of disability, of
incapacity to work, of distress.
- structure of the community : groups, leaders.
socio-economic life s sources of income,
income range
employment pattern or occupation
pattern of expenditure
educational level
assessment of local resources for the programme
felt needs
local customs
regarding health
- what it means to be sick ?
- what people do to avoid sickness ?
- what people do to cure sickness ?
- to whom people turn when they are sick ?
- who gives them advices ?
- what is the importance of different food^
food-rituals, births, deaths, marriages,
etc.
other health facilities.
' c ) identif y _and_ anally^e_the.._c.pj^un^ityJ s__heal 1h problems
(diagnose the cause of the ill-health)
B) set the priori ties, .and £goals for the programme
I
- health care facilities
- specific health improvement objectives
- health-related development work
. ..4.
6
/
Curriculum proposed in "the new health plan for the nation”
(Raj Narain)
fundamentals of health sciences
measures for maintaining good health
hygiene - personal environmental
treatment of common infectious diseases
maternity and child care
treatment of common ailments
first aid.
The sponsoring centre should provide referral service and extend
all professional help needed.
HR ALTH PROMOTION
Let us look at medical care not from the standpoint of illof health. In the past we have lost sight of the primary
ness 99 but
I
objectives : to keep people healthy and out of the hospital in the
first place. We have organised for sickness.
In the future we must organise for health.
Fundamental ques ti ons •
If the concept of health is
then health care
non-illness
cure of disease (curative medicine)
or eradication of disease (preven
tive medicine)
Isn’t health more than non-illness?
Isn’t there more to life than keeping disease-free?
Isn’t there more to being human than just being well?
The more revolutionary advance in modem medicine is the re-disco,
very of the wholeness of the human personality, (see Jesus’ heal
ings) .
It is a well known fact that the overall well-being of a person
depends considerably on the quality of the environment and the
social relationships.
Better health care requires attention to the total develop
ment of the whole person, to the needs of individuals, families
and communities.
It includes awareness and willingness to do something
about such problems, as environment, malnutrition, balance bet
ween population growth and development.
"The primary task of a hospital is to be viewed in terms
of human learning :
to enable patients, their families and the staff to learn
from the experience of illness and death how to build a
healthy society" (Dr.M. Wilson).
A comprehensive view of health demands to relate our
hospital system to the process of human development taking
place in the country. This implies to aim at self-relaint grow
th, social justice and peoples participation.
One of the crucial factors in this process is educati_pn,
not of the formal type, but the type that transforms the minds,
and changes attitudes and age-old patterns of behaviour.
A new consciousness is growing of the role of the hos‘ j, making use of the existing opport
pitai in health promotion
group, discuss!ons.
unities of listening, conversations,
con. ..7.
5 -
c ommunity
“ Community involvement demands that, before any step is taken,the/
- must be consulted,
- their opinion should be considered
- they should be involved in every decision that
is taken.
“ A be al t h-ac ti on c pmmi 11 e o should be formed, to secure active cooperation of the people.
“ Information about the village and its people will need to be
collected, by simple methods and using relatively unskilled wor
kers (ex: school teacher, or even illiterate women - see Rajupeta
chart)
v Local leadership must be inspired - and initially it may be up
to the medical and nursing profession to provide inspiration and
direction.
“
health workor should be selected by the commmaity to be
served.
"
- training should be organised as near as possible to the, vi 11agcs
to be served, so that the trainee can keep in contact witli his
or her family. Exposing the trainee to urban or westernised
nillieu too often leads to the loss of community identity, and
will make the return to the community difficult.
- medical training must enable the trainee to lenow what ailments
he or she can treat, and what he should instead refor for medical
treatment - and how urgent the referral is.
- medical training demands some, clinical experience in a hospital
or dispensary, where the trainees can see patients and understand
the clinical picture of diseases.
- J^on, the spot’1________
training must help the trainee to tackle simple
and basic health problems, and to learn basic health, p romot i_on
and health education.
“ supervisi on of the paramedical worker is necessary and should be
carried out regularly with s
visits by the supervisor to the paramedical workers site
regular meetings and training sessions at the hospital
or dispensary.
reports from the local community health committee about
the health promotor’s work, its quality, and the accep
tance of the fees charged.
-
00or-scrvice should be decided locally, so that the community
will pay for the services required.
if the community provides resources, they will be concer
ned that these are well used.
- the health committee should be informed of the price of
the basic medicines the health promoter’s will be supplied
with by the sponsoring centre.
- the health promoter should continue his or her normal life
and work and do the health work on a part time basis ( 2 3 hours daily)
- the sponsoring centre should work out the training progra
mme considering :
- what kind of education should bo given in the particular
si tuation.
t what should be the motivation of those who are trained.
- can some traditional skills and systems be utilised
(ex: massage).
. .6.
6
i
Curriculum proposed in "the new health plan for the nation"
(Raj Narain)
fundamentals of health sciences
measures for maintaining good health
hygiene - personal environmental
treatment of common infectious diseases
maternity and child care
treatment of common ailments
first aid.
The sponsoring centre should provide referral service and extend
all professional help needed.
BE ALTH PROMOTION
Let us look at medical care not from the standpoint of ill
ness, but of health. In the past we have lost sight of the primary
objectives : to keep people healthy and out of the hospital in the
first place. We have organised for sickness.
In the future we must organise for health.
Fundamental questi ons :
If the concept of health is
then health care
non-illness
cure of disease (curative medicine)
or eradication of disease (preven
tive medicine)
Isn’t health more than non-illness?
Isn’t there more to life than keeping disease-free?
Isn’t there more to being human than just being well?
The more revolutionary advance in modern medicine is the re-disco
very of the wholeness of the human personality, (see Jesus’ heal
ings).
It is a well known fact that the overall well-being of a person
depends considerably on the quality of the environment and the
social relationships.
Better health care requires attention to the total develop
ment of the whole person, to the needs of individuals, families
and communities.
It includes awareness and willingness to do something
about such problems, as environment, malnutrition, balance bet
ween population growth and development.
"The primary task of a hospital is to be viewed in terms
of human learning :
to enable patients, their families and the staff to learn
from the experience of illness and death how to build a
healthy society" (Dr.M. Wilson).
A comprehensive view of health demands to relate our
hospital system to the process of human development taking
place in the country. This implies to aim at self-relaint grow
th, social justice and peoples participation.
One of the crucial factors in this process is educatioil?
not of the formal type, but the type that transforms the minds,
and changes attitudes and age-old patterns of behaviour.
A new consciousness is growing of the role of the hos
pital in health .promotion, making use of the existing opport
unities of listening, conversations, group, discussions.
. ..7.
V
7 HEALTH
EDUCATION
This is a process which effects changes in the health practicies of
people and in the knowledge and’ attitudes related to such changes.
' Through health education a nurse should aim at :
a change of knowledge
change in attitude
change in behaviour
^change in habit
change in custom.
Contents of health education ;
human biology
nutriti on
- care of mothers and children
- pretention of communicable
diseases.
hygiene : personal environmen
tal.
~ use of health services.
Principles of health education :
Interest
: bring about recognition of the needs 9 to
catch people’s interest.
Participation
: active learning
From known to unknown : start where the people are and precede to
new.
C omprehensi on
: communicate in a language people understand
Reinforcement
: repetition at intervals - ’booster dose’.
Motivati on
: awakening the desires
Learning by doing
: action-process
action-process.. ”If I hear I forget; if I
see I remember; If I do I know" (Chinese
proverb).
C ommunication
: on emotional 9 cultural and intellectual
plane.
Prior knowledge of the
people
: customs, habits, taboos, beliefs, health
needs.
G-ood human relations
: people must accept the educator as their
real friend.
A nurse’s teaching is best done in an informal way 9 making use
of actual situations to impart education :
Home-visits are very opportune times for health education.
We should organise formal teaching sessions.
To he successful communication these should be :
Brief
Simple
Seen
:
Heard
:
Remembered:
5 to 10 minutes.
make one or two points clear. We should not
confuse with too much information.
use visual aids, or tools when possible.
speak aloud to capture interest
use local events to illustrate - it helps to
remember.
How to prepare the teaching :
Teaching guids
Visual aids
to get them from or how to prepare
0 where
them ouhselves and use them.
...8.
i
8
Demonstration
As much as possible choose the subject in relation to a sit
uation or an event.
Then
follow-up
see what people have understood
clarify
repeat occasionally
advise concretely
encourage to apply, to change habits.
Every staff member must responsibly include teaching in his/her
daily work.
But to stimulate, co-ordinate and follow-up the health edu
cation programme it is better to have one person who takes special
responsibility for it.
•k- -x- -«■ -x- -x- -x- -x- ->f * * *
MEDICAL CAHE ACCESSIBLE TO THE MASSES
GUIDELINES IN PLANNING
on awareness of;
effective demand ;
(minority)
reflects the ability of powerful groups in society
to influence the allocation of resources to produce
certain types of goods and services to meet their
needs.
voiceless needs
(majority)
of the relatively poor and unskilled rural majority,
where the index of health is lower.
J ARENAS
\*\ W
\\ AWW
20%
OP
ARGAS
Health Services should be;
1)
elements of accessibility;
ACCESSIBLE;
- geographical;
within walking distance
(maximum 5 to 7 miles)
—study the area, its map,
transportation facilities,
existence of other facilities
(avoid overlapping)
financial;
” psychological;
2)
low-cost
(strive for self-sufficiency)
acceptability, familiarity, confidence.
COMPRENHENSIVE; integrating - curative
- preventive
- promotive
action
The provision of even basic health services is met with
minimum effect unless;
a)
the community is motivated for the necessary changes
in the socio-cultural environment.
b)
the community is provided with adequate nutrition ?
safe drinking water and a reasonably sanitary
environment.
...2/
2
5) - COMWNITY-BASED
we must seek and encourage peopled participation in
different aspects of the programme.
new perspective : viewed in the whole process of human
development, we are partly responsible for the whole,
not wholly responsible for a part.
many of the health problem of the rural villages are of
a nature which cannot be solved by individuals but
require the combined effort of many or most of the
inhabitants.
4) - accompanied by continuous EVALUATION.
and modifications according to the findings.
(objectives, data and statistics, records, cost
effectiveness) .
DECIDE OBJECTIVES AND PRIORITIES considering :
socio-economic development of the people
patterns of disease :
identify health conditions in the community and problems
causing them.
what people think of health and disease
local needs. particularly the needs of special groups and areas .
degree of support from the community
resources available in money, man-power and materials
need for co-ordinated and joint action of different service agencies (voluntary
and governmental) for a total and integrated community development.
INTEGRATED HEALTH PROGRAMME
Health services (whether hospital, dispensary, health centre or community health
ppogTATmne) need be integrated in the overall effort of human, community and
national development.
Por too long the interaction between the health services and the community they
serve was ignored or.denied.
New perspective »
I
as ’’health workers", we arc partly responsible for the whole
not wholly responsible for a part.
Health planning belongs to society ( not only to specialists )
Health action needs to be linked with the broader community goals.
The socio-economic situation of the patient and the community must concern the
health team.
The importance of the health service as an information service should be clears
informations about the symptoms and signs of what is going wrong in a society
may be more important than treating the symptoms which, in the long run, could
conceal the real trouble.
II - Many of the problems of the rural villages cannot be solved by individuals,
but require the combined efforts of the inhabitants, the health workers
and the government services.
ex;
environmental hygiene is the responsibility of the community.
To make a contribution to the equitable distribution of the health services to
the masses of India, all hospitals should give priority to the planning and
development of primary health and community care, taking into account government
and civic programmes, and chiefly the prople themselves.
1)
Basic health education to the people.
3/-
5
2)
Work on some preventable diseases ( exs blindness, T.B., leprosy, etc.)
- camps
- special clinics (also pre-school children, F.P., etc)
3)
Organisation of rural health zones and health centres.
4)
Promotion of auxiliary personnel (p ara-professionals)
COMMUNITY-BASED PROGRAMME
?■
Considering the local needs,
« select a community of a defined and accessible geographical area.
B ’- study the community characteristics
- demographic dynamics s birth rate - death rate - age pyramid causes of
death, of disability, of incapacity to work, of
distress.
structure of the community :
socio-economic life :
groups, leaders.
sources of income,
income range
employment pattern or occupation
pattern of expenditure
educational level.
assessment of local resources"for the programme
- felt needs
- local customs
regarding health
- what it means to be sick?
- what people do to avoid sickness?
- what people do to cure sickness?
- to whom people turn when they are sick?
- who gives them advices?
- what is the importance of different foods, food
rituals, births, deaths, marriages, etc.
- other health facilities.
C)
identify and analyse the community's health problems
(diagnose the cause of the ill-health)
D)
set the priorities and goals for the programme
- health care facilities
- specific health improvement objectives
- health-related development work
community should be actively involved in steps B)9c) and D)
There is need for s
— agreement upon the problems to be tackled
- agreement upon the solutions within the village
. a village organisation ( exs health commi11ee )
to gather the village resources
and promote effectiveness action
The potential for health promotion and improvement within the community needs
to be awakened and released. It is bound to be more effective than interventions
” from outside ”.
xxxxxxxxxxxxxxxxxxxxx
Three Principles for financing community health programmes
Community health programmes can be self supporting under certain conditions.
The following are some edonomics which make it possible for a programme to e
:self-supporting.
4/-
4
I
Obtain community support
Too often we organise our programme without any consultation with the community
leaders, then we wonder why we are left to pay for it! Besides meetings with
governmental authorities, there should be detailed - discussion with village
or community leaders. The programme should be a co-operative effort.
II
gedal power is cheaper than motor power
We could buy 120 bicycles for the cost of one Ambassador car: the cost of
running a motor vehicle can be equal to the salary of a specialist doctor.
Our programmes should be within walking or cycling distance, or accessible by
bus travel. We may need to consider skills when making an appointment, Every
jawan does not need to ride in a tank!
III
Doctors are not needed for routine work
In battle a few officers can command many jawans! Six village level health
workers can give simple health to 15.000 people, Their salary will cost the
same as one MBBS doctor. This does not mean that doctors are not needed.
Ear from it. But doctors can train semi-literate or illiterate women health
workers to give simple health care.
TRAILING- 0? PAWIEDICAL CQMICTITY HEALTH WORKERS
Tiat are the most important assets of a poor country?
its man-power ; the people and their skills,
there are many potentialities still to be developed.
In the field of health services, our initiative ways and the eagerness to obtain
help from others, without first building up our own potentialities, have brought
a help that leads to a new kind of helplessness.
To provide simple medical facilities to the rural areas, the first step is to
train and organise paramedical health workers.
the process of providing medical aid to the village ’’from outside” njiust be
reversed :
local personnel should be enrolled and
the village people must be involved in the decision-making.
0ommunity invo1vement demands that, before any step is taken, the community
- must be consulted,
their opinion should be considered
- they should be involved in every decision that is taken.
A health-action committee should be formed, to secure active co-operation of
the people.
Information about the village and its people will need to be collected, by
simple methods and using relatively unskilled workers (ex; school teacher,
or even illiterate women - see Rajupeta chart)
Local leadership must be inspired - and initially it may be up to the medical
and nursing profession to provide inspiration and direction.
the health worker should be selected by the community to be served.
training should bo organised as near as possible to the villages to be served,
so that the trainee can keep in contact with his or her family. Exposing the
trainee to urban or westernised milieu too often leads to the loss of community
identity, and will make the return to the community difficult.
medical training must enable the trainee to know what ailments he or she can
treat, and what he should instead refer for medical treatment - and how
urgent the referral is.
medical training demands some clinical experience in a hospital or dispensary 9
where the trainees can see patients and understand the clinical picture of
diseases.
5/-
>/*■
5
"on the spot" training must help the trainee to tackle simple and basic
health problems? and to learn basic health promotion and health education.
supervision of the paramedical worker is necessary and should be carried out
regularly with ;
visits by the supervisor to the paramedical workers site
regular meetings and training sessions at the hospital or dispensary
reports from the local community health committee about the health
promotor’s work, its quality, and the acceptance of the fees charged.
fee-for-service should be decided locally, so that the community will pay
for the services required.
if the community provides resources, they will be concerned that these
are well used.
the health committee should be informed of the price of the basic
medicines the health promoter’willrh^ Supplied-* withoby the sponsoring
centre.
the health promoter should continue his or her normal life and work
and do the health work on a part time basis (2-3 hours daily)
the sponsoring' centre should work out the training programme considering:
what kind of education should be given in the particular situation,
what should be the motivation of those who are trained.
can some traditional skills and systems be utilised (ex: massage)
Curriculum proposed in "the new health plan for the nation" (Raj Narain)
-
fundamentals of health sciences
measures for maintaining good health
hygiene - personal environmental
treatment of common infectious diseases
maternity and child care
treatment of common ailments
first aid.
The sponsoring centre should provide referral service and extend all profess
ional help needed.
HEALTH
PROMOTION
Let us look at medical care not from the standpoint of illness, but of
health. In the past we have lost sight of the primary objectives : to keep
people healthy and out of the hospital in the first place. We have organised
for sickness.
In the future we must organise for health.
Fundamental questions :
If the concept of health is
then health care
non-illness
cure of disease (curative medicine)
or eradication of disease (preventive medicine)
Isn’t health more than non-illness?
Isn’t there more to life than keeping disease-free?
Isn’t there more to being human than just being well?
The more revolutionary advance in modern medicine is the re-discovery of the
wholeness of the human personality. (see Jesus’ healings).
It is a well known fact that the overall well-being of a person depends
considerably on the quality of*.the environment and the social relationships.
Better health care requires attention to the total development of the
whole person, to the needs of individuals, families and communities.
It includes awareness and willingness to do something about such problems 9
malnutrition9 balance between population growth and develop
as environment, malnutrition,
ment.
"The primary task of a hospital is to be viewed in terms of human learning :
6
to enable patients^ their
'
families and the staff to learn from the experience
of illness and death how to
build a healthy society" (Dr. M. Wilson)
-- I-ill
A comprehensive view of health demands to relate our hospital system to
the process of human development taking place in the country.
„ , This implies to
aim at self-relaint growth, social justice and peoples participation
One of the crucial factors in this process is education
______ 9 not of the formal
type, but the type that transforms the minds, and changes attitudes and age-old
patterns of behaviour.
A new consciousness is growing of the role of the hospital in health promotion,
making use of the existing opportunities of listening, conversations, group
discussions.
HEALTH
EDUCATION
This is a process which effects changes in the health practices of people and
in the knowledge and attitudes related to such changes.
Through health education a nurse should aim at s
a change of knowledge
change in attitude
change in behaviour
change in habit
change in custom.
Contents of health education ;
human biology
nutrition
hygiene : personal environmental
care of mothers and children
pretention of communicable diseases,
use of health services.
Principles of health education :
Interest
bring about recognition of the needs, to catch people’s
interest,
active learning
start where the people are and precede to new
communicate in a language people understand,
repetition at intervals - ’booster dose’,
awakening the desires
action-process, ”If I hear I forget? if I see I
remember? If I do I know" (Chinese proverb),
on emotional, cultural and intellectual plane.
Participation
Prom known to unknown
Comprehension
R cinf o rc emen t
Motivation
Learning by doing
C ommuni cation
Prior knowledge of the
people
Good human relations
s
customs, habits, taboos, beliefs, health needs,
people must accept the educator as their real friend.
A nurse’s teaching is best done in an informal way? making use of actual
situations to impart education :
In the hospital we come across so imany situations raising problems and
questions, which can be the starting point for discussing and teaching.
Home-visits are very opportune times for health education.
We should organise formal teaching sessions.
To be successful communication these should be s
Brief
5 to 10 minutes,
Simple
make one or two points clear, We should not confuse with too
much information,
Seen
use visual aids, or tools when possible.
Heard
speak aloud to capture interest
Remembered: 'use local events to illustrate
it frelps to remember.
How to prepare the teaching
°o
Teaching guides jj
Visual aids
jj where to get them from or hov; to prepare them ourselves and
use them,
.. 7A
7
Demonstrations
As much as possible choose the subject in relation to a situation or an
evento
Then
f Oil OV,-up
see what people have understood
- clarify
repeat occasionally
advise concretely
encourage to apply, to change habits.
Every staff member must responsibly include teaching in his/her daily work.
But to stimulate, co-ordinate and follow-up the health education programme
it is better to have one person who takes special responsibility for it.
WELVE GROUPS OF AXIOMS ON MEDIQ/iL CARS
MAJOR AXIOMS
0?E
The medical care of the common n&n is immensely worthwhile.
WO
Medical care must be approached with an objective attitude of mind
which is free as far as possible from preconceived notions exported
from industrial countries.
THREE
The maximum return in human welfare must be obtained from the limited
money and skill available’
(a) In estimating this return means must not be confused with ends.
(b) Medical care must be adapted to the needs of an intermediate
technology.
THE PATTERN OF A MEDICAL SERVICE
FOUR
A medical service must be organized to provide for steady growth in
both the quantity and the quality of medical care.
FIVE
Patients should be treated as close to their homes as possible in the
smallest, cheapest, most humbly staffed and most simply equipped unit
that is capable of looking after them adequately.
SIX
(a) Some form of medical care should be supplied to all the people all
the time.
(b) In respect of most of the common conditions there is little relation
ship between the cost and size of a medical unit and its therapeutic
efficiency.
(c) Medical care can be effective without being comprehensive.
SEVEN
(a) Me Heal services should be organized from the bottom up and not
from the top down.
(b) The health needs of a community must be related to their wants.
THE ROLE OF THS DOCTOR & THOSE WHO HELP HIM
SIGHT
The role a doctor has to play in a developing country differs in
many important respects from that he plays in a developed one.
NINE
The role played by auxiliaries is both different and more important
in developing countries than in developed ones.
TEN
All medical workers have an educational role which is closely linked
to their therapeutic one.
(a) Skilled staff members have a duty to teach the less skilled ones.
(b) All medical staff have a teaching vocation in the community they
serve.
THE ADAPTATION OF MEDICAL CARE TO LOCAL CONDITIONS
ELEVEN
In developing countries medical care requires the adaptation and
development of its own particular methodology.
TWELVE
Medical care and the local culture are closely linked.
(a) Medical care must be carefully adapted to the opportunities &
limitations of the local culture.
(b) Where possible medical services should do what they can to
improve the non-medical aspects of a culture in the promotion
of a’better life’for the people.
■
■
X?
TWELVE GROUPS OF AXIOMS ON MEDICAL CARE
(MAURICE KING)
MZlJOR AXIOMS .
The medical care of the common man is immensely
worthwhile•
One
Medical care must be approached with an objective
attitude of mind which is free as far as possible
from preconceived notions exported from industrial
countries.
• Two
Three
The maximum return in human welfare must be obtained
from the limited money and skill available;
a)
In estimating this return means must not be
confused with ends.
b)
Medical care must be adapted to the needs of an
intermediate technology0
THE PATTERN OF A MEDICAL SERVICE.
Four
A medical service must be organised to provide for
steady growth in both quantity and the quality of
medical care.
Five
Patients should be treated as close to their homes
as possible in the smallest, cheapest, most humbly
staffed and most simply equipped unit that is capable
of looking a.fter them adequately.
Six
a)
Some form of medical care should be supplied to
all the people all the time.
b)
In reepoat of most of•the common conditions there
is little relationship between the cost and size
of a medical unit and its therapeutic efficienty.
c)
Medical care can be effective without being
comprehensive•
a)
Medical services should be organized from the
bottom up and not from the top down.
b)
The health needs of a community must be related
to their wants.
Seven
THE ROIE OF THE DOCTOR AND THOSE WHO
HELP HIM.
Eight
The role a doctor has to play in a developing country
differs in many important respect from that he plays
in a developed one.
Nine
The role played by auxiliaries is both different and
more important in developing countries than in
developed ones.
Ten
All medical workers have an educational role which is
closely linked to their therapeutic one:
a)
9
b)
Skilled staff members have a duty to teach the
less skilled ones.
All medical staff have a teaching vocation in
the community they serve.
2
J
*.•
2
THE ADAPTATION OP MEDICAL CARE TO LOCAL
CONDITIONS^
*“ * “rr-ri“- I—» i •**■■■ r
mm
........................... .... ii
i
i i.r.WM» Jyw> —, ri» ..n ■■■«».» ■»
----------- -
------- n
Eleven
In developing countries medical care requires the
adaptation and development of its own particular
methodology.
Twelve
Medical cere and the local culture are closely
linked•
sspd .
14.5.1979.
e.)
Medical care must be carefully adapted to the
opportunities and limitations of the local culture.
b)
Where possible medical services should do what
they can to improve the non-medical aspects of a
culture in the promotion of 1 better life1 for
the people.
a
(
)
NATIONAL INSTITUTE OF ADVANCED STUDIES
BANGALORE
Indian Institute of Science Campus
Bangalore
I
NATIONAL INSTITUTE OF ADVANCED STUDIES
This is the age of scientific renaissance with explosions of information in all fields of
knowledge. While one welcomes this and the new technologies it has given birth to,
there is also a growing concern that there is a need to integrate this information and
examine the new technologies in the historical, social, cultural, political and economic
context of the increasingly complex societies in which the latter will take root. Further, one
requires to take into account the values and the psychological propensities of those who
will make use of this information. Are they well versed just in their respective field of
specialisation or do they approach problems from a broader perspective? Unless all this is
done, the very harbingers of human progress can spell its doom. It is this realisation which
has inspired the creation of the National Institute of Advanced Studies.
(
This Institute (subsequently referred to as NIAS) is a Centre for higher learning with twin
objectives. The first is to provide an atmosphere in which, through exchange of ideas,
exposure to new knowledge in different areas, introduction to. nation's socio-cultural
heritage and understanding of the strengths as well as weaknesses of human personality,
one could move towards that widening of mental horizons, which makes for more
accurate and effective decision making. The other is to support and lead
multi-disciplinary research on the borderlands of material sciences, social sciences and
humanities; helping the researchers from different disciplines work together, understand
each other's language and attack complex problems in a comprehensive fashion.
That there was a need for such a commingling of different disciplines was clear.to
Jamshetji Tata who in 1904, while gifting to the nation first ever Institute of Science and
Technology, had clearly remarked that there should be a place for humanities in such an >
Institute. A reference' to this philosophy was made again by Mr. J.R.D, Tata, who while
speaking at the Platinum Jubilee of the Indian Institute of Science, said the following:
"It has been said that education is what makes a man what he is, the way he .
conducts himself, his interests, his values, his personality. The load of work imposed on
young men and women pursuing advanced studies in our Institute is such that they
have little time or opportunity to expose themselves to literature, the arts, drama,
poetry, music, history, philosophy, which, though unconnected with their study or
research work, are important elements in the make-up. of a civilized, liberally
educated person such as Jamsetji Tata had in mind.
. Many of the thousands of young men and women who emerge from our Institute
would, I think, appreciate the opportunities to nourish their minds and expand their
horizon beyond their immediate course of study. If I am right, may I end my remarks
with the suggestion that we consider introducing in the Institute wholly optional
programmes of study or discussion in some of the subjects I have just mentioned, and
thereby send out into the world better informed and more lively citizens who will, in
turn, play a fuller part in making this great but impoverished country of ours a better
place to live in?"
i
2
making integrated learning its very raison d'etre.
9 'he above Philosophy,
History
disced2nsM;nJd^ataXdb;eo ~mber°o? d^noX?0'h
*hroU9h ™">'
administrators before it too its final shape I wa c eTnJ
request of the Sir Dorabji Tata Trushby aTomS^^^^
'ndustrialis^ and
*the
1. Prof R.D. Choski
Trustee
Sir Dorabji Tata Trust
2. Dr. Safish Dhawan
Senior Adviser
Indian Space Research
Organisation.
3. Mr. L.K. Jba
4. Prof. M.G.K. Menon
5. Prof. Philippe Olmer
6. Dr. H.N. Sethna
Former Chairman
Economic Administration
Reforms Commission and
ex-Governor of Jammu
and Kashmir.
Member
Planning Commission
Govt of India.
Hon. Professor at the
University of Paris
Formerly, General Director
of Higher Education
Ministry of Education
Paris.
Retired Principal Secretary
to the Government of India
and ex-Chairman, Atomic
Energy Commission.
Gandhi, who ^Iso'iSeTan^aN^5 ^°med. bV the Prime Minister. Shri Rajiv
possibility of finding a location for it ^n'DelN'blowl Off,^alS ^oncerned« regarding the
and offered did not meet the^eauir^^^
he allernate locations available
Governor and the Chief Minister of West Rennet
nefw’lnstltute- Subsequently, the
offered a suitable location for it in tho ®-?9a
Informed about the project, also
Sir Dorabji Tata Trust and the Director de^n^t of ^al^utta- Finally, the Trustees of the
to the unanimous concrustonS heS
® ,°f th® '^ltute- Dr Raja Ramanno. came
most effectively achieved by its locatior'in r35
ob?ectlves ofthe institute could be
Institute of Science.
7
Bangalore in close proximity to the Indian
3
■
The Institute was registered in Bangalore on the 20th of June 1988 under the
Karnataka Societies Registration Act. Dr. Raja Ramanna took over as the Director of the
Institute in August 1987. Dr. R.L Kapur joined as the first Professor on the Faculty in October
1988. The first formal activity of NIAS. i.e. a course of lectures to the senior administrators in
Government and Industries was held in Jan-Feb. 1989.
It was in March 1989 that the Council of the Indian Institute of Science gave on
license, 5 acres of land within the campus of the I.I.Sc for the NIAS buildings The Visitor of
the Indian Institute of-Science, the President of India, gave his consent to this welcome
gesture in December 1988. In September 1987, the Government of Karnataka had
promised an interest - free loan of Rs. one and a half crores to construct the buildings.
Jhe National
1989 by Mr. J.R.D. Tata.
of Advanced Studies was formally inaugurated on January 16
The Administrative Structure
NIAS is an.independent organisation registered under the Karnataka Societies
Registration Act. It is financed by the Sir Dorabji Tata Trust and the Government of
Karnataka.
There are three Authorities for the overall administration of the Institute These are the
Counod of management (subsequently referred to as 'Council-), the Holding Trustees and
the Academic Council.
The Council has the full powers and authority on overall management according to
the Rules and Regulations of the Institute, it has the following) members:
a.
b.
c.
d.
e.
f.
Two nominees of the Sir Dorabji Tata Trust,
Director of the Institute (Ex-Officio),
Two nominees of the Government of India,
One nominee of the Government of Karnataka.
Director, Indian Institute of Science, and
Not more than three persons to be co-opted by the above from time to time for
a period of five years. No action of the Council shall be invalidated by the mere
fact that co-option of the three members as provided above, had not been
made.
AH nominated members will hold the office for 5 years. Chairman is elected by the
Council Members for a period of 3 years.
The Academic Council looks after the academic programmes and advises the
council on academic matters. It has the following members:
4
»
a. The Director, who is the Chairman of the Academic Councilb. Members of the Faculty, that is to say, the Director and Professors and any other
member of the academic staff of the Institute deemed to be a Faculty Member
by the Council; and
c. Not more than five experts in the relatedfields to be appointed by the Director.
The Holding Trustees review the overall functions of the Institute and have the..
following members:
a. Chairman of the Council
b. The nominee of the Sir Dorabji Tata Trust
c. The nominee of the Government of Karnataka
d. The Director of the Institute
e. The Director of the Indian Institute of Science.
The Director is the Executive and Academic Head of the Institute. He is a member of
all the three statutory bodies. He shall have the general control over the Institute and shall
give effect to the decisions of the authorities of the Institute.
The Programmes of the Institute
As decided by the Academic Council and the Council of Management, the main
programmes of the NIAS will be as follows:
1. To conduct 40-day residential courses for persons in senior positions from 'I
Government, Industries and Universities. In these courses, a galaxy of renowned scholars
and experts from all over the country will acquaint the participants, not only with the new
developments In various fields of knowledge but also put them in touch with nation's
socio-cultural roots and its experiments towards becoming a modern state without
parting with time-tested traditional values.
Besides taking part in the lectures and discussions, the participants will also make
their own contributions through talks on subjects of their own interest, presenting critical
reviews of selected books, taking part in panel discussions and carrying out specific
projects.
The Government, participants are expected to be the officers at the level of Joint
Secretary and those from Industries will be from senior management cadre. One expects
a very creative atmosphere with mature participants from different backgrounds
interacting in and out of formal sessions.
During the residential course, the participants will be the guests of the Institute who
will arrange their accommodation, food, entertainment and visits.
if
5
2. To conduct workshops on developmental policies of national importance. Experts
will be called in to spend 8-10 days examining a given policy or a new idea, both in its
concept as well as in the details of its application, looking into its successes and failures,
the reasons for both and suggesting.new directions: thus providing for our legislators and
administrators the much needed information and expert opinion.
3. To conduct socially relevant multi-disciplinary research on the borderlands of
science, social science and humanities.
4. To invite visiting faculty on long-term basis from six months to a year. During this
period, the visitor could put finishing touches to his on-going research and also interact
with the permanent faculty in planning and executing new or on-going research
programmes.
5. To invite key administrators from the Government and Industries to come as Visiting
Fellows for six months to a year. Here they would pursue any new developmental ideas
they have, fill in the gaps in knowledge pertinent to their tasks, and test out their ideas
with the permanent and Visiting Faculty. Some of these ideas could become foci for the
national workshops mentioned in (2) above.
6. To publish books, monographs, periodicals and papers.
7. To co-operate with other Institutions and Organisations and contribute knowledge
at inter-disciplinary level.
6
a
MEMBERS OF THE COUNCIL
Mr. J.R.D. Tata
Chairman
Tata Sons Limited
Bombay House
Homi Mody Street
Bombay - 400 001.
Chairman
2.
Mr. J.J. Bhabha
Managing Trustee
Sir Dorabji Tata Trust
Bombay House
Homi Mody Street
Bombay - 400 001.
Member
3.
Dr. Ashok S Ganguly
Chairman
Hindustan Lever Ltd
Hindustan Lever House
Backbay Reclamation
Bombay - 400 020.
Member
4.
Mr. Keshub Mahindra
Member
Chairman
Mahindra & Mahindra Ltd
Gateway Building
Apollo Bunder
Bombay - 400 039.
1.
,
5.
Prof. M.G.K. Menon
Scientific Adviser to
Prime Minister
& Member, Planning
Commission (Science)
Government of India
Yojana Bhavan
New Delhi-411 001.
Member
6.
Dr. Francis A Menezes
Director
Tata Management
Training Centre
1, Mangaldas Road
Pune-411 001.
Member .
7.
Prof. C.N.R. Rao
Member
Director
Indian Institute of Science
Bangalore - 560 012.
8.
Dr. Raja Ramanna
Member
Director
National Institute of
Advanced Studies
Indian Institute of Science
Campus
Bangalore - 560 012.
9.
Mr. T.R. Satish Chandran
Director
Institute for Economic
and Social Change
Nagarabhavi Post
Bangalore - 560 072.
10.
Mr. Manish Bahl
Member
Secretary (Personnel)
Ministry of Personnel, Public
Grievances and Pensions
Government of India
New Delhi - 110 001.
11.
Mr. B.N. Yugandhar
Member
Director
Lal Bahadur Shastri Academy
of Administration
Government of India
Mussoorie - 248 179 (U.P.)
‘Member
7
A
MEMBERS OF THE ACADEMIC COUNCIL
1
Dr. Raja Ramanna
Director,
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore - 560 012.
2.
Shri S.T. Baskaran
Postmaster-General
Office of the Chief PMG
Bangalore-560 001.
• Member
3.
Prof. Andre Beteille
Professor of Sociology
Department of Sociology
Delhi School of Economics
University of Delhi
Delhi - 110 007.
Member
4.
Shri K.A. Chandrasekaran
Joint Secretary (Training)
Department of Personnel and Training
Government of India
New Delhi - 110 001.
Member
5.
Prof R.L. Kapur
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore-560 012.
Member
(Ex-Officio)
6.
Prof. N. Mukunda
Chairman
Division of Physical &
Mathematical Sciences
Indian Institute of Science
Bangalore - 560 012.
Member
7.
Prof. K. Subrahmanyam
Nehru Fellow
. The Institute for Defence
Studies and Analyses
Sapru House
Barakhamba Road
New Delhi - 110 001.
Member
Chairman
8
*
i
48
|
p
THE FACULTY
DR. RAJA RAMANNA is the Director of the Institute. A Ph.D. from London University
and awarded the D.Sc (Honoris Causa) by many others, he has formerly been Director
Bhabha Atomic Research Centre, Bombay (1972-1978) and (1981-83); Scientific Adviser to
the Minister of Defence, Government of India; Director General, Defence Research and
Development Organisation; and Secretary for Defence Research (1978-81); Chairman,
Atomic Energy Commission and Secretary to the Government of India, Department of
Atomic Energy (1983-87). He has also been Chairman, Board of Governors, Indian Institute
of Technology, Bombay (1972-78) and is, currently, the Chairman of the Governing
Council of the Indian Institute of Science, Bangalore. He is a. Fellow of the Indian
Academy of Sciences and the Indian National Science Academy and has received
various national awards including Shanti Swarup Bhatnagar Award (1963)- Padma Shree
(1968); Padma Bhushan (1973); and Padma Vibhushan (1975).
’
Dr. Ramanna also brings to the Institute an abiding interest in Arts and Philosophy. He
has a deep knowledge of Music both Indian and Western and is an accomplished Pianist,
having performed to many a distinguished audience in various parts of the world.
9
so
•■'A'
DR. R.L KAPUR is the first to join the permanent Faculty of the Institute. He is a
Psychiatrist with a Ph.D from the University of Edinburgh. Formerly, he has been the
Professor of Community Psychiatry and Head, Department'of Psychiatry, National Institute
of Mental Health and Neuro Sciences (N1MHANS), Bangalore (1975-83); Visiting Professor,
Centre for Theoretical Studies, Indian Institute of Science, Bangalore (1983-89); Visiting
Professor, School of Medicine as well as the Divinity School, Harvard University, U.S.A.
(1985-86). He has also been a consultant to the World Health Organisation. He has
received various awards including the Medical Council of India Award for Community
Research. He is a Fellow of the Indian Academy of Sciences, the Indian Academy of
Medical Sciences and the Royal College of Psychiatrists, U.K.
His research interests include Cross-cultural Psychiatry and Psychological concepts in
Ancient Indian Philosophy. He has researched on Yoga, having taken an Indian Council
of Medical.Research’sabbatical in 1981-82 to study under a Guru.
?
•ii
i
11
Report on the First NIAS Course for Senior
Administrators in Government and Industry
A. Aim of the Course
The first course, designed by the National Institute of Advanced Studies to acquaint
the senior administrators both from the Government and Industries with the latest
advances in knowledge as well as to remind them of their socio-cultural roots, was
conducted at the Tata Management Training Centre, Pune from 16th January to 18th
February 1989 (total duration : 5 weeks).
The course did not attempt transfer of any new skills; nor did it aim to provide any
information directly pertinent to the participant's current work assignment. Instead, the
focus was on the widening of mental horizons in such a manner as would improve the
officer's decision-making capacity and give him or her a fresh, broader perspective from
which to attack the problems in course of his or her work. It was understood that such a
change comes slowly and in a subtle manner and can be gauged only through
examination of subjective satisfaction immediately and long-term performance in the
long run.
B. Course Formulation
A variety of subjects, from the material sciences, social sciences and the humanities
were included in the course. The faculty was carefully chosen, keeping in mind the
lecturer's proven scholarship and communication abilities. Each lecturer was told about
the overall purpose of the course and then asked to talk about his subject in five half day
sessions. The choice of topics was entirely left to each lecturer's discretion. Besides the
exposition of some major themes, separate individual lectures on some significant topics
were also included.
Besides the lectures, some field visits to scientific organisations as well as some major
industries were also organised. A highlight of the course was a visit to the National Centre
for the Performing Arts, Bombay, where the participants were treated to a lecture, a tour
of the Centre and a play in the evening.
C. The Participants
There were seventeen participants from the Government and eleven from the
Industries. The list of participants is given on page 20. The Government participants were
selected by the Department of Personnel and Training, Government of India, and those
from the private and public sectors were deputed by the individual companies in
response to communications sent by the Chairman of the Council and the Director NIAS.
I.
12
The overage age of the participants was as follows:
Government candidates: 48.7 years.
Industries candidates: 41.3 years.
D. The Inauguration
There was a brief inauguration ceremony in which Mr. J.R.D. Tata, Chairman of the
Council, NIAS, spoke about the history of the Institute, the inspiration from similar institutes
of excellence in France, the contribution of various distinguished scholars and experts
who had met in various committees to elaborate on the original theme and finally the
concretisation of the objectives when the Institute was registered under the Karnataka
Societies Registration Act on June 20, 1988. Mr. Tata reminded the audience of the desire
of Shri Jamshetji Tata to have material sciences and humanities flourish under the same
roof and its realisation now, with NIAS coming up on the campus of the Indian Institute of
Science.
The Director, Dr. Raja Ramanna, welcoming the participants and the distinguished
guests, explained the overall aim of bridging the gap between sciences and humanities.
He also gave a description of the course.
E. The Conduct of the Course
The main method of teaching was a lecture followed by discussions. While each
lecture lasted 1-1 1/2 hours, the discussions often went on for 2 to 2 1/2 hours. It was
heartwarming to see that everyone participated in discussions. Many participants
continued with discussions afterwards and it was common to see small groups meeting
the faculty members later in the evening.
»
Most teachers used audio visual aids like overhead projector and slides. In the
Psychology course, there was an exercise in which the participants assessed their own
personality and also a session in which Dr. Kapur took the participants through
YOGA-N1DRA.
About 7-10 days after the beginning of the course, the participants had a meeting
with the NIAS Director and faculty in which, among other things, they suggested that the
participants should give short talks about their own work. This was organised. Half-hour
presentations were made by ten participants and were greatly appreciated.
The participants were taken for several visits which were vastly enjoyed. In the visits,
there was a judicious mixture of science establishments, industries and entertainment.
In the T.M.T.C. there were facilities available for croquet, tennis, badminton and table
tennis and these were well utilised by the participants. While not available initially,
arrangements were later made to provide T.V. and video facilities during week-ends.
ft:'
WHS
!
ShriJ.R.D. Tata signing the Golden Book
at the inaugural ceremony.
1
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a \-fis
ill
Participants of the first NIAS course with the Director.
4^
Prof. R.L.Kapur, Dr. Raja Ramanna,
Shri J.R.D. Tata, and Shri Jamshed Bhabha
at the inaugural ceremony.
ww
■
1
The Director, Dr. Raja Ramanna and
Prof. Romila Thapar with the participants.
The participants in an attentive mood.
*
WA'-'-SsJ
■
* -• v
Participants enjoying dinner time
conversation with Prof. Narasimhan.
- j" .
The participants enjoying the
'End of the Course' celeberation
5?r
Mrs. Krishna Singh presenting the
memento of participants' appreciation
to Dr. Raja Ramanna.
I. T
4
13
F. Evaluation of the Course
Since this was the first course of its kind, special care was taken to make an
evaluation through a variety of means. Every week after one lecturer completed his
assignment, the participants evaluated his course using a specially prepared
questionnaire. Also, there were three meetings during the progress of the course when
the participants aired their criticisms and gave suggestions.
On the basis of the evaluation, the following imrpovements will be made in the next
course.
1. a.
b.
Mutual introductions by exchange of bio-data
"Creative problem solving through group processes* - workshop on the 1st
day of the course
c. Talks by the participants about their own work
d.
Book reviews by the participants
e.
Panel discussions with the panel involving representatives from the
participants
2.
Additional lectures and discussions on some new subjects, e.g. Advances in
Biology and Ecology as well as workshops on Art Appreciation
3.
Collective project work.
*
THE LECTURE THEMES
*
NAMES
LECTURE THEMES
1.
Prof. Andre Beteille
Sociology
2.
Prof. R.L Kapur
Mental Health and
Human Management
3.
Prof. S.S. Barlingay
Philosophy
4.
Prof. Romila Thapar
The Interpretation
of History
5.
Dr. F.A. Mehta
Economics and the
Developing World
6.
Mr. Hiten Bhaya
Development Administration
7.
Mr. T.R. Satish Chandran
Development Administration
8.
Prof. K. Subrahmanyam
Politics and Defence
9.
Prof. A. Neelameghan
Informatics
10.
Prof. Renuka Ravindran
Elements of
Mathematics
11.
Prof. V.G. Tikekar
Computers and
Computing
12.
Prof. N. Mukunda
Philosophy of Science
SPECIAL
i
I
LECTURES
13.
Dr. S. Gopal
The National Movement
14.
Prof. R. Narasimhan
Natural Language
Development
15.
Prof. John Barnabas
Evolutionary Molecular
Biology
16.
Dr. Francis A Menezes
Dreams
17.
Prof. B.V. Sreekaotdn
Physical Creation
i
i
.1
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T
15
T
The Visiting Faculty
i.
Prof. Andre Beteille, Ph.D., Professor of
University of Delhi.
Formerly
Sociology,
Fellow
Jawaharlal
Nehru
1968-70;
Commonwealth Visiting Professor, University of
Cambridge 1978-79; Visiting Fellow, Wolfson
College, Oxford 1978-79; Visiting Professor,
Tinbergen Chair, Erasmus University, Roterdam
1984; Visiting Professor, London School of
Economics 1986. Research Interests: Social
Inequality, Social Justice, Sociological Theory.
Publications: Essays in Comparative Sociology;
Caste, Class and Power; Inequality and Social
Change - Studies in Agrarian Social Structure;
Castes: Old and New and several academic
papers.
2.
Dr. Surendra Shivdas Barlingay, Ph.D., Emeritus
Professor, Department of Philosophy, Poona
University. Formerly Professor, Indian Philosophy
and Culture, Zagreb University, Yugoslavia
1962-64; Prof. & Head, Department of
Philosophy, Poona University 1970-80. Visiting
Professor, University of Western Australia
1968-70; National Lecturer, University Grants
Commission 1974; Fellow, Indian Council of
Historical Research; Fellow, Indian Council of
Philosophical Research; Research Interests:
Indian Philosophy and Culture. Publications:
Poverty, Power and Progress; Beliefs, Reasons
and Reflections; Kala aur Saundar/a and
many other books and academic papers.
3.
Dr. John Barnabas, Ph.D., Head, Division of
Biochemical Sciences, National Chemical
Laboratory,
Pune.
Formerly
Professor,
Post-graduate School for Biological Studies,
Ahmednagar; Fulbright Fellow, Yale University,
U.S.A.
1958-59; Netherlands Government
Scholar, University of Groningen, Netherlands
1960-61; Shantiswarup Bhatnagar Award 1974;
Jawaharlal Nehru Fellowship 1983-85; Fellow,
Indian Academy of Sciences; Fellow, Indian
National Science Academy. Research interest
Molecular
Genetics
and
Evolution;
Publications: many academic papers.
€
i
■■
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■>..
■ ■■
■
.
.> .
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16
'
4.
Shri Hiten Bhaya, Member, Planning Commission,
Government of India since 1985. Formerly
Chairman, Hindustan Steel 1972-77; Director, Indian
Institute of Management, Calcutta 1977-81;
Adviser,
Government of Ghana and Guyana;
Director of several public and private sector
companies.
5.
Shri T.R. Satish Chandran. I.A.S. (Retd). Director,
Institute for Social and Economic Change,
Bangalore from 1988. Formerly Adviser (Energy),
Planning Commission and Secretary, Ministry of
Energy, Government of India 1976-83; Chief
Secretary to Government of Karnataka 1983-87;
Fellow, Indian Institute of Engineers; Member, Indian
Institute of Public Administration.
6.
Dr. S. Gopal, D. Litt. (Oxon), D. Phil (Oxon); Fellow,
ST. Antony College, Oxford; Emeritus Professor,
Jawaharlal Nehru University; Corresponding Fellow,
Royal Historical Society; Sahitya Academi Award
1976. Interests: History , Culture. Publications: Several
books and papers including a three-volume book
on Jawaharlal Nehru.
7.
Dr.Fredie A. Mehta, Ph.D., Director, Tata Sons Ltd;
& Chairman, Forbes Group of Companies;
Chairman, Investment Corporation of India;
Director-in-charge, Tata Economic Consultancy
Services; Chairman, Siemens India Ltd; Member,
Executive Committee and of the Board of
Directors, IDBI: Member, Advisory Board of the Unit
Trust of India & Member, Securities & Exchange
Board of India. Formerly Director of several
multinational, companies. Interests: Economic and
National Planning.
1
I
I
V
to
t
F
■•p
17
a
8.
I
V
9.
I
10.
Prof. N. Mukunda, Ph.D., Chairman, Division of
Mathematical and Physical Sciences. Indian
Institute of Science, Bangalore, from 1985.
Formerly Research Associate, Princeton
University, U.S.A. 1964-66; Research Associate,
Syracuse University, U.S.A. 1966-67; Fellow, and
then Reader, Tata Institute of Fundamental
Research. Bombay 1967-72; Professor, Centre
for Theoretical Studies, Indian Institute of
Science 1972 onwards; Chairman, Centre for
Theoretical Studies, l.l. Sc., 1973-1979; Visiting
Professor, Institute of Theoretical Physics,
Gotenberg, Sweden 1979 and . 1982; Visiting
Professor, University of Texas, Austin, U.S.A. 1973
and 198'2; Visiting Professor, Duke University of
Naples, Italy 1980 and 1983. Fellow, Indian
Academy of Sciences; Fellow, Indian National
Science Academy; Bhatnagar Award 1980;
Jawaharlal Nehru Fellow 1987-89. Research
Interests: Classical and Quantum Optics.
Publications: 115 Research papers and 2
books.
Dr. Francis A Menezes, Ph.D., Director, Tata
Management Training Centre, Pune, since
1970. Formerly Executive Director, Indian
Society for Applied Behavioural Science
1971-73; Council Member, Systems Research
Institute 1975-78; Director, Indian Airlines.
Research Interests: Dreams and Creativity,
Motivation,
Management
Research.
Publications: Several books and Academic
papers.
Dr. R. Narasimhan, Ph.D., Senior Professor, Tata
Institute-of Fundamental Research, Bombay,
since 1973. Formerly Chairman, CMC Limited
1976-79; Jawaharlal Nehru Fellow 1971-73;
Padma Shree 1976; Dr. H.J. Bhabha Award
1976; Om Prakash Bhasin Award 1988.
Research Interests: Computational modelling
of behaviour, natural language behaviour
modelling. Scientific methodology.
/ fSO
IE, -
K I
18
A
11.
Prof. A. Neelameghan, Visiting Professor, Indian
Statistical Institute/Documentation Research
and Training Centre, Bangalore, from 1987.
Formerly Professor and Head, Indian Statistical
Institute/Documentation Research and Training
Centre .1962-78; Chief Technical Adviser,
UNESCO 1978-82; Visiting Professor, various U.S.
Universities; Consultant ( information system) for
SIET, HAL, ONGC, CLRI, CMTI, HMT, etc.
Publications: over 200 research papers and
technical reports, 5 books.
12.
Prof. Renuka Ravindran, Ph.D., Professor and
Chairman of Applied Mathematics, Indian
Institute of Science, Bangalore from 1988
Formerly Humboldt Fellow, Gottinghen 1976-77;
Visiting Associate Professor, Cornell University,
U.S.A. 1983-84. Research Interests: Flows in
compressible
fluids.
Publications:
Several
academic papers.
I .
13.
14.
I
I.
Prof. K. Subrahmanyam, I.A.S. (Retd). Nehru
Fellow from 1988. Formerly Director, Institute for
Defence Studies and Analyses, New .Delhi
1968-75; Member, UN Inter - Governmental
Experts Study Group on the Relationship
between Disarmament and Development
1980-81; Jawaharlal Nehru Visiting Professor,
University of Cambridge, U.K. 1987-88.
Dr. B.V. Sreekantan, Ph.D;, Indian National
Academy
Srinivasa
Ramanujan
Science
Professor, Tata Institute of Fundamental
Research, Bombay, since 1987. Formerly Visiting
Scientist, Laboratory for Nuclear Science,
Massachusetts Institute of Technology, Boston,
U.S.A. 1954; Visiting Scientist, Centre for Space
Research, M.l.T. Boston,U.S.A. 1965-67; Director,
Tata Institute of Fundamental Research 1975-87.
Fellow, Indian Academy of Sciences; Fellow,
Indian National Science Academy; National
Lecturer U.G.C. 1981-82. Member, Atomic
Energy Commission 1986-87; Padma Bhushan
1988. Research Interests: Theoretical Physics
Publications: Several books and academic
papers.
•’*4^
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'7
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as
1
19
15.
■■ Thapar,
-f Professor of Ancient Indian
Prof. Romila
i uo.^. . Centre for
History,
U. Historical Studies, Jawaharlal
Nehru University, New Delhi. Formerly Distinguished
Cornell University, U.S.A; Visiting
Visiting Professor,
f .
University
of California, Berkely, U.S.A;
Professor,
Directeur des Etudes, Maison des Sciences de
L'Homme, Paris. Fellow of the Royal Asiatic Society;
President, Ancient South Asia Section, British Assn, of
Orientalists; National Fellow, Indian Council of Social
Science Research. Publications: A History of India;
The Past and Prejudice; From Lineage to State and
many other books and academic papers.
16.
Prof. V.G. Tikekar, Ph.D., Professor, Department of
Applied Mathematics, Indian Institute of Science,
Bangalore, from 1988. Formerly Visiting Fellow at the
Computing Laboratory University of Newcastle
upon Tyne (U.K.) 1975-76; Fulbright Fellow, University
of Michigan, Ann Arbor (USA) 1987-88. Life Member,
Indian Mathematical Society. Research Interests:
Linear
Programming, Theoretical
Computer
Science,
Numerical
Mathematics,
Statistics,
Mathematics Education. Publications: Several
academic papers and books for NCERT and
Karnataka Directorate
of Text books.
■»
A SHORT NOTE ON THE NATIONAL INSTITUTE OF ADVANCED STUDIES
INDIAN INSTITUTE OF SCIENCE CAMPUS
BANGALORE
560012
The National Institute of Advanced Studies (NIAS)
has
It is regulated under
been established since August 1988.
the Karnataka, Societies' Registration Act and is financially
The Institute has
supported’by the Sir Dorab.ji Tata Trust.
been licensed 5 acres of land within the campus of the Indian
Institute
of Science,
where the buildings are
under
construction.
Dr.
Raja Ramanna,
the distinguished Nuclear
Scientist,
was the Director till he became the Minister of
State for Defence,
Government of India, and since then Prof.
C.N.R.
Rao,
Director,
Indian Institute of Science, is also
Di rec tor,
the Honorary Director for the National Institute of Advanced
Studies.
This Institute is a Centre for higher learning with twin
objectives.
The first is to provide an atmosphere in which,
through exchange of
ideas,
exposure to new knowledge in
introduct ion
different areas,,
introduction
to nation’s socio-cultural
as
heritage and understanding of the strengths as well
one could move towards that
weaknesses of human personality ,
which makes for more accurate
widening of mental horizons,
The other is to support and
and effective decision making,
of
research
on the borderlands
1 ead mult i-d isc ip 1inary
helping
Social
Sciences
and
Humanities;
Material Sciences,
together,
the researchers from different disciplines work
understand each other's language and attack complex problems
in a comprehensive fashion.
More specifically, the aims are
as follows;
1 . To conduct 5 weeks residential courses for persons in
and
from Government,
Industries
senior positions
renowned
In these courses,
a galaxy of
Un i versi t i es»
scholars and experts from all over the country will
the participants not only with
the new
acquaint
developments in various
various, fields of knowledge, but
also
put them
in touch with nation's socio-cultural
socio-cultural
roots
and
its experiments towards becoming a modern
state
without parting with time-tested traditional values;
policies of
2. To conduct Workshops on developmental
to
national
importance.
Experts will be called
in
spend 8—10 days examining a given policy or a new idea,
both
in its concept as well as in the details of
its
application,
looking
into its successes and failures,
the reasons for both and suggesting new directions:
thus providing for our legislators and administrators
the much needed information and expert opinion;
1
«
3.
To
conduct
socially
relevant
multi-disciplinary
Social Science
research on the borderlands of Science,
and Human i t i es;
4- To invite visiting faculty on long-term basis from s i x
During this period,
the visitor
months to a year.
research
could put finishing touches to his on-going
interact with the permanent
faculty
in
and
also
and executing new or on-going
research
planning
p rogrammes;
nr
and
To
invite key administraters from the Government
months
Industries to come as Visiting Fellows for six
any
new
to
a . year.
Here they would pursue
in
developmental
i deas they have,
ideas
fill in the gaps
knowledge pertinent to their tasks,
and test out t h e i r
Some of
ideas with the permanent and Visiting Faculty,
nat i ona1
these
ideas could become foci
for the
workshops mentioned in (2) above;
<b.
To publish books,
and
monographs,
periodicals and papers;
To co-operate with other Institutions and Organisations
and contribute knowledge at inter-discip 1inary level.
R.L. KAPUR
THE DECENTRALIZATION
AN EXPERIMENT OF BANWASI SEVA ASHRAM IN DECENTRAL I ZfiD
PRIMARY HEALTH CARE
L- Z-'H
We are Living in an era, in which the achievements of man in the
field of Science and technology, have revealed a lot of wonders, given
him power over the nature, offered him a number of Immries and brought
different human habitations in cleBEr contact. All this did contribute
to happiness of the man but, at the same time it has also created
problems.
One of the main features of the era is the production of consumer
goods on a mass scale, on the basis of the energy (other than human)
■ of..the diesel - Petrol, Electricity, Atom, etc. The natural outcome of
the policy of mass production with profit motive, has been centraliza
tion of the authority regarding accesses to nature’s resources and
the licencing, the royalties and the taxations on the raw material and
the produce.
These industrial production units save their expenditure on anti
pollution measures, find out ways and means to keep labourers in a
temporary status to avoid the responsibility of their welfare, t
to evade taxes, take every opportunity to raising the prices. These
units are not oriented to meeting the needs of the community. Rather
they contribute to the ihcrease in the needs and the cost of living.
This industrilization has slowly extended its field and now-even-farmirg
and forestry is also planned and operated on the principle^of mass
production and treding for the benefit of profit in rupees and in
foreign currency. This Commercialization of the life has contributed
to disruption of local and regional self-sufficiency in basic needs
of life, it has also caused unemployment among the rural artizens and
initiated their migration to the cities. The "fev/nships and cities
need these people for the building construction works and other
miscellaneous jobs. But, they do not wish to provide space and
facilities to them. Thus two worlds, the urban and the slum are seen
to exist side by side in the citieso
The present day educational system does not impart skill
and
^4
2
confidence to student^/stend on tils own. It elso does not give the
student any abilities to Critically study, analyse or understand the
present situation. It neither gives him information on his constitutional
rights, the laws relevant to his living nor the information on the
organisations and services promoted by the Government or available
otherwisezfor employment opportunities or availing the welfare facility•
j.t contributes nothings to the building of sound personality and a
sense of social responsibility. What it contributes to is, the Devclopment of aspirations for a lighter work, desk worK, managerial or
consulative work
different kinds of jobs with better remuneration and
better prev—leges. ’There is nothing wrong in aspiring for better living.
Only thing is, it should not be at the cost of some others, ilhat is
understood is that there is a limit to the possibility of jobs of that
nature and the increase in the remuneration. A society which promotes
such aspirations can not always provide appropriate opportunities on the
same scale. It is not feasible also. It only leads to unhealthy competi
tion, correuption, inflation and breaking down of the economy and social
order.
The National Governments are owning the total responsibility of the
welfare of their people. There is nothing wrong in owning such a
responsibility by the well meaning elected representative body. What
is wrong about it is - that it does not envisage any role for the people
to share in the responsibility. Actually, the nature of the care and
protection has to be such that it simultaneously promotes among people,
an understanding of the situation,develops appropriate skills and
abilities to face the situation and manage their basic needs of life
on a regional self-sufficiency basis. This has not hapoened. it was
not planned, ihe result is, that there is an increase in the dependence
or the people on the Government and also there is an increase in the
people's demands. The situation has reached a
stage where it seems
beyond the means and capacity o£ the Governments to £„l£il the responsdbility it owns.
illness In times of need. The health becomes feasible if the life sto
is favourable
to health( nneds of the body and mini) and toe
3
living habits are oriented to-^to building-up of health and its
protection. The situation to-day is adverse.every wherefore so in
rural areas and worse in tribal areas. As one moves away from city
one also notices the lack of proper medical facility♦
To-day . the whole thing has become such a
P uiat
a m^-u
mix-up
that rne
the common
fealing is, that it is difficult to manage living with honesty and
sincerely, a sense of social responsibility, or a spirit of service
ano sacrifice. A break-through out*the
out^the situation is an urgent need
of the time. The important aspect
aspect of
of it
it is,
is. that it has to be construG TLX v e •
Gandhijee talked of a Constructive Programme in the context of an
alternative social order to the present
one of industrialisation and
centralization. His Constructive Programme
offered common people, a
chance to participate in the action for a ,
change-the constructive
revoluation. The programmes offered
were such that an average and
a genious both could participate,
could join heads and experience and
visualize the relief it brought to the
troubled people and the
This contributed to the development o- a
7“*“'
co™it7a
hope
and
confidence
future. His phllosouhv and
an conf^dence In better
pnixosophy and programmes, inspired
inspired some
a.
devote all their 11 -Fo
"
e
Actuals to
an their life to practice, develop and extend
Programmes. Ban was! Seva Ashram is
u
idSa
the
one such
experiment inl-t-i
4
the year 1954 by the followers of Gandhi
ifL
lnitiated in
dec“
The health project was initiated in
40
1968. it operates in the
tribal area of the Sonbhadra
1 (old Mirzapur) district of Uttar Pradesh
and covers the villages in 4
community development blocks, in 1968
the area was 0uch backward, ,
and the people faced
a continuing challange
of poverty, deprevistion and
exploitation. The
community had traditions
of barter, but was finding it difficuit
Many families were already in debts of to produce enough for sustainance
money lenders and in many
instances the land and the
man had become bonded
for generations. Though
there were traditional lnatglnous
practitioners and almost every family
used house-hold remedies,
these did not seem to
help them cure the
illnesses, it did provids
them relief. Neither the
health and medical
4
care nor the other welfare activity of the Government was functional. Sore
was the status of the community development blocks, only the Police
and Revenue functionaries were active and alcohal distillation and its
illegal and legal sale points helped people to earn as well as get drunks
and indebted. In a way, the area was most appropriate for an integrated
development pfogramme^. The whole community needed a helping hand on
various fronts.to come out of the situation.
The
compulsion of the situation/was to/orient Bonese If to
the problems fased by the people and find solutions those which could
be implemented banking upon the skill potential of the people before
planning on extension activity. This meant having a continuing process
of study, experimentation,evaluation, project formulation, extension of
successful experiments and reformulation of action plans from time to tire
as per the need, it also meant diverting energies for arranging relief
in situations of drought every 3rd-year and famine once in 10-years,
Industrial invasion, problem of land rights and reserve forest etc.
All this had to be managed with the help of the local people, as
recruiting staff was out of question. Job seekers had no attraction
for the place and the remunaration also could hot be attractive o The
"//tx
/4> r
t\C
few motivated persons/'from outside was the only resource for implementa
tion of experiment. In a way, this proved to be a boon in disguise because
on the one-hand technology and methodology had to be oriented to local
skill potential and minimum dependance of markets, organising training
in new skills,upgrading the existing ones and on the other hand it also
meant participation of the people in their own development the socio
economic and of the personality.
Though, people were in need of health and Medical care, it did not
prompt them to immediately believe in the new medical service offered rThey took their own time to test the relief offered and believe that
the service offered was of some standered. They also had an apprehension,
that the motive behind this noble work is either to force family planning
or it was just to complete the formality for earning one's own better
livelihood, similarly they had a feeling that they belonged to a different
eWorld and the health advice given had no relevance to their situations.
Soon, it became clear, that their feeling also was a part of reality.
Actually, after studying their living conditions and the decree of poverty
5 -
it became clear that under-nutrition and almost absence of fat in diet
and not the protein and -Vitamin deficiency, were the main nutrition
problems. It influenced the growth and delayed the puberty and caused
early appearance of cataract and aging. It contributed to chronicity of
even ordinary illness''and infections. Under such conditions, it was a
wonder to see clear cases of chronic pulemonary tuberculosis with
history of haemoptysis live an active life to old age. The underfed
also could do hard work to earn livelihood. Endemic Malaria manifested
more as anaemia and only at times as high fever.^When the rapport was
built.the people narrated two incidents relating/the health care. One
was the campaign by a fairy-well-built Government doctor who moved in
bullock-cart in the area and treated cases of Yaws with injections which
also cured as per their version •Sujak* and ’Garanti• (venereal infections)
.he other was the anti-Malaria drive-the D.D.T spray. They had all
admiration for the -doctor and credited D.D.T spray with Malaria control.
They accepted conjunctivities and night blindness as an yearly happening
of a transitory nature. It was true. Because Kerato-malacia was a rarity.
Their knowledge about the nursing care and quarenteening of pox cases
appeared sound. They did not defecate in the fields from where they picked
up leafy vegetables. Though they had not read medical books, they could
narrate well the clinical features and the course of the common seasonal
ailments and describe the complications that would develop which showed
their capacity of self-learning. At the same time, because being out-off
from outside world they were ignorant of the advances in medical treatment
and refused to take cases to hospitals in neibouring townships.
As the roads and communication facility was non-existent, the people
had to find a companion to walk through the forest to reach the clinic
and in case the patient was serious they had to wait till a few others
could carry him on cot or chair. Going to clinic also meant-making
arrangements for the care of the children, the animals and the house. All
these circumstances and the poverty conditioned their chances of receiving
treatment in time and till they recovered fully. The absence of hospital
facility and the constraints in the life of the patients was an excuse for
new learningrmore dependence on clinical observations and manggement of
home nursing. Similarly, out-breaks of conjuctivites, scabies, Gastroenrritis etc. gave a chance to study the environment and living habits
in more detail. The whole situation was a difficult one from the point
6
view of scheduled implementation of any pre-planned standard health
care programme. At the same time, the situation was most favourable
for the trial of a decentralized primary health care.
Banwasi Seva Ashram for achieving its objective of healthy community
adopted a strategy of decentralization of responsibilities. The main
reasons for doing so were:
(1) To achieve the objective of healthy community, health care
services have to be within the reach of the community and
within its means.
(2) Health care for each village on the basis of the infrastructure
of paid workers is not feasible. It is beyond the means of a
voluntary agency to sustain such a structure. It is also beyond
the means of the Government.
(3) There is also no likelihood of qualified doctors moving into
villages and even if they did, they were bound to exploit people
rather than serve them.
(4) If the programme is implemented by involving and arranging
proper training of local personnel, there is a fair chance of
the continuity in the service created.
(5) The involvement of the local persons will also help proper
orientation of the plans and programmes as compared to the ones
that are based on the attitude, information and skills of
perons belonging to an alien culture and social situation.
After a preliminary rapport building effort, the first health and
first-»aid training course was organised in February, 1989, for the
literacy teachers and others.lt was felt>that even though they were
to treat the ordinary cases it is essential to orient them to clinical
history taking and examination. Hence, weekly clases were organized for
those persons who opted ror voluntary village health friendd service.
The experience of the experiment in terms of its feasibility, quality
and utility was proved within first three years. The only limitation
was that it could not be extended to the desired number of villages
because of lack of communications. The potential workers could not
attend the follow-up classes. It was felt that there will have to be a
few full time workers, who would keep a continuity in the contact
established with potential village health friends
- 7 -
Though a decision was taken to have an intermediary cadre, it
took 4-5 years to motivate the people to join a residential course
of 6 months duration. To get over this difficulty, two decisions were
taken. The one decision was to organize a programme of health meetings for
men and women every winter to communicate to them prevention of certain
selected ailments and also few tested household remedies. Special health
courses were also organized for 3-5 days at the development centres for
the village leaders and potential health friends once a year. The other
decision was to involve the staff, the persons in charge of village
sub-centres of Ashram, looking after the implementation/integrated
development programme.
-These persons had already attended the health education courses and
R.'hew a bit about the primary medical care. These^people were specifically
instructed in treatment of cough and cold,malaria,diaroheQ,dysentry
and vitam^in deficiencies. This helped them as well as the villagers.
Later, after a period of 3-4 years it became possible to inspire assistant
worker?,one each from 6 centres to take up the training of gramin doctor
(a full time health VToxkor) . Here again, the experience has been encoura
ging. The only tiling which was a little disturbing was the need to
interrupt the course when farming opprations and household responsibili
ties demanded their presence at home. Within a period of two years,
these trained persons were sent to plains in the north of the district
to provide medical relief to the people of the flood affected villages.
The services of these village functioneries were much appreciated by
the people in comparison to the practitioners of those villages.
The director of the project had to manage atl=alone-the clinic the
extension work, and the training of clinic assistants and associates for
field work. Thought this added to the strain of difficult living condition
and the work load, it also was educative.starting from simple jobs the
skills were gradually upgraded as per the potential and the reliability
of the Individual.The persons associated with the clinical work were
told about the basics of anatomy physiology,pathology,pharmocology, the
writing of case history, the clinical examination and the assessment of
the seriousness of the illness. The other point that was impressed upon
was not to try to treat serious cases and the conditions that they have
no knowledge about, but to refer cases in time to proper institutes.
8 -
This approach has paid. The clinic is now managed by a locally trained
person to the satisfection of the director of the project(who now
plays the role of a consultant) and the people. The people from long
distances are attending the clinic.
Thus/ the rural health service structure which has evolved over
the past years has four links:★
The first link is the voluntary village health friend
*
The second link is the full-time paid worker/ the Cramin-dpctor
giving primary health and medical care to a group of villages.
*
The third link is the Ashram clinic / the staff of which is also
responsible for the training of the functionaries/study and
evaluation and co-ordination of the work of Gramin Doctor.
*
The fourth link is the referred Hospitals in the townships and
at the district head-quarters.
As the people of the area have shared in the responsibility of
implementing the primary health care programmes, they have also shared
in the expenditure incurred by way of contribution towards the cost of
the medicine. As a rule,every patient is to pay the bill for the treatmert
received. The bill does not includfi. the cost of establishment and the
salaries of the staff. The treatment charges are kept to minimum by
avoiding unnecessary injections and other sofisticated medicines. As a
rule, every patient is to pay the full amount,if not possible^he
'
pay the remaining later. No needy patient is refused for want of money.
Rather, if felt necessary, food and other help is arranged. When ever
possible, an effort is made to rehabilitate the deserving patient.
While being generous, there is always a need to be vigilant about
recoveries from the clever patients, who proudly pay heavy charges to
private lay practioners.
The staff of the proj ect also contributes to funding in a-*'.indirect
way. The whole staff works,.on the basis of an honorarium and lives a
simple life in hormony of the surroundings. Same is true about the get up
of the clinic.
The study of the indeginous medicines and the*/household^use
in primary medical care has helped in many ways. In some cases it has
replaced the marketed products/ in others instances/ specially the
<r
9 digestive,respiratory, heat exposure and skin cases, these'have
proved to be a boon. The use of these simple remedies ha«* not only
contributed to the recovery the patient to normal but have also
contributed to reduction in the charges for the treatment.
The formal structure of primary health care gets the support
of the socio-economic development activity of the Ashram.These
activities help to motivate the people to receive and use the health
information. They also imporve the living conditions in favour of
health, thus increasing the feasibility of healthy living.
The project has been in operation for more than 20 years. The idea
of decentralized primary health care have proved its worH>. But, at the
same timey it has not been possible to extend it to the whole area,
mainly because of the difficulties in identifying and training the
personnel required. The programmes could reach'about one third of the
villages of the area of operation of Banwasi Seva Ashram.
A regular evaluation of the various aspects of the programmer was
undertaken from time to time. In the first evaluation done at the end
of second year(1970), it was observed that people felt happy about
the health information extended and said that it maX'kes life better.
The second evaluation made in 1974,looked into the acceptance of the
small family norm and family planning practice. It was seen that an
educational approach to family planning extension was effective in
introducing it, not only as a means of limiting the size of the family
but as a way of life. The third evaluation study done in 1979, looked
into the achievements of a comprehensive development programme,
including health and medical care, in a sample drawn from the
beneficiaries of the economic programme. The findings of this survey
are; 1) more people had adequate food,clothing and boarding, 2) functional
educatiobal programme has succeeded to the extent of increasing literacy
from 14% to 27%, 3) the percentage of families that owed to money
lenders decreased from 42*60% during 1974-75 to 23.47% during 1970-79.
The latest evaluation has been conducted in the year 1987. The sample
for this study has been based on random sampling of the villages and
that of families in sample vilIagos of the area of operation of
Banwasi Seva Ashram. This study evaluated the overall impact of
problem oriented action plans like mobilization of bank finance, land
I
10
and irrigation development, tree plantations, obtaining land o^ership
rights etc. The other component of this study wan the reassessment of the
random sample of families, from the sample of 1979 study, on the points
elicited earlier. The information obtained from the-data of both these
samples la presented here:
TABLE NO, 1 ;
Benefits from health education activity in the sample families
of 1979 survey as expressed in the year 1979 and 1987:
Benefits
No. of
families in
1979.
1) personal cleanliness
Ill
48
6
92
50
90
113
107
9
108
97
127
70
91
74
107
107
110
2) compost making
3) Use of trench latrine
4) Safe drinking water
5) Right cooking methods
6) ^pi&.feg^us^ytrltlon
No# of families
in 1987
Muhua.
7) Improved child care
8) prevention of disease
9) Use of household remedies
Health benefit shows a satisfactory improvement on all points
except that related to the use of laterines. The availability of
sufficient and safe drinking water and nutrition supplements still seems
to be a problem for a significant number. This must have influenced the
possibility of getting benefitted from the information on the child-care
and prevention of illness.
In the 1987 survey - the respondents were asked to narrate their
nutrition information, in relation to the health of the ma-tfcer and
child , the seasonal special dietetic needs, and proper cooking and
the source of information. They were asked to give their opinion about
the seasonal prevalence of illness and their causative factors. The
questionaire also included questions on attitude and practice of family
planning# The objectiveJ v/as, (1) to assess the impact of nutrition
11
education, 2) to know about the common prevelant illnesses suffered
and have a comparison with the findings of the clinic,3) to know how
Such thought they have given to knowing the cause of illness and
its prevention and,4) to assess the attitudinal change in favour of
family planning.
It was observed that out of the total-1706 respondents had
r-eceived’■information on—diet 1066 had knowledge about nutrition of
the child, 990 new about the nutrition and care of the mother,520
possessed knowledge related to proper cooking and 435 knew about the
special seasonal food requirements. The major source of information
has been Ashram in general followed by elders in the family and friends
and then the published literature. What is seen to corroborate with th?
clinical experience is the lack of knowledges in the family about
proper feeding of the child. Only 20 respondents^ said that they
received information from the elders. Simiiar corroboration is seen
in the respondents opinion and the clinic records about the seasonal
prevalence of illness. The understanding of the people about seasonal
prevalence of illnesses and their causative factors as reflected in tie
the samples is as given below:
TABLE NO , 2
The opinion of the respondents about common illnesses, their
seasonal prevalence and their information on the causative factors:
Illness
Favoured
seasons.
CANSATIVE FACTORS
Rel evan t
answers
% of total
opinion.
’ T?he mo s' t impor t afo
factors emerged
% of relevant
opinion•
1) Malaria
Rainy-Winter
2) Gastro entreaties Summer
81
95
Di ar ro hi a,
Dys entry.
3) Fever
Mosquito - 63
Contamina- 39
ted food
and watcc.
Summer—Win ter
54
4) Cold & Cough
Winter
79
5) Eye Diseases
MosquitoExposure
to heat.
Exposure
to cold.
Summer
80
Exposure
to heat
& inf.
53
44
62
100
100
12 1
6) Pox
7) Skin diseases
0)
Tuberculosis
2
3
4
Slimmer
29
win ter
79
Whole year
77
Change in the
weather.
unhygienic
conditions.
Infections.
Infections
diseases•
75
69
31
70
The people have mentioned weather condition
causative factors in a fow instances, it can be 1 t0^ °f
untoward influence of weather condition<
nterPreted as the
to the infections. At the same time, it is aiT^5^ (SUCeptab±llty
c^saa constant effort is made
know-how on the findings and incorporate’it inX'i
patients given in the clinic in thA
regular health talks given. '
7 PreVentive
'
instructions to
terature produced and in the
The data on the r
family planning r*‘ *
attitudes and practice revealed
that out of 1206 respondents,
1170 have given
-i their opinion. Those
who said that family planning is
very essential were 366, those who
favoured it were 416 and those
not in favour
were 388. About two-third
respondents had a favourable c
attitude to ffamily planning. Absolute
silence on the
topic r observedL by one-third
-d of the total sample
(536 .respondents),
—
is also signified.
Out of the 782 who favoured
family planning 395
J had adopted it.
The method of choice
in 45% cases, vassetomy in 25%
was ffubectomy
cases, indigenous medicine
self-control in 12% snd other
in 15% cases,
contraceptives in 7% cases,
number 28.8% of the
acceptors had adopted family planning A significant
the child birth.
for spacing
The information on medical
care was elicited in
i.e. 1979 3^3 1937* The
both tlie surveys,
cange that has come over in the
attitudes
regarding treatment can be
seen in the sample of 1979
which was also
interrogated in 1987.
13 TABLE MO. 3
Medical services availed by the sample families of 1979> survey
in the year 1979 and 1987:
Services availed
in 1979
often some times
Charms & Amulets.
Indigenous medicine
Government Hospitals
Ashram’s health centres
Ashram’s clinic
private practioner
27
13
00
44
62
0
in 1987
often some
times.
6
15
13
102
88
0
51
67
02
07
34
0
15
65
23
14
44
12
It can be seen that now there is reduced faith in charms and
amulets, that the Government services have become available and that
the private practioners (TI-I-trained—persons) have started operating.
In the survey of 1987 which had a wider sample(served and not
,<30^ered by Ashram's primary health care), /information was sought on
the source of medical treatment for various common illnesses and
its beneficiary effect. The following picture has emerged:TABLE NO. 4
The source of medical treatment and its beneficiary effect as
expressed by the sample families of 1987 survey
Source of Medical treatment
Home remedies
Ashram’s medical centres
Government Hospitals,
other Doctors.
No. of persons
who availed.
1516
1067
1674
47
Mo. of persons
benefitted.
670
1040
1593
19
(44%)
(97%)
(95%)
(45%)
It is seen that in terms of obtaining relief the diagnosis
based treatment has been more effective than that based purely on
symptomatic relief.
On the whole, it can be said that Ashram’s efforts to promote
health have yielded results, it has contributed to increased awareness
and practice with regard to heal th"'living, family planning and medical
14
care of the diseased♦
The participation of the local community as a tunctionary of
primary health care has also been successful. Among the staff of 15
only three persons have had their training in regulaii teaching
institution^ the Director, a Homeopath and a mid-wife. The rest are
trained at Ashram. There are about 250 village health friends, who
have taken initiative in helping the villagers. An evaluation of the1.^
turnover was done on two occasions, once in the year 1974 and recently
in the year 1986. In 1986 survey a total of 46 health friends were
interviewed. Out of these
were working .for more than 5
years.
The findings have been encouraging with respect to their contribution
and the potential. But, at the same time it is observed that in the
early years, when the life was less complex and the contact was more
regular, their turnover and social contribution was better. Out of 46
health friends interviewed,38 were willing to give 5 to 10 days a year,
and 25 were willing to give one-day every 2 months for gaining more
knowledge about health and medical care. Twenty five were willing to use
literature as a source of information (11 health friends were just
literate and 18 were ui^to primary) • All- together, with some variation
health freieds were able to treat simple manifestations of about 15
common illnesses with home remedies. They were able to extend to
community the knowledge gained about clean living habits,safety of
drinking water, improved methods of cooking rice. Roti,green vegetables,
milk and the use of nutrition supplements like gingilly seed, edible
oil, Amla, milk, Mahua flower. Fifteen health friends out of 46
expressed their desire to gain more knowledge to improve the health
standard of the community. The feed bake obtained from the study is,
that there has to be a continuous effort to identify and train health
friends, as a few would be loosing interest in social work for various
reasons. This is actually true/about the training of personnel to work
A.
full-timeln the project. Three senior staff persons left the job, two
of them have started private practice. About 10 persons of the level
of Gramin Doctor also left the job. In early days, it was difficult to
find persons willing to undergo training, now many come not with the
idea ofl serving the community, but with the idea of easy ^earning for
remunerative private practice. Thus, even today very few get selected
for training and even in that sometimes either the trainee dropjout
or he needs to be discontinued. •>
(c>
.■•.t /c
i
• ■ t
C' i -
a
15
As regards the Illness pattern manifested in the records of /Ztc
clinic and the health centres. Malaria is the most common illness
(nearly 50% patients) then comes the upper respiratory infections
and vitamein deficiencies, followed by the gastro-intestinal distur
bances and then the protein calorio deficiency. These findings and
the opinion^ of the respondents in 87 about prevalent illnesses makes
it clear that the immunization programme/ has very little to offer
by way of prevention of morbidity and mortality.
The gramin doctors and doctors at the clinic feel, that the
illness pattern is showing changes with the change in living and
working conditions and change in living habits. This means,reorienta
tion of the contents of health education. There is also the problem
of treatment by the less-tramed private practitioners. The cases
get complicated because of their interventions in illnesses about
r/
which they know very little. The road accidents, and injury^cases^have
increased in certain groups of villages which are near to the industrial
projects. Thus, there is always a new food for thought.
The experience with regard/ to home remedies is encouraging.
It has made village health friend service more meaningful, its
incorporation in routine prescriptions has helped to reduce other
medication and helped recovery of the patient to normal health.
On the whole, one feels happy and satisfied while working with
the community and for the benefit of the community, in a way that
helps them improve upon their own abilities to resolve their problems.
★*^****
People's Perception of Health Care
By Kaipane Sharma
The question of health touches everyone.
It is a subject that no
one can ignore.
Yet the aspect from which health care is viewed
differs greatly amongst different classes of people and between
urban and rural dwellers.
A mirror of people's perception of health care is the media,
it
It plays a dual function in that
especially the print media,
their
views
and
complaints
provides an avenue for people to voice
in
about
the health care system and it also plays a role
i
ssues
.
determining people's perceptions towards hea1 th—re1ated
thereby
It does the latter by the choice of subjects it covers,
an
determining
an order
order of priorities which does not necessai ily
that
of the majority of readers.
coincide with
i eadei s,
From letters to the editor and other feedback from
at
one can
can deduce some of the health care issues that
interest
heal
th
least the
city dweller.
These range from personal
the
med
ical
questions,
which newspapers answer through columns by
o ver
practioners, to complaints about the public health system,
prescription and malpractice by private practioners and the sale
of adulterated and sub—standard drugs.
These
newspapers
readership?
devoted.
)
time,
At the same
issues are covered by the press,
sma
11
a
introduce subjects which would interest only
i-s
space
which an inordinate amount
of
yet to
In a country
for instance, the issue of euthanasia.
Take ,
is taken out
like India, where the choice whether to live or die
because of
of the hands of the vast majority of our people
nan-ex
istent
almost
lack
of
an
adequate
diet
and
the
poverty,
’
to end
whether
some
people
should
have
the
right
hea1th care ?
their own lives hardly qualifies as the burning health subject of
clippings
the day.
Yet, if you look through a file of newspaper
m i nor
and
be
amazed
at
the
number
of
major
on health, you will
items on this issue.
Another current media obsession, which is, peihaps, a little
Almost
justifiable than euthanasia, is the fitness
fad.
more
carry
every newspaper and magazine now considers it essential to
to
how
"Total Fitness", which includes tips on
a column on
th^
and
exercise and how much, what to eat and what to. avo i d
state of m i nd one should adopt to remain fit!
over
on
suff i c i ent
i nformat i on
□n
the other hand ,
banned
on
the
poor
quality
of
drugs,
prescription by doctors, on
to be
and harmful
drugs as well as useless ones that continue
There is sporadic .wri t ing
dispensed in India, is found wanting.
issues
but
journalists
engaged
in such exposes have
c* n these — — — — —■ —
1
often encountered difficulties from their own managements who are
anxious not to displease some of their important advertisers
who
just happen to be pharmaceutical companies.
Similarly,
although all newspapers undertake
sporadic
exercises
in assessing the state of public hospital s and health
fac i1i t ies, especially after a scandal or deaths through neglect,
not
enough attention is paid to private hospitals and nursing
homes.
While
the majority of the poor do frequent
the public
insti tut ions,
we overlook the fact that because people perceive
the
quality of health care in these institutions to
be
inadequate,
even poor people skimp and save to go
to private
nursing homes and clinics, little realising that the conditions
here are often worse than in the public facilities because of the
almost
total
absence of accountabi
Consequently
accountab i1ity.
the
problems that arise in these places are rarely publicised.
While there are occasional stories about malpractice
of
c e oorr
med i cat i on
wrong
medication
being prescribed,
inadequate
there
is
information given on patients' rights, on safe drugs,
especially
for children, on questions patients must ask their doctors.
From my personal experience as an editor, I know that when
we introduced a column called Medisense in Express Magazine,
in
which we attempted a kind of health education and
consiousnessraising, the response was very positive from the readers.
)
The problem editors face is the lack of specialised wr itens
in these issues.
One cannot always ask practising med ica1
doctors to write as this can be construed as free publicity for
the particular medical pr ac t i t i oner .
And unf or tunatel y
t here
are only a handful of journalists who have made health
their
bus iness
and endeavoured
to keep abreast of
the
latest
developments so that they can write with insight and authority on
the
subject,
The need for such specia1isation has become
increasingly
evident as the possibilities that new
techno log ies
and
medical discoveries open up for curing what was considered
incurable or for prolonging life.
Sim i lar ly j, information about occupational health hazards
is
now available from groups around the world who have specialised
in this issue.
We require people who will
investigate the
cond i t ions in this country, write about them, and inform and warn
people so
that those who are able to can avoid these hazards.
Here again a certain amount of specialisation is required.
Badly
researched articles written from half knowledge can either result
in unnecessary panic or a cover up of a potentially
dangerous
situation.
Only an informed journalist can sift
through
the
of
mountain
information and actually
draw
authoritative
cone 1usions.
A word on women's health.
Newspapers seem to have dec i ded
that
the only aspect of women's health worth mentioning is that
which
is connected
to the reproductory system,
Therefore
contraception,
pregnancy, sex-determination tests etc
form
the
2
I
bulk of the writing on women's health.
Although
A1 though one does not
doubt
that these do constitute the major
health
ma j o r
i ssues
women, they do not represent the complete picture.
confronting women,
women ?
Working
women,
for
instance, have a set of spec i a1
heal th
wh ich directly relate to the nature of
problems which
their
wo r k.
These are rarely addressed.
Also,
subjects such as the need for safe contraception
or
the post—operative problems women face due to lack of after care?
are also rarely investigated.
One finds routine
items about
abort ion deaths.
Yet no one seems to be asking
the o b v i ci us
ques t io n 3 namely that if women die after a routine operation like
an abortion;, then
1'
isn't there something seriously wrong with
our
health care system?
An
issue like sex-determination, on
ci n the other hand,
has
grabbed a great deal of media attention as also
infertility and
a
in-vitro fertilisation techniques and the test tube baby,
These
interest a relatively small, better-off minority of readers,
Yet
both English and regional language newspapers have devoted
a
considerable amount of attention to these subjects.
So m e of the coverage on sex-determination tests may have
contr i buted
to popularising the misuse of this technology..
For
i nstance 3
in Express Magazine, when I decided to
invite two
writers critical of sex-determination tests to describe
a new
technique that was being introduced in India,
although
their
perspec t i ve came through the article very clearly,
we rece i ved
c a 1 ]. s from distant places asking us the name and address of the
doctor who would perform such a test.
One wonders,
theretore,
whether
the press can play any role*in shaking the beliefs
that
people already have on these issues.
However , there have been some instances where the press has
played an exemplary role in informing the public on
hea 1 th
issues.
For
instance, the coverage of the proceedings of the
Lent in Commission set up to investigate the death of 14 peopl e in
J. J. Hospital in Bombay through adulterated glycerol,, was such
an example.
The Times of India and the Indian Express carr ied
cletai led daily reports on the proceeding s of the commission,
thereby serving an important public function.
Through
these
reports,
people
could
understand
the
system
of
drug
adm i n i s t r a t i on ,
the manner
in iwh i ch hospitals obtain
their
supplies,
how
the manufacture of adulterated o r sub-standard
drugs takes place and who
is responsidle f or such
gross
neg 1 igence-.
A possible indication that more people are now turning
away
fi om allopathy to
traditional and alternative system can
be
gauged from the increase in the number of columns
in various
newspapers on homeopathy and ayurveda. This could
indicate a
possible loss of confidence in western medicine caused
by the
increasing
incidence of over-prescription by allopathic doctors
which have adversely affected patients.
3
While for most ordinary people,
health care basically
revolves around the state of their own health, the press should
little
intervene at the
level of policy.
There
is precious
on
the
discussion on health policy, on budgetary allocations,
hea
1 th
desirability of decentralisation, and on laws relating to
1
aws
includ
ing
issues and how they can be made more .efficacious,
that
issues
that protect the rights of patients.. These are
at
should be accorded a much higher priority than they are
the
present and should engage people’s attention as much as
recent debate on media autonomy.
Unfortunately , this is an area
is
where the media’s perception of the importance of health care
sadly deficient and could do with some urgent medical attention.
J
4
I .
r
Peoples Perception of Health Care
Paper to be presented in Session III
on Thursday 20th 1990, in the Workshop
’Towards a Decentralised Health Care;
A fresh look at the National Health Policy
Dr Orn Prakash
Head, Division of Medicine,
$
♦
St Martha’s Hoopital,
Bangalore•
L ■
t
i
i
i
i
-
I
PEOPLE'S PERCEPTION OF HEALTH CARE
Human health is a complex entity.
and meanings.
It has several connotations
In this paper I make an attempt to view people's
Being a physician, it is necessarily
perception of health care.
impossible for me to view this subject from the layman's angle,
and what follows is rny own perception of what people at large think
and do as regards health.
The comments are applicable to urban
setting in contemporary India and perhaps apply to most large cities.
WHAT IS HEALTH ?
When asked thus, most people would answer, 'Freedom from illness';
a few ftould perhaps further qualify and add, 'Freedom from physical
and mental illness'. One can hazard a confident guess that most
people do not view health as a POSITIVE copcept.
Nor do most lay
people think of health as a holistic entity with physical, emotional,
sociocultural, ethical and spiritual dimentions.
Thus it follows
that mostly people perceive health as a restricted phenomenon, as
something that is appreciated only when some of it is lost,
perha.p.s
the remark attributed to an Eastern philosopher is apt in this
context.
When asked to define health, he stated, * Health is the
crown on a well man's head, which only an ill man can seel ' In
more serious terms, this is the bane of contemporary society which
K seems to take little interest in participating in health planning
and care.
WHEN 1)0 PEOPLE SEEK MEDICAL HELP ?
There are many variables which determine when a given 'Person*
becomes a 'Patient' and seeks medical attention*
important of these arc :
Nature and intensity of illness
Sociocultural aspects
Level
of anxiety
Situational factors
Awareness
Educa ti onal background
Coping ability
Stoicism etc.
Some of the more
_-.u^r: suim.-M' • <
xj; M’a
. ■ • 3..’■ V,;; ,-
/.
- 2
In other words, given the illness of the same nature and inten
sity, different patients seek help at different times,
put the under
lying dominant theme would be one of anxiety; anxiety about becoming
dysfunctional, disabled, dependent or dead.
Needless to say, the
inherent nature of the disease plays a major role.
In a majority of
cases, there appears to be a lag period from symptom formation to the
decision to seek medical opinion; this lag is again conditioned by
factors inherent in the human personality.
WHERE DO PECPLE SEEK MEDICAL CARE ?
Once the patient decides to seek help, he has many options,
Per-
haps the most readily available source of help would be the general
practitioner or at times the family physician.
Familiarity, geogra
phic proximity and convenient timing often make the G P the first
line of contact.
The G P is ideally situated to deliver initial health
care; he often knows the patient and his family well and established
rapport makes it easier.
However, for a variety of reasons, the role
of the GP is being eroded, an unfortunate development.
Often, a nearby nursing home or hospital serves many people as
the initial care provider; the advantage for the patients being the
availability of help at night when a GP may not bo readily available.
Previous contacts at nursing homes or community hospitals prompt
’people to use these frequently.
It is also seen that many a patient
referred by a GP for a particular purpose to a hospital often conti
nues to return to the latter, perhaps with a belief that the care
is better.
In recent times, consultants and even specialists in various
branches of medicine may be called upon to serve as initial care
givers.
Many patients ’bypass’ the GP or their family physician and
consult an internist.,for instance.
Often this is needless and tends
to strain the specialist and dilute his practice.
A more formal and
orderly system of referral and return would be welcome; but many people
seem to boliovo that no matter what they suffer from, they need the
•senior’ opinion.
This necessarily erodes the relationship with a GP
or family physician who would be otherwise taking care of most
problems.
'-irmr.—
ttawwnr
’ • ..Wilw. •
- 3 -
In more recent times, medical centres, both diagnostic as well
as treatment centres incorporating modern and state of the art techno
logy have started functioning in metropolitan cities.
These are
centres capable of offering complex procedures such as renal trans
plants and coronary surgery. They are essential for tertiary care
of patients who need care with methods developed at considerable
cost in more recent times. Needless to say, those centres are very
expensive and hence can cater only to a fraction of the society which
is affluent enough to afford them. It must be emphasised that while
these centres are needed, they are relevant only to small segents
of the large patient population.
A matter of concern has been that
uhese centres often provide so called Health Checkups in attractive
packages and attract people to avail of them.
While such screening
evaluations are good, there must be a proper followup by the primary
doctor who refers the patients for checkups. Perhaps one salutary
effect of these high-tech centres is that they make people more aware
of the need for periodic medical examinations. Yet one gets a strong
impression that most people do not have a clear concept as to what
a screening programme mearK and how to use it to advantage with the
aid of their personal doctors.
General piactitianers, consultants, nursing homes, community
’hospitals as well as teaching hospitals all servo the community in
terms of primary care. This is not the ideal situation as a lot
of the time of more senior professionals is taken up at the cost
of patient's time for more complex cases. This is essentially because
the people at large do not clearly understand the stratification of
levels of medical care.
.PHOPLE*S PERC.OTION
In theory it is accepted that the members of the coinnunlty
should take an active part in health matters, particularly in
aspects of preventive medicine. But in reality this is rarely ;seen.
Most people relate/ to health in a stance of individuality and can
rarely approach problems with a general stand. Partly this is beca
use most people think of medical care as curative one and not the
other aspects. .It is rather curious and pathetic that largo sections
•
W
- 4
of people take an intense and persistent interest in matters such
as politics, religion and territorial imperatives; yet when matters
of health are involved, it is difficult to find community partici
pation in an active and aggressive manner.
Even a cursory lock at
the history of medicine has clearly shown that the standards of
medical practice are dictated more by the demands of the public
Until this happens in our own
than by the plans of the profession.
context, dertain anomalies and major deficiencies in the existing
system will not be corrected.
OBJECTIVE KNpy/LEDGE ABOUT ILLNESS:
Optimal management of any illness demands that the patient
understands the essential nature of the disease as well as tho role
of the therapeutic measures advised.
This is all the more important
in chronic diseases,such as diabetes, hypertension, asthma etc. But
it is seen that most lay patients are not very keen to appreciate
tho need for educating themselves.
Compliance on the part of the
patient is largely a matter of the understanding of the nature of a
given illness and the implications of poor control of the illness.
We have a long way to go in this direction; mass media have made
some initial inroads in this regard but the Himalayan task is still
’ahead.
The reasons for poor patient education are multifacted and
form a rich field for future studies.
VjHAT DO. WE CONCLUDE?
Health of an individual is a complex concept and is not restri-
cted to the physical reelin.
Most people at large do not seem to
think of h-alth in preventive terms and are rather passive in this
context.
Lay people think of health in somatic terms and are gene
rally not very keen to acquire objective and scientific knowledge
about their diseases and the treatment modalities.
This leads to
poor compliance in disease management and followup.
Tho community
at large does not seem to be aggressively involved in health matters,
particularly as regards preventive and promotional aspects.
General
improvements in health care seems to demand an active participation
from the community with regard to both preventive as well as cura
tive care.
- 5 Future trends should appreciate these facts and ensure that
the lacunae are corrected to the extent possible. The experie
nces of developed countries are before us and the developing
countries can ill afford to repeat the errors of the past.
GUEST PARTICIPANTS
Prof. B.K. Chandrasekhar
4032, 28th Cross
17th Main, Banas hankari
560070
Banga1 ore
I I Stage
Mr. C. Narayana Swamy
Adhyaksha
Bangalore Rural Zilla Parishad
Old District Board Buildings
Kempegowda Road
Bangalore - 560009.
Ms. Nupur Basu
B/IV/29, NIMHANS Staff Quarters
Byrasandra
560011.
B a n g a 1 ore
Mr. Phi 11 pose Matthai
Secretary to Government
Rural Development & Panchayat Raj Dept.
Government of Karnataka
Room No.311, III Floor, 1 I I Phase
Multi-storeyed Building
Dr. B.R. Ambedkar Veedhi
Bangalore - 560001.
Dr. B.S.
B. S. Paresh Kumar
No. 27, Patalamma Temple Street
Basavanagudi
560004.
Bangalore
Dr. R. Srinivasa Murthy
Professor and Head
Department of Psychiatry
National Institute of Mental
Health and Neuro Sciences
Bangalore - 560029.
1
Prof. N. Mukunda
Chai rman
Division of Physical and
Mathematical Sciences
Indian Institute of Science
Bangalore - 560012.
Mr. S.T. Baskaran
Postmaster-General
Karnataka Circle
Bangalore - 560001.
Prof . J. Pasupathy
Centre for Theoretical Studies
1 n d i a n Institute of Science
Bangalore
560012.
Prof. D.P. Sen Gupta
Department of Electrical Engineering
Indian Institute of Science
Bangalore - 560012.
Prof. M. Gadgi1
Cha i rman
Centre for Ecological Sciences
Indian Institute of Science
Bangalore - 560012.
Dr. K. Jayanth Kumar
Assistant Professor
Department of community Medicine
M.S. Ramaiah Medical College
Golula Extension Post
Bangalore - 560054.
Mr. N.S. Narasimha Murthy
Assistant Professor in Statistics
Department of community Medicine
M.S. Ramaiah Medical College
Golula Extension Post
Bangalore - 560054.
2
Dr. M.K. Vasundhara
Professor & Head of Department of
Preventive &< Social
Medicine
Bangalore Medical Collge
Bangalore - 560002.
Dr. Sat i sh
Bangalore Medical College
Bangalore - 560002.
Dr. D.0. Gangadharaswamy
Bangalore Medical Collge
Bangalore - 560002.
Dr. S.M. Channabasavanna
Director
Professor of Psychiatry
National Institute of Mental Health
and Nouro Sciences
B a n g ai or©
560029.
Dr. Shekhar Seshadri
Assistant ProfessorDepartment of Psychiatry
National Institute of Mental Health
and Neuro Sciences
Bangalore
560029.
Dr. San jeev Jain
Assistant Professor
Department of Psychiatry
National Institute of Mental Health
and Neuro Sciences
Bangalore
560029.
Dr. Jayashri Ramakrishna
Head of the Department of
Health Education
National Institute of Mental Health
and Neuro Sciences
Bangalore - 560029.
3
Dr. Shreeram
Dept, of Psychiatry
National Institute of Mental Health
and Neuro Sciences
Bangalore
560029.
Dr. K. Shekar
National Institute of Mental Health
and Neuro Sciences
B a n g a 1 ore
560029.
Dr. C. Vldyasagar
19, 3rd Block
Sarjapur Road
Koramanga 1 a
Banga1 ore
560034.
Dr. S. Kalyanasundaram
34. ITI Colony
Sarakk i
J.P. Na gar
560078.
Bangalore
Prof. D.U. Sastry
14/239, East Kothapet
Madanapa11e
517 325
Andhra Pradesh
Dr. U ma
51/2, Lavelle Road
Bangalore - 560001.
Ms. Sr i1 a ta Ba 11i wa11 a
Mahila Samakhtya Karnataka
33422, 1st Floor, 6th Cross
13th Main Road. HAL I 1 nd Stage
Indiranagar, Bangalore - 560038.
4
Prof . V.S. Rama Rao
72/4. "PRAYAG"
V Main Road
Chamara jpet
Bangalore - 560018.
Prof. V. Benjimin
B c11ne Road
cooke Town
Bangalore
560005.
Mr. S.P. Tekur
804, Sri Nivas
16th Main. 19th cross
Banashankari II Stage
Bangalore
- 560070.
Mr. G. Gururaj
Dept, of Epidemiology
National institute of Mental Health
and Neuro Sciences. Hosur Road
Bangalore - 560029.
Ms. Vanaja Ramprasad
839, 23rd Main
J.P. Nagar I I Phase
Bangalore - 560078.
Dr. Gerry Pais
DEED for Development
through Education
Post Box No. 20
Hunsur - 571 105
Karnataka
Dr. K.V. SRIDHARAN
51/2. Lavelle Road
Bangalore - 560001.
Dr. Ramesh Kanbargi
Asst. Professor
Population Research Centre
Institute for Social and Economic Change
Nagarabhavi Post
Bangalore - 560072.
5
♦
LIST
OF NAMES OF EXPERTS
INVITED FOR THE WORKSHOP ENTITLED
"TOWARDS A DECENTRALISED HEALTH CARE:
A FRESH LOOK AT THE NATIONAL HEALTH POLICY
TO BE HELD FROM 20-23 SEPTEMBER,
1990
Dr. N.H. Ant i a
D 1 rector
The Foundation for Research
in Community Health
84-A, R.G. Thadanl Marg
400 018.
Wor1i, Bombay
Prof. Ashish Bose
Jawaharlal Nehru Fellow
Population Research Centre
Institute of Economic Growth
University Enclave
Delhi - 110007.
Dr. Abhay Bang
Director
Society for Education, Action
Research in Community Health
At P.O. Gadchiroli
442 605.
Maharashtra
Ms. Anisha Shah
Research Investigator
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore - 560012.
Dr. A.V.
A. V. Ba 1asubramanian
C/o PPST - Foundation
Patriotic and People Oriented Science
and Technology Foundation
No.6, Second Cross Street
Karpagam Gardens, Adiyar
Madras - 600 020.
1
Dr. V. Balaji
C/o PPST - Foundation
Patriotic and People Oriented Science
and Technology Foundation
No.6, Second Cross Street
Karpagam Gardens, Adiyar
Madras - 600 020.
Mr.
B.N. Betkerur
Secretary
Department of Health 2* Family Welfare
Government of Karnataka
Mu 1ti-storeyed Building
Bangalore - 560001.
Dr. Darshan Shankar
Academy of Development Sciences
Kashele, Karjat Taluk
Raigad District
Maharashtra - 410 201.
Dr. C.M. Franci s
Di rector
St. Martha’s Hospital
Nrupathunga Road
Bangalore - 560009.
Mr. H.Y. Ghor pade
Minister for Rural Development
and Panchayat Raj
Government of Karnataka
Vidhana Soudha
Bangalore - 560001.
Prof. M. Gadgi1
Cha i rman
Centre for Ecological Sciences
Indian Institute of Science
Bangalore - 560012.
2
Dr. Harcharan Singh
Adviser
Health and Family Welfare
Planning Commission
Government of India
Yojana Bhavan
Sansad Marg
New Delhi
110001.
Prof. L.C. Jain
Member
Planning Commission
Government of India
Yojana Bhavan
Sansad Marg
New De 1hi
110001.
Ms. Kalpana Sharma
Senior Assistant Editor
The Times of India
Dr. D.N. Road
Post Box 213
Bombay - 400 001.
Prof. R.L. Kapur
Deputy Director
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore - 560012.
Dr. S.K. Lal
Co-ordinator, CMS
National Academy of Medical Sc 1ences
Mahatma Gandhi Marg
Ansari N^gar
New Delhi - 110029.
Dr. Meera Chatterjee
E-6/14, Vasanth Vihar
New Delhi - 110057.
3
Dr. N.N. Mehrotra
Scientist
Doc. & Library Services Dlvn.
Central Drug Research Institute
Chattar Manzii, Post Box. 173
Lucknow - 226 001.
Ms. Han isha Gupte
C/o Dr. N.H. Antia
Director
The Foundation for Reseach
in Community Health
84-A, R.G. Thadani Marg
Wor1i, Bombay
400 018.
B) The Foundation for Research
in Community Health
62, Anand Park
Oundh, Pune
Dr. 0m Prakash
5/A, Kumarakrupa Road
High Grounds
Bangalore - 560001.
Dr. Prem Chandran John
Asian Community Health Action Network
61, Dr. Radhakrishnan Road
Madras - 600 004.
Prof. K. Ramachandran
Professor and Head
Department of Biostatistics
All India Institute of Medical Sciences
Ansari Nagar
New Delhi - 110029.
Dr. Ravi Duggal
C/o The Foundation for Research
in Community Health
84-A. R.G.
R. G. Thadani Marg
Worli, Bombay - 400 018.
4
Dr. Ravi Narayan
Community Health Cell
47/1. First Floor
S t. Mark’s Road
Bangalore - 560001.
Dr. M.N. Sr i ni vas
Chai rman
Board of Governors
Institute for Social and Economic Change
Nagarabhavi Post
Bangalore - 560072.
Mr. T.R. Satish Chandran
Di rector
Institute for Social and
Economic Change
Nagarabhavi Post
Bangalore - 560072.
Prof. A.V. Shanmugam
Indian Institute of Management
10 K.M. Bannerghatta Road
Bangalore - 560076.
Dr. H. Sudarshan
Hon. Secretary
Vivekananda Girijana Kalyana Kendra
(Vivekananda Tribal Welfare Centre)
B.R. Hi 1 Is P.O. 571 313
Via chamarajanagar
Mysore District
Karnataka
Dr. Thangappan
Kerala Sahitya Parishad
Tri vendrum
5
** »
Dr. (Mrs.) Thelma Narayan
Community Health Cell
47/1, First Floor
St. Mark’s Road
Banga1 ore - 560001.
Prof. R.M. Varma
No. 2, Laxmi Road
111 Cross
Shanthinagar
Banga1 ore
560025.
/U-«
i
6
0
I
"TOWARDS A DECENTRALISED HEALTH CARE:
A FRESH LOOK AT THE NATIONAL HEALTH POLICY
WORKSHOP
ORGANISED BY
THE NATIONAL INSTITUTE OF ADVANCED STUDIES
INDIAN INSTITUTE OF SCIENCE CAMPUS, BANGALORE
ON 20-23 SEPTEMBER, 1990
VENUE: RUSTUM CHOKSI HALL,
IISC CAMPUS
PROGRAMME
20 September,
Thursday
1990
09.00
9.30 A.M.
REGISTRATION
09.30
10.30 A.M.
SESSION I
INAUGURATION
Welcome and
Introductory
Remarks
Prof. R.L. Kapur
Deputy Director
National Institute
of Advanced Studies
Inaugural address: Dr. M.N. Srinivas
Chai rman
Board of Governors
Institute for Social
and Economic Change
Bangalore
Address by
10. 30
11.30 A.m:
Mr. M.Y. Ghor pade
Minister for Rural
Development and
Panchayat Raj
Information and
Publicity
Government of Karnataka
Reg i s trat ion (contd.)
Coffee
1
I
i
11.30
1.30 P.M.
SESSION II
Current Status of
India’s Hea1 th
Coord i nator: Prof .
R. H.
Speaker
Dr.
Varma
K. Ramachand ran
Discuss 1 on
1.30
2.30 P.M.
2.30 - 5.00 P.M.
(with tea break)
Lunch
SESSION III
People’s Perception of Health Care
Coordinator
Prof . Madhav Gadgil
Speakers
Dr.
Ms.
Ms.
Om Prakash
Kalpana Sharma
Manisha Gupte
D i scussi on
21 September,
Fr i day
09.00
1990
11.00 A.M.
SESSION IV
Decentralised Health Care in Karnataka
Coord i nator
Speakers
: Mr. B. N. Betkerur
Mr. T.R. Satish Chandran
Topic : Problems of
Decentrai isation
Ms. Anisha Shah
Topic : A report on Workshop:
Panchayat Raj and
Hea1th Care
Dr. C.M. Franc is
Topic : Role of Secondary &
Tertiary Hospitals in
a Decentralised set
up
Di scuss i on
2
11.00-11.30 A.M.
Coffee
11.30- 1.30 P. M.
SESSION V
Pluralistic Approach to Health Care
Coord inator
Speakers
Dr.
N.H.
Ant ia
: Prof. R.L. Kapur
Topic: Redefining Health
Dr. Darshan Shankar
Topic: Role of Ayurveda in
Decentralised Health
Care
Dr. A.V. Ba 1asubramanyan
Topic: Role of Folk Medicine
in Decentralised
Hea1 th Care
Dr . N.N. Mehrotra
Topi c: A Strategy for
Involvement of Local
Health Traditions in
Primary Health Care
Di scuss ion
1.30
2.30 P.M.
2.30 - 5.00 P.M.
(with tea break)
Lunch
SESSION VI
Some
Innovative Experiments in
Decentralised Health Care
Coordinator
Dr.
Speakers
Dr. H. Sudarshan
Dr. Abhay Bang
Dr. Thangappan
Prem Chandran John
Di scuss i on
7.00 P.M.
Pub 1ic
Lecture by
Topic:
3
Dr. Harcharan Singh
Adv i ser
Health and Family Welfare
Planning Commission
Government of India
My Vision of Health Care
in India
22 September, 1990
Saturday
09.00
11.00 A.M.
SESSION VI I
Mode 1s for Decentralised Health Care
Coord i nator:
Prof.
Speakers
Dr.
Dr.
Ashish Bose
N.H. Antia
Meera Chaterjee
Discuss ion
11.00
11.30 A.M.
Coffee
11.30
1.30 P.M.
SESSION VIII
Education for Hea1 th
Coord i nator
Dr.
Speakers
Dr. R.H. Varma
Dr. Rav i Narayan
S. K.
La 1
Di scuss i on
1.30
2.30 P.M.
2.30 - 5.00 P.M.
(including tea break)
Lunch
SESSION IX
Research Issues in Decentralised Hea1 th
Care
Coordinator
Speakers
Prof . R.L. Kapur
: Dr. (Mrs.) Thelma Narayan
Topic : Medical 1ssues
Dr. Ravi Duggal
Topic : Economic 1s sues
Prof. A.V. Shanmugam
Topi c : Managerial Issues
Di scuss i on
4
7.00 P.M.
Va1ed i ctory
Address by :
Topi c
23 September t
S unday
09.00
11.00
Prof. L.C. Jain
Member
Planning Commission
Government of India
Panchayat Raj and the
Welfare Programmes
1990
11.00 A.M.
11.30 A.M.
SESSION
X
Recommendations: Dr.
N.H.
Rapporteurs:
Anisha Shah
Meera Chatterjee
Coffee
5
Ms.
Dr .
Ant i a
Role of Secondary and Tertiary Care Hospitals
in a Decentralised set up
Dr* C.M« Francis
Whatever be the political system, hospitals (secondary
and tertiary) need great attention^ because they
1 • are the most visible part of the health care
system,
2. are centres of excellence (?),
3* have large budgets.
4* make use of a large number of personnel, exp.,
the highly trained professionals, and
5» are prestigious.
Health services at the secondary and tertiary levels are
typically organised as bureaucracies characterised by
1. division of labour based on specialisation, according
to jobs and tasks,
2. hierarchical structure of authority,
3. systems of? rules and procedures for employees and
the work to be performed; rules, procedures and
activities often become the goals,
1
4. selection based on qualifications and technical
competence, and
5. resistance to change.
1.1. Pyramidal structure
We have accepted a pyramidal structure as the model for providing
health care services.
Successive levels of care (?) are provided.
2
- 2 -
lhey are expected to meet effectively the needs of the people
with appropriate combinations of personnel and facilities at each
level*
has been defined exhaustively
•I*
including the one given at the Alma Ata conference.
For our purpose (organisati<jal; institutional),
it is care provided by the community, health
guides/workers, daia, multipurpose workers and
similar health care workers and care provided
by the Primary Health Centres, It is the first
line of health care services.
specialised (specialist) care.
provides
It is provided
by community health centres, subdivisional or
taluka hospitals, district hospitals, medical
college hospitals and specialised centres and
institutions •
The number of beds may vary from
the 30 bedded Community Health Centre Hospital
to 1030 beds or more.
The dividing line between the secondary
and tertiary levels is not clear cut.
Divisions
can be made on the basis of more specialised
care (subspecialities) or greater attention focussed
on the proolem by way of investigations, management
and research, utilising the advances in medical
science and technology.
Most of the hospitals,
irrespective of size, are secondary care institu
tions.
Among the tertiary care hospitals will be
many of the medical college hospitals, advanced
3
- 3 centres, and institutions dedicated for single
speciality care.
Many of them are urban, may be of
an All-India character or serve the entire stale.
They will not come under the Zilla Parishad.
Some
of them may be autonomous.
For our present purposes, we will club secondary and tertiary
care hospitals together, though some of the implications can be different,
administratively and politically.
2.
DecenteraHsation
There is no doubt that for more effective functioning of any
activity, decentralisation is necessary. The Alternative Strategy
for Health for All (ICSSR/iCMR-19Sl) had suggested that all the
integrated health services upto and inclusive of the District Health
Centre should be placed under the Panchyati Raj Institutions.
We believe that such decentralisation, is
essential and that the people should be placed in
effective charge of the health services at these
levels"•
In and by itself, the setting up of local bodies at two or more
There is
levels will not necessarily create a decentralised order.
need to develop -te dgvelsy democratic 'dgcentj^lisaJ^^ with local
self-reliance and sjlf-jregula^o^.
Decentralisation should enable
decision making power closer -to the level of action, with the full
realisation of responsibility and the necessary analysis of
information.
This particularly true about health care.
There is no doubt that people’s health must be in people’s hands.
Hut there are many factors wiiich may counter the situation.
Legislation by itself is not enough.
There is need for social
awareness and action arising therefrom.
4
-4 2*1. De centralisation and hospitals
With the people who have the authority and who are affected
by the activities being on the spot or closeby, better monitoring can
be expected of the work done by the staff and utilisation of the
facilities. There is likely to be greater
• T^e
community can monitor the extent to which their needs have been met,
tasks fulfilled and resources promised made available.
The needs of the people are likely to be met better,
whether they be in the quality of care provided, use of drugs or
procedures undertaken.
in our hospitals?
Can we expect a more rational use of drugs
Can we expect a more appropriate use of science
and technology to improve the health of the people, being aware of the
resources and the economic and social implications?
Can we get an
ethical answer to the question "who shall receive what health care?”
It depends on whether the people’s representatives are sensitive to
the issues, are knowledgeable and have the will to take decisions and
implement' them.
We have to evolve a system which will avoid conflicts
with respect to the relative authorities of the PancliayatiRaj leaders
and the Directorate of health services regarding supervision of the
duties of the district health officers and other staff.
We need not
worry very much about “serving two masters”, as long as they are not
opposed to each other.
I
2•1•1• Need for better appreciation of the roles
With Panchyati Raj and decentralisation, there is
need to appreciate the changes.
action.
Knowledge should precede
In fact, there should have been a process of
building up awareness:
5
- 5 -
i. On the part of the people’s representatives, an
awareness of the current concepts of health, as also
of the many programmes sponsored, financed and
administered by the Centre and the State.
It is not
that they should become proficient in health care.
Hut they must have sufficient knowledge and the
attitude to understand, when explained, why particular
activities are important.
They must also ue enabled
to understand the organisation and structure of the
health services.
They have to be given brief training
in the essential components of the health development
and the objectives of the hospital.
ii. On the part of the health professionals and the
personnel of the hospital, and. understanding of how
to interact with the peoples’ representatives in the
changed situation.
They must understand that doctors,
nurses, and other personnel are there to help the
people achieve and maintain health.
Alma Ata Declaration (1973) states:
”45. Health personnel form part of the
Community in which they live and work.
A continuing dialogue between' them and
the rest of the community is necessary
to harmonize views and activities relating
to primary heal tn care".
Such dialogue
is probably even more important
when dealing with the secondary and tertiary care hospitals.
A major problem is that the people’s representatives and
the health professionals use different "languages", leading to
misunderstanding.
There is need to come together in a few
"understanding" sessions®
6
- 6 Politicians often defer to medical opinion, especially if
the doctors are specialists with big images.
At the same time,
doctors may give in to pressures from politicians for a variety of
reasons.
It is necessary that the major objectives of health care
be always kept in view, to improve the quality of life.
Orientation programmes for members of the Zilla Farishad
and Mandal panchayats and the health professionals and personnel
are needed to avoid friction.
Suitable methods, including audio
visuals and literature, could be useful.
2.2. Some questions
With decentralisation, if improvement is to take place, the
people’s representatives will have to ask a number of questions: What
are the hospitals doing at present?
What should the hospitals be
doing? How can they be enabled to do so?
1. ±re the services rendered by the hospital coping with the needs
of the people? Are the services adequate?
An answer to this question can probably be given by
simple surveys of the patients referred to the hospital.
But
there may be patients not referred because people know that
the particular hospital does not have the facilities necessary
to .provide the kind of intervention required.
It will be
necessary to get information from the periphery.
2. Are the people utilising the services?
In our country, the quantitative utilisation of the large
majority of the hospitals is most often more than complete. There
are a few exceptions. Such hospitals are sickly and likely to
die soon.
. 7
- 7 -
3. Is there adequate quality of care?
Many hospitals fail to pass this test. Various
explanations are given. Main problems are a lack of commitment
and motivation on the part of the personnel at all levels.
Added to it are the lack of resources, es'p., financial.
4. Are the services provided by the hospital relevant to the
health problems of the people?
Are they able to deal with the
major health problems effectively?
A new orientation and a new way of managing hospitals
are needed to make the hospitals relevant to the urgent needs
of the people.
The hospitals must be re-oriented to increasingly
participate in comprehensive health care.
Can decentralisation help?
It must.
The people’s
representatives have the responsibility to make the services
relevant and adequate with good quality care and utilised fully
by the people.
2.3* Involvement of the people
Decentralisation must mean full involvement of people.
It is not only a question of transferring authority.
be responsibility.
There must
The failure of many of our schemes, like the
Community Development Blocks, has been because we are not willing
to shoulder responsibility.
We often tend to become part of the
problem rather than of the solution.
I was amazed, to read, in the report of the meeting held
by the National Institute of Advances Studies earlier that "Zilla
Parishada find it difficult to keep hospitals clean because of
above order by the Government on recruitment to group C and D staff” •
This is precisely the bureaucratic way of thinking and finding
8
- 8 excuses and scapegoats,
If there was true decentralisation
and democratisation, tae people coulo. have been uiobilised to keep
the hospitals clean. There has been too much dependency on State
Governments •
collaboration^
2.4.
It is a well-known fact that for promotion of health,
there is need for intersectoral collaboration.
The National Health
Policy states:
ii
it is necessary to secure the complete
integration oi all plans for health and human
development with the overall national socio-economic
development process, especially the more closely
health related sectors"
The Alma Ata conference declares: "Health for AL1
by the year 2000 cannot be achieved by the health
sector alone".
Specific linkages between health and other sectors have to oe
forged.
With decentralisation, greater integration can be expected.
The people's representatives at the district and local levels can help
in providing a net work between the various sector.
3* Referral system
One of the major objectives and functions of the secondary and
tertiary care hospitals is that they should
serve as Referral centres.
The Alma Ata Declaration (197G) says. "36.
..... Primary health care
activities in the community are supported by successive levels of
referral facilities".
Referral system ensures a more fair distribution
of health care facilities.
It helps to maintain a proper balance
between the nature of the health problems and the corresponding provision
of care required, with appropriate combination of health personnel and
facilities at each level.
9
i
- 9 The National Health Policy says:
”8.
For want of a well established referral system,
those seeking curative care have the tendency
to visit various specialists centres, thus
further contriouting to congestions, duplication
of efforts and consequential waste of resources.
8.(2) The success of decentralised primary health
care system would depend vitally on the organised
building up of individual self-reliance and
effective community participation; the provision
of organised, back-up support of the secondary
and tertiary levels of the health care services,
providing adequate logistical and teclinical
assistance.
8.(4) The decentralisation of services would require
the establishment of a well worked out referral
system to provide adequate expertise of the various
levels of the organisational set-up nearest to
tlie community” •
What is a ’’well worked out” referral system?
what level?
When?
Who can refer to
How?
Can the patient, family, community (leaders) refer straightaway
to the secondary or tertiary care service, bypassing the primary care
service, to avoid delay, if they considered that tertiary care is necessary?
Can the village health worker refer to the secondary and tertiary care
facility bypassing the primary health centre?
Can a private practitioner
(belonging to any system of Medicine) refer a patient to the secondary/
tertiary level?
i
10
- 10 Will, it be a two-way process?
WiJl there be a ref err al
back from the secondary and tertiary level hospitals to tho person who
referred, once the immediate requirements are met, for follow-up and
further management?
What all records will be sent to the person referring?
Will priority attention be paid by the specialist at the
hospital to the referred patient?
Will there be adequate transport facilities?
Can the referral process be such that specialists will visit
the primary health centres and other less specialised areas?
There are
many advantages:
(l) The specialist gets the opportunity to observe the
service conditions and constraints under which the
generalist functions.
7
(2) The specialist can guide and educate (continuing
education) the generalist to manage the patient with the
available resources and facilities.
(3) There is mutual interaction; rapport can be built up.
The A.l. Jain Committee had recommended
(i) regionalisation of specialist services witn adequate
laboratory and diagnostic facilities,
(iijj development of district hospitals into full fledged
referral hospitals to overcome the deficiency in the
numoer of teaching hospitals.
(iii) flexibility in referring patients to suit the
conditions of the patients, and
(iv) mobile teams of specialists to visit subdivisional
hospitals and primary health centres at regular
intervals.
11
11
The Governments had passed orders asking the specialists
in Medical College Hospitals to visit the District Hospitals and the
Specialists in District Hospitals to visit ind advise the doctors in
the taluka hospitals.
The experiment was a failure.
The idea of making the district hospital the apex body in
general health (medical) care had been advocated earlier.
Jr. A.
Lakshmanaswamy Mudaliar. had suggested that every district hospital be
upgraded to make it a teaching hospital for fifty medical students.
The Bhore Committee had suggested the three million (district) health
plan with the 3-tier referral system.
4.
Soyemnwi^ and, npn-government^ hftgpj.igjjs
Our health care systegi is characterized by a mix of public (central, stat^
local) and private.(no-profit and for-profit) hospitals.
significant numbers of
There are
hospitals and hospital beds ib the private sector.
These were mostly voluntary, no-profit hospitals with a sprinkling of
private individual entrepreneurs, which were mostly in the nature of
nursing nomes.
While the no—profit hospitals were spread out in urban and
rural areas, the for-profit nursing homes were in the urban areas.
a few co-operatives.
Recently, there has been a growth of corporate
hospitals; these are mostly in the cities.
part in the
There are
They probably would play little
decentralization under Panchayati Raj •
In a decentralised situation, it is important to take note of the
presence of the private hospitals, in the rural areas.
This is emphasized
in the National Health Policy: n 5>..* adequately utilizing the services
being rendered by private voluntary organisations active in the Health
Sector11 •
The policy further states: n5(l)*
There are a large number of
private, voluntary, organisations active in the health field, all over the
country.
Their services and support would require to be utilized and
.. 12 ..
.. 12 ..
inLermeshed with the governmental efforts, in an integrated manner”.
i
Hospitals and hospital beds (1936)
Beds
Hospitals
Governmental
4,093
3,94,600
Non Governmental
3,331
1,41,100
7,474
5,35,700
There has to be complimentarity between the public and private
hospitals.
The activities of the two sectors or groups must fall in
line with the general objectives of health care in the country.
need not be^’
They
and should, not be, the same as regards the detailed
and specific objectives.
One of the inportant advantages of the private
sector in health care is that these hospitals and health care facilities
can experiment.
They can afford to take risks th a greater measure than
any Governmental institution.
They can be innovative.
The successful
innovative programmes soon influence the remodelling of the health policy.
The presence of governmental and non—governmental hospitals also
provide a choice for the consumer.
It also helps in reducing the financial
strain on the government.
All hospitals, governmental and non-governmental, should avoid any form of
rivalry.
Eacn must be supportive of the other, so that together the
heal.th needs of the people are met.
Networking of the hospitals in a region
will be useful for exchanging information and providing cohesion and mutual
supjort for action.
If the voluntary non-governmental hospitals are to playa greater
role in health care, they must be encouraged.
On the contrary, there is
a feeling among the hospialsin the voluntary sector that they are being harassed
by certain rigid, and sometime erroneous interpretation of rules and
regulations^with understanding can help.
Whether Zilla Parishad will
be able to do anything susbstantial in this regard has to be s en.
.. 13 .o
fi
!
13 ..
At present, the voluntary hospitals do not get any subsidy.
It would be
worthwhile to help those hospitals as are non-profit-oriented and willing to
provide free and concessional care to the poor and needy.
Many of such hospitals
are charitable institutions, providing good quality care at low cost.
There are
many examples of countries with a mixed system
pr oyi di ng subsidies.
One. such is the New Zealand System with its area
(district) boards. The Hospitals and Charitable Institutions Act provides
for patient subsidy to private hospitals, equal to the amount spent
for patient-day in the public hospitals.
The Zilla Par is hads (or Mandal Panchayats) must emphasize the thrust
areas in health care. The support to the voluntary hospitals must be such
that these hospitals are supportive of primary health care.
Emphasis
must be placed on such activities as promotion of health, prevention of
disease, rehabilitation and, in the curative services, on maternal and child
care services, mental health and infectious diseases.
qualityof life must , also receive encouragement.
states:
The efforts to improve
The National Health Policy
'’8 (7): With a view to reducing governmental expenditure
and fully utilising untapped resources, —— ---- - increased investment by
non-governmental agencies in establishing curative centres and by offering
i
organised logistical, financial and technical support to voluntary agencies
active in health field11.
The support should not be restricted to curative
care; it should be more for efforts which promote health and improve
quality of life.
CONCLUSION
Gandhiji visualised a Swaraj with generally sell-sul f idient and
self reliant village community.
The secondary and tertiary care hospitals
in the rural areas can help towards that self-reliance, with respect to health
care.
14 ..
i
.. 14 ..
There is oound to be tension between the persoihnel
and the Zilla Parishad and Mandal Panchayats.
of the hospitals
As long as such tensions are
healthy, they can be helpful for better functions and services.
The main
object ves must be the same.
There is need for flexibility.
States differ in their size, population,
level of literacy, stage of development, rainfall and opportunities for
employment.
So also districts vary.
Rural ana the backward Raichur.
provided by hospitals vary.
Compare
Villages vary.
the highly developed Bangalore
The size, type and services
The health care needs of the people vary.
Such flexibility is more easy with decentralisation.
Decentralisation can help in providing better service through the
secondary and tertiary •care hospitals, if the people and their leaders function
in a responsible manner, responsive to
(1) .
(2)
■die real needs for health of the people, and
the call for equity in the distribution of the health care services.
REDEFINING HEALTH
R.L. KAPUR*
World Health Organisation defines health as "a state of
complete physical,
mental and social well being,
not merely
the absence of disease or infirmity”.
I have a great respect
for those who have drafted this definiton because in one bold
step they extended the concerns of
health professions,
planners and educators,
beyond the confines of physical body
and bodily disease.
But,
there is a lot which
is
left
unsaid.
What
is
this condition which is more
than
the
absence of disease ? What does well-being mean ?
Is there a
way of identifying it ? Is there a method of inculcating it?
The definiton does not cover these aspects.
It hides
more
than it
reveals;
it promises more than
it delivers,
However, through
its
tantalising
its
tantalising
incompleteness,
it
introduces a creative doubt,
nudging us into
introspection,
As we continue working in the health
hea1 th centres,
delivering
health
care,
preparing health programmes
pro grammes and
holding
Workshops on health policy,
the definiton keeps reminding us
that the term health,
the way we use it, is but an euphemism
for sickness-care; we do not know what it really means.
It is my intention today to share with you a few ideas
and bits of concrete information, • which may bring about some
conceptual
clarity to the term health and indicate means
to
achieve it.
Let me starts with the description of the ’’systems view”
1 ifeA
of
According to this view,
life is organised at
var i ous
ascending levels,
each higher level having its
own
laws of operation,
none of which can be reduced to the
1 aws
of 1ower 1 eve 1.
At the lower most level,
we are all atoms
and molecules,
When the atoms and molecules combine to form
living ceils,
the laws which govern the living processes are
not just the sum total of the laws of chemical and physical
interaction.
Similarly, while organs are made of cells', the
way they function can never be fully understood, however we 11
we understand the cellular processes.
Again,
whi1e menta1
*M. B.B.S. , Ph.D. (Edin.), D.P.M.
F.R.C. Psych. (U.K.), F.A.Sc.
F I . A. M. S
Nat i ona1
Deputy Director
Institute of Advanced Studies
1
functions cannot exist without the Brain, these are more than
soci e t i es,
just the brain processes.
Proceeding higher up,
go
though constituted of people,
have their own laws which
societies of human beings
beyond the individuals.
Finally,
in fact,
the earth as a
with other living beings,
interact
organisation,
whole and these links have their own laws of
physico-chemical, •
These may be respectively referred to as,
Social and Ecological levels
of
Biological,
Psychological,
organ i sat i on.
constant
for
Each of
these
levels is a substratum
so
that
dynamic
balance,
activity geared towards keeping a
organisation.
1
eve
1
of
the functions pertinent to that
The body fluids keep up
continue to be discharged smoothly,
their pH and ionic concentration within a resonabie range, so
The heart keeps pumping at a
that the ceils
cel is keep alive,
supply
reach all
the
organs,
resonabie rate so that blood
interacting
to
The thought
processes and emotions keep
The
i nd i v i dua i s
individuals
interact
maintain a sense of
‘seif’,
continuously to keep a social cohesion and finally the 1 i v i n g
and non-living constituents of this Earth keep interacting to
the right mixture of
gases
maintain the right temperature,
so that this world in which we live does not fall
and so on;
All this keeps happening in the' face of forces which
apart.
The dynamic balance
is
wou 1 d trip the balance any moment.
kept not only at each level but between the different levels
and any inbalance at one level can disrupt the balance at the
other levels.
Some very interesting research studies have demonstrated
our
social
interactions and our
how our
daily habits,
personalities can influence our bodily health and also giving
some startling information about the mechanisms through which
influences operate.
the
in the United States
I n a study carried out
two States,
Nevada and Utah were compared
inhabi tants o f
that
11 was found
impact of daily habits.^
It
regard ing the
popu
1
at
i on
the
population
of
Utah
where
majority
of
amongst
smoke
and
keep
regular
do
not
drink
or
Mormons
who
is of
the dealth rate was 40% less than that in the
daily habits,
have
similar
These two populations
Nevada popu1 at 1 on.
med i ca1 faci1ities.
San
In a study carried out in the Alameda county near
o
.3
check
ing
up
foil
owed
up
af
ter
7000 people were
r ancisco,
found
i
t
was
medical
details.
After
several
years,
the i r
f ew
with
divorced,
widowed,
that those who were single,
to
and
relatives
as
well
as
those
who
didi
not
wish
friends
2-5
participate
in community organisations,
died at a rate
for
times greater than those with social ties,
controlling
all
other factors which could produce disease.
In another
thus
and
study^P Japanese who left Japan to settle in U.S.
in
the
excellent
social
support
system
lost the security of
.
2
Japan had a much higher rate of
heart disease than those who
did not migrate.
Harold Horowitz a Professor of Biophysics
reviewed the data’of the Hammond report on smoking and found
that the effect of divorce on the death rate was as much as
of smoking 20 + cigarettes per day.
In a Swedish study** of
old peoples’
homes,
those who took part
in community
activities had much better health than those who did not.
How does the social cohesion or its absence
influence
the death and illness rate ? There is evidence that working
through the brain and neural hormons it directly affects the
number
of
those while cells
in the blood which
are
responsible for body’s immunity.
There is now the whole new
out
discipline of psycho-neuro-immuno 1ogy which is bringing
i ncreases
very startling findings.
Social connectedness
bodily resistence.
Relaxation training increases bod i1y
bod i1y
resistence.
Taking part in selfless acts increases
cells
resistence - all this through increase in those white
which raise immunity.
Against this stress in life, need for
power and
feelings of hostility,
all decrease the number of
these immunity cells and hence bodily reistence.?
is
further evidence that not every one
falls
There
illness
under conditions of
s oc i a 1
victim
to bodily
There are the hardy personalities who actus 1 1y
d i srupti on.
A study conducted by Suzanne
thrivea under these conditions.
to
Kobasa shows
that those who have a sense of commitment
those who maintain a sense of
self,
to work and to family,
and
control
rather than show helplessness in face of stress
rather
those who see changing life situations as a challenge
i11nesses
in
than threat,
experience much lower level of
"Hardies"
their
lives as compared to those who do not.
transform problems
into opportunities and thereby do not
on
elicite the stress response in the first place, "Softies"
entertainment
the other hand distract themselves with drugs,
or inane social interaction.
"This kind of avoidance coping
can be useful
when the problem is
insoluble,
but when
something can be done to alter the stresor
and is not,
the
source of
stress remains and is more likely to mobilise a
chronic stress reaction with illness as a consequence."
Research
is also showing that the thoughts and be 1i ef s
of people about their own health do affect their
i11ness
rates.
People who
live
in hope suffer
less
i 1 1nesses.
People who have a sense of coherence about the wor1d,
who
feel their lines are meaningful have lower illness rates
and
finally people who believe they are healthy have an overa11
lower illness rates.
My
teacher N.C.
Surya who was the Director of National
Institute of Mental Health and Neuro Sciences,
when I was a
student,
describes an instance of a boy whom he saw on
the
railway platform with one leg amputated,
hopping along quite
cheerfully
testing his ability to go as far as possible, with
one
leg without any crutches.^ This is health and
it
can
3
which coexist with infirmity.
There are many examples
in
1i terature and amongst the people we know who
conti nued
to
use whatever resources they had at their disposal to do what
they were committed to,
to do that had to be done,
At this
point,
one becomes aware of the remark" but what about
average people - after all I am an ordinary human being,
I
cannot be expected to be a saint",
It is precisely because
you are a human being that you have a range of
poss i b1e
responses to a given situation.
situation,
An animal has a
1imi ted
response to its inner needs or outside pressure.
When hungry
it eats.
when threatened it fights or escapes to save his
life,
Human beings are able to respond to hunger by offering
food to someone else who needs it more.
In a war situation a
soldier
is able to keep his mouth shut when hit by a sniper
so that his screams do not make his friends vulnerable.
Human beings can choose to be hardy,
can choose to be
hopeful can choose to be confident, can choose to be healthy.
Choosing to be healthy brings health.
What is health
then?
Hea1 th amongst human beings is a conscious attempt to keep
the dynam i c balance at the physical,
mental,
social
and
soci a 1
Eco1o g i ca1
1 eve 1 .
It is not a static entity but an act i ve
process.
It is not well-being in the sense of alway wearing
a beatific smile:
it is accuracy and precision,
One may not
succeed
in the enterprise but this conscious effort
to
mantain the balance i s hea1 th i tse1f.
You may be
lucky enough to be born such a person
or
having the right kind of training in childhood,
If not you
need to practice these attitudes till verba 1
understand ing
becomes body
learning.
’’Abhayasa" is the key.
I f what
I
have said sounds familiar.
it is so,
because most r e1i g i ons
and spiritual
phi 1osophi es of the world have said the
same
many
times.
One would
like to believe
that
these
phi iosophies were concerned not* only about
the
ethical
behaviour but
in a wider sense,
with people’s hea1th as
a
who 1e.
Can we teach people to be healthy?
Coherent
societies
have r i tua1i sed
the ways of teaching people about hea1th:
through parent-child interaction,
through stories,
through
"Satsangs" and through intellectual d i scour ses.
One person who needs to be taught about health but
is
never taught is the doctor in our kind of medical education.
He is taught about disease but not about health.
I shall end
my talk with a beautiful anecdote of an unhealthy doctor
given by Surya.
"This
is a young
doctor sitting in his chair
in a
village dispensary .
There is the village woman with her
child who has high fever,
a running nose and rattling noises
in throat and chest.
There is no penci 11 in in the dispensary
and no means to get white-blood-counts.
The doctor is waving
his arms about and giving went to his anger.
"What to do! No
4
pencil 1 in!
No microscope!
The stupid Government sends me to
this place!
Take the child to the big hospital.
You are
asking me how to go.
Take a bus,
take a bullock cart,
do
something,
I am not here to tell you all that.
What !
you
are aksing me to give some medicine or other!
Do you think 1
am a quack to give you some coloured water or other?
I
am
Now don’t holler
M and so on.
not a cheat.
doctor
has
lost
ail
sense
of
personal
This
Simultaneously he has lost the
responsib i1i ty and dignity.
ears,
head,
heart and limbs.
His whole
use of his eyes,
paralysed and he can only talk^of things that are
brain is
the
He talks of
not there and of the things he cannot do.
of the microscope wh i ch he
pen i ci 1 1 i n which is not there,
t he
has
systematically ruined by neglect,
and of
himself
government about which he can do nothing.
If
he had some respect for himself and his body and its
he would have found time. interest and energy to
capac i ties,
note:
The child is having a high temperature, but in a child
not necessarily dreadful.
A little sponging could be done on
in
the
the spot.
The child is producing fearsome noises
throat and chest,
but is really quite alert.
Was she not
the
pulling at his stethoscope and showing interest around
place?
A little cleaning up of the nose and throat could at
least make the child look less frightful.
About pencil iin,
of whose absence he moans,
does he not remember the nuisance
of sensitivity tests and the fact that with all
precautions
some people do die of it and that is not a panacea,
and that
born
before penicillin came and before he himself
was
in the circumstances
chi 1dren were being taken care of
Could he not
to them by the best of physicians?
avai1ab1e
ammoniata
and
few
drams
of
a
mixture
with
quinine
give a
of
t he
cardomum,
which would improve the morale
syrup of
and
so
on.
the quality of her attention to the baby,
mother,
moan
If he was really so worried about the child and if he
he would have noted that just
about the things he cannot do,
then a visitor’s car was going to town and he could have
easily arranged for woman to go wo hospital.
5
I
I
REFERENCES
1. Capra
F
2.
Fnchs V.R.
3.
Bel 1oc
The Turning Point,
265,
• Who shall
Basic Books,
N. B.
and
1 i ve
Bres1ow L :
4.
1972.
Marmot H.G.
and Syme S.L.
Eped imio1o gy 104: 225-24,
Norowi tz
H :
Acculturation and coronary
B. B.
i so 1 at i on
Hammond
Report,
Hospi ta1
1975.
et
of
Amer ican Journa1 of
1976.
Hiding in the
Pract i ce 35-39,
Arnetz
phys i ca1
Prevent i ve lied icine,
heart disease in Japanese Americans,
5.
New York 1974
Relationship of
health status and health practices.
1, 409-21,
Bantam Books New York 1962
a1
:
An experimental study
elderly
metabolicc effects
peop1e:
of
socia1
Psychocudocrine
Psychosomat ic medicine,
and
45,
395-406,
Brain,
138-160,
1983.
Orns te i n
R
and Sobel D:
The
Hcaling
MacMillan London 1988.
8.
Kobasa
et a 1 :
Hardiness and Health:
study
J ourna1 of Personality and Social
168-77,
1982.
A prospective
Psycho 1o gy
42,
9.
Surya N.C.:
The Physiology of Aim, Her i tage June 1989
10.
Surya N.C.:
Personal autonomy and instrumental accuracy,
Psyychotherapeutic Process, N1MHANS, Bangalore
1978.
6
i
■?s: H
PEOPLE’S PERCEPTION OF HEALTH CARE: A RURAL EXPERIENCE
HANISHA GUPTE
"People’s
Perception
of
Health Care”
cannot
be
compressed
into a single,
homogenous category,
Different
s ect i ons
of
society will
necessarily
have
different
(sometimes,
conf 1i ct ing)
perceptions about the
their
i r bodies,
the i r concept of illness or well-being and it would be
safe
to asume
that the milieu
in which people
1 i ve
live
(social,
economic or cultural) or the collective experiences of
any
single group (urban.
rural.
men,
women and so forth) wou 1 d
generate differing seif perceptions,
ail of which wi 1 1
1 ead
to varying theories and ideas about i 1 1ness.
In
this
dea1
paper,
I
will
deal
specifically with the
perception of rural people.
including women.
women,
The exper ience
is
restricted to a few villages
in Pune district
in
Maharashtra State, yet the observations are not very strictly
area specific.
because the people represent three re 1i g i ons
(Hindu, Muslim, Neo Buddhist) as we 1 1 as different classes.
Illness
that reduces the productive potential
of
a
person is.
understandably, seen as important and a situation
that merits treatment.
A person suffering from tuberculosis
may not generally comply with the long, tedious and necessary
reg i men
of treatment,
yet if thQ. tuberculosis prevents him
or her from reaching the fields or a construction site,
a
doctor will be sought and temporary relief (through v i tarn i n
injections or cough mixtures) obtained.
Needless to say,
those
individuals who are considered more important within
the household will receive better treatment.
"better” often
"better"
meaning expensive.
Thus, women as a group are disadvantaged,
and especially so if they are childless or they happen to be
unwanted daughters.
Our study of the OPD of the local
PHC
show that
girl
children are the single most neglected
category where health services are concerned.
Also,
when a
male with TB for example becomes a burden on the family,
the
t i tude
entire at
attitude
towards him changes over a period of a
few
Even women members of the family may then grudge him
years.
his daily meals.
Old.
Old,
especially senile persons also
fall
from grace, should they require constant medical care.
1
One of
our studies showed that women suffer more from
chronic a i1ments
(backache,
white discharge,
weakness,
prolapses,
menta1 stress) as compared to men.
Since these
vague,
yet
persistent problems are more a reflection of
drudgery and poverty, poepie learn the hard way that they are
i ncurab i e.
Therefore,
in a vicious circle,
women will not
circle.
seek medical attention for their problems and will
theref ore
cont i nue to suffer ill health along with overwork.
Women are seen as a means to producing healthy sons,
bes ides being unpaid manual workers at home and ail
the i r
hea1 th
problems
are viewed from this
narrow
ang1e.
Unfortunate iy,
even the modern medical sciences hold
this
biased perception of woman.
Much worse, even a good maternal
health programme does not reach out to all Indian women,
The
rural
masses are largely left to fend for themselves,
in a
situation where safe deliveries are not always possible and
where detection of high risks in preganacy is unheard of.
This
total
lack of control over one’s body and
the
micro-environment in which one lives,
leads to the cr eat i on
of a wide plethora of superstitions and victim blaming myths.
For
example,
in my area,
it is widely believed that if
a
pregnant woman crosses the seeds of the papaya fruit, she and
her
progeny will become night blind.
So rampant
is night
blindness among pregnant women,
that it is considered a
natural part of being pregnant.
infact, people will say that
the
goddess "Paachvi" is worshipped on the fifth day after
delivery with the express request of curing the new mother of
her night blindness.
Similar are the practices of naming children
in a
derogatory fashion - such as Dagadu (stone) or Chindhi Crag).
This
f oo1 the evil spirits who may otherwise kill
is to fool
the
chi Id.
Also, 1 ack of creche facilities leads to doping
the
chi Id
with opium.
In
lullabies and
folklore,
opium
is
mentioned with 1 ove and pride.
Help!essness,
whether at the whims ica1 deci s ion of t he
uds
to make or break the farmer,
or at
the sight of
children dying,
leads to an atitude of i nert ia.
"God gives,
God takes" becomes the maxim (and the escape) to cope with
repeated tragedy.
Appeas i ng of
gods,
thus becomes a major
route
to
safeguard one ’ s hea1 th.
I 11hea1 th
is seen as an act of
puni shment.
Some gods
have been d i sp1 eased,
somewhere.
Part icu1 ar 1y potent are the local dieties,
They can protect,
yet they are short tempered and malevolent,
When we went to
the villages four years ago.
the people assured us that they
2
sought
western med i ca1
treatment for
every
conceivable
a i I m e n t.
Today we know differently.
There are around 20
exorcists
in our
village (population 3,000) and as many
trad i t i ona i hea1 ers.
The formidable consultants however are
the exorcists because they exercise great control
over
the
minds of t he 1 oca 1 peop1e.
I 1 1hea11 h
is also seen as a punishment for
"dev i ance”
from social mores,
Sexual indulgence leads to leprosy,
for
example.
Stigma towards one’s own body is also reflected
in
the perception of illness.
Those illnesses that secrete body
wastes
(tuberculosis or white discharge for example) or are
aes thet i ca11y
shattering
(leprosy)
are
espec i ally
s t i gmat i sed
and repulsed.
This
"clean"
""unclean"
or
is
phenomenon
is
extended to menstruation and childbirth as
well.
Some sections,
such as women are therefore "Unc1ean"
by nature,
and others,
the dalit castes are "unclean" by
birth.
People from the "clean" hemisphere can be defiled by
illness and then they are also thrust into the dark world of
stigma.
Since "scientific" reasons are not available,
the
degradation of humans to such horrible depths can only be due
to immoral or blasphemous acts.
Superst i t i ons
and
myths,
thus
serve
as
cop i ng
mechanisms.
Though these beliefs affect access to
hea1 th
care,
they are,
in fact,
the product and not the cause of
poverty or of ill hea1 th.
A wide variety of mental i11nesses
exist,
and
one of
the most common coping mechanisms
is
through being possessed by a wide range of
spirits and
demigods.
If one observes c1ose1y,
it becomes evident that
women, whether chi 1d1e s s, post menopausal or adolescent, form
the bulk
of
the persons afflicted by hysteria,
Nervous
breakdown
is
common among the unemployed youth,
so
is
depress i on.
society,
Rural
fortunately has great
tens i1e
strength and will readily accept a person who was
"mental"
(the expression commonly used to denote madness) ear tier.
Modern medicine,
unfortunately reinforces ail the anti
poor,
antiwoman biases that already exist in society.
The
concept
of
redeeming people through
improved hygiene or
persona 1
habits
is one example.
Assuming that people are
stupid
and that they are incapable of acting towards
their
own good is another.
The overemphasis of the public health services on family
pIanning
is a case reflecting this
"do god" bias,
where
against
the will
of the people,
this coercive programme
conti nues
to functions.
The already low access to hea1 th
care
is
further reduced,
because people feel uneasy about
pub 1i c health services.
A lack of
answerabi1ity to
the
peop1e.
both of public and private health care services also
3
discourages
people
from
seeking
medical
at tent ion.
Inf ormat i on
is doled out whimsically,
such as needing a
hys terecomy because there are ’’worms” in the uterus,
This
inscientific and malafide information by an MBBS doctor is in
no way
better than that of the local healer,
who cures a
person of
rickets and malnutrition by ” removing maggots’1
from the
spinal
column.
Similar is the case of
giving
unnecessary bottles of saline intravenously to ’’reduce heat”
or to ”purify blood”,
An irrational demand for
inject!ons
(created by doctors in the first place)
is another example
of cheating gullible popu1 at i ons.
A
cur i ous and sad mixture of underuse and overuse of
med i caI
care
emerges bcause of
this
confusing
seif
percept i on.
The urban high tech. modern medicine becomes the
unat ta i nab Ie
role model.
When people
do seek med i ca1
i n.tervent i on,
the
’’value” of
the
illness
i s direct 1y
propor t i ona1
to the number of injections or saline bottles,
or hospital admissions it required.
This pride is ev i dent,
not only among r i ch farmers,
but also among the poor working
class;
t he
latter get
into heavy debt for
irrational
treatments
of tuberculosis or of
diarrhoea.
Since people
have a low self perception and have lost faith in some of the
sound home or folk remedies for common ailments, they are not
totally convinced of simple treatments 1 ike ORT.
C1i ched as
it may sound,
the on 1 y way to
improve
peop1e’ s
percept ion about health care is to
improve
their
access
to
resources - whether it be
food,
clean water,
emp1oyment,
education or health
facilities,
Reducing
unnecessary drudgery and overwork would give some breathing
space to the poor, especially to women.
This wou 1 d create an
incentive for
people to question inequality,
discrimination
and stigma,
Abolition of superstitious fears or of their own
negat i ve
seif perception would be a happy product of such
progressive questioning.
4
regional review meeting on primary health care system
SlOWNT HELD AT BANGALORE : PRESENTATION BY
BRS°C SHARMA, ASSISTANT DIRECTOR GENERAL (HA)
J
I
»?
a
in Alma-Ata ’PHC
Following international conference
as a new approach, to
health care system’ came into existence in
different approach
1978 - a cpialnatively
health problem of the
-to deal with the
country.
This approach envisages a system
of health care based
the life pattern of the communities, involving local resources
on
■and. participation, with inter-sectoral coordination, attempts at
providing integrated, interventions at the periphery.
India
has
The Govt, of
adopted target oriented, time-bound approach with main
emphasis on the following aspects Decrease in mortality in children and mothers
1.
women
Vaccination coverage to children and pregnant
2.
and delivery
Care of mothers during pregnancy
growth rate by increasing
Decrease in the population
3.
4.
the couple protection rate to 60%
This is being achieved by
the following measures
Strengthening of the existing
1.
health infrastructure
birth attendants
Training of the traditional
2.
3.
4.
Providing health worker
for 5000 population
the form of
Involvement of the local communities in
the community health guides
5.
General development activities
Through the universal provision
Health Care (PHC) Services, India is
11
Health For All by the year 2000
of comprehensive Primary
committed to the goal of
In UFA concept every
: 2 :
person should be able to achieve a level of health that would
enable him or her to lead a socially useful and productive life.
Such a level of health would improve the quality of health and
bridge the inequalities and is to bo achieved through PHC approach.
Health has been declared a fundamental human right which
means that the State has a responsibility for the health of its
people.
Efforts to achieve and maintain health, prevent disease and
deal with it when it occurs, require joint efforts by providers as
well as acceptors.
In other words, the individual, the family and
the community is to share the responsibility with the State.
'Health Care' is not same as 'Medical Care'.
Health care
covers a broad spectrum of present health; services, ranging from
health cdu; . /ion uid information, prt?vcntion of disease, early
diagnosis and treatment and rehabilitation.
On the other hand,
care which is provided
medical care includes domiciliary and hospital
directly by the physician or at his behest, and has a limited sphere.
of sanitary requirements
Earlier, health care was generally a matter
and legislation while m-edical care
generally concerned itself in
prescribing and dispensing medicine dui.ng sickness.
In a joint
report in 19^5, WHO/UNICEF gave the term 'basic health services'
which envisages a net work of coordinated peripheral and intermediate
health units competent to perform a set of functions essential to the
health of an area through competent professional
in an effective manner.
and auxiliary personnel
These ideas formed the basis of national
health planning in our country and led to
establishment of Primary
Health Centres and Suh-ccntres.
After India became a
Signatory to Alma-Ata Declaration of
;'• - developrnent o f
1978, the Government has started concentrating on
.
.
: 3 :
.
.
rural health infrastructure so as to provide health care services to
about 80% of rural population which
had. by and. large remained neglected.
The stress in the National Health Policy is on
the provision of preven-
tive, promotive and rehabilitative health services to the people.
thus representing a shift from medical care
the urban to rural population.
to health care and. from
The main objective is to place the
health of the people in hands of the people through the primary
health care approach.
PHC is the foundation of rural health care system and forms
>
For developing the
entry point to the National Health Care System.
for the acceleration and speeding
country’s vast human resources and
of socio-economic
development for avcaening improved quality of life,
PHC is ac- <-jtcd .1.3 one of the mam instrument of action.
In the
rural areas health services are provided througn a net—work of
integrated health and family welfare delivery system.
To achieve
consolidation of the PHC
this objective ezctension, expansion and
infrasiructure viz.
sub-centres, primary health centres, community
health centres has been taken-up extensively with trained village
health guides and trained dais at village level.
In order to make health services available, accessible and
involve other functionaries i.e.
acceptable, efforts are being made to
Village Health Guide (VHG), Traditional Birth Attendants (TBAs)/Bais
)
and Multipurpose Workers (MPW) and Social Workers (iM) by imparting
them training and support.
Medical Officer, alongwith these categories
a
of workers is the leader of the ’Health Team’.
j
In This way the health
to people's home as possible
services are to oe made available as near
and at work places with good referral system.
■V.-a-_ous systems of
1
1
: /I :
medicine including ISM and homoeopathic systems are to be provided
depending upon the local acceptability of the people.
these,
Besides
community participation , multi-sectoral coordination and political
will, are other basic principles on which PHC approach is based.
To optimise and further improve the efficiency of the available
health infrastructure, programmes will have to be identified on the
basis of priority and some way require modifications for effective and
concerted interventions in the critical areas, especially in health
manpower development and other health problems.
Quantitatively these
achievements are impressive in terms of establishment but it
been
has
observed that they are not operationalised fully and the services
ovided at these centres need have to be improved to bring in the
It
■ required credibility for efficient working of the health system.
is also
rv lai '’or the PHC System Development that the knowledge and
skill of the health functionaries match their job requirements.
The
basic training, in-service training and continuing education should
therefore receive the highest priority and advance planning should
be done both at the State and District level to ensure that the required
equipment, trained personnel and other physical facilities are available
not only for the new infrastructure to be created but also for making
up the deficiencies in the existing infrastructure.
PHC infrastructure comprises of health units from the
community level service to the Community Health Centre (CHC) level
which has been developed and should be strengthened and revamped
further by involving VHGs and Dais after giving them training.
In community level services VHGs and Dais form the most
important inter-face between the community and health functionaries in
the delivery of PHC.
incept ion.
There are about 3.9 lakh VHGs trained since
that there is
Additional VHGs will have to be trained so
: 5 :
one VHG/1000 population/per village.
The accountability of the
VHG, payment of their honorarium and. money for the medicines etc. may
be handed over to Panchayati Raj System including their training and
re-training.
5.7 lakh training birth attendants (TBAs) have been
trained in the country so far.
conducted by TBAs.
About Qty/o of deliveries are still
Their training and re-training has to be continued.
They should be allowed to play greater role in the care of pregnant
women by providing them with pre-sterilised disposable delivery kits,
weighing scales and educational materials.
The present,
recoupment amount of Rs. 3/- for soap, cotton etc. has to be performance
linked and enhanced to Rs. IO/- per case reported.
The training
programme of TBAs should be intensified.
SOT-CENTRES :
A Garget of 1.3 lakh sub—centres was aimed at on a population
norm of one Sub-centre for 5^00 population in plain areas and dne for
3000 in difficult,hilly and tribal areas, with one Female Health Worker,
one Health Worker (Male) and one voluntary worker.
are in position as on 31.3.1989.
Out of this, 1,20,767
This has to be stopped up appi’opriately
by providing buildings for all established centres, in-service training
to workers at the sub-centre level, male health worker in each sub-centre
areas; and enhancement of budget for drugs and furniture etc.
PRIMARY HEALTH CENTRES :
This provides preventive and promotive health care to a
population of 30,000 in plain areas and 20,000 in hilly and tribal
areas.
Of the 21,666 centres required by the end of the 7th Plan,
18,811 are functioning as on 31.3.1989.
This has to be strengrhened
appropriately by establishment of PIICs / n difficult areas, posting of
second Medical Officer wherever resources porm.r:
referably a lady
doctor, creation of post of Public Ileal Lh Nur cc U'llN), ealianccniciit
■ “o
:
of budget for drugs, creation of functional buildings by
using
■
locally available material, strengthening of health education component in
training programmes etc.
COMMUNITY HEALTH CENTRE :
At present one Community Health Centre is to be established.
for every one lakh population with the specialities of Medicine,
Surgery , Paediatrics and Obstetrics and Gynaecology having 30 beds,
X-ray and Laboratory facilities.
This unit functions as a referral
hospital and coordinates with the Primary Health Centres oi its area
in preventive and. promotive services including family planning.
As
out of a total oi' 2708 required
on 31.3.1969 there are about 1631 CHCs
by 31 J. 1990.
Being
a referral system from village upwards, proper
buildings, appropriate start, sufficient equipment with vehicles and
a sound neanh riruiagement info rmatio n syotem should be undertaken to
optimise and further improve the PHC System Development.
In addition, health manpower development and training of all
categores of staff and functionaries in both basic and in-service
training should be given duo priority in future.
Community should be involved tor the effective health care
delivery services end in health education.
For this, the Village
Panchayats may be utilised for selecting VIlGs, formation oi village
health committes, etc.
Voluntary Organisations should be encouraged
to establish and run sub-centres, PlICs ;ind Government should provide
full support
for the referrals done by them.
Monitoring and evaluation system should be geared up and
the goals set for various indicatonof health and Frunily Welfare
<7
-
1
■
’
■
: 7 :
programme may he evaluated periodically
at reasonable intervals
■by conducting field surveys and feed back given to the appropriate
authorities for correcting the do!iciencies*
Operational research on PHO System Development should be
undertaken to
identify cost effective strategies of health services.
xx
References :
»
1.
o
W.H*9. (1974) : Modern- Management methods and the
organisation of health services• Public Health
Papers 55
WIIO/UNICEL'’ (1973) : Primary health cure. A joint report
by W.H.O. International Conference on PHC, Alma-Ata,
USSR
!
3.
WJ1,O. (1979) • Formulating strategies for health for
all by the year 2000
4-
Bulletin on Rural Health Statistics in India
(December 1988) : Directorate General of Health
Services, Ministry of Health & Family WElfare,
5-
Working Group Report (June 1989) : Planning
Commission
Position: 3733 (2 views)