C,H,W.PAPERS ON VARIOUS ASPECTS OF COMMUNITY HEALTH
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- C,H,W.PAPERS ON VARIOUS ASPECTS OF COMMUNITY HEALTH
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RF_COM_H_35_SUDHA_PART-1
REPORT OF THE EXPOSURE PROGRAMME OF FR. THOMAS JOSEPH OF THE
CATHOLIC HOSPITAL ASSOCIATION OF INDIA, TQ COMMUNITY BASED
HEALTH PROGRAMMES IN THE PHILIPPINES (SEPT.11 TO OCT.?,1985)
I. BACKGROUND of the visit.
*
II. OBJECTIVES OF THE VISIT
III. ACTIVITIES IN PHILIPPINES.
IV. ASSESSMENT OF THE CBHP.
V. RELEVANCE OF CBHP TO THE COMMUNITY
HEALTH PROGRAMME IN INDIA.
VI
AREAS OF CO14MON INTEREST.
"Q
O * ",'
t I
i •
VII. SUGGESTIONS FOR FUTURE.
VIII. CONCLUSEON.
' ’’
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2 "
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I.
Background of the Visits:
The visit of Fr.Thomas Joseph, the Programme Director
of the Community Health Department of the Catholic Hospital
Association of India, for an exposure to the different activi
ties of the Rural Missionaries of the Philippines, especially
to the CBHP was based on the suggestion of Misereor vide their
letter 300-0/0CK.Ta dated, January 10th, 1Q8U- addressed to
Indian Social Institute. According to the proposal a team from
India including key person from ISI, VHAI and CHAI involved in
C.H. promotional work were supposed to visit Philippines.
In a; meeting of the heads of the 3 institutions (ISI,
CHAI &VHAI), Sr. Hildegard and Fr. Thomas Joseph were delegated
from ISI and CHAI respectively, to visit Philippines in August
198^. The VHAl was not in a position at that time to suggest
one representative from the Organization. Eventualy Sr.Hildegard
visited Philippines in August, but Fr. Thomas Joseph couldn’t
make it at t^at time. However the idea of the visit was not
dropped but rather postponed for a more appropriate time
in 1985.
*
In the mean time, through the initiative of Mr. Tony
Fernandez of C eb emo, Dr. Jimmy Tan visited India and worked with
CHD/CHAI in F^ruary-March (Feb.23rd to March 23rd) 1985.
During this period there was an extensive mutual sharing of the
C.H. Programmes in India and Philippines 5 and this resulted
in tentatively fixing up the date of Fr. Thomas Joseph’s visit
to Philippines in August ’85 as well as the specific aspect of
CBHP for detailed study. Accordingly the proposal was made to
the RMP. Later RMP suggested a change in the proposed time
and thus the date was fixed for Sept. 11, 1985 to Oct. 5? 1985*
Ever since the proposal for the study of the CBHP in
Philippines was mady by Misereor, some friends of CHAI in
India suggested that it would be worthwhile to visit few other
CH programme in some neighbouring South Asian Countries,
...2/
2 -
especially in Indonesia, Hongkong and Thailand. This idea was
discussed with Dr. George Krause' of Misereor during his visit
to India in 198^.
Due to the time constraint of Fr. Thomas Joseph only the
following projects were selected for study:
Christian Medical
1.
Kwun Tong C.H. Project of the United
Service in Hong Kong.
2.
The C.H. Programme in Rural Jawa - in Indonesia.
’Drug Study Group’ and ’Traditional Medicine in self
Cruing Project* - in Thailand.
3.
/
II. General objectives of this visit to Philippines
1.
To learn about the process and dynamics of the formation
of RMP and their various involvement in the rural
areas especially in CBHP
2.
The Socio-Political background of the origin of the
CBHP and the factors that contributed, to make it a
nationwide movement.
3.
To study the methodologies, strategies, training techni
ques and. community organizational dimensions of the
CBHP, and the constraints and limitations experienced
in the process.
U.
To study the role of faith dimension in the CBHP and the
replicability dimension of the Philippine experience ip
the Indian context.
5.
To study about the integration of indigenous and traditrional medicine in CBHP.
6.
To study the linkages established between voluntary
organizations, trade unions, acadamic institutions and
government sector.
7.
To explore areas of common interest for possible collab
oration between the CH programmes in India9 especially
those initiated by the CHAI, and CBHP in Philippines, by
means of exchange of experiences and resources, and to
workout a proposal with BMP for a three year programme.
To learn about Philippines and it’s people and the
impact of multinational corporations in the life of
the country.
The scope of this report, however, is limited to the
study of the CBHP of the RMP in the Philippines. Reports of the
8.
...3
-3visits to HongKong, Indonesia and Thailand are made separately.
III. Activities in general during the visit to Philippines,
Sep. 11th
12th
13th
1*+th
15th
Arrival in the afternoon and discussion with the RMP
board about the objectives of the visit, and with
Belinda and Dr. Jimmy on the itinerary.
Visit to Thahanan Social Service Centre of the
Augustinian Sisters and the Urvan Health Programme.
Ocular survey of the Govt. Health Services in Manila,
and discussion with Sr. Clementia Flora, the National
Co-ordinator of RMP in the afternoon.
Participation in the Negros solidarity day at the
office of the Ecumenical Movement for Justice and
Peace.
Journey to Infanta Prelature with Bishop Labayan and
visit to R.M. House: orientation and stay in the
villag e.
Visit to Infanta Bishop’s House: cone el ebrat ion with
the Bishop on Philippines Tribal Sunday Celebration.
Discussion with Bp, Labayan on liberation theology,
the RM. movement and the Basic Christian Communities
Participation in the Students' Bible Reflection
Group; and visit to the Broadcasting station.
Slide presentation to the R.M. sisters on CHD/CHAl
vision and Philisophy on C.H. and traditional
Herbal Medicines in India.
16th
17th
18th
19th
Visit to the Govt. District Hospital in Infanta and
the Rural Health Unit in Real and discussion with
the people in charge.
Evaluation of the two days, visit to the R.M.
Programme at Real.
Return to Manila.
Visit to Rosseria and Kavite and participation in
- Women’s leadership training programme
- Fishermen leader’s group meeting.
Personal discussion with Sr. Imelda (RM) at Rossario
and the Parish Priests in Kavite.
Discussion with the Parish in Rosario and Silang.
Discussion with Sr. Flora, the Principal of the
Infant Jesus Accadamy High School in Silang.
Participation in the multisectoral meeting of the
peasants in one of the village and stay with the
peasants.
.. >/
1+ -
20th
Participation in another multisectoral meeting in
the same village.
Visit to the tailoring centre in the village chapel.
21st
Participation in the mass protest rally in Manila
on the occasion of the 13th anniversary of the
proclamation of Martial Law in the Philippines.
22nd
Discussion with Sr.Inex from Vietnam on the SocioPolitical and religious situation there.
23rd
Discussion with Sr. Fransisca and Ms.Theresa about
the socio political and religious situation in
S.Korea.
Meeting with Fr. John Vattamattam, the Executive
Director of CHAI, who was on a short visit to Manila,
for an Asia-Oceania meeting on promotion of Justice, »
Peace and Development.
Visit to the BCC-Co inter-regional office in Manila
and discussion with Sr. El vie on BCC in the Philippines.
2^-th
Arrival in Isabela and participation in the CHW
meeting in Tugggarav.
Discussion with Sr. Eva on the CBHP programme of
the BMP
2?th
Participation in the staff development programme
of the BCC-Co of Isabela Diocese of Cauayan.
27th
Participation in the provincial convention of the
farmers at Hagan Pastoral Centre.
28th
Visit to the Council of Primary Health Care in Manila.
Participation in the symposium on "The Peasant
situations in Philippines".
Meeting with Fr. John Vattamattom and Dr. Jimmy
30th
Visit to OHD office with Fr. John and discussion
with Fr. Desmond D’ Souza.
Business meeting with the Council for Primary Health
Care, on
<
possible links between CPHCand CHAI in
futurej. This meeting was attended by Mr. Gerry,the
administrative officer of CPHC, and Frso John and
Thomas Joseph of CHAI.
Visit to Asian Social Institute and discussions with
the president (Miss.Mina) and the Director of the
Communication Departmentu Mr. Augy Lurthusamy.
..az
-5Oct. 2nd
Visit to Bata Parish in Bacolod, (Negros Occidental)
and discussion with Fr. Greg, the Parish Priest, on
the different educational and developmental programmes
in the parish especially Basic Christian Communities.
Participation in the parish co-ordinators and
sub-committee meeting.
Visit to Sisters of the Rural Mission, (a Diocesan
— -P TTT.TT? I
Congregation) and discussion on training~ of
VHE’s
use of Herbal Medicines, /Accupunture, Accupressure,
etc and ocular survey of the herbal gardens in the
campus.
3rd
Visit to EPIC in Quezon city
Visit to AkAP and discussion with Dr. Manual Dyrit.
Discussion on Urban Missionaries, with Sr. Marietta
CFIC.
U-th
Sharing CHAI activities with the R.M. office staff.
^th
Sharing of the exposure report with R.M. office
Personnal.
Afternoon left for Indonesia.
1
IV Assessment of the OBHP:
1. Background; The CBHP programmes of the Philippines were
initiated and developed by the Rural Missionaries of the
Philippines. A background information on the formation and
development of the Rural Missionaries of the Philippines will
serve as a basis for a better understanding of the CBHP.
The worsening Socio-economic situation of the Philippines
in the i9601 s, and the growing miseries of the people in the
rural areas, vis a vis the concentration of one third of the
total women religious in the Greater Manila area and the consp
icuous absence of the church in remote rural areas on the one
hand, and the teachings of the Vatical II on the other, made it
imperative for the people in the Catholic Church Organization
NASSA (National Secretariate of .Social Actions) to make a serious
look at the social relevance of the Church in Philipnines. This
critical reflection, finally led Bishop Labayan (then National
Director of NASSA) to request the Association of Major Religious
Superiors of Women in Philippines (AMRSWP) in 1969? to release
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-6sisters specialy for rural Apostolate. Thus in August 1?, 1969?
Iffhe RMP came to exist, with 19 sisters from seven congregations.
Ever since its formation, the RMP underwent thorough process of
evolution within its own membership, organization, ideology and
involvement. They started with community development and slowly
moved towards social analysis and has now reached the liberational
thrust.
The Rural Missionary Sisters (RMS) are involved in many
activities today, based on the needs of the people and time.
Some oftheir major activities are CBHP, Lay assistants 5 training
programme, BCC-Co, Cathechetics, Family life education, cottage
industries, Vocational skill training, organization of peasants,
fishermen, youth, women, primary education for tribal
Philippines etc.
Today there are 7^ RM Sisters, belonging to
congregations
and their work is extended, in 27 Dioceses all over the Philippines.
Three priests from two congregations and one brother from OFM
are also members of RMP today.
IV.2 History of CEHP °e The inadequate and miserably inefficient
Government heelth infrastructure in Philippines was the motivat
ional force behind the CBHP programme of RMS, which had its
beginning in 197^, in the outskrits of Manila city, in anurban
setting. Initially it was a para-medical workers training
without any structural analysis. The model followed was the one
that was run by Dr. Dilapas in Dabo city in Mindanao. The
programme was extended to rural areas in 197?, starting with three pilot projects in Lu&on, Illagan) Visayas and Mindanao.
During this time CHW training was conducted in a Central Place
for selected personnel from the village.
In 1976, the first evaluation of CBHP programme was done.
In 1978, there was a joint consulation of people involved in
CBHP programmes in Philippines and committed medical professionals
at Cebu (Processional convention), and it was then that the
structural analysis of the society in relation to the ill-health
of the people was done for the first time, and the programme was
named as CBHP, with significant thrust on Community organization.
Ever since, the evaluation of CBHP is done annually. In 1978
...7/
- 7 evaluation, it was realised that the: personnel involved in CBHP
was finding it difficult to do both <community organization and
health programmes and then the responsibility of community organization was shared with the Basic Christian Community - Cominuni£y
organization (BCC-CO), wherever the latter existed, However in
those places where there are no BCC' s with C.O. component, the
community organizing is done by the CBHP.
Process of Organizing CBHP
Eveh though the CBHP was started
initialy as a programme by the RMS,the years of their experience
in the field has brought about a radical change in the thrust
as well as the strategy of organizing and extending CBHP programmes
to other areas. Instead of a centralised training as in the
beginning stage of CBHP, today the RMS have devised different
steps at different levels for the training and extension of the
programme.
•3
I
Once the area of involvement is identifed by the RMS. after
the initial study, contact ismade with the parish structure, to
4
brief about the programme. Then it is the parish structure tint
makesthe contact with the Village Assembly for the RMS to explain
to the community about the CBHP, after which they are left to
themselves for a period of time for internal discussion and
decision as to whether they need health programme; in their
Village. If they are interested, the people themselves select
the candidates for CHW training and make a request to RMS to
train them. Then the training is taken up by the sisters in
the village itself, where the selected candidates from all the
'Puroks' (Wards) are gathered, together with an orientation
programme for the village community, A health committee is also
formed in the village to monitor and assist the CHW's to carry
out the programmes. Wherever there is a health ministry
committee in the parish council, they are trained as middle
level workers by the RMS.
The duration of the training is usually one year, and it
is conducted an weekends, when the people are free. Eventhough
there is a systematised syllabus, the topics of the training
are kept very flexible and the health skills related to the
pressing needs and health problons of the people are always
-8-
given priotity. The.' approach has boosted the enthusiasm
and the interest of the community as veil as that of the CHH’s,
since they could become functional right at the start of the
programme itself.
At the initial stage of the training itself, the CHW's are
enabled to do the research into the traditional medicines of the
people, and to collect as much information as possible from the
people themselves. This process is followed by the efferts by
the programme to give scientific explanation and meaning to the
of the People and also to remove magical
aspects.. Alternatives also are suggested in certain cases,
( g. Fugigation, Spraying etc. instead of burning the house
after the death of a person, which was a tribal custom), or
i
giving religious meaning to some of the tribal custom^ (eg. the
custom of burning the cloth on the third day at the graveresurection and life after death) etc. During the training
programmes, the traditional healers in the Villages are invited
to share their experiences with the CHW. The programme helps
the people to und er stand t heir history, to accept their culture
and to be proud of themselves. This approach of starting of the
programme from where the people are, served as a springboard for
the CBHP and related activities in the area.
In the beginning of the CBHP programme, the CHW's were
given a medical kit by the project, but it has been discontinued
now, because of the attitudinal changes observed in them, and their
own emergence as elite class and mini doctors ! However, the
CHW's keep few western medicines with them but the bulk of the
medicines they promote are herbal medicines which also includes
promotion of herbal gardens at the backyard. All the
CHW's
are trained in Accupressure and some are trained in Accupuncture.
The activities of the CHW's include systematic immunisation
programmes, health education programmes, Anti- TB programme
Dais work, MCH, House visits etc. In those areas where the
CBHP is linked with a hospital (Eg. Cagayan Valley) the CHW's
refer the patients to the hospital on particular daysand the
doctor recognizes and upgrades the skills of the CHW, through
his/her participation with the doctor in the diagnosis of the
patient. This increases the morale of. the CHW on the one hand
and the confidence of the people in the CHW on the o: er.
- 9 The CHW's in the CBHP are not given any monetary remunerat
ion: even though the Govt. Barrangay (Village) health workers are
paid. But the programme has developed other mechanisms to encour
age and support the volunteers, eg: CHW day celebration, which
is marked by sharing, reflection, evaluation, conscientization
programmes, slides show etc. Also from among themselves, co-ordi
nators are selected and they organize their own monthly meetings
in each area. When there are full time co-ordinators or when
a co-ordinator is assigned duties outside his/her own area, they
are paid a honorarium by the project. Some times the CHW's
receive donations from the people but the amount is put in a
common fund to be used for common activities in the village or for
the purchase of simple equipments like thermometers, BP apparatus,
stethoscope etc. Also a mutual support system is developed among
the CHW's at the village level where they consult each other and
refer patients to those CHK's with more skills. In Mindanao and
Cagayan valley, the CHW's are formed into associations with
legal status.
Since the training of the CHW's are decentralised. and are done
at the village level, the expenses are ccmsid
erahiMost
considerably
low.
of the provisions for the CHW training and their diocesan. or
regional meetings are met by the participants themselves in cash
or in kind. Those areas where the foreign missionaries
rwer e
involved with the dolling out approach, the CBHP had a hard
time? compared to those places where the programme could be
launched on a clean state.
The enthusiasm, seriousness and the commitment of the CHW's who
IV.
were met during the visit to different places is inspiring,
and undoubtedly it is no less than the RMS who are the motivating
and driving force behind the programme.
CBHP AS A MOVEMENT IN THE PHILIPPINES
To situate CBHP in the overall socio-political situation of the
Philippines reality and the existing health infrastructure in
the country one has to understand Govt, health sector and the
non Govt, health sector in Philippines.
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A. Govt. Health Infra-structure.
This can be better depicted in the following diagram.
Ministry of Health at the National Level.
Regional Health Department
!
Provincial Health Department
!
!
Municipal health Department
In urban areas
In rural areas
J
Health centre on health
Rural Health unit
i
department (staff structure
with the following
J
is same as the rural unit )
persons
Highly institutionalised and
Do q tor
J
structured without a team
z
J
approach
Nurfse
J
Mid wife
1
Sanitory inspector
Barang ey Health Worker
(paid by Govt)
There are also special national programmes under the ministry
of health or provincial health department.
I
-hT
They are:-
- T.B. Control programme
- Nutrition promotion programme
- Schistoromiasis control programme.
(This is a special disease, caused by certain parasites
entering the body from stagnant waters. This fatal
disease- :*is wide spread in certain provinces (esp. in
First Lady’s province), and is also found in Jalpan).
(The malaria programme of the govt, is quite controversial as
reliable information from Municipal Health Department has
confirmed the rumour that the govt, is facilitating mosquito
breeding and their immunity in Bicon and North Luzon areas to
spread malaria* as these are NPA infested areas. (National
People’s Army - militant and armed peoples army indulging in
guerilla warfare against gmt.) Many had to resign from municipal
health department as they refused to co-operate with the govt.
In 198^2.2 Billion Pesos constituted the health budget of the
country. Out of this ,53.7% is earmarked for maintenance of
sophisticated hospitals and the infrastructure. 29% is allotted
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-11for rural areas and the next 17.3% goes back to the national
treasury, (the reversal flow into the treasury is based on a
presidential decree after martial law)
B.
Non Governmental Health Sector ;
They are of two types, a) Service organizations and
b) Organizing type organizations.
a. Service organizations: They are mainly CBHP advocates and
they render health services to the people. Three national
agencies under this category are:
1
1. Rural Missionaries of the Philippines (RMP) which gave birth,
to CBHP in Philippines and also today, co-ordinates the
Catholic Church based initiatives in CBHP in the Philippines.
2. National Ecumenical Health Concern Committe (NEHCC) :
Which functions'and er National Council of Churches in
Philippines (NCCP), and is the protestant counter part
to BMP, coordinating programmes in their religious sector.
3. Council for Primary Health Care (CPHC): which is a non
sectarian organization, started in 19 83 and is composed
of representatives from RMP, NEHCC and other regional
bodies (eg: Mindanao), assisting and co-ordinating
service organizations through training, research,
publications and programme mamag era ent etc. As regards
the collaboration of these service organizations with
the Govt, are cone ernedz attempts were successful only at
the Municipal Health Department level, and as one goes
higher on the level more suspicion and opposition to the
NGO’s, is experienced.
b- Organizing t^pe health organizations:
In this sector there are four major categories.
1. Student organizations.
They are:-
Philippines nursing stud entTs association.
Philippines medical students association.
2. Suh sectoral organizations:
Alliance of health workers.
(some kind of trade union, which does not fight for their
own interests, but for people’s).
There are other traditional organizations like
nurses association, doctor's association etc. but
are not involved in issues.
...12/-
-123. Human rights organizations
Medical action group (MAG)
(organization of radical doctors vhich include social
workers also, and are involved in fact-finding missions
etc)
Health alliance for democracy (HEAD)
(organization of politicized medical professionals,
most militant group in terms of political issues:
exerting pressure against Trans-National corporations
(TNC's^etc )
1
*+. Health issues organizations
Health Alliance (HEAL)
issues alone.
they mainly tackle health
As reference was made earlier in this
report CBHP was a natural
outcome of the Christian
response that the RMS made to the
deteriorating health situation of the poor, oppressed, depressed
and the exploited little
people in the Urban quatters and the
Godforsaken rural areas
, with vhom the sisters identified and
whose life and suffering they shared.
Even today 62/100 die
in the country without
any Medical help. This situation is
still getting further depressing, as Philippines continuesto
lbe the vo rid * s numb er
one exporter of nurses and number two
exporter of doctors,. Pneumonia, T.B., and upper respiratory
diseases are the major killer diseases in the Philippines
However, ever since the proclamation of the martial law in V 72
militarisation and Uo imperialism has become the major killer
disease that disables millions and kills thousands in Philippines.
incere search for theradical reasons of the ill health of
the people, and a critical analysis of the socio-political
system Xi tJe^TX
COUntry’ specially the healthcare
lead the RM<1
6 P ayGd by the multinational drug companies,
o look for alternative methods of health care
where the people thanselves
uld look after their own health.
CBHP irvZ6^111! t0
hGre
thS baS1C PhlloS°Phy of the
y much similar to the philosophy of CHAI,
...13
-13The major factors tlfit contributed to make CBHP a movement in
the Philippines ares
- Clarity in the understanding and the experiencial
knowledge of the RMS.
- The unique socio-political situation in the cnuntry.
- Inadaquate and insufficient govt, health infrastructure
especially in the rural areas.
- The existence of BCC’s in the country side and the links
RMS enjoyed with them, being a task force of the AMRSP.
- The contacts of the RMS with the academic institutions like
medical collages, nurses training centres and the
involvement of medical professionals in the CBHP.
- The ecumenical character of the church in Philippines and
the collaboration between catholic and protestant organi
zations at different levels,"and the uni-religious
character of the country (85% Christians).
- Regular and ongoing reflection and consultation on CBHP
with different organizations involved in health through
which many groups would'.be brought into the main stream
of CBHP approach.
by
- The co-ordinating role played/the CPHC in promoting
CBHP approach in service organizations.
-The involvement of the RMS in trade unions, peas ent movements
fisher f;>lks, tribals, yauth, vomen etc.
- T^e^grocess oriented rather than target oriented approach
- Less involvement of the outside money, and reliance of the
programme on the people and the local resources, Eg. Herbal
Medicines, Accupressure, Accupuncture and the voluntary
service of the CHW’s)o
- The direct introduction of the programme to the people rather
than the mediation'of institutionalised health institutions,
and the minimium administrative structures at the peoples
level, in contrast to the project level.
V. Relevance of CBHP to the COH
Programme in India,
The approach and philosophy enshrined in the CBHP is embodied and
more clearly articulated in the philosophy and the new vision of
CHAI on C.Ho though in practice it is more evident in the
Philippines. To understand this phenomenon better, the difference
in the situational context in which the CBHP in the Philippines
and CoHo programmes in India function has to be assessed.
.. .1V
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INDIA
The
/Health service is a major
apostoiate of the church in
India, and is highly institutio
nalized right from the top to
bottom and rural to urban and
are widely spread all over the
country and has absorbed the
religious health personnel
exclusively.
PHILIPPINES
The institutionalize health
services of the church were
largely concentrated in the
urban setting to the execlusion
of rural areas.
The income of the health inst
itution, both rural and. urban
from rural dispensary to the
Urban hospital, constitute a
major source for the main
tenance of the congregation and
the formatuon of the new
members. Hence CH programme
is seen as a threat.
The congregations does not d epend
on the incomes of their health
services in the rural areas
•
and they were not seen as a source
of income.
The health sector has become a
business industry in India and
the health apostoiate of church
also has been drawn into it
where cut-throught competition
and capitalistic values
pr evail.
The understanding of the exploit
ative health system posed a
challenge to the socially orient
ed organization and RMS to develop
an alternative system of health
where people can be independent.
Less critical reflection on the
charisms of the congregation
and.minimun exposure to the
social realities around, because
of ’overworkr in the
institutions.
An ongoing critical reflection
on the charism against the
acute and repressive socio
political situation, and exposure
to the theology of liberation..
’Minority consciousness’ of the
church, and an Out effort to
establish credibility at the
national level providing
quality service to the elite.
The majority consciousness of
the church and efforts to
establish itself as champions
of the cause of the poor and
exploited.
Less exposure to the experienceces in the third world countr
ies and the laissez faire
mentality and cornplecent atti
tude of the hierarchy in the
church
More exposure to the Neocolonial situation of the Latin
Am eric al countries, and the
emergence of a progressive
section within the hierarchy.
Easy money from the:‘foreign
funding agencies for institu
tional based health programme
Critical understanding of the
socio-political factors effecting
health proved the futility of
institutional health care.
*
-5The insecurity feelings invo
lved in taking risk and trying
newer methods to work with
people because of the pagan
milieu and lack of experience
in people based programmes
either in one’s own or other
congregations and less openness
to the experiences of Non
Christian voluntary organizat
ions or action groups.-
A
and integrated programmes and
the prevailing target oriented
approach Vs. process oriented
approach.
The support of the congregational
structure (institutional support)
to experiment different approaches
the relatively independant
character of the RMS and the links
with other individuals and
groups, and the Christian millieu.
Ongoing study, reflection and
evaluation among different
groups indivldualy and jointly
at different levels and the
process dimension.
There could be many more points one could enumerate to understand
the different contexts and situations that exist in the two
countries.
Neverthesess, the social9 economic and political situation in
both the countrios(except the martial law and the continuing
militarisation in Philippines) manifested in the situation of
the peasants, agricultural laboureres, industrial workers, slum
dwellers, tribals, harijans and fishermen, the plight of
children and the exploitation of women- etc. clearly indicate
that the experiment of the RMS in the CBHP has got great
relevance to the Indian context. The experiment CHD/CHAI his
started with the mission sisters of Ajmer,
- in the Diocese of
Rajkot, and with the society of the missionaries of St. Thomas
in three different parts of India, for the coneretization • ■ of
its philosophy and vision on CH will hopefully open up a new
face in the Community Health movement that is gaining momentum
in the country with more and more individuals, groups, and
congregations joining the fray. Moreover the role that the RMS
and the major religious superiors in Philippines can play in the
re-orientation of especially the women religious in India thoough
a possible exchange programme is of great slgnificanb.e.
.•..16/
16 -
However at the CHD/CHAI level the following points could be
seriously considered with the new insights gained from CBHP
programmes through this visit to the Philippines □
- Considering the inbuilt limitations of the institutional ■‘V
catholic health care system in India, efforts should he made
to initiate CH programmes independent of institutional base,
whether through religious groups or lay groups.
- Attempts should bemade'to identify the existing socially
oriented congregations to facilitate inter congregational links
and joint programmes including inter-congregational community
living.
- Facilitate exchange of experiences between the RMS and the
religious congregations in India. This Could be started with
international congregations having fountations in both the
countries. This should be done with a long range plan to link
up the conference of Religious of India (CRI), especially the
women religious and the Association of Major Religious
Superiors in the Philippines (AMRSP),5 especially the women
r el ig io us (AMVJR SP).
- The existing programme of CHAI to reorient the CBCI and the
CRI in the health apostolate should be continued, drawing more
examples from the Philippines experience.
- Being an association of the Catholic Hospitals and Health
Care Institutions in India, the CHD/CHAI cannot just ignore the
presence of these institutions and the potential resources that
they have in terms ofmoney, material personnel and other infra
structure for the promotion of people based health programmes
in the country. Gradual and systematic efforts should be made
by CBB/CHAI to persuade them to fall into this mainstream
through providing guide lines to initiate C.H. programmes in
their own different situation Eg. Hospitals, Health Centre,
Dispensary.etc.
- The efforts CHD/CHAI has already begun to establish links
with existing health organizations (national, state, regional)
to share and promote the new vision on CH should be pursued
further with more vigour and urgency.
...17/
-17- CHAl/CHD should arrange
exposure programme^ for major religious
superiors and heads of the health institutions, to create
awareness in them, by bringing them face to face with the
realities of ill health and misery bf the poor in the slums and
in the rural areas.
- Exposure programmes also should be arranged for students in the
medical colleges, Nurses training ' schools, etc. to increase
their .iwareness of the situation of their bretheren and to
instill in them commitment to their own people, rather than
looking for service op'ortunities abroad.
Also in this context the suggestion already made by Dr. Jimmy
fan in his report of March 1985, regarding the documentation
and information syston tie CHD/CHDI should begin, can only
be further endorsed to expand and strengthen the community
health programmes in India.
- The CHD team of CHAI should be constantly alert to the general
trend of the CH programme in different parts of the country
and make its own assessment of the situation and the changing
trends, and workout methodology to play an effective role to
make the CH programme in India, really community based and
lib erational.
VI. Areas of Common Interest
F
Under this sedfe-on ,
efforts are made to highlight some areas of
mutual interest for both India and Philippines in each other’s
country. This could serve as a background for the next section
of this report where in suggestions are made for an exchange
programme between the CH programmes in India and CBHP in the
Philippines.
A. Potential areas of Interest
Indian Side
Philippines Sid c
The origin and development of
The social9 economic, political
the Rural Missionaries of
cultural and religious situation
Philippines. The social9
of India and the influence of
economic, political and cultural MNC’s on ths life of the people
situation of the Philippines and especially on health,
the influence of MNC’s and US * .
imp erial sim in the life of
the people.
...18
18
The various involvement of
the religious of the
Philippines and especially
that of RMS.
An exposure to the different
religious congregations in
India and the Major areas of
their involvement.
The different phases and
strategies of initiating CBHP
the training of CHW's the
involvement of the community
ano the self-help nature of
the programme.
The different pluses and strate
gies of initiating CH, the
training of CHW's, the involvement
of the community and the self-help
nature of the programme.
linkages of the CBHP with
other academic institutions
and the collaboration and
co-ordination with like
minded agencies.
The linkages of the CHP with
’
other academic institutions and the
collaboration and co-ordination
with like-minded agencies.
Methods of social preparation
and community organization
in CBHP
Integration of traditional
medicines especially herbal
remedies, accupressure, aid
accupunture in CBHP.
Evaluation methodologies,
research designs and
documentation pattern of
CBHP
The factors that contributed
towards the re-orientation of
the Church in Philippines
with special reference to the
religious congregations and
the medhodologies adopted
to further and deepen social
awareness and the religious
challenges.
Methods of social preparation
and community organisation in
C . H0
Integration of traditional
medicine especially herbal and
home remedies, and other
indigeneous systems like Ayurveda
Sidha, Unani, Homeopathy,
Naturopaty, Yoga etc.
Evaluation methodologies, research
design and documentation pattern
in C.H.
The factors that contribute
»
or limit the church in India
for meaningful social involvement
especially the religious
congregations.
The health care infrastructur
existing in Philippines both e The health care infrastructure
existing in India both at the
at the govt, sector and
government
and non government
nongovt, sector vis a vis the
sector
vis
a
vis the general
general health situation in
health situation in the country.
the country
..19/-
f
-19'7
The BOO-CO Programme in
Philippines.
The influence of religion on
the Indian people, especially
the.caste systete, and how
religion and culture justify
and maintain the status quo.
Different models of C.H. prog
ramme in India.
Role of faith and life reflection
as a motivational force in C.Ho
training.
How the church based health
institutions came to involve in
CoH. and its evaluation
These are ofcourse but a few areas that could be of interest to
the respective countries. Many more could be added to this
list depending on the need,interest and attitude of the
individual member of the team representing the country.
VII.
A
i
-Suggestions for mutual collaboration and exchange Programme
between CHAI and BMP.
-ns India and Philippines share almost equally the fate of the
third^world Asian countries, and the similar social, economic
political and cultural problems resulting in a constant and
disheartening state of misery of the majority of the
population, efforts to share the experiences and achievements
in the field of C.H. programmes
--------- ' -be of great significance
would
and mutual enrichment .. The
n"
possible areas of mutual interest
enumerated in the proceeding section
__ should
----- _d form the basis
for mutual exchange programme. It is hoped that the initial
exchange between these two Asian countries could eventually
lead to a ■process
of meaningful exchange between many more
Asian countries- with
-----1 similar socio-economic situations and
problems.
I. A few jaggestions for exchange
programmes°
a . The time period for the
two country exchange programme
initialy could be programmed for a three year period; and
duration ofstay in the host country should be five to six weeks.,
b. The team from India should consist of A to 6 key personnel
with decision making pwer and long standing experience in
...20/-
20
C.H. Programmes which has liberational thrust, To b egin with,
it could be women religious, if possible with regional
representation.
e.The team from Philippines should consist of Ho 6 key
personnel from theRMP. (either present or past members) involved
in the implementation of CBHP at the national, r egionnl or
provincial levels,
it is suggested that initialy this team
should ;
consist of women religious preferably those belong
ing to the progressive international congregations, which has
got foundations also in India.
t
d.This two country exchange programmemay be naded as India
Philippines Exchange Programme (IPEP) and the duration should
,
* *
be of three years, beginning with the year 1986. The project
should consist of two visits each to the other country in'the
first two years (1986-'87) and a two country conference in the
third year vhich could also include like minded catholic
groups or organizations involved in C.H. in the South East
Asian countries.
e.The programme could be launched in January 1986 with the
Philippines group visiting India. It could be scheduled any
time between Jan.and March as it is the most convenient time
for CHD/CHAI. And later this could be reciprocated by the
visit of the Indian team in June-July. During this time
plans could also be made for the exchange programme in 1987.
f.The financial requirement of the IPEP for the proposed period
as well as the programme could be bornsby Misereor, as the
proposal of this programme was initialy made by
Dr .M.Ob erhof f er of Misereor and the investment for the visit
of Sr. Hildedgard of ISI and Er. Thomas Joseph of CHAI was
already made by them. The project proposal for this could be
done by both CHA I and RMP for the possible expenses they
would incur for the guest team visiting their respective
countries.
(This is important since the Indian team can only
take a limited. amountAof the country. And the proposal of the
two country conference could be made by CHAI and the conference
could be hosted by India in 19 83. This could also be a joint
financing programme of Misereor and CEBEMO as in the case of
present C.H. programme of CHAI This could "be discussed between
Misereor and CEBEMO.
...21/-
-21If the idea of IPEP is acceptable to both the countries involved
the exchange of periodicals, resource papers, evaluation reports 9
etc. could begin immediately. These exchange/materials could
include those prepared or published by CHAI and BMP and those
printed orpublished by other groups or organizations in the respeQtiy,$.Qountri.QS considering its usefulness and relevance to the
partner country.
VIII.CONCLUSION;
This was a fruitful visit as the objectives initialy set are
fulfilled. I am happy to have made this visit, having been
impressed by the radical commitment of the RMP to the cause of the
poor in Philippines, and their participation in the creative
struggle of the people to bring about a just society, where the
reig.n of God will prevail.
1
»
It would have been better if a comprehensive orientation to the
different aspects of the Philippines situation and the involvemct
of the RMp against my objectives and expectations were given
to situate my exposure and search contextually and concretly.
Also I feel it was a draw back on my side that I could not be
exposed to the stand of the traditional and conservative Church
and other groups, responding in their own way to the distressing
situation in the Philippines.
*
<
I express my deep gratitude and sincere thanks to the RMP 5 who,
despite their heavy schedmile, facilitated my exposure in
Philippines and spared no efforts to make my stay pleasant,
confortable and fruitful, and also to Misereor whose assistance
made it possible for me to make this visit. My experiences in
Philippines have inspired m;e and has raised many challenges to
my own attitudes, thinking and life style. It is hoped that
this visit will further strengthen the ties between the C. H.
Programme in India and the Philippines for the greater good of
the Millions of people whom we serve, in these two countries.
Octoh er 5,
1985.
Er. Thorn0 s Jo s eph
Programme Director,
Community Health Dept
Catholic Hospital Association of India
C.B.CJI CENTRE,
Goldakhana P.O., New Delhi - 110 001
INDIA
22
COpy of this report is given to:
1- The Rural Missionaries of Philippines.
I
2. The Executive Director, CHAI.
3. Dr. Galvez Jimmy Tan.
Misereor.
5. Mr. Tony Fernandez of Cebemo.
6. Mr
Rudy Lobo and Sr
7. AMRSP
N.B.
Clo
Hildegard of ISI.
Sr. Carmeia Carpio Maryknol.
The following Health Related Organizations also were
visited (See separate repott'
1. Council for Primary Health
2. AW.
1
0000000000
0000000000
0000000000
t j ska
Care - Manila
PECTIFJ S PARTICIPATTON Iff HEALTH
Some decades ago, development of undeveloped, communities meant doling
out food, clothes, medicines and money to the poor who were just passive
recipients. Gradually a realisation came that this was a-bottomless pit
which would never fill. So came the concept that ’people’- should work for
their own improvement. However it was soon realised that people could not
be- made to work unless they were involved in the process of development.
Ihus came the idea of people’s participation.
There 6.re three questions I want to ask.
1 . What do we mean by people’s participation?
2. Who are the ’People’?
3. Is people’s participation possible in community health?
j
Different people have different meanings for people’s participation.
Some project workers say that there is overwhelming people’s participation
in their peojects; thereby meaning that the people are taking benefits of
the programme. Does merely taking benefits of the programme or participating
as beneficiaries mean people’s participation?
Some call it people’s participation when the people are receiving
benefits not as charity but are paying or rather are forced to pay for the
benefits. Does such payment for semces mean people are participating?
Then people are very actively participating in the whole of the commercial
system today where everybody pays for whatever he or she . gets. Then can
compulsory payment for the benefits, which is glorified as ’economic
contribution of the neople to the programme’ be a hallmark of people’s
participation?
A very successful community health project claims that ’the villagers
collectively constructed a road from our hospital to the village so that our
health team would reach the village’, and foreigners are much impressed by
this ’people’s participation’* One however finds that the road was
constructed by the labourers of the village in ’food for the work’
programme and the villagers were mainly paid labourers.
The same community health project says, ’’our village health workers
ha-^ze been selected bv the people of the village and our project has a
peonle’s committee as advisory board. ’Though this is meant to be
participation by the people in decision makingon closer enquiry, one
finds that almost , every V.H.W.was selected by the head of the village
and two or three influential persons and the project staff. The people’s
committee consists of established leaders and the rich people of that area.
I oes the decision nakin -; power given to the few rich and established leaders
of the village and mutely followed by the rest of the villagers mean
people’s participation? By this definition the whole political system
today has very wide people’s participation.
Obviously all these are not exai-iples of people’s participation.
The last point takes us to the next question, ’who are the people’?
This is quite a tricky and political question. A big power invades a small
nation and nuts its ’yes man’ in power and says people of this nation
have invited us to liberate them. Do mere heads of government mean people?
A rich man who
also heads the Tram Panchayat takes a decision as to who
should be the W from that village. Is he the people?
The male head of the family says ’the tradition of our family requires
women to remain in purdah and all people approve of this tradition’ . Is he
the whole family or are the males alone, the people?
....2
♦
:
2
No ’ In all these instances decision nakingdoes not represent the
desire of all the people, definitely not of those who have no voice and
freedom to speak but who very badly need an opportunity to take part in
the decision making to ensure that it is in their interest and not to
oppress theni
Thus I have tried to show what is not people’s participation and who
are not ’the people’ : If this is not people’s participation then what
is it?
Who are the people?
Probably
Probably everybody
everybody bom
born as
as a human being has a right to be included
in the ’people', be it the oppressed or the oppressor.
But for operational purposes, we will have to say that the oppressed,
the exploited and the needy should ha^ priority in the comprehensive
f.
definition of the people.
When these people understand the situation and iesues by critical
consciousness and take part in decision making, imlementation and evaluation
of programmes and take the responsibility of the work as well as share
in the benefits....it becomes people's participation.
There cannot be genuine people’s participation without a proper political
atmosphere and educational process, Even then true people ’ s participation
may be a distant goal.
Prerequisites of people’s participation
Today’s political and socio-economic system is directly opposed to real
people’s participation. How can there be a true people’s participation when
women have no equality, the poor have no strength to assert and the oppressed
have no opportunity to participate in the decision making of the political
system? When we, the enlightered elite citizens of the society have no
scope to participate in the affairs of the nation except to vote for the
best of the available bad choices once in 5 years or to write a letter
to the Editor once in a while, how can those who are weai, poor, oppressed
and ignorant, really participate?
It is obvious that the real people’s participation is a distant dream
to be achieved by a process of economic, political and cultural liberation.
When one views the objectives and the claims of people’s participation
in community health projects one cannot help but laugh. The present system o'
anti-participatory. Moreover there are more vital fields in which people
would prefer to participate first. Health is a low priority issue.
The expectation that people will participate in a real sense in a mere
community health programme is unrealistic. This conclusion is also supported
by the experience of numerous workers in community health who have learnt it
the hard way that people cannot be mobilised and organised through ano for
health work. It does not mean that there should be no efforts towards
people’s participation in health programmes, AU efforts to involve the people
the people, especially the needy and the oppressed in making decisions and
their implementation should be made. This will marginally help a
participatory culture to be created. But it must be realised that people’s
participation is essentially an objective of political and educational
process, and health work has only weak political implication. If community
health work is a part of political activity, it will get it’s backing
and advantage. But without a proper political context, not much of genuine
people’s participation can be achieved in community health work alone.
Hence people’s participation per so cannot be a primary objective of
community health programme.
k
J
: 3 : If people’s participation is real and genuine, one should not talk
of people’s participation in the project’s health programme but of the
project’s participation in the people’s health programme. But realistically
this cannot happen through the health process a3one.
Seme workers use another misguiding term, ’community participation’
in community health .programmes. There are two obvious fallacies. One,
there is no organised entity as ’community’ in the villages today. There are
individuals, families, castes, classes, political groups and one cannot
create communities out of such individuals and groups for the purpose of
and through mere community health work (though community health work might
marginally help this process). Secondly, though claims are made of having
achieved community participation, in reality only the existing social
organisations (Panchayats, etc.) and established leadership are involved in
decision-making, We have already seen that such leaders alone are not the
people and hence they cannot replace the community.
Economic self-reliance: Why ?
Another popular fashion-word is ’economic self reliance’, commonly
used as a criterion of evaluation and boasting feature by many agencies
and projects in community health. How did this come to be given such an
importance that it has almost become an important objective of community
health programmes?
The workers keep on desperately running after this
objective, forgetting that economic self-reliance is not the purpose of their
work and they cannot afford to sacrifice their original purpose i.e. to improve
the health of the vulnerable people.
With growing realisation in the developed (exploiter) world- that mere
doling out of food and clothes Cannot permanently, improve the life of the poor in
the undeveloped (exploited) countries, a concept was born that people should
be given such economic programmes which can generate income for themselves
and hence they don’t have to depend, on outside help eternally..
Self-reliance Lo^ic
Fine’. Good policy’. But then this has to be an objective of economic
programmes to be -achieved through economic activities. This has been
implicitly accepted in the field of community health also. This has caused,
tremendous diversion and confusion and a time has come t.o challenge this
assumption. There are many reasons. When a community health project tries to
become economically self reliant, it adopts two methods.
(a) It starts charging the rich to gain more income, (the so called
’Robinhood.’ method). Ultimately this results in the community health
project becoming dependent on rich clientele for it’s economic selfreliance. To satisfy this clientele comes the sophistication. X-rays,
E.G.G., more indoors, more specialization, and more and more workers and
time to cone up with all this. Also come in the unscientific, unethical
practices like giving unnecessary injections, tonics, mystifying the
symptomatic relief etc. to draw and retain the paying patients.
The rich class is much more shrewd than community health projects.
It is almost never dependent on this community health project alone for its
own health care (though occasionally individuals may need and seek such
curative services, such examples don’t prove that the whole class is
dependent on community health projects) • They almost always get their
health needs fulfilled through the commorcial private health system.
....4
■-
»-■
•
:■
,
I
- : 4 : Only in very remote places, persons from such class might depend on community
health projects. Thus the community health project becomes dependent on the
rich class for its income and surxdval rather than otherwise. This brings
gradual changes in the priorities, strategies, methods, behaviour, and
relationships of the community health project and it. ends in serving
pidmarily the needs and priorities of the rich.
An analysis of the clientele of most 'of the mission hospitals, who
in an attempt to become economically self reliant started charging the cost
of the treatment to patients, shows that liltimately- they ended with two
maladies. They were underutilized, and were utilized predominantly by the
rich class.
Sathyamala from VHAI has described (Health For The Millions,
February 1980) how she saw at many places voluntary hospitals half empty, beds
occupied by the rich, who only could pay the charges; and the next door
Government hospitals and dispensaries-inefficient, low quality, corrupt but
still overburdened, full of poor patients. What, an irony I Then why should
dedicated missionaries run such hospitals ? Even the. private commercial
health care system (eg. Jaslok Hospital) can do and does the same role.
Then where is the difference?
(b) To raise incane, the second strategy adopted is to charge the poor
more and more in an attempt to make them pay at least the cost of the
treatment. We have already seen how it results in elimination of the poor
from the curative health care. 60% of admissions in a hospital of a
famous community health project which claims to be economically self reliant
project. Remaining include rich &nd poor from the project area but again
in what proportion ? The hospital is mainly utilized by the rich.
Ah argument forwarded is that the pocr are given primary health
care through VHWs financed by the income generated from the rich in the
< hospital. It moans the VHWs givehelementary care in the village to the
poor and rich also but doctors and hospitals are mainly for the rich. Such
discriminatory strategy becomes inevitable when community health project
accepts the objective of economic self-reliance and tries to raise the •
income through health programmes.
It is true that the poor also should be charged a little for health
care so that they do not become objects of charity and pity. Also, if they
are charged they feel that they have paid for health care and so the care
must be of some quality, earned by them. It is common -experience that
the poor also value such treatment and advice for which they have paid..
But this logic is then taken to its extreme that the poor should pay the
whole cost of treatment. Which is pretty high in the present system. The
poor, already exploited by the present economic system has very little
resource, on which community health project further puts its claim.
An argument is often put forward that the poor also have the
capacity to pay for curative services. They manage to mobilise .the resources
when you make it compulsory for them to pay. This is the philosophy of the
private doctors. Once, when I put this argument before a poor man, he
said nLook Doctor SahabT.. If I am ill and dying and if you press me for
.charges' I shall sell my house. My family shall starve and then only I
will be able to pay your money. Put if I do it does it mean I had the
capacity to pay you ? ”
...3.. ' H
I
:• 5 :
When this objective of economic self reliance is almost thrust on.
community
health projects in the voluntary sector by funding agencies
the
let us ask a few Questions.
Who is self-reliant today ?
Is the government self-reliant in thej sense it generates all its
I It depends on squeezing the
necessary income by productive activity °? No
I
None
of
the welfare programmes of the
people by taxes, direct and indirect, f
government are selfsufficient..
Are the funding agencies-self reliant ? In spite of decades of
working, all of them continually depend on donations from people in the
developed countries. They
r~- v do
’ not’ ~generate their own income by an economic
programme run by themselves, even though their main field of work is fund
raising.
Funding agencies can raise money through Western capitalism. However
this Capitalistic system denends, at least partly on the developing countries
market is the source of income for capitalism.
for its market, and remember, the
‘
It is unrealistic to expect in such a situation that community health
projects should be able to generate enough income to become economically
self sufficient.
Health and education are the responsibilities of the state and society,
Voluntary agencies enter in it because the government
as is law and order.
cannot do it adequately for the people.> The government gives free health
care to all, specially to the poor* Then why should the voluntary community
health projects charge poor patients to whose rescue they claim to have come ?
Many community health projects tacitly accept this objective of
economic self reliance under increased pressure by funding agencies and.they
are forced to either deviate from their primary objectives or to do.various
manipulations and show that they are economically self-reliant. This includes
artificially swelling the health income, (some times by selling the
donated drugs or by including the farm income) or by hiding certain
expenditures of health nrogramme. Some projects reduce the expenditure
by underpaying their staff. AH these compulsions come because of the
acceptance of the criterion of economic self-reliance.
Having observed closely many community health projects in India and
abroad, and following our own experience* I wish to say that no community
health project which is predominantly preventive and educative in nature
and which serves mainly the poor can become economically self-reliant. All
such claims need to be reexamined because they create illusions.
Projects should try to generate income either through economic
programmes or from committed supporters who have money to donate for the
cause. Such income generation will make it less dependent on outside aid.
This cannot however be the primary objective of community health work.
6
: - 6 - :
false limitations
Another aspect which community health projects should not uncritically
accept is trying to see that the per capita health expenses in their community
health programme is equal to that of the government. Government spends a lot
of money on wrong priorities and aj-locates meagre resources for health due o
which the poor mainly suffer. \ oj.uaucu-y iiualth projects need not take i u as
their responsibility to show ways to fulfil health objectives within the false
limits set by the government. It usually means deprivation of the poor.
What voluntary agencies could be doing is to decide the minimum.health
care every person should, get and try to show the . ways of doing it at the ow.
cost level whatever thet cost should be compared to the government1 s per capita
health expenditure. This is the way by which one can press a'system to mend
its ways. Voluntary health projects should not try to fit into the system, s
false limitations, While deciding the minimum health care, the nationTs
economic standard (GW or per capita average income) should be taken into
consideration but net the per capita health expenses by the government. Otherwise
we land up with the solutions and ways of community health care which are less
than minimum t the real needy.
(This is a ^lightly abridged version of an article that first appeared
here
courtesy
in MFC Bulletin, April 1981 * ?Reproduced
,
.
. MFC-Fd. HFM. MFC is t
publish this antf other importent articles in a book form.-. For .retails
contact MFC or us) .
Source : Health for the Millions, Vol-VIII, No.3, June 1982
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CCMHUNITT
HEALTH
IN
iroiA
X
- A Study Reflection
ai*id. a stimulus
—-*. — — - for further study
1-.
Introduction to Paper
2.
Reflections
Health Care in India - An Historical Overview
I.
Health Care in Post Independent India - An
Overview
III. Health Situation in India (1990)
IV. Community Health in India s Recognising the New
Paradigm
Community Health: the axioms of’a new-approach
V.
II.
VI.
3
Is Community Health Growing as a Movement in India?
c? Oii'C
Methodology of Use
(Alternatives)
1. The paper could be read at one sitting taking all the
reflections together to get an overall understanding.
2. Each reflection could be read by a group and reflected upon.
Identify group consensus on the issues raised. Also ideutigy
areas of differing opinion and newer questions/doubts that
may arise in the group discussion.
to all the 10 key sources is made possible then
members of the group could read through the original sourcj_
and step 2 could be done againi so that this paper and its
supplemented by
conclusions would be ^^^1-...
. other analysis/
conclusions in the sources, adding to the richness of the
discussion„
3. If access
I
RAVI NARAYAN
SOCIETY FOR COMMUNITY HEALTH AWARENESS, RESEARCH AND ACTION
(COMMUNITY HEALTH CELL)
326, V MAIN, I BLOCK, KORAMANGAJU^, BANGALORE
(AUGUST - 1992)
560 034.
1
COMMUNITY HEALTH IN INDIA
A Study-Reflection
INTRODUCTION
These notes are part of a background preparation that I made for
a ’reflection’ with the participants of the Community Health Forum,
at Secunderabad in July 1991.
The framework given to me was
i) A recapitulation and consolidation of the health scene
in India.
ii) The evolution of the Community Health Process in India.
iii) Some reflections on the thrusts towards the 1990’s.
After the meeting, in the discussions that followed and later in
correspondence with some of the members I was asked to include
Health Statistics of India; the social model of health, latest
trends in health care systems; NGO’s in Community Health in India
in the 1980’s; different aspects of community health in India;
new policy by government on health. I realised that putting all
these together in a single article would mean writing a whole book
on the subject.
However since the obj ective of . . the exercise is to inform the group
about the key issues.and build a framework for further study and
reflection, I have decided to put-together my notes interspersed
^j^i-th some reflections from well known sources (books already
available) hoping to stimulate the members of the forum to make a
serious study of the ‘reading list’ provided and to build on the
evolving reflections of a large number of individuals and groups
who are recognising and building a ’social model’ of health.
During this study they should temper the reflections with their
own field experiences and those of other members of the forum,
shared during the annual and regional meetings.
’Cemmunity Health
in India’ is an evolving idea, an emerging process and we all
need a much deeper understanding and linkage if we wish to
facilitate and or participate in Health as a movement.
I present this study-reflection in the form of short reflections
and include extracts from a few of our CHC papers as well as from
the. 10 key sources which I recommend as ‘basic reading’ material
for the group. These are
Source
1.
Name
Authors & Year
National Health Policy
Statement
Health for All - An
Alternative Strategy
0.0.1.(1982)
3‘.
Health Care Which Way
to Go
medico friend circle
4.
Health Care in India
Rakkus Story
George Joseph et al
2.
5.
ICSSR/ICMR
(1981)
Sheila Zurbrigg
(1982)
CSA (1983)
CSA (1984)
2. *
Source
Name
6O
Health and Family Planning
Services in India
D. Banerji, Lok Paksh (1985)
7O
Dev 1opment with People
Walter Fernandes, ISI (1985)
8.
Taking Sides s The Choices
Before the Health Worker
Sathyamala et al
9.
Health and Power to the
People - the Theory and
Practice of Community
Health
CHAI-CHD
,10.
Community Health in India
Health Action - July 1989
Authors & Year
(1986)
(1986)
A supplementary list of 40 titles on the Indian experience which
includes the 10 above is given in the Health Action special issue
(source 10)
•*
All these books and groups do not necessarily understand and use
even the term'Community Health' in the same way - there are diverse
interpretations but the main point which I wish to stress is that
in al^ these groups and reflections some common thread of assum
ptions and perceptions are emerging. While not ignoring the
differences I feel the common threads must be identified and
focussed so that a broader and deeper collective understanding
emerges which will promote linkages and the development of larger
and larger numbers of health action initiators convinced and
committed to the Community Health movement in India.
H.B.
Source
1/2z3z7
Source
4, 5
Source
8,9Z10
Source
6
Source
1,2,10
Available from
Voluntary Health Association of India,
Tong Swasthya Bhavan,
40, Institutional Area, Near Qutab Hotel,
New Delhi - 110 016.
Available from
Centre for Social Action,
Gundappa Block, 64, Pemme Gowda Road,
Bangalore - 560 006.
Available from
Catholic Hospital Association of India,
157/6, Staff Road, Gunrock Enclave,
Secunderabad - 500 003.
Available from
Lok Paksh,
110 067.
Post Box 10517, New Delhi
Available from
Community Health Cell,
326, V Main, I Block, Koramangala,
Bangalore - 560 034.
1
I
REFLECTION - l/A
HEALTH CARE IN INDIA - AN HISTORICAL OVERVIEW
Vedic Period - to Indian Independence
*
Records of Health writings and health care in India goes back
in History to over 5000 years and is marked by many significant
developments which include particularly
i) the concepts and 'technology' of Sanitation in the Indus
Valley; (3000 B.C.)
ii) the chango from magico religious medicine to a_more rational
therapeutics in Vedic medicine - representring the development
of Ayurveda, Siddha & Yoga;
iii) the development of Social Medicine and hospitals for
humans and animals during the Ashoka/Maurya Phase (279 236 B.C.).
* The
growth of Ayurvedic and Siddha medicine is marked by the
development of famous treatises and writings of great doctors
Charaka, Susruta, Athreya, Jivaka and these traditions were very
adaptive and integrative. The strengths even in these traditions
available to this day are the sensitivity and closeness to local
culture, the stress on healthful living and not disease, and the
close links with home remedies and people’s health cultures.
The weaknesses on the other hand are that these are based on
empirical logic some of which may have stood the test of time .
but has not been supported by experimental logic; there has been
stagnation due to inadequate professional organisation and some
of the ills of Society be it class or gender inequality have got
internalised without being reviewed from a rational stand point.
It must be also mentioned that due to the factor of colonialism
some of it which continues even today in the form of cultural
colonialism, through the dominance of the western allopathic/
technocentric model (that was transplanted into the developing
health system especially during British rule) these traditional
and indigenous systems have not been adequately studied or
reviewed and have been neglected by the official health system^
A serious study and research are needed to identify the strengths
of the indigenous systems and integrate them with the dominant
system and develop a truly National System of medicine.
*
A word of caution at this stage is that efforts towards study
and integration of indigenous systems should be done without
undue romanticism or misplaced nationalism. At the same timt
care must also be taken to differentiate between People’s
health culture, local remedies which are under the autonomous
control of the people and the relatively more organised systems
that have their own practitioners, medicines and training as
well as care strategies.
* During the British
Colonial phase western allopathic medicine
developed greatly in India. While it had already been introduced '
by the Jesuits in Goa in 16th Century it did not spread till
after the advent of British rule. The Health Services during
. .1-2
I - 2
this phase primarily grew with the intention of services for the
army and civilian elite of the developing towns and cities in the
country.
Rural areas 1were neglected
. - in
.
general though there was some
missionary work that took some basic
---- health
----- 1 care to many interior
areas as well,
People had to rely primarily on traditional health
care.
It must be noted that while there .was an overall neglect of the
rural against urban in health service development (a...f..act that
is as true of the situation today as in the 1850's, the development
of health services during British rule was affected by the Public
Health revolution taking place in Europe at that time and inspite
of the overall colonial effect there were many positive develop
ments that must be recorded.
- Public health concepts came into the country in a big way with
organisation of epidemic measures and other forms of prevention
on-arlarge scale.
- The increasing focus on women and children and the increasing
training of women for health services was another positive
development. Much of the missionary work in Health was for
women and children and by women.
- After some hesitation training of local doctors and nurses and
para medicals began and the state began to take growing
responsibility for Public Health.
* Since there were many small and large princely kingdoms in India
even at the height of British rule,, these did not always keep
track of the inewer developments in the British presidency1s.Local
traditional systems got, patronage and some jthrived.
However '
Mysore and Travancore were two kingdoms that evolved very progressive public
1health and' health
-—L-’i care policies laying the foundations so to speak for the very different situation in ’Kerala’
and ‘South Kanara' in present day India.
*
In 1943-46 the Health and Development Committee (also known as
Bhore Committee) drew up the comprehensive blue print for Health
Indiao While this was a pre-independence committee
Services for India.
set up by the Provisional Government, the recommendations were
very progressive and farreaching. Three significant developments
in 1920’s to 1940’s definitely inspired this committee. The
influence of socialism and the health services of the socialist
states, the European Public Health movement and the post world
war welfare state concept as well as the growing National movement.
(The Sokhey report of the Indian National Congress is a fore
runner to a new vision of health/health care).
*
The Bhpre Committee recommendations included the following s
- Health should be an integral part of socio-economic
development.
- Adequate health care for All
- Free health care for All
- Reach out to vast rural population
- Correct rural-urban imbalance
- Emphasis on prevention, promotion and education
- Key role of self help and active cooperation of people
through representations and committees.
- Health as an individuals responsibility.
. .1-3
.
.
.
'
■'
-A:
■
'
’
■
’ .
;
1-3
* The Bhore Committee evolved .the concept of the Social Physician
worker . cooperate in team work...
- “Scientist and social worker..
close touch with people... serving disinterestedly... friend
and leader... protecting people and guiding them to a healthier
and happier life/’
* While in retrospect we
now know that there were some flaws in the
expert prescription in the form of unrealistic targets, vague
budget allocation and distributions, complete bypass of the"'"' indigenous systems of medicine, and the abolishment of the
licentiate scheme for training doctor, the Bhore report built
the framework and remained the inspiration for much of the Post
Independent Health Planning in India.
A VISION OF COMMONITY HEALTH CARE
Bhore Committee, 1946
"In drawing up a Health plan certain primary conditions
essential for healthful living must in the first place
be ensured. Suitable housing, sanitary surroundings
and a safe drinking water supply are the pre-requisites
of a healthy life. The provision of adequate health
protection to all covering both its curative and
preventive aspects, irrespective of their ability to
pay for it, the improvement of nutritional standards
qualitatively and quantitatively, the elimination of
unemployment, the provision of a living wage for all
workers and improvement in agricultural and industrial
production and means of communication particularly in
the rural areas are all facets of a single problem and
call for urgent attention. Nor can man live by bread
alone. A rigorous and healthy community life in its
many aspects must be suitably catered for. Recreation,
mental andphysical plays a large part in building up
the conditions favourable to sound individual and
community health and must receive serious consideration.
Further, no lasting improvement of the public health
can be achieved without arousing the living interest and
enlisting the practical cooperation of the"people
themselves".
•*
additional reading
01. ’The Traditional Systems1 and ’The British Period’ in
Chapter 1? The Historical Background.
(Source 4)
02. Historical Development in Chapter III - The Health
Care System. (Source 5)
03. Health Culture of India and the Colonial legacy in
Chapter 1, Environmental Setting and Political Economy
of Health and Health Services.
(Source 6)
04. Health issues and the National Movement in Chapter 2,
Colonialism^ the National Movement and the Health
Services. (Source 6)
. .1-4
I
-
IC-
.
'■
■
■
4
■■■•
QUESTIONS AMD TASKS
■
'■
-
..
’
'
01. History teaches us a. lot about the factors that have
contributed to health services development - those
that have been obstacles and those that have been
promoters. In your own region find out about the
history of.specific institutions and locate them in
the context of the wider historical developments.
02. Identify all the components of Health Services
currently available in your area including
traditional systems of medicine. Try and build
up a local history and historical context for your
area.
r
Q. How does study of history and. medical culture help us?
A. The history of medicine is both history and medicine.
It is a historical discipline like the history of
art or the history of. philosophy.
It helps to give
us a more complete picture of the history of civili
zation, because it is obviously not unimportant to know
what diseases affected the.people in the past, what
they did to protect and restore their health and what
thoughts guided their action'...
But the history of medicine is also medicineo
By
analyzing developments and trends it permits us to
understand a situation more clearly and to act more
intelligently. We all know that success or failure of
our medical work depend not only on the scientific
knowledge we possess but also on a great variety of
other "nun-medic-al—factors, on economic, social, religious,
philosophical, political factors...that are the result of -historical developments. Unless we are aware of them and
understand them many of our efforts will be wasted.
. --Henry Eo Sigerist
SOURCE; Report of the Health Survey and Development
Committee (Bhore Committee), Vol,III - Appendix 47.
-x-x-x-
1
II
REFLECTION - Il/A
1
HEALTH CARE IN POST-INDEPENDENT INDIA
An Overview
The Constitution of India adopted in 1950 clearly recognises the
government's responsibility for the health of all the people.
This commitment has led to the evolution of a large number of
health programmes over the last 40 years.
Constitutional Pledges
The State shall regard the raising of the level of nutri
tion and the standard of living of its People and the
fteen'sureas among its primary duties.
* that the health and strength of workers, men and
women, and the tender age of children are not
abused....
*
that children are given opportunities and facilities
to develop in a healthy manner..„.
It shall make
■k
provisions for securing just and human conditions of
work and for maternity relief....
and
*
for public assistance in cases of unemployment, old
age, sickness and disablement and in other cases of
undeserved want.
- Constitution of India
These included the
- Development of the Primary Health Centre concept for every one
lakh population.
- The training of health teams including doctors, health inspectors,
lady health visitors, auxiliary nurses, midwives, basic health
workers, block extension educators for these health centres.
- The National programmes for communicable diseases like Tuber
culosis, Leprosy, Malaria, Filaria, Plague, Cholera and so on.
- The Maternal and Child Health, Nutrition and Family welfare
programmes.
- Efforts at re-orienting medical and nursing education.
- Establishment of research and specialist institutions.
- The integration of programmes at PHC level, evolving the multi
purpose health workers and health supervisor cadres.
- Establishment of pharmacies and training of pharmacists.
- Production of medical technology needed for hospitals and
dispensaries.
9all-2
II r 2'Taking Stock
In 1972, when we celebrated the Silver Jubilee of our independence,
there began a critical reflection and introspection on the prece
ding twenty five years of development. This was an important
milestone and it became a focus to take stock of the strengths
and weaknesses of our planning and development particularly in
the context of the continuing poor quality of life of a large
majority of Indian citizens. All aspects of national development
came under scrutiny and health policy was no exception.
Assessing achievements/failures
A study group of the Indian Council of Medical Research and the
Indian Council of Social Sciences Research in 1984 listed out the
achievements and failures of the whole health care strategy.
Achievements
- Life expectancy doubled
- Health care services expanded
- Manpower training centres increased
- Small-pox was eradicated
- Plague, Cholera and Malaria controlled
- Maternal and Child Health and immunization programmes
increased
- Largest Family Planning Programme in the world
I
i
Failures
- lie
Health
notU j.11
integrated
a J_ l_l 1 HU
cey j_ a ceu with
wjl c-i i Development
v
a.
11-1
i
- Little dent on Malnutrition and Environmental Sanitation
- Morbidity patterns not materially changed
h
- Health Education neglected
- TB, Leprosy, Filaria yet to be controlled
- Infant and Maternal mortality rates still very high
- Population stabilization - a long way to go
Overall
1. The model of health care was outdated .and counter
productive benefitting thfe rich and well-to-do upper
and middle classes.
2. Health was a low-priority national investment.
____ __ Source r-TCMR/lCSSR
Quantitative Expansion
We had made some rapid strides and a phenomenal quantitative
expansion of health care services. This increase in manpower and
infrastructure development continued into the eighties.
By 1984, we had,increased the number of hospitals and dispensaries
three-fold, doctors five-fold, nurses ten-fold and dental colleges
seven-fold — remarkable development indeed it seemedl
However, when we compare this infrastructural development with the
Bhore Committee's long term goals; enunciated in 1946 itself,
find the situation very different and the so called 1 rapid ggrowth'
becomes questionable.
Increasing numbers with goals and base lines can be very misleading!
3
II
Critical Introspection
In the seventies, the Government of India set up an expert group
on Medical Education and Support Manpower to take stock of the
situation and suggest proposals for reforms.
This i£-what the expert committee (Srivastava Report, 1975) had
to say :
1. t;A universal and egalitarian programme of efficient
and effective health services cannot be developed
against the background of socio-economic structure
in which the largest masses of people still live
below the poverty line. So long as such stark *
poverty persists, the creative energies of the
people will not be fully released; the State will
never have adequate resources to finance even min
imum national programmes of education or health; and
benefits of even the meagre investments made in
these services will fail to reach the masses of the
people. There is, therefore, no alternative to
making a direct, sustained and vigorous attack on
the problem of mass poverty and for creation of a
more egalitarian society. A' nationwide
'
,ri“ programme
- of
health services should be developed side by side as
it will support this major national endeavour and
be supported by it in turn."
2."We have adopted tacitly, and rather uncritically the
model of health services from the industrially adva
nced and consumption-oriented societies of the West).
a
1
• i —
1 +“ "K
This
had-1 its
own inherent fallacies; health
gets
wrongly defined in terms of consumption of specifid
goods and services; the basic values in life which .
essentially determine its quality get distorted;
over—professionalizatiQn._increases costs and reduces
the autonomy of the individual; and ultimately there
is an adverse effect even, on the health and happiness
of the people. These weaknesses of the system are
now being increasingly realized in the West and atte
mpts are afoot to remedy them. Even if the system
were faultless, the huge cost of the model and its
emphasis on over-professionalization is obviously
unsuited to the socio-economic conditions of a
developing country like ours. It is therefore a
tragedy that we continue to persist w.ith this model
even when those we borrowed it from have begun to
have serious misgivings about its utility and ultimate
viability. It is, therefore, desirable that we take
a conscious and deliberate decision to abandom this
model and strive to create instead a viable.and
economic alternative suited to our own conditions,
needs and aspirations. The new model will have to
place a greater emphasis on human effort (for which
we have a large potential) rather than on monetary
inputs (for which we have severe constraints)."
3."In the existing system, the entire programme of
health services has been built up with the.metro- >
politan and capital cities as centres- and it tries
I
II
4
to spread itself out in the rural areas through
intermediate institutions such as Regional, District
or Rural Hospitals and Primary Health. Centres and its
sub-centres/ Very naturally, the quantum of quality
of the services in this model are at their best in
the Centre, gradually diminish in intensity as on&
moves away from it, and admittedly fail at what is
commonly described as the periphery. Unfortunately,
the ’periphery' comprises about 80 percent of th0
people of India who should really be the focus of
all the welfare and developmental effort of the State.
It is, therefore, urgent that this process is rever
sed and the programme of-national health services
is built with the community itself as the central
focus. This implies the creation of the needed
health services within the community by utilising
all local resources available, and then to supplement
them through a referral service which will gradually
rise to the metropolitan or capital cities for dealing
with more and more complicated cases.”
4. "Throughout the last two hundred years, conflicts have
arisen in almost every important aspect of our life,
between our traditional patterns and the corresponding
systems of the West to which we have been introduced.
In many of these aspects, the conflicts are being
resolved through the evolution of a new national
pattern suited to our own genius and conditions. In
medicine and health services unfortunately, these
conflicts are yet largely unresolved and the old and
new continue to exist side by side, often in functi
onal disharmony. A sustained effort is, therefore
needed to resolve these conflicts and to evolve a
national system of medicine and health services, in
keeping with our life systems, needs and aspirations”.
Maay other expert committee reports and policy statements of the.
seventies began to make critical observations about the inadequacies
of the present health care model and exhorted all concerned to
search'.for more relevant alternatives and approaches.
Prof. Banerjee of JNU (Source 6), offers a deeper social analysis
to explain this growing dichotomy. His contention is that the
post-independent leadership had two basic choices in front of them.
Either to expand health services along the pattern set up by the
Britishers choice or to introduce radical changes to answer needs
of the ordinary masses, while the latter was the choice in most
policy documents the class character of the leadership affected
the realities in practice. The old colonial traditions were
perpetuated with the focus on urban and curative. The doctors.
came from the privileged classes and had internalised the elitist
and modernising- ethos. The humanitarian principles and socialist
declarations notwithstanding/ the overall focus was on a capitalist
framework. Health policies of the 1950’s end 1960's mainly
answered ideals/aspirations /needs of upper and middle classes and
the health professionals who belonged mainly to these classes, The
focus was mainly on hospitals, medical colleges, and curative
services in cities whilst rural areas got low Quality curative care,
some communicable disease control and more family planning services.
..11-5
II
5
. This basic dichotomy of needs and aspirations and class character
of leadership explains the overall consistent lack of political
will; the increasing dichotomy of services for the classes and the
masses; the increasing urban-rural differential; the over emphasis
and target orientation of Family Planning; the promotion of the
health industry; the increasing corruption in the services and
growing ethos of private practice; the neglect of the indigenous
systems of medicine; the populist modification of programmes; the
statistical misinformation; the verticalization of programmes;
the increasing neglect of public health standards and practice;
the inadequate health education and awareness building strategies
and the more recent glorification of technology and the promotion
of privatization in health care.
Some of this is echoed in the National Health Policy of 1982 which
is part of the growing rethinking on Health Care in India.
’Community
Health
’ \ ”
“ ' Action*
’ is therefore to be seen in this broader context.
II/B-
ADDITIONAL READING
01. The Post-Independence Model in Chapter I The Historical Background.
(Source 4)
02. Towards a Proper Analysis, Chapter 4
03. The Health Care System, Chapter 3.
(Source
(Source
4)
5)
04. Forces Shaping the Health System, Part III. (Source 5)
05. Health Services Since Independence, Chapter 3.(Source 6)
06. The Development of Health Services in India, Section III
Chapter 1. (Source 8)
Il/C-^ QUESTIONS AND TASKS
01. Visit the nearest Primary Health Centre and Sub Centres
in the Taluk/Block in which you are working. From the
PHC doctor and health centre staff find out about the
organisation and functions of the centre, What are their
problems and difficulties.
02. Talk to groups of people in your community from different
socio-economic and cultural groups and ask them about their
experiences of health care in the government PHC or
sub-centres.
03. From these two steps build up your analysis of the
situation of health care in your area - the projected
achievements and the actual realities.
04. Try and identify the factors that operate at the local
level/di.strict level/state level promoting or obstructing
health service development, accessibility and efficiency.
* * * *
* -A- *
-k *
*
..11-6
■'.'i
II/D-
II
6
STATEMENT ON NATIONAL HEALTH POLICY, GOVERNMENT OF INDIA, MINISTRY
OF HEALTH & FAMILY WELFARE, NEW DELHI, 1982 (An Extract)
The Existing Picture
exxs
?ty
of their lives. The mortality rates for women and children are
still distressingly high; almost one third of the total deaths
occur among children below the age of 5 years; infant mortality
is around 129 per thousand live births. Efforts at raising
nutritional levels of our people have still to bear fruit and the
extent and severity of malnutrition continues to be exceptionally
high. Communicable and non-communicable diseases ^Lndness
be brought under effective control and eradicated. Blindn
,
Leprosy and T.B. continue to have a high incidence. Only 3U of
the rural population has access to potable water supply and 0. /»
enjoys basic sanitation*
1) High incidence of diarrhoeal diseases and other, preventive and
infectious diseases, specially amongst infants and children,
lack of safe drinking water and poor environmental sanitation,
poverty and ignorance are among the major contributory caus
of the high incidence of disease and mortality*
2) The existing situation has been largely engendered by the^almost
wholesale adoption of health manpower development policies an
the establishment of curative centres based on the Western models,
which are inappropriate and irrelevant to the real needs of our
people and the socio-economic conditions obtaining in the country.
The hospital-based disease, and cure-oriented approach toward th
establishment of medical services has provided benefits to the
uocer crusts of society specially those residing in the urban
areas. The proliferation of this approach has been.at the cost
of providing comprehensive primary health care services o
entire population, whether residing m the urban or the rur
areas. Furthermore, the continued high emphasis on the curative
approach has led to the neglect of the preventive, promoti ,
public health and rehabilitative aspects of the health care, The
■
'
----- "3 and building
existing approach instead of- improving
awareness
tended
to
enhance
dependency
and,weaken the
up self-reliance, has
-The prevailing
community's capacity to cope with its
policies in regard to the education and training of medical and
P
health personnel, at various levels, has resulted in ~ ®
ment of a cultural gap between the people and the personn 1
providing care. The various health programmes have, by and
large, failed to involve the individuals and families in esta
blishing a self-reliant community. Also, over the years,
planning process has become largely oblivious of the fact tha
the ultimate goal of achieving a satisfactory health status
for all our people cannot be secured without involvi g
community in the identification of their health needs and
priorities as well as in the implementation and management of
the various health and related programmes.
III
1
REFLECTION - IIl/A .
HEAILTH SITUATION IN INDIA (1990)
* Since independence there have been much efforts to improve the
health status of the people and in the 1980's policy statements
a 'commitment to health as a social goal with emphasis on
equality of health service for all social groups in the country
has emerged.
*
“A detailed examination of available information on mortality
(death rates), morbidity (illness rates),' delivery of health
services and development of humanpower and their deployment
reveals that the picture of health status in the country is
not as rosy as it seems on the surface".
*
Mortality in India
(National in 1988
11,8 Rural
7.5 Urban)
- Rural and Urban death rates S(CDR) show a continous decline in
the period studied 1971-1988.
- Rural death rates are substantially higher than urban rates
in all the states with the singular exception of Kerala.
- Rural death rates in Bihar, Madhya Pradesh, Rajasthan and
Uttar Pradesh are substantially higher than national average
and the urban-rural differential is unacceptably high.
* Age
and Sex specific death rates
- At newborn male and female weights and heights are similar,
if anything the female child is slightly better off.
- Below 10 years of age the death rates in females both in
urban and rural areas is clearly higher than in males. The
inference therefore is inescapable that the family and social
environment in the early years is adverse for the female child.
- In 10-14 age group the rates are similar in rural areas and
female is better than males in urban areas.
- In age 15-34 female death rates are higher than males, the
difference being much higher in rural areas and in younger
ages.
- Beyond 35 years female enjoy a lower death rate -when compared
to males.
Inference s Child bearing takes a heavy toll of death in women
in the country especially rural sector and reflects poorly on
the Health Services.
* Infant Mortality Rates
(National in 1988
102 Rural, 61 Urban)
- Infant mortality rate is above 100 in Assam (101), Bihar (100),
Gujarat (101), Madhya Pradesh (127), Orissa (127), Rajasthan(111),
Uttar Pradesh (132) in 1988 and below 100’ in all the other
states. Kerala is the lowest with 30.
..111-2
Ill - 2
'
- In Punjab, Haryana, Himachal Pradesh and Uttar Pradesh IMR is
higher in females than . in .malesIn Assam, Andhra, Karnataka,
Kerala, Orissa, Jammu & Kashmir and West Bengal, IMR is lower
in females than in males. In all the other states it is more
or less similar.
- Rural IMR’s are substantially higher than Urban IMR with
exception of Kerala.
- Neonatal and post neonatal mortality rates show a decline in
all states from 1970 to 1985 except Haryana. Rural rates are
substantially higher than urbah rates.
* Maternal Mortality Rates
(National in 1987
= 3.6)
- One percent of all rural deaths are reported to be due to
child birth and pregnancy in India.
- In 1987 the national average was calculated at 3.6/1000 live
births. Uttar Pradesh (7.1), Himachal Pradesh (6.5), Bihar (6),
Madhya Pradesh (6.1), Rajasthan (4.5), Orissa (4.3), Haryana(4).
All the other states had lower than National average with Kerala
being the lowest (0.6) and Karnataka a close second (1.0).
- Rural MMR in India is about 15 times more than what it should
be for an Asian country and probably 60 to 80 times more than
that in developed countries of the West.
- In a study in Anantpur District (Bhatia, J.C., IIM-Bangalore,
1984-85) MMR was higher in 15-34 age group and nearly half of
all deaths in 20-24 age group was due to maternal death.
43.5% of maternal deaths was on day of delivery and 41.9%of
deaths due to bleeding and infection(1).
-70% of all births in rural India are attended to by untrained
persons.
- An ICMR study on the quality of MCH services in rural India
published in 1989 shows that elementary care of women during
delivery is grossly inadequate in India.
* Causes of Death
- Tuberculosis, Pneumonia, Anemia, Gastro-enteritis, Dysentery
and Typhoid account for 20% of all deaths in India.
- Communicable diseases account for 40% of all deaths in India.
- Diarrhoea is a major cause of illness and death in children
in India.
* Nutrition Status
- The National Nutrition Monitoring bureau monitors’nutrition in
the states of Kerala, Tarnilnadu, Karnataka, Andhra, Maharashtra,
Gujarat and Orissa.
- Barring Gujarat and Orissa all other states have shown an
improvement in nutritional status from 1975 to 1989.
- The girl children have shown greater improvement than the boys!
..111-3
III
3
- Moderate and severe malnutrition among tribal boys and girls
is high in all these states.
"V
- Vitamin A deficiency in pre-school children ranges from 5-10%.
*
Communicable and Non Communicable Diseases Mortality
Tuberculosis, Leprosy and Malaria .are still major probl eins.
Progress in control of TB is disappointing. In Leprosy’ with
the introduction of multi drug therapy.there seems more hope.
Malaria has shown an increase from 1986 to 1988 (data available)
in the states of Andhra, Gujarat, Karnataka, Madhya Pradesh,
Maharashtra, Rajasthan and Tamilnadu.
* Goitre, Cancer and Blindness are increasingly being
recognised
as major problems.
Health infrastructure and health manpower
■jSr
There is growing evidence that1’the large functional infrastructure
claimed to have been created in the country only exists largely on
paper.
* Official
statistics indicate that the objective of having a
subcentre for 5000 people1 in rural areas and 3000 for hilly and
tribal areas and a primary health centre for every 30000 population
is very nearly achieved. On the other hand, the National Institute
of Health and Family Welfare's National review of Immunization
programme shows that only 45% of district have subcentre for every
5000 population.
* The ratio
of male to female multipurpose worker which should be
Isl is Is 1.6 which shows a shortage of male workers.
* The availability of
all types of nurses is inadequate.
* The practitioners
of the indigenous system are about 4 lakhs
(registered) but are yet to be involved meaningfully by the
health care system.;
“In summary, it is no exaggeration to say that the health scene
in the country is really grim even after 40 years of independence.
It is being increasingly realised now that the goal of good health
for the people of India can only be reached through a process that
is multidimensional, encompassing appropriate universal education,
better environmental manaqement both at home and outside, well
integrated social services, an acceptable minimum living standard
and of course health and medical care of acceptable quality!
The message from the even the limited data presented in this pape£
is loud and clear. The medical model of health which merely
concentrates on the use of technological resources in freeing man
from clinically identifiable disease or disorder is at its best an
inadequate and at its worst an uneconomical and unproductive
approach for the improvement of the health of a people. The medical
..111-4
ITT -.4 ’
model has to be tempered by the social model of health which as
mentioned earlier approaches the goal of good health through a
multi-dimensional process. Health development has to become an
II
integral part of the socio-economic developmental process
(This section is principally and substantially an edited and
summarised version of a recent paper (1990) on 'Current Status
of Health in India* presented by Prof. K. Ramachandra, Professor
of Epidemiology and Statistics of All India Institute of Medical
Sciences, New Delhi. The original paper is 8 pages with 23 pages
of tables as appendix and is available on request from CHC,
Bangalore).
III/B-
ADDITIONAL READING
01.
'The Current Health Situation* in Chapter 1
Wanted an Alternative National Health Policy.
(Source 2)
02.
'The Post Independence Model1 in Chapter 1
The Historical Background.
(Source 4)
03.. The Present Situation - Chapter 3.
(Source
4)
04. Many interesting tables in different chapters
in Dr. Banerji’s book. (Source 6)
05. The development of Health Services in India
including health of children, women, adults,
nutrition. Health Education and'Family Planning,
Page 125-235.
(Source 8)
III/C-
SOME QUESTIONS AND TASKS
01. From all these source prepare a statistical profile
of the state in which you are working.
02. Compare your state's situation with the other
states. What does, this exercise teach you.
03. Visit the nearest government primary health centre
and or the District Health Officer and find out the
latest statistics for your area/region. Reflect on
these in light of some of the issues raised.in the
paper.
04. Send these region/district/state profile prepared
by you to other forum members and resource groups
to initiate a reflection on diversity of needs and
local situation.
IV
1
REFLECTION - IV/A
COMMUNITY HEALTH IN INDIA
RECOGNISING THE NEW PARADIGM
Since the mid-sixties there has been a growing disenchantment with
the models of development including health care services, which
we adopted, somewhat uncritically, from Western industrialised
nations. This stemmed from the growing field experience of the
inadequacies of these models to meet the needs of the large
majority of our people and a growing realisation that "development”
is a socio-economic-political-cultural process, which must evolve
its own local solutions. These solutions must involve, a critical
appraisal of technological packages and their adaptation to fit our
own, rather different social realities.
This disenchantment took many forms including the evolution of much
analytical and imaginative writing, innovative field projects,
ideologically based people’s movements and protests. Besides
questioning and challenging the assumptions and values of borrowed
models and methods, there was also a re-examination and reappraisal
of the experience and thrusts of the post-independence period as
well as our own cultural traditions. This quest for new values,
new attitudes, new processes of social change has pervaded all
aspects of development in India and Health care is no exception.
Since the early seventies a large number of initiatives and projects
have been established outside the Government system by individuals
and groups keen to adapt health care approaches to our social
realities and this response has grown. Broadly classified as
voluntary organisations or NGOs, these initiatives were predominantly
rural to -begin -with but in recent years the focus on tribal regions
and urban slum communities has grown. Starting with illness care,
most of them moved on to a whole range of activities and programmes
in health and development, described later. Initially th£y. de-velcped
independent of each other but, over the years some networking and
training programmes emerged inspiring similar attempts elsewHere.
As the phenomena evolved community development projects and
community education experiments also began to add dimensions of
health in their approaches. In more recent years further networking
to share ideas and experiences, evolve some common perspectives and
organise some collective action on broader health issues has taken
place.
;•
In the late 1970s I. believe there were two distinct schools of
thought on Community Health (refer Source 3).
* The
first school of thought understood the real cause of ill
health as being rooted in the present economic—political system.
It believed that nothing can be done or should be done unless
the present economic-political system could be changed. This
generated an inactive cynicism about the health of the people.
The political activists of the left parties particularly belonged
to this school.
.
* The second school of thought believed that the panacea for all
health problems had been found in the ’alternative approach' utilizing non-professionals and appropriate technology and
some micro-level management innovation. Village Health Workers
and ’appropriate low cost technology’ was felt to be the answer.
This generated an ill founded euphoria. The group evolving under .
the amorphous- title of voluntary agencies (volags, NGO’s)
belonged to this school.
o.IV-2
.1
IV
2
* While the first school did not understand the 1 social' meaning
or potential of health the second school did not locate their
action in the context of social change. Much more energy was
spent attacking each other than jointly countering the medical
model of hdalth.
* In the latel970's - some integration began to take place through
greater and deeper understanding and the more integrated concept
of ‘community health emerged as an essentially multidimensional
process -including socio-political, socio-cultural, technological
and managerial components (See Source 10). This generated a shift
in the understanding of health from its medical technologised
model to its social model - with health being seen more and more
as an empowering/enabling process rather than a provision of a
package of services.
Networking among individuals and groups around issues of health care
began in the early seventies. The medico-friend circle - a pionee
ring example among these, was a loose-knit network, (of all those
who shared a common conviction and understanding that the present
health services and medical education system was lopsided in the
interest of the privileged few and must change to serve the
interest of the large majority - the poor people of India) that
began in 1974. It saw itself as a thought current upholding human
values and certain new attitudes in health care and medical education
(see box) and 1 offered a forum for debate and dialogue to share
experiences and experiments’ and * for taking up issues of common
concern for action1.
The medico-friend circle —
works towards a pattern of medical care adequately geared
to the predominant rural character of our country.
works towards a medical curriculum and training tailored
to the needs of the vast majority of the people in our
country.
wants to develop methods of medical intervention strictly
guided by the needs of our people and not by commercial
interests.
I
stands for popularisation and. demystification of medical
science.
:
believes in a democratically functioning health team.and
democratic decentralization of responsibilities.
stresses the primary role of preventive and social measures
to solve health problems on a social level and the impor
tance of planning these with active participation, of the
community.
works towards a kind of' medical practice built upon human
values^ concern for human needs, equality and against
negative, unhealthy cultural values and attitudes in soci
ety e.g., glorification of money and power, division of
labour into manual and intellectual, domination of men
over women, urban over rural, foreign over Indian...,
beljeves that non-allopathic therapies be encouraged to take
their proper place in the modern system of medical care —
— medico-friend circle — perspective and activitieso1984
. \rv-3
*
’•
IV - 3
, While the medico-friend-circle represents a network of individuals,
the All India Drug Action Network which emerged in the early eighties
is another pioneering example of networking around a common health
policy issue. Keen to promote a rational drug policy and more
rational prescribing practices in the Indian situation, this
network includes a large number of health groups and associations,
consumer groups, social activists, trade unions, university depart
ments and hospital associations. This is again a significant
development since the Health for All study group had warned in its
report ‘that eternal vigilance was required to ensure that the
health care system does not get medicalised, that the doctor
drug-producer axis does not exploit the people and that the abundance
of drugs does not become a vested interest in ill-health1.
In the last decade many more initiatives and networks have emerged
representing the rich", diversity “of this--ferment. •
—-------
The peoples science movements in Maharashtra and Kerala states
(Lok Vidnyan Sanghatana and Kerala Sastra1 Sahitya Parishad) are
prototypes of science movements that are beginning to address
health issues in their campaigns. The LOCOST experiment in low
cost, quality tested supplies of drugs to voluntary health organi
sations and small hospitals in Gujarat is another, more focussed
but relevant example. The inclusion of wider ‘health policy' and
social issues on the agenda of junior-doctor movements., the emer
gence of the. Socialist Health Collective, the regional or state
level drug-action forums are more examples. The establishment of
the Asian Community Health Action network, -encompassing much of
Asia, is another example”'of commitment:’ ter •similar concerns- -in----health care and symbolises the fact that this trend, being.described
in India, is part of a much wider regional trend.
"The Asian Community Health Action Network views health.as
the physical, mental, social, spiritual, economic and
political wholeness of the individual and the community .
It believes that health problems and•priorities, should.be
viewed in terms in which the community sees them and that
the community should be actively involved in the planning,
implementation, monitoring and evaluation of health care
programmes ......
It seeks to spread a philosophy 'of' community based-heal-th--care that envisages a process of self-reliant human
development for the oppressed poor in Asian communities
which will result in genuine social change.'1
- An introductory pamphlet of Asian Community
Health Action Network, 1982.
The Voluntary Health Association of India, which began in the early
seventies as the coordinating Agency for Health Planning was a more
formal attempt to bring together this growing commitment to alter
native and community approaches to health care. As a federation
of state level networks linking over 3000 health institutions and
community health programmes in the country VHAI has been spearheading various
aspects
of
’
” a ‘health
for and by the people1
o oIV-4
i
approach through informal workshops and training programmes,,
H
What is our new vision of health care?
Community Health1 . We begin with the Community. Our
goal is a healthy community, We believe in health by
the people.„..
We promote social justice in the provision and distri
bution of health care....
We encourage people to demand health services as a
human right...o
Our old health services have been built to favour the
educated, the privileged and the powerful....
We wish all goods and services, to be more equally shared :
with the whole community....
We assist in making community health a reality for all
the people, of India, with priority for the less privi
leged millions, with their involvement and participation
through the voluntary health sector."
-— Introductory pamphlet
Voluntary Health Association of India.
In the early eighties two other formal coordinating agencies o_f
hospitals and dispensaries under ’church’ sponsorship, the Catholic
Hospital Association of India (around 2000 member hospitals and
dispensaries sponsored by the Catholic Church) and the Christian
Medical Association of India (around 300 protestant institutions
and about 5000 individuals associated with these institutions.'
have both begun to reflect this changing trend in policies and
programme directions.
(See boxes). Their policy statements
illustrate their awareness of our ’health care' realities and
their attempts to respond to these needs through a re-orientation
of their earlier preoccupations.
"Health is the total well being of:individuals, families
and communities as a whole and not merely the absence
of sickness. This
7' * demands an environment in which the
basic needs are fulfilled, social well-being is ensured
and psychological as well as spiritual needs are met...
The concept of Community Health .. should be understood
as a process of enabling people t.Q. exercise collectively
their responsibilities to maintain theiir health and to_. J
demand health as their right. Thus it is beyond mere
distribution of medicines, prevehtion of sickness and
income generating programmes.
— Policy statement of Catholic Hospital 1
Association of India, 1983.
..IV-5
1
IV
5
“CMAI emphasises its commitment to Community Health - an
approach that takes into consideration the needs and
problems of the community and begins with a strong
community based primary health care system. Community
Health Care starts with people - the community and is a
process that recognises their right to health care. It
enables or empowers them to work together to promote
their own health and to demand appropriate health care
services. It encourages people to take responsibilities
for their own health and to influence decisions that
affect their future. It expects health care services
to be relevant, low cost, effective and acceptable to
the people.”
- Policy Statement, 1986; Christian Medical
Association of India.,
and
A very recent addition to this trend/analysis, though more compre
hensive and scholarly, is the rather voluminous 'Epidemiological,
socio cultural and political analysis' of the health care situation
in India (Banerji, 1986).
This attempts to formulate the postulates of a new theoryz a new
framework within which the ‘evolving health care’ ferment could
be placed (refer box).
"Health service development is thus
a) a socie-cultural process;
b) a political process; and
c) a technological and managerial process with an
epidemiological and sociological perspective.
There is often a lag between socio-cultural aspirations
of the people and their articulation by the political
leadership; the lag is much more between aspirations of
the political leadership and the community health physi
cians who have the responsibility for building the needed
edifice of the health services. The task is to narrow,
if not totally eliminate, lags that may exist within the
three tiers.
Formation’of a critical mass of community health physici
ans and other members of the team which can take full
advantage of the scope, offered by the base (i.e.,
the
(i.
complex of ecological, epidemiological, cultural, social,
political and economic factors) are needed and require.
a new approach to education of community health physici
ans and other members of the team.”
Do Banerji (1986)
jr_ of 'Community Health' in India must be understood. as an
The_ concept
evolving perspective that has diverse interpretations and varied
formulations as the above sources exemplify but there is also an
evolving common thread between these newer analysis, exhortations
and actions.
(adapted from Source 10)
IV/BIV/C-
ADDITIONAL READIWG
SOME QUESTIONS AND TASKS
- Refer end of REFLECTION VI
- Refer end of REFLECTION V
. . IV-6
IV
IV/D -
6
VALUES FROM OUR TRADITION
For the Alternative-.Paradigm
There are five major contributions which our traditions can make to
the development of values which underline the alternative model of
health care,.; -
1) The basic philosophy of our tradition, with its ashram concept
of stages in life can prepare an individual better to accept
life and death; he grows up as a disciplined young man (Brahmacharya); lives his life fully-in 'adultho.od (Grihastha) ; adjusts
to old-age and begins to withdraw from active live (Vanaprastha);
and finally becomes totally uninvolved and gets ready to meet
death (Sanyasa). The more•widespread such outlook becomes, the
better will be the basis of health among the people, because it
will inculcate the right attitudes to pain, to growing old, and
to death.
2) Another valuable aspect of our tradition is its no.n-consumerist
approach to life which is in total contrast to the consumerist
civilization of the industrialized West. Our tradition would
make health an individual responsibility and root it in simpli
city and self-discipline. The concept of health in the industrial
civilization is that of a commodity. This model has created its
own problems even in the affluent countries and health is becoming
a costlier and rarer commodity all the time. For developing
countries like ours, this model can only be a disaster. A return
to our own tradition in this regard is the only road to good’ health.
3) In our tradition, health services are essentially an individual
and community responsibility; each corfimunity organised its own
health services and maintained.them and the Stat^, had no han4 in
the matter. We have now borrowed the concept of State support
for health sendees with a vengeance. The sense of individual
responsibility has thus begun to be eroded; and we are not
allowing the community to undertake even those services which
it alone can organise, and have created an attitude of total
dependence on a. State which is incapable of providing the services.
What we have to do is to combine our traditional concern for
community participation with discriminating but substantial State
support.
4) Yoga can be a jpowerful instrument for physical and mental health.
It needs to be popularized through the educational and healthi
;
systems.
5) Our tradition places a strong emphasis on simple but effective
things such as naturopathy, the use of simple medicines, tpe
practice of growing herbs needed in day-to-day illnesses in
backyards or other places in every locality; games and sports
which require -.1 ittle equipment or space; and so on. These
valuable ideas ^should not be allowed to die out in preference
to the costly life-styles with which a profit-motivated, capitalist
civilization tries to encourage consumerism.
(Source ; Health For All - An Alternative Strategy, ICSSR and
ICMRZ pages 96 and 97)
9
A
V
REFLECTION-V
1
THE COWMTTY HEALTH APPROACH
In an informal study-reflection process we initiated.in India over
the years 1982-86 we discovered that this term means different
things to different people and there are a very large range of
ideas and dimensions that are included by health care action
initiators when they use this term to describe their action or
their approach. Our objective was not to build a single, well
defined, definition acceptable to all concerned but to probe the
depths of the definition and identify the richness and diversity
of the possibilities. What we discovered, was a range of dimensions
far beyond what we generally understand or describe as "primary
health care" or "community medicine". We outline these possibi
lities to help evolve the component axioms of a new approach encompassing its philosophical assumptions, goals and methodologieso
Building on the CHAI vision of “enabling people, ’to exercise
collectively their responsibility to their own health and to
demand health as their right, we evolved a more detailed.formulation
of the approach.
These were
The "Community Health" Approach
involves the increasing of the individual, family and community
autonomy over health
and
over the organisations, the means, the opportunities, the
knowledge and the supportive structures that make health
possible.
The "Community Health" Approach
includes an attempt to integrate health with development
activities including education, agricultural extension and
income generation programmes;
an attempt to orient existing medical programmes towards
preventive^ promotive and rehabilitative actions;
a search for and experimentation with low-cost, effective,
appropriate technology in health care, health communications
and recording systems;
a recognition and involvement of local, indigenous, health
resources like traditional birth attendants (dais), traditional
healers, folk-medicine practitioners, non-allopathic systems
of medicine, herbal medicines and time-tested home remedies;
a training and involvement of village-based health workers;
a initiation of greater community organisation through farmers,
youth and women's clubs;
an increasing involvement and participation of the community,
through formal and informal organisations and, health .committees,
in decision making for health action including planning, financing,
organising and evaluation of health actions;
. .V-2
V - 2
a quest for generating greater community support in health action
through cooperatives, health insurance and other schemes as well
as tapping locally available labour, human skills and material
resources;
an organisation of informal and non-formal, demystifying and
conscientizing programmes of education for health.
The Community Health approach
is essentially a democratic, decentralised, participatory, people
building and people empowering activity
and.
,
recognises that this new value system must pervade the interaction
between the community and the" "health action" initiators as well
as within the team of "health action" initiators themselves.
To enhance the "community health" approach it is therefore nece
ssary for "health action" initiating teams to evolve a greater
democratic, non-heirarchical, participatory, team building and
"team empowering" ethos in their own relationships as individuals
and members of a team.
The Community Health Approach
recognises that in the present inequitous and stratified social
system there is no "community" in the real sense of the word and
hence community health action will invariably mean, the increasing
organisation, involvement and participation of the large sections
of the community, who do not participate adequately in decision
making at present i.e., the poor, the underprivileged, the margi
nalised.
Such attempts will invariably be opposed by "status quo" forces
and all those who draw greater advantage from the present situationa
A "community health approach" will recognise the presence of these
conflicts of interests and the inevitable social tensions conse
quent to community health action but being committed to a
"community empowering" process it will support actions and
struggles as they go beyond "health" issues.
The Community Health Approach
.
recognises that the large majority, the poor and the disadvantaged
are not themselves "one community" even though they are.linked
by their poverty and social situation, since they have interna
lised various social, cultural, religious and political diffe
rences that divide society at large.
It therefore accepts that in terms of process, efforts to imbibe
the concept and the spirit of community, to improve group dynamics
and group inter-relationships are preliminary to evolving commu
nity actions of any sort. Hence through all its component
programimes and activities, the community building process will be
promoted and enhanced.
The Community Health Approach
recognises that the present over-medicalised health care system
is characterised by certain features viz., heirarchical team
functioning and non-participatory decision making;
water-tight division of responsibilities with over-emphasis on
the role of doctors;
V-3
.<
*
V
3
--
quest for specialization and compartmentalization of professional
activities;
a preoccupation with the understanding of human illness in terms
of an organ-centredness and at intracellular, molecular leve s,
forgetting the whole "being" in the process;
a clear distinction between "providers” of the service and the
"users” of the service;
an overemphasis of the “physical" dimension of health and a
disregard for the psychological, social cultural, spiritual.
ecological and political dimensions;
over-professionalization, which controls the spread of technical
knowledge and skills to members of the health team and to the
people at large;
‘‘providing'’ orientation of services and action rather than the
“enabling” orientation;
an over-emphasis on drugs and technology leading to a complete
dis-regard for non -drug therapy and skills;
a preoccupation with the allopathic system of medicine ignoring
the existence or utilization of the culture and practices of the
other systems of medicine and healing.
Community health:action initiators even though they most often
emerge from these medicalised environments, do not see themselves
as just extensions of this medicalised system. They constantly
confront these issues in their approach and actions and try .o
evolve new attitudes, new skills and new approaches that are
people and community oriented and place medicine, professional
skills and technology in their right and limited contex .
The Community Health Approach
rnn-Frnni--ina
evolves action from the community outwards and upwards confr
g
the various components of the existing superstructure of
of health
healtn
services which includes
.
the primary health centres, dispensaries, hospitals, teaching
and research institutions the medical, nursing, paramedical
and public health teams and professional training centres anc
associations;
z, \
the health programmes and health institutions under government
or non-government voluntary agency auspices.
It confronts the superstructure to 'become -v.
.
a) more “people” orientated
j_s sensitive to the realities
x. —. ——•- -- -- of the life of the large
majority of people - the poor and the underprivileged.
b) more "community” oriented
■ ” } context of the problems of
i.e., understanding health in the
its
and not just as
the whole community and all i'— sections
individual problems.
. o V-4
V
4
c) more 11 socio-epidemiologically" oriented
i.e., recognising the biological, socio-economic/ psycholo
gical, cultural, spiritual, political and ecological
dimensions of health,
d) more "democratic"
t
i.e., participatory in its growth, planning and decision
making processes.
e) morej "accountable11
i.e.z increasing the subservience of medicine, technology,
structures and professional actions, to the needs and hopes
of the people, the patients, the consumers, the "benefi
ciaries" and the community which they seek to serve.
The Community Health approach
is therefore not just a speciality, a new professional
discipline, a new "technology fix" or a new package of actions.
It is predominantly a new vision of "health" and "health care"
a new attitude of mind, a new "value orientation" in health
action and a new perspective for the future linked to a new
vision of society.
It must therefore pervade existing health care systems, insti
tutions, research efforts, training programmes, professional
ethics and health planning exercises.
Community Health action
is closely interwined with efforts to build an alternative
socio-political-economic-cultural system in which health can
become a reality for all people.
The "community health approach"
therefore recognises that the components of actions are means
and not ends and will therefore be flexible enough to reorient
reprioritise, disband or change towards more relevant actions
and directions as they evolve in the interactions at the^ .
community level.
(Source s Community Health ; The search for an alternative
process j
Report of a Study reflection action experiment
by CHC Bangalore, Jan. 84 - June 86.)
REFLECTIMS TV & V
SOME QUESTICBNIS AND TASKS
01. Community Health in India .1^ an evolving concept and all the
above sources explain their understanding of it. Reflect on
these and evolve a working definition for your own group action.
02. Start with the statement on Community Health in the earlier
minute of the CH Forum and build on it adding points and
issues from the CH£ reflections and other sources mentioned.
03. Identify through reflections on your own field experiences/
the factors that promote community health and those that are
obstacles to it. Identify and evolve the components through
practical action-reflection.
*
*
VI .1
1 REFLECTION - Vl/A
IS 'COMMUNITY HEALTH1 GROWING AS A MOVEMENT IN INDIA
Are there signs of such a movement evolving in the country? The
trend is not conscious but implicit in many developments in recent
years which are possibly creating the right social milieu for such
an evolution. The delay has been due to a double failure - a
failure of community health projects to see themselves as part of
a larger socio-political change process in society and the failure
of political activists, mass organisations and people's movement to
recognise the value and true meaning of health. Yet probably a
beginning is being made.
The pre-requisites for the development of a Community Health
movement are many:
i) Firstly there is a need for a clearer understanding among all
concerned about Health as a 'social justice’ and 'civic right*
issue.
ii) Secondly more and more groups should recognise that community
health action need not always be a providing/distributing
process but can also be a enabling/empowering process.
i ii)Finally this understanding and dialogue must be actively
initiated at the grass roots level with the people at the
community level recognising the significance of collective
action. in their daily life struggles.
health action,
Today there r^re positive
*‘ ’
trends supporting this possibility and
negative trends which will
-L-llsuch
-- h a development.. What are
ill stall
these?
Positive trends
Firstly there is a growing army of villagers and lay 'workers who
have been trained as health workers both by governmental and nongovernmental
voluntary
, ,
- agencies.-• Whatever the quality or orientation
overall. a phenomenal process of de-mysti—
or training, taken in the overall,
•f-ation of health problems has already been initiated.
Secondly there is a growing number of individuals - development or
political activists - who are beginning to recognise the non-medical
dimensions of health and are including it in their action programme.
Thirdly there is a.growing body of health knowledge which has become
part of the syllabi of adult education and non-formal education in
the country. Science education experiments have also introduced
health aspects into the innovative curricula developed by them.
Fourthly people-oriented science movements like the Kerala Sastra
Sahitya Parishad, the Lok Vigyan Sanghatana (Maharashtra) and many
other smaller forums are actively taking up health issues in their
awareness building programmes, in their Jathas and their exhibitions.
Fifthly there are a series of evolving people’s movements around
forest issues, environmental issues, other social issues which have
’health of people’ as an intrinsic component though not always well
recognised. f'
”
Sixthly
there is an evolving interest in the trade
union movement,, the
women's movement and other mass movements about
the importance of health issues and the need to include them as
components of the wider struggles. Seventhly, even within the
’ VI. 2
2
*
medical and nursing professional and institutional networks there
is a growing sensitivity to the needs of linking health activities
with the broader issues of social change and not to see them as a
narrow technical or professional enterprise.
Finally even expert documents on health in the country are beginning
to echo this challenge. The ICSSR-ICMR (1981s94) report clearly
states that the conditions essential for success of the 'health for
all' goal is "to reduce poverty, inequality and to spread education;
to organise the poor and the underprivileged groups so that they are
able to assert themselves; to move away from the counter-productive,
consumerist western model of health care and to replace it by the
alternative based in the community".
Negative factors
However, there is no cause for unbounded optimism. The trends
favouring the evolution of the community health movement are
definitely there but the trends opposing and most often neutralising,
the gains made are equally there and probably stronger.
Medicalisation, professionalisation, and the consumerist orientation
of health oare is increasing and is symptomatic of the overall
situation in the country. Many so-called health projects are
mushrooming all over the place goaded by foreign funding agencies
vying with each other to invest in the alternative; or by industrial
houses as part of the rural development oriented income tax benefits;
or by professionals interested in involvement for prestige, status
and power and for many other objectives counter to the spirit of
community health. This band wagon nature of the growth of
’alternative health care’ out of context of social analysis,
understanding of peoples needs and insensitive to social change
process is going to be rather counter-productive.
A lack of. adequate networking among the committed community health
catalysts to share perspectives, support each other, evolve a
common understanding of a highly complex situation is a serious
lacuna o
Finally the ability of the existing exploitative socio-political
system, the bureaucracy, the health planners and the decision
makers to internalise the ideas and experiments in Jargon and
rhetoric but defeating the spirit of the process is phenomenal and
rather confusingo
To sum up then in the early 1990’s - community health movement is
far from becoming a reality. There is a potential for such an
evolution but there is much more ground work to be done. The first
is to recognise partners in the movement and establish linkages and
interactions that go beyond ideological debates, individual egos,
and institutional/project frameworks. The second is to have a
deeper study reflection on the nature of the paradigm shift that
has to actively take place in the understanding of community health
and community health action - from a 'medical model’ to a 'dynamic
social model'. Thirdly is to support existing struggles and or
initiate new ones all over the country, around issues related to
health - be it towards a rational drug policy; towards supports to
peoples health culture and traditions; against corruption, medical
.oVla3
VI. 3
malpraxis and unethical practices or towards communities demanding
components of primary health care as their right.
It is by this three pronged strategy that a movement can be
generated, and all committed Community Health activists have to
seriously
face up to this challenge in the years ahead.
REFLECTIONS IV TO VI
.ADDITIONAL READING
01. The Alternative Model : General Principles and Organisation,
Chapter 6 & 7 (Source 2)
02. Medico friend circle s Which Way to Go?
Page 219 (Source 3)
a debate
03. Possibilities of Relevant Action - Chapter 6 (Source
04. The New Vision of CHAI - Appendix II.
05. Some Alternative Programmes
Chapter 27
06. Epilogue Postulates of a Theory
4)
(Source 4)
([Source 6)
Chapter 30 (Source 6)
07. Community Health, the quest for an alternative,
Chapter 4.
(Source 7)
08. Widening the Scope of health work. Chapter 5
09. Health and Power to the People
(Source 8)
(Source 9)
SOME QUESTIO
NS AND
TASKS
(FOR VI)
1
■?■ m1 r a r- ■ — ■
:
clt i wi i
i iii i
01. Identify in your region of the country all the individual
groups/projects/processes who are potential partners in a
Community Health movement of the future. Visit them. Interact
with them. Get to know their plans and perspectives. Evolve
linkages and some common action for the area however limited.
02. Identify the' problems that come in the way of such a '1 inking
process'. Are these problems ideological, psychological,
sociological or any other issue-related. Discuss in your
regional and national forum meetings how to get beyond them
-x-x-x-x-x-
Csw) H ST- S
HSALTH HAZ^DS QI1' !2KL WILL ENVIROWNT
In the devoioj-in world, the cxrvironuont in ur1 an areas is
generally better ccntroiled than the environnent in pniral areas where
polluti on ;poe s on unc.' -ated •
Legislation e.iciin^ o.t the yrovisicn. of an environnent conlneivo to •’-rcT.iotin;: healthy physical ani nental 'lovclopnont is enforced,
in towns but jcncrclly no 1 oct o'-1 in the rural, areas. In the rural
areas cnfcrcerient officers arc. net available in sufficient numbers,
the population is uncoeporative because of ^llitorac^’ air1 the funds
necessary for d dvelopr.iont ar insuffie lent /'ll those factors., added
to which are tra.iiticnal. habits and superstitions, wake the life of
tlie peasant hard and hazardous.
THE CH/1LENGES FACED BY THE HEALTH TEAM ARE 1'IMEE^CUS BUT, WITH
TAiCT, KNOWLEDGE AHD lATIENCE, THEY C/N BE TACKLED SUCCESSFULLY .
5-1
HEALTH ELZAKPS IGTH REICH THE HEALTH WCTKER HAS TO 3EAL
Every situation presents its own hazards air’’, in this Manual
it would not bo possible to deal with individavl situations. The
general hazards tc which a rural ccnrunity is expose-1 include, tjie
folio win,;:
1. Hazards cwt side the hone such a.n bad roads, collections
of refuse, breeding of diseaso-cafrying isocts and
vernin, stray -logs, unprotected water ccllections, wnhygienic eating places, or unprotected cloctrLcal instaUn.tions.
2. Ifczards in the hone such as open fires, sharp inpleuonts,
overcrowding, badly constructed houses, unhygienic food
and water storage arrangononts, insanitary latrines, or
unccntrcllcd disposal of waste water and solid wastes*
3- Hazards in the fields such as accidents related to the
use of agricultural tools, snake bites, scorpion
stings, diseases related to the use of pesticides, or
diseases related tc contact with plants and pollens*
4» Hazards related to cottage industries such as accidents
with riachinery or health hazards to potters, weavers,
and dyers.
5. Hazards related to traditional habits such as those
connected with the collection of anirial wastes for
household use, or hazards related to the breedingof livestock.
6. Hazards related to lack of education about honl-hhv
such as poor personal hygiene or wrong food habits.
7 „ Hazards rel ated to poor medical facilities such as- lack
of trained personnel, dispensaries” and drugs.
8. H zards related to poverty such ar ualnutrition, lack of
shelter or inadequate protective clothing.
5-2
HELPING THE COllWJIIY TO OVllCQiL_2JEJffiZLTH
HAZARDS OP TI11.F<AL,EWIBQ111M .
You as a health werker, have been trained to be able to
cope vri-th post of
hazards of living in a rural environment and
t i.jr will rely on you to a great extent to rromote liealthy,
living and develcpnent.
-;
/.
: 2 :
nqv vrin®. KNOWLEDGE
SS TO
SKILLS TO T. E BEST /DVAi-iTAGE AND DC NOT
sumviscB's awrcis jm> WB ra<M3 »■»
TIUT YOU ARE
TOM'S CCOBMHOtlBEil ECSlUtt •
WORKING AS A TEAM WITH 1. COiI'.ON GOAL AD YOU’ AuIil.lTIEb l-Ubi
BE DEVELOPED AS A TEAM_____________
5.2.1 HAZARDS cutside the home
1. Bad Roads: While the inporveuent of roads is not the res
ponsibility' of the health worker, as a cowunity worker you
in motivating the .ccnnunity tc improve their own reads to red
risk of accidents, as well as to iwrevo ccoavnications.
In .Chapter 13, 'Accidents’, you will find instructions on how
to deal with accidents.
2. Collections of Refuse: In many rural areas refuse is.composted
fnr use cn a-Ticultural land and the collections of refuse outside
£ses nS bo lirited. However, it still happens that refuse is moved from
£ ^to 4 open place near the village, because of lack of' facili- .
ties for transporting the refu^o to a safe distance aways £ron hous S.
I cur " duties as a health worker in tl-is case are
section 6.4*
cnunera’tocl in
VTi L•'■ G17 LABOUR lAY BE REQUIRED TO HELP YOU FEWER REFUSE COLLEC-
ZSs S®SaKY . IN Tins CASE COl^SULT THE CO1S UNITY LEADS S AND
TRy'tq' GET VOEOHTAFY LABOUR FOF.TKS COIi-iON HEED OF’ THE COM-UNITY.
3. Breeding of Disease-carrying Insects and Vcrnin: The breeding
of flies and rats is closely connected with refuse disfosal, Doth out-
SafttS 5™so «1» 03 ‘J» 1AS» promos.
This brodins
bo :rod«~4
or yrefcrably conplotcly prevented if diarrhoea, plague and typhus fever
arc" to be kept under control.
------------ —
-------"-----VOlACiaJS FOOD EATERS A© CONSUHE
■^lElffiEE
ALSO
TiiAT
RATS; ARE
-vtlHABLE FOOD WHICH TIE C01-WNITY NETOS - WHAT THEY DO NOT EAT
THEY SPOIL BY THETT URINE AND FAECES rEI©ERING L/FGE QUANTITIES
OF FOOD UNFIT FOF HUMAN’ CO' 'SUi lHTON i
IN THE FACE OF THE HAZATDS OF LiALlUTn TION. TIE-T'''T bW.CE
ASSUi ES EVEN GFEATEF IMFOr’TMCE .
Proceed as follows:
a. Fly Control
refuse
of
Ensure that household ---- —is hygtenically
y disposed
on--a
a corrunity
ccnrrunity basis (connunal
both in the house and on
refuse should be burnt or buried).
ii. Ensure that sanitary latrines are ■used for the disposal
of liunan excreta*
#
iii. Ensure that aninal excreta is disposed of in a sanitary
waySoo section 6.3 for details.
b. Rate Control
i. Ensure the proper disposal of household rofVsc and connunal
refuse tips (conr/unal refuse sheuld bo burnt or buried, •
ii. Store the feed in rat proof containers.
iii. When the rat population grows to eonsidcrablo proportions,
call upon your supervisor to arrange for trapping or
pcisoring rats <
.. .Cortc’s/3~
3
RErEI4BER THA.T TXTS GO IN SKtNCE OF FOCD X1D IF FO' D IS NCT
AVAIL/vBLS ’THSI
T TJ._Tj FT-NIESNS •
c•
Mosquito control
The .breeding habits of the nalaria nos quit o (Anopheles) and
those of the mosquito (Culox) that carries filariasis differ. The
former breeds in stagnant or slow moving water in natural habitats
and the latter in ste.gnant water in artificial habitats.
The malaria mosquito breeds in stagnant or slow Drying water,
wells and ether collections of water outside the house. These will
require:
i. to be emptied if the collections o,re small, c^g., holes in
the road or by t??o roadside;
ii. to be treated ’ith malariol or other larvicides if the pools
are largo;
iii. to be removed by filling in or complete rcmovri, e.g., holes
in tree trunks must be cut so that water will not collect
in them.;
iv. to bo irrigated’if the collections arc At the side of streams.
The filaria-cararing mosquito breeds in tins, old car tyres,
watejr tanks in hoi sos and other mna-mde water collections. Those w£Ll
’require.
i. to be emptied and turned upside down so that water cannot
collect in them;
ii. to be completely removed;
iii. to be treated with, malariol, if the containers are t oo large;
iv. to be covered so that mosquitoes cannot enter then.
4. Stray Dogs: Stray dogs abound in villages and rummage for
food around human-habitations. The biggest hazards they pose, besides
biting people who disturb them, is the hazard of rabies. Rabies is
a very serious virus disease which affects the nerv-.us system, and
once the signs and syntpons of the disease arc* established death is
certain.
THE ONLY WAY TO TACKLE THE FLOBLEH (F BABIES IS TO HEVENT IT .
THIS CAN BE ACHIEVE’ ONLY BY II'2'UNIZING AI;L-DOGS AdAIMST RABIES OR
DESTIOYIHG AI.L STRAY DOGS,
Proceed as follows:
i. If a person has boon bit ton by a dog., take the precautions
enumerated in section 18.12.
ii. Report to your supervisor the presence of stray dogs in your
area, especially when their numbers' bocone unctcnrollablc.
IT IS THS DUTY OF THS lE/JuTIi A SISTANT (WIE) TO AFR/JIGE FOL, STRAY
DOGS TO BE DESTROYED *
iii. Educate the comunity on the hazards attached to the presence
,of stray dogs in tlio area and elicit their cooperation to
control this liazard.
5* Unprotected Water Collections: Unprotected water collactions
con be used for drinking purposes or arc sinply rain i;ator collections.
Both present hazards to health, the forcer in the spread of intestinal
diseases an/1 the latter as breeding places for nosquitocs. The danger
of cliildron drowning in water pools is always present.
. . » -CoTTt.r?//^
: 4 :
Your duties in relation to unprotected water collections used
for drinking purpesos arc enumerated in section 6*1-7-
Your duties in relation to water collections which are a hazard
through providing mosquito brooding sites arc dealt with in section
5-2.1See section 20-9 on how to deal with a person who has drowned.
6. Unhygienic Eating ELaces: In rnny villages, restaurants and
the people
joople cat
cc.t
sopl-isticdod eating places arc net usually found as tho
at home. However, tea shops where snacks arc prepared usually exist.
It is your duty as a health worker to keep a watchful eye on these
places.
Proceed as follows:
a* Take an inventory of all the tea shops in your area and ciT.rt
thorn on the map rt tho subcontrc.
b. lake an initial inspection to assess the follov/ing:
i. tho state of tie building and whether it is hygienics or
lends itrolf to the contamination of food;
•ii thoso; roe of t’.o water supply and water used for the
washing up of eating and cooking utensils*
iii. tho types of food served;
iv. tho apparent state of health of the food handlers.
c. Advise the tea shop owners on how to improve conditions
which are found to bo below tho required health standards* .
'd* lake periodic visits to those' shops to btect early detori ora
tion in their practices and to ensure that tho standards arc
maintained.
- ■
KEW'IBER T1LCT THE TEA SHOP IS O IjEAL VEHUE FOP. PASSING INE-OImATION
TO -TI-E- CQL UNITY AI^- THIS O-PPOITUIH-TY SHOULD BE AVAILE-' • OF WHEN HEALTH
EDUCATION ACHVITHS JT.E BEING 0TC-AHIZE3 . __________________________
7- Unprotected Electrical Installations: In many rural areas
electrical installations arc insufficiently protected and carry danger
warnings which are of no use to illiterate, people. They pose hazards
of electrocution, particularly to children.
As a health worker, it is your duty to spot these hazards
and bring them to the notice of tho responsible authority.
See section 20.8 on how to deal with patients who have been
electrocuted.
5-2,2
IIAZAFJS IN THE HOLE
1. Open Fires: Tho use of open fires for cooking purposes,
and in tho winter for heating purposes pose hazards to health, parti
cularly to children.
Whenever you. cone across an open fire in ahoiao, bring to
the attention of the mother tho donger an open fire creates for
ch51 dron and the importance of keeping chUdron away from unprotected
firesIf a child or any other person is burnt or scalded proceed
as- detailed in section, 1$ .8.
IF COW JU® IS U-SEJ FOP FULL. SHOW THE HOUSEIIOL’'ET HOW TO BUILD A
SIIOKSLESS CHULA UTILIZING COW JUNG FUEL.
2. Overcrowding: Overcrowding in itself creates hazards
to health, cspoeailly in the spread of air-borne diseases and contact
diseases, c’-ig., leprosy. In the rural area houses- arc not supplied
with rueh ventilation, •
•moreover, -..hat little is available is
. ... CoutV?-
/ 5/
blocked up for fear of thieves or w51d animals.
As a health worker your rcijpensitilitics are to inform the
ec^nnity of the health hazards posed by overcrowding and advise
on ways to solve them.
Proceed as fellows:
i. Educate the household on the risks of over crowding
in the homes end the way diseases are spreadii. Take this as'an opportunity to spread the family .
planning .pro erammo, if it is not already a coopted m
that particular household.
iii. Educate the family on the special precautions which
which rust be taken to prevent the spread of respira
tory diseases.,; o.g., tuberculosis, especially to
children, if any rienber of the family is suffering
from such a disease.
iv. Discuss the advantages of proper ventilation in
overcrowded houses3. Badly Constructed Houses: Badly constructed houses pose a
health hazard because if they collapse they can cause permanent injury
or death. Not only the material used but also the way the house as
planned may bo dangortrs.
Whenever you find a badly constructed house, proceed aa-fellows4-i. Advise the householder whore he can get help for
improving the safety of his hpusc.
ii. Hastening the walls will prevent the brooding of
sa,ndflics and other insects- Advise the householder
to smocthcn the walls using locally available materialiii« Smooth floors : revent the spread of dust and locally
must be used to pack the floors to
availpblo material
;
rcnovc the dust hazard.
iv. Pay attention to the roofing, of the house to protect
against adverse weather conditionsv. Heli:, the hcvscflioldcr to inprevo the plo.nning of his
house to Jake it nore habitable and conducive to healthy
living.
vi. Educate the household on the advantages to health o.t
well-constructed houses.
A. Unhygienic Food Storage Arrangements: Food in rural areas
is in Short supply and its j-ropcr storage is drirortont to -.rotoct it
against being oaten by rats, as well as against contaeinriion by file
and other insectsProceed as follows:
i. I-'.sroct the food storage arrangements.
ii. A-vise on the improvement s necessary to protect • he
food frrm being eaten or shoilod by rats, er ccntarnnatod by. flics and weevils.
iii. E'uceto the family on the importance of eating clean food
and discusrs with then the diseases that are spread by centominatod food.
. '
,
iv. L ck at the arrangements for storing gram and make ..ire
ttot the container is protected ffon infestation J
rats and other vermin.
Contd/6-
: 6 :
The Food Safe: the Food .Safe shown in
in figure
figure 5.1
5-1 is
is easy
easy and
and
cheap to construct. It has the following advantages:
The food is protested against flics and other insects
bake sure that the wire mesh is of the right
and verriin. rake
b “
si,?.®.
. ii. The food is ventilated and can be kept firly cool if the
safe is placed at the proper place in the house.
iii.• Tt can locked against stealing of . he food.
iv. B3 placing. each leg of the safe in a tine containing water,
or bp hanging the safe to keep it off the floor, you w 11
protect the food against invasion by ants.
ADVISE THE HOUSEWIFE against storieg
cooked FOODS FCP TOO-----Bam!
WjP A3 7.ZT CAH CT SmM AST TCTS
■
5.
7Insanitary Latrines: The hazards of insanitajy latrines in
homes have teen described in section 6.3.
YcfL1 f?Cn'id de‘bect the number of insaitary latrines in your
area during the base-line survey. This survey will also givj ySTthe
op^rtunaty t° assess the number of households which have to lltrine
pS sSE SSrggg,;
If possible construct a water-seal latrine (e.g., RCA or PRAT)
^demonstrate tew a s^taxy latrine can be built and how it is te be
Soo section 6.3 .1 for further details «
Contd/7-
: 7 :
6. Uncontrolled " isposal of Waste Water and Solid Wastes:
The hazards to health following uncontrolled disposal ofUiquid
and solid wastes arc described in sections 6.2 and 6.4 whore uothods
fortbho sanita^ disposal of these wastes are .also do senbod.
The inforation collected during your initial survey for base
line data will give you an idea of the nagnitucl^ of the rroblcn in
your area. Proceed by drawing ur a prograuno, w. bh tlx help of your
supervisor, to deal vrith the probion piooomal. ■
YOU WANT TO ACHIEVE I-TBB- AliEOT IFiH'OWECTS IN METHODS CF WASTE ”
DISTOSAL . TEE BEST WAY TO ACHIEVE T IS IS THTOIGH A TL/IIN®
' STIjF*BY-STEP E0GBAI1E BASH’ ON LOCii CONDITIOLS, HABITS AND
TABOOS. TRY TO AVOIR A17Y CRASH IIOGEA1IIES WHICH N-AY NOT LhA- 10
TT-iEDESIIABIE PETi'ANENT RESULTS . .
------------- --- —---- -
JffimiBEn THATTOUT. SUFECTISGl IS SOCIALLY TT/JK
EmrOfOTi
BL FlTH AIL ALL YOUI ErVOLTS IN TAIS -FILL! SHOULD BE ClOoELY JLAUN
RO vATTH IM AIY THLOUGH HIS ADIVCE ...................................... ......................
5.2.3. HAZARDS IN THE FIELDS
The farrier s;dn<1 s nest of his work ng dry in the iiold where
ho is -sing agri cultural tools, mechanized or otherwise, and where
ho is in constant contact with plants and chonocals, .11 those create
occupational health hazards of winch ho lias to b e node aware by tl c
health worker so that good health is pronoted and mintainod.
1. Accidents Elated to the use of Agricultural Tools:
Agricultural tools whether' cicchanizod or not, usually consist of heavy
oquipnent supplied with sharp blades Which arc often unguarded.
Accidents from such tods include.
i. cuts -reducing wounds of varying degree and sewtity;
ii . fractures, which :ay be simple, ccnpound or. ccnplicatod,
iii. crvshi-.-g injuries which nay result in injuries to vital
organs;' those arc wore likely to occur when tractors are used
in farming.
Sec the chapters relating to the various trpos of injuries and
follow the steps suggested therein for tte- ■trootn.nt of accidents.
■™4FMBET'' TH/I FIELDS LEE ALWAYS FULL OF i AI'TUi E WHICH IS USED
T FEITILIZir.: SO E'SUL Tffil EVEHY AOCrm INVOmNG A WOOTEIWSTBE GIVEN IETAIHS TCi^OID 0" /j’TI-TETANUS SZRUM._----------------- -
2. Snake Bites: As -rakes are usually found in the countryside, it
is not surprifing that the najority of snake bites occur in Treiers,
T-rticularlv during the harvesting of sugar cane, wheat, etc., wl.en
the habitats where snakes live arc being destroyed. Special precau
tions oust, therefore, be taken during this period.
See section 18.9 for the procedures to be followed in cases wi’tlx
snake bites.
3. Scorlon Stings: As scorpions also live in the rural areas,
farners arc iiorc prone than other people"to scorpion stings. However,
scorpions often enter ho- sos in villages and live under boxes, etc.
sc that the connunity is also at a high risk.
Soo section 18.10 for the procedures to be followed in scorpion^,
stings.
0onl4/8-
:3 :
4. Diseases. Related to use of festicides:
wants to feet a good income « selling hrs^cr
•te)
S pesticide s
crops•
to
The fanaer who
has to ensure that they are
& pest control
™J tOT *aW
® pestle U
a
Seh
tl“ J5?®-?r °E°“coSSttitd. th« plicida day jr^uce
my resnlt in chrerac disease.
-nay result.
p^theraore, certain
.
5fflOT-TXtoB
to ®
iicn MUST BE T^®rTB UST^ I^TTCmEp
“cioi'ttC
Sc'Soimi
' INCAPAOITATI®
GCiOfiOdS'lin EECCriE ESTiEEISrlZD •------ - --------- - --------- -------------
Proceed, as follows.
.
^q+aeides in vso in P™' area-
1. Aoguaim r^solf «tth tte knar ■>«
th
srorvisor and tie agricnltnralcT&eOT
" ' ’iXAS; cow-unity
ridAed gof the dange s to
iii. Infora the
+v,o,r miqb take to prepesticides arc badly handled..
iv. Infora then of the P5?cavti°n® J Oning Pton pesticides.
L. - vent cents.ct
that Mldren -are not expc sea
(••
V* •Ensure
TF'YOU SE. A-'- SLEGSTFT'
the doctcr without delay.
Hants and Pollens: Allergies to
S. Diseases Related to frequently in rural areas where plant.
plants and pollens occur
more
xto ibe
who is sl@ns
round.. Very
q V Often a
t.person
nG Qf the
of vericus kinds are
allerric to specific plants
If thealalergy is specific to one
Pd sraptoms of cilery occur. ), desensitisation is possible but
a?d
fuhich is' seldom the case • j to be done by a- skin specially .
Sts is a lengthy procedure and has
with farmers because the> allergy a^s
In practice it doos not happen
7d desensitra-atran
w^fld then
often of a multiple nature
bone occur in the fora'of:
/dlergic 'srapt
nsthra (see section 20.4.1)
I • at tacks of a
■ ii. —the. relevant
jta a»sc 3y.-.ra» ‘n® treat as
“
: mu (sc,
.sections .rofcracd. to -abora- ■
«.n..
7 VJHS’T rniEY 00 CUP KT A
TIIESE C/kOBS TEFER. THE
........... Coitl/9 -
: 9 :
Your responsibilities in preventing the occurrence of allergies include:
i* educating the farmers on ths cuasos of asthma and all or .pi p.
skin diseases;
ii. advising then on the use of protective clothing to prevent
contact between plants and the skin;
iii. advising then on the use of inhalers when signs start to
appear.
6. Diseases Related to Field Dust: In the dry season, the fields
arc- drj^ and dusty. . Particles of dust are inhaled and. may cause bronchial
irritation giving rise to attacks cf bronchitis. Continuous exposure —
to the inhalation of dust will result in chronic bronchitis, which nay
slowly incapacitate the farmer from doing-a full day’s work.
IT IS YOUR DUTY TO ADIVSE FARI-iERS TO SEEK EARLY I EDI CAL TREATI-IENT F(R
AMY CHEST CL EDITIONS TO FEEVEl'JT THE ESTABLISH! ENT OF CHR 10 CHEST
DISEASES.
...........
"..................
Irritation of the eyes is more frequent in the rural areas-.during
the dry season than at other tines of the year.
5.2.4
HAZARDS RELATED TO COTTAGE INDUSTRIES
. Snail industries are established in many rural areas, where
the activities are developed in the-home and- the products- are sold. .
through cooperatives or directly. Tho most popular of these industries
are weaving, dyeing, and the production of textiles, and potteiy.
Machines nay be used to'a large or snlll extent and a number of people
nay g?t together at the place cfvrrk, constituting a snail factory.
Unless proper precautions arc taken, these industries nay pose health
hazards and it is ycur duty to advise on the health of the workers.
Proceed as ’follows:
a. Carry cut a survey of all the cottage industries in your
area •
be Note the typo of industry and the nunbor of workers that each
cnploys...
c. Noto the type of building where ’ tho industry is carried out
with special reference to:
i. lighting;
ii • ventilation;
..
iii. drainage, if water is used in the procoss.
d. If nachinery is used, e._
• g., sowing mchino-s, loons, or potter’s
wheels, note whether the nac
os protected, against .
---hi
J no.re
accidents.
e. Koop a supervisory control. an the health aspects, of the
industries •
1i Accidents with Ifechinery: Mechanical mohinos which a^ec used
in cottage industiros should be properly protected to prevent accidents.
Particular attention should bo paid to chopping and turning iiachinos in
which fingers can be crushed or got amputated. The machines used for
chopring up animal food is often the cause of abated fingers, especially
in c..ildren who arc not aware of the hazard it carries. As this machine
is found in many rural hones, you should pa.y social attention to it.
Contd/10-
.
<■
■
: ID :
''TECHNIWS APFB-OHIIATE FOP. THE
VILLAGES # SOPIELEXAKFLES
Wheirevei^iiicLchines .are used, proceed as follows t ;
During your ■visit to the villages, note whether the--.nachines are
poperly guarded and used.
Advise on any changes that my he necessary to render machinery safd*
iii* Note the lighting and ventilation and advise ch any inprovement-s you
consider necessary to promote a healthy working environment.
In case of accidents with machinery treat as suggeatei_under 'the -chapters
dealing with wounds and fractures.
2. Health Hazards of Potters, Weavers and Dyers; Pottery is a common
s
source of employment as containers for carrying water and other pottery
utensils are in common use- The material 'used by the potter contains
silica, which when "inhaled give's’rise to irritation of the bronchi and
lungs and may result in chronic lung diseases. A12j.o the risk of bums
from kilns -which are used for baking the po ttery pose a hazard to health
^unless proper precautions are iaken. Textile j^ayi^^...-p.axpet.. weaving and
other industrie’s^where (jetton is used pose a health hazard because cf^the^
fine cotton dust which is inhaled^uCCTSing bronchial and lung irritation
It is,, therefore, very important that adequate-.-^ventilation be provided
x'
in places where those tpades are conducted ’ so that the fine cotton dust
is carried away from the ■ orking environment . Extya(?tor fans arc a big
help in reducing this occupational hazard,- while at the sime time-'they^
-cheap to purchase, easy to fit -and cheap to run. .
’.
-u - .
hyiLDFEN SIOULD NOT BE ^ALLOW TO WORK IN INDUSTRIES 11IERE. COT-TON IS
USED AS fERMAIffl'IT INJURY TO THEIR HEALTH rAY RESJLT..,
Chemical dyes are usually used in the dyeing of cotton fabrics. ''Thqse
dyes if ingested in large doses, may have a harmful effect on the Ijody.
Children should fee kept away from dye vats in which the dyeing process
is carried out as the after finishing work to remove the chemical
their hands*
:
If any of these trades are in.operation in ycur croa^ proceed as follows:
a. Pottery
'
io Check that the dust from the potter’s wheel is carried away
from he pottef .and it is not inhaled.
ii. Cheek.that the machinery used is not liable to cause accidents-.
-Ht. Check that the waste water is drained away in a sanitary .way♦
Iv. Educate the potter how'to take pre ovations to protect his health#,
v. If a kiln is used, ensure that the..hazards of fire are removed..
b. Weaving/
'
.
....
*
i. Check the jresnises. teiere weaving industries are carried out to
eiisure that the, premises are. generally suitable.
il. Check the ventilation tofcensure that cotton dust is carried away
from the' f-uildirg-. ’
.
: • . .
ill-. CLock the medjh.ods employed for the disposal of .waste products.
‘ / Pa; cote the workers invays of ymteCting their health-against
the loeasur .■ .rising cut of their employament.
- Advio'v - irTfrcpoment-s—ichmti y "■hri
1jimuue
luce’ss
ssar
ary
y Ht~cui?.ender the
uorkf-. g on itonment healthy-. •
vi-.- .1...' v sc o;a : v’) i-ipcrtanco of s coking early treatment for diseases with
- .
-'
st sl<r s in •:y’.ptons. ’• ■ '
1IEG Iii
V^T'- O" kV
.. Zl lOUB ZrijRWSOR- WHEN CARBYING OUT ACITLVITC COT’TAGfe IlvDliSTRIES. AS HE,IS INA POSITION TO COOJERATE
■TRnTirLW V^TH GOmrNI-TY- DEVELOPS OT- I1TOS-TRIEAL-
Z'
-
11
_ _«
v.,If a kiln •is used^ ensure that the hazards of fire are
removed.
b. Weaving:
—Check the premises where weaving industries are carried out to
ensure-that'the premises are gnerally suitable.
11 Check tho ventilatiop to ensure that cotton dust is carried
away from the building.
iii. Check the methods empolyed for the disposal of waste products.
iv. Educate the workers in ways of protecting their health against
the diseases arising out of their employment.
v. Advise on improvements which may be necessary to render the
working environment healthy.
•
vi. Advise on the importance of seeking early treatment for diseases
with chest signs and symptoms.
•
KEEP VERY CLOSE COKTACT ”ITH Yflffi SUPERVISOR UHEN CARRYDG OUT ACTIVITIES
related to cottage.industries as he is in a position to cooperate
OTHER OFFICERS CONCERNED V±TH COMMUNITY DEVELOHIEKT INDUSTRIAL - PRQJECTo .
c . D/cirg:
i Check that the sullage wager is disposed off in a ssinitary vFay.
ii* Advise -those handling dyes’to wash their hands nronerly before
eating.
5.2.5
HAZARDS RELATED TO TRADITIONAL HABITS
Traditioi*'and necessity demand that certain practices which nose hiealth
hazards be carried out in rural areas. Livestock and chickens are kept toprovide Mik and food and to uso in land tWLing and cultivation where necha^ed
asriculture is not.yet developed or on snail holdings, uslo, the limited,
inwne of the small farmer demands that. naxLmura use be made of wastes to nro-r..
vide comoost and fuel, both of which create health hazards.
1. Health Hazards Connected with the Collection of Animal Wastes Cor
Household Use: Cow dung is collected in many villages for making into cafces v
which are used to Tjrovide fuel for cooking and heating. The dung is collected
by hand, mixed with husk and flattened out into shape for drying in the con n
sun
This method of collection and nremration is insanitary and, uartitnularly--’--^.
•i -f the nerson handling the dung has cuts on the hand, exnoses him or her to
tto
UoSS
ottor infections. This, oounlel with fly hreodtn®
and the lack of personal hygiene leads t- a high incidence of diarrhoeas
among children.
*
’
If you are working in an area where cow dung is collected for use as
fuel, take the following nrocautions to safeguard, the community's health::
i . educate the - connunity on the risks connected., with this habit;
ii. impress unen the community, mrtiqularlX'thO|.children emnleyed
1--T :
in this 'trade', the need for personal hygiene and ■ the ira^rtanec
of not letting cow dung get anywhere near the mouth ^0^8
fingers and hands. The importance of washing-the hands and es
pecially the finger nails with soap and water before eating must
,v M particularly stressed.,
e
iii. Discuss the hazards of handling cow dung when cdts are rr esent
on the hands.
- • - - place
* iv. Assist the coiawnity in finding suitable
seaway- from the
cakes to reduce the fly breeding
house for drying the cow dung
’1
dangers.
. Assist the houseowner in construction smokeless chulas for use with
^ow dung eakco.
*'
.
,. n
vi. Impress uoon cow dung handlers the importance of seeking medical
treatment for cuts and other injuries.
V
Ikr:
a12
3.
i— 42 -
Cow dung is also used in corroosting and in manure nits. Fer details
the control of these nits to render the nrocess sanitary see section 6.4.2..
on
2. Health Hazards Related to the Breeding of Livestock: livestock is
nart and narcel of every village house and forms the major
.
a te
It is essential for nutrition and serves an a source of income. Lt is necessa y,
however, that cows and buffaloes be kept in hygienic conditions which do no
create health hazards •
Your duties t* oromotc the community ’s health require that you:
i. advise the heuse owners to nrovide adequate snace for their livestock
to avoid their being too near the house itself;
IT IS WORTAHT THAT STABLES SHOULD BE PROVIDED FOR LIVESTOCK SEPARATE
FROM THE LIVING QUARTERS .
ii. advise that refuse from stables should be collected regularly and
composted in a sanitary way;
iiK- advise that livestock should bo kept clean to avoid iiy
infestations;
iv. advise that the cow’s udders sheuId be cleaned before milking
and so should the milker’s hands;
livestock should be raised
v. advise that the feeding places for -off the gound and kept clean;
vi. advise that sick cows and
a- buffaloes should be kent in isolation
and treated;
vii. educate the community on the diseases related to livestock which
could be passed on to man, e.g., tuberculosis from caws or undulant
fever from goats.
THE FAMILY AND EHVIROUMENT IN VTHICH IT LIVES ARE INSEPARABLE^^AFD^THE
HAVE A DEI EFICIAL EFFECT OF THE ____
FORMER.
IMPROVHIEFT OF THE LATTER MUST
-----------------
5.«.6< HAZARDS RELATED TO LACK OF EDUCATION
J
1
l
One should distinguish between education and schooling. A person
may be an excellent scholar but his or her ideas about healthy living may
be grossly lacking. It is your duty to teach the community how to develop
environment.
goed personal habits and how to ensure a healthy environment.
Y*ur duties
include:
i. participation in health education programmes fer school childm;
ii. teaching school children how to keep healthy through personal
hygiene^ the care of their teeth, the use of clean clothing and
iii. bedding, healthy sleeping habits and good nutrition;
iii. teaching children the importance of physical exercise for the
proper development of the body and the mind;
iv. educating the children regarding the importance of a healthy
home for maintaining good health;
v. educating the community leaders to appreciate their
in health promotion activities to improve the community
environment;
vi. educating the heads of the households on. ways to promote the
health of their families through improving the enyjpnment of
their households;
vi-i r educating the mothers on how to loek after their children and
promote their health through regular immunization, good
nuttition and healthy living.
Ikr:
Contd./<..13
i
s
14
YOU MUST ALWAYS KEEP GOOD RELATIONS WITH ANY MEDICAL PRACTITIONERS
WORKING IN YOUR AREA. REMEMBER THAT THEIR OBJECTIVES ARE THE SAME
AS YOURS, ’TO PROVIDE HEALTH FACILITIES TO THE COMMUNITY AND TREAT
THOSE WHO ARE SICK’ .
Communications in many rural areas are not very.satisfactory and
patients may have difficulty in reaching the Primary Health Centre
when they are feferred to the doctor. As far as possible you should
try and arrange transport for such patients. In
1 n cases of emergency,
elicit the assistance of the village panchayat and other community
leaders who may be able to help in providing some form of transport.
UTILIZE TO THE MAXIHUM THE VISITS BY THE DOCTOR AND THE SUPERVISOR
IN EXTENDING THE MEDICAL FACILITIES TO THOSE WHO HAVE NOT GOT THE
MEANS TO TRAVEL.
YOU HAVE A MA30R ROLE TO PLAY IN THIS FIELD AND IT IS HOPED THAT YOUR
PRESENCE IN THE COMMUNITY WILL PROVIDE BETTER HEALTH CARE AND BE THE
MAIN FACTOR IN PREVENTING SIMPLE AILMENTS FROM BECOMING MAJOR COMPLI
CATED AILMENTS BY RECEIVING FROM IT AND ADEQUATE MEDICAL CARE OR
EARLY REFERRAL.
Both you and your team make, the health worker (female), are expected
to spend to considerable part of your time in home visiting. Do not
miss this opportunity to look after the health needs of the family
in its own home.
KNOW YOUR LIMITATIONS AND REFER PATIENTS TO SEE THE DOCTOR IN GOOD
TIME. THIS WILL HELP THE PATIENT TO RECEIVE A BETTER QUALITY OF
HEALTH CARE THmN.:"KT PRESENT.
5.2.8, HAZARDS RELATED TO POVERTY: i
Millians of people in India live below the poverty line, i . e . they
cannot afford the basic requirements of food and shelter, The average
imcome in rural areas is blow that of urban workers, but the needs
of rural populations are also less than those of town dwellers.
Poverty bb itself may not affect health adversely, but when it is
combined with .ignorance and a lack of education then the effects on
health become manifest. The lack of adequate schooling facilities
in rural areas reduce opportunities for health education of children
and the establishment of good living habits among them.
Bad nutrition i.. rural areas :is often attributed to poverty. however 9
it is clear that poverty alone is not to blame, but cooking habits
and eating fads play an important role in the high incidence of
amlnutrition in India.
YOUR ROLE IS TO GET THE MOST OUT OF UHAT THE PEASANT IN THE RURAL
AREA CAN AFFORD UITH HIS LIMITED INCOME. PAY SPECIAL ATTENTION TO
NUTRITION AND COOKING HABITS AND TO THE IMPROVEMENT OF THE ENVIRONMENT
TEACH AND SHOW PEOPLE HOU TO SPEND THE LITTLE MONEY THEY CAN AFFORD
IN THE BEST POSSIBLE WAY.
s
15
Ypu can help the community in your area by*~
i) getting them advice on what crops to grow for food (food
crops) and for selling (cash crop); this will help their
nutrition as well as give them an income;
ii) teaching them how to get good nutrition from cheap foods 9
iii) demonstrating to them how to cook foods as tn retain their
nutritions properties; take the cooperation of the Health.
Worker (Female) in this activity.
iv) teaching them to maintain good health; this will save them
money which they would normally spend □n medicine;
ii
v) Motivating them to practise family planningj so that the
little wealth they have will not be dissipated among many
persons;
vi) tolling them how to keep fit □□
oo that they can work rmre
and earn more money for their food and comfort.
--------- .
■
■
,
|,
■
|| |-
—L
I ■
... Uli..-
J.
I'
................................... ..............
,
'
..................... ■■■I-
'
'I
- "
■
REMEMBER THAT POVERTY IS A SYNDROME CAUSED BY A NUMBER OF FACTORS. .
IDENTITY THESE FACTORS AND FIND SOLUTIONS TO THEM.
YOU WILL FIND
THAT TO SOLVE THE MANY PROBLEMS YOU WILL HAVE TO COOPERATE WITH
OTHER OFFICERS? e.Q. AGRICULTURAL, EDUCATIONAL, AND COMMUNITY DEVE
LOPMENT,9 WORKING IN THE SAME BLOCK AS YOUR SELF.
n j B
^win
•■jM-irin ■■ f
--t~
■■■—— ut-j-
ljlx i-«»i ■■■ nma
■ ri> i—ii ■ —ii ■ ii
i—i—i
T~~-— iMirBTnTrm~Trw—
ir"Trr"
— - **r- --■-.--W’’-
i« iuBVi-uriwj-r aiKiuBiia
AS A HEALTH WORKER v0U ARE A COMMUNITY WORKER AND ALTHOUGH YOUR WORK
EMPHASIZES HEALTH YOU MUST REMEMBER THAT HEALTH IS RELATED TO MANY
FACTORS..
SO BEHAVE AS A COMMUNITY WORKER AND THE COMMUNITY WILL SEEK
YOUR ADVICE.
.***************
/ ***-ft -ft -ft-ft ft ft ftft ‘
F
H
t 7^.
L1st of Health Projects
1 .
Dr Premchander John,
Deenabandu Medical Mission Centre,
R K Pet
631 303
Chingleput Dist.
2.
Dr Daleep 5 Mukarji,
Programme Director,
Rural Unit For Health
R K Puram, Kavanur P 0
Via K V Kuppam
632 201
North Arcot Dist.
Social Affairs,
.. I am sure you know a great deal about these projects.
3. Mr P N Dhawan,
General Secretary,
Punjab Association,
Lajpat Rai Bha’-an,
Pos t B ox no. 416,
1 70, 1 71 , 1 72 Peters Road,
Roy ape t tah ,
Madras
600 014.
.. This project has a very big employment scheme for women
and the health programmes are out in the villages very interesting - sseerns to receive a great deal of
money which they raise locally and from the Government.
Quite a different type of an approach. Mainly charity
as far as health programme is concerned. Would be
good if you could share some thoughts with them about
integrating their health programme as part of their
total development programme.
4.
Dr Kesavalu,
C/o Village Health Worker Project,
Dept, of Paediatricts,
Govt Rajaji Hospital,
Madurai.
• •
5.
Mrs lucila Pandia,
Island of Peace,
Kalakad P 0 627 501
Tirunelveli Dist.
..
6.
Village Health Work ersprogramme which seemed to have
been/on the right lines has got into problems
/ / run nirg
due to interdepartmental jealousies.
A total approach to development but the section that
seem to have gone ahead is that of the social work
which is involved in health, balwadi, tailoring and
employment programing for women.
Fr T James,
D i re c t o r,
Kottar Social Service Society,
B is hop’s House,
Nagercoil
629 001 .
..
Excellent project which deals with various aspects
of community development and health. Projects under
this umbrella are - health cooperatives, health
clinic, fishermen sangams, potters sangams, land
reclammation, boat building, housing etc. Strongly
advise you to
visit them.
7.
Brother James Kimpton,
St Joseph’s Boys’ Village,
Ganguvarpatti,
Periyakulam Talu
624 203
Madurai Dist.
.. A small leprosy rehabilitation project with other
c(□mmunity
- • .
. development
work which is well run. Not
far from Madurai
------ ~ you ^rill find it interesting.
8.
Miss Dora Scarlett,
Seva Nilayam,
Raja thani,
Via Andipatti,
Madurai Dist
6 26 51 2
•• Rural medical care
9.
Dr M K Vaidy a ,
K H I Hospitals,
Karnatak Health Institute P 0
Ghataprabha
591 310
Belgaum Dist.
•• Village Health workers programme run by the Mahil a
Mandals which are very very active and effective,
Th e main 1thrust
‘
or the rural development project
are programmes run through Mahila Mandals.
1 0.
0r Hiremath,
India Development 3ervice (I ) ,
98 /2 Kelgeri Road,
Dharwad 580 008.
11 .
Dr R Rathnaraj,
Medical Superintendent,
CSI Campbell Hospital,
Jammalamadugu
516 434
Cuddapah Dist.
•• Nutrition^rebabilitation and Village Health Worker
project, '.'e would also suggest that you visit RAID
which is being organised by Michael Ratnaraj. An
excellent programme of community involvement and
partrci pation. Rather radical but much can be learnt.
1 2.
Dr L M Hogerzeil,
Victoria Hospital,
Dichpalli,
Nizamabad Dist.
••
1 3.
Village Health Worker programme with outreach clinic
ifif some of •the villages. The program e had a big boost
when Drs Jok■;e
Bas Mesquitas helped the nurses to take
over the entire
--.-j running of clinics both at the Centre
and at the villages, Would be interested to hear how
they are progressing. It is more than a year since
Oxfam h as stopped its 's-upport. Atxleas: txDr xRaxawRXwaxa
They' now receive assitance
fromICCO.
Dr B VParameswara Rao,
Bhagavatula Charitable Trust,
Yellamanchili 531 055
Vizag Dist.
* *
^i^lage Health &. Village Health Worker programme
which started of with
— i a very big bang but unfortunately no village participation has been developed
and village health workers have stopped into the
role of glofified ayahs> at the clinic. Other programme of B C T could b e interesting. At least Dr.
Parameswara Rao is a very interesting person.
1 4.
Dr □ Salins,
’Velemegna’ Goodnews Society Hospital,
G olakhana,
B idar.
•• Dr 5alins/far too many ideas and finds it difficult
to knuckle down and concentrate on what is urgently
needed. Perhaps a visit from someone like you may
help him to pull back and concentrate in a smaller
area taking up one problem at a time - Bidar is a
lovely place to visit apart from anything else espe
cially if you are interested in history. It was the
seat of the Bhamini Dynasty.
1 5.
Br Paul,
Bethany Colony
Bapatla,
Guntur Dist.
Leprosy
Association,
runs a leprosy programme and a rehabilitation programme
for urchins•
-
■
'
-
■■
■
■
■
■
■
’
. 1
/has
fliggujision pappy op Comntunitv Health
OXFAH’s decade of experience in promoting CH projects, has been an
eye opener in many ways. There has been involvement with many groups
spread in various parts of the country, covering e spectrum of activities.
OXFAM’s interaction with theee groups has been a learning experience only
to trigger more involvement. There has also been the need for a more
comprehensive analysis of ths accumulated experiences and sharing between
groups.
As a first stop towards this clarity is sought on some of the issues related
to community health. This paper is an outcome of such an effort. It is
hoped that through this short discussion paper and later coming together of
groups in the field it will provide a^n opportunity to share
of the groups and contribute to the growing needs and awareness in
< comsunity
health.
The basic questions to begin with are Can community health programmes be conceived of ae a component of total
development and can they become means to a process of transformation of
the structural realities that cause or perpetuate the state of ill health#
Can community health be instrumental to a process of liberation where
health is not only considered a basic need but also a basic human right?
Approach to
community health
health received
racsived a lot of attention in th. .avantias
Approach
to coamunity
aSS there is a wealth of information that is availabl.
over the country. Soma of the experiments m community health both in the
voluntary sector and by the government have focu.ed on tha vulnerable gr p.
such as the mother and the child, and these model, have
as very imminent. To this model of MCH services was added ’Technology in
the crucial areas of immunisation, oral rehydration, growth
and
safe delivery. Ad a result many community health programmes have found
their bearings in these services.
This approach has however come under criticism in the recent times for two
reasons. One, the primary concern is that such a strategy becomes meaningless
ritual since it tends to ignore the social constraints for the effective
use of
of these
these services.
use
services. Secondly the triumphs themselves demonstrate the
problems inherent in the assumptions and the methods*
While on the one hand cownunity health as an evolving science has converted
abstract concepts into model, of health action, on tha other hand there
has been lack of vision and pers^ctivs that Community Health has ®nd»d
up as routine activity. In this unending quest for development and better
health and as partners in this search we wish to raise a few queetions
What is our perspective of community health action?
When do we see a need for community health action in the total develop
What havs been our strengths and weaknesses?
How do we measure our progress?
Is there a questioning process?
as the community view our activities?
How does
activitiee?
Do we visualise health action for the community or by the community?
These and many more questions that are at the heart of the problem need
to be examined*
We do realise that with your involvement inCommunity Health and first
hand knowledge of the field you mey have a lot more xasuee to
a brief account of your field experience, with the bqck dr p
fl
raised. This we hope will provide us the material to organise a network
of groups.
Vanaja Raapraaad.
o
\l
*’
A
*'
- H G: A VT H Fx £ A Lu
A
DECADE » PRIHARY MSALTH—CARE
WHAT WENT WRONG ?
More than a decade has now passed since the declaration of
the ” Global Strategy ” of * Health for AH • by 2000 A.D,
We do not need statistics to tell us that today we are
hardly anywhere near the goal of * Health for all," W^y 7
What went wrong ? The usual liberal analysis is 1 * The
strategy was alright, but was not implemented due to lack
of adequate political commitments " But firstly was the
strategy really Alright ? Secondly, was it only the question
of political commitment ? Thirdly, was it not naive to
expect unified political commitment to this programme from
the powers that be? Let us examine these questions one by
one.
There is no doubt that there are many elements
in the lPHC-approach • which are a radical break from
the dominant pattern of individual!zed, privatized medical
care that existed then and continues even today. The clear
recognition that M governments have a responsibility for
the health of their people#”
health and socio-economic
development are intrinsically interlocked; is also a clear
break from the privatized, purely curative oriented techno
cratic view of health-care. The declaration in 1978 at the
Alma-Ata conference that I ” Primary health care is essential
health care based on practical, scientifically sound and
socially acceptable methods and technology made universally
accessible to individuals and families in the community
through their full participation and at a cost that the
community and country can afford to maintain at every stage
of their development in the spirit of self-reliance and
self-determination. It forms an integral part of both the
country1s health system, of which it is the central function
(Ctd
• 2.
and main focus, and of the overall social and economic
development of the community. It is the first level of
contact of individuals, the family and community with the
national health system bringing health care as close as
possible to wh re people live and work, and constitutes
the first element of a continuing health care process."
is thus quite in contrast with the dominant view of
health-c ire. But there were some basic problems with the
Alma Ata declaration. The side-tracking of these problems
lead to undue expectations. What are these problems ?
Firstly, except for the importance attached to
the role of paramedical workers, there was hardly any new
positive principle in this Declaration. Coming from the
offici il represent >tives of various Governments all over
the world, and the representatives of the leading inter
national e-eg agencies,
it is significant that the
Declaration clearly kept away from the forces for priva
tised, commercialized model of health-care. ( Today this
lobby for privatization has made inroa s into the strategy
of Health for all.*) But that's all. T•^he
he Alma-Ata
declaration was actually a climb-down from the earlier
policy of ’Comprehensive Health Care1 which was to be
complete, continuous, competent, compassionate. * In
India, the ^hore committee had splelt out in some det til,
five criteria of comprehensive Health Service and Primary
Health Centres were started in 1952 as part of the commu
nity Development Programme. These criteria were 8
(a) provide adequate preventive, curative
and promotive health service,
(b) be as close to the beneficiaries as possible,
(c> has th? widest cooperation between the people,
the service ani the professionl
(d) is available to all irrespective of their
ability to pay for it.
I
.4.
This climb-down from comprehensive to Primary Heilth
Care was felt necessary by the ruling class because tbe progra
mme of * Comprehensive Health Care “ was found to be clearly
beyond their capacity# Por example! in India, compared to
the Bhore-Committee Recommendations, the achievements in
setting up of PHCs, training of doctors, nurses, raidwives by
1978, was, 16*, ^6%, 5%, 30% respectively. The kind of deve
lopment generated by Modern Imperialism is economically and
ecologically so demanding on the resources and is socially so
inefficient that it invariably leads to islands of unviable
developmental models and vast tracts of underdeveloped, deprived
sectors. But for these deprived, exploited sectors, some kind
of health-care had to be offered to avoid political dissent
and to get fresh, healthy labour power from those sectors.
There was thus the need for a cheap and efficient health-care
system, meant for the rural masses. Hence the slogan of >
11 Health-for All.* The programme of ‘Health for All* is in
the long term interests of the capitalist class as a whole.
But capitalist class is not a homogenous entity, The myopic
interests of one of its factions- the medical industrial
complex-demands that resources be spent in catering to its
growth. Hence in the essentially chaotic, unplanned capitalist
society, * Health-ffcr
Health-f$r all * was not goihg to be implemented
as xxunifiedt an all-inportant programme. It was naive to expect
a unified political commitment to this programme from the
ruling-class. It could not have curbed the interests of the
exploitative, wasteful activities of the medical-industrial
complex without a powerful pressure from below. Such a
pressure was lacking.
The principles of organization of health-care in
the programme of ^rimary-Health-Care are quite rational and
when used properly, they have yielded good results in some health
care projects ^pd in post-revolutionary societies like* China*
Vietnam, Mosambique* Primary Health Care includes at least I
• 2«
and main focus, and of the overall social and economic
development of the community. It is the first level of
contact of individuals, the family and community with the
national health system bringing health care as close as
possible to wh re people live and work, and constitutes
the first element of a continuing health care process.*
is thus quite in contrast with the dominant view of
health-cire. But there were some basic problems with the
Alma Ata declaration. The side-tracking of these problems
lead to undue expectations. What are these problems ?
Firstly, except for the importance attached to
the role of paramedical workers, there was hardly any new
positive principle in this Declaration. Coming from the
offici il represent itives of various Governments all over
the world, and the representatives of the leading intern
national
agencies,
it is significant that the
Declaration clearly kept away from the forces for priva
tized, commercialized model of health-care. ( Today this
lobby for privatization has made inroads into the strategy
of Health for all.*) But that's all. The Alma-Ata
declaration was actually a climb-down from the earlier
policy of ’Comprehensive health Care* which was to be
complete, continuous, competent, compassionate. * In
India, the Bhore committee had splelt out in some detail,
five criteria of comprehensive Health Service and Primary
Health Centres were started in 1952 as part of the community Development Programme• These criteria were 1
(a) provide cidequate preventive, curative
and promotive health service,
(b) be as close to the beneficiaries as possible,
(c) has the widest cooperation between the people,
the service ani the profession!
(d) is available to all irrespective of their
ability to pay for it.
•“3—
(e) look after more specifically the vulnerable
anl weaker section of the cammunity, and
(f) create and maintain a healthy environment
both in homes as well as working places**
The Alma-Ata declaration was glorified without
noticing that the shift from Comprehensive Health Care to
Primary Health Care was conceptually and programmatically
a step backward in respect of the reach of the health
programme. ( Now there is a further narrowing down to
Selective Primary Health Care.*)
Secondly, though the Alma-Ata declaration says
in the beginning that health is w* a state of complete physical,
mental and social wellbeing, and not merely the absence of
disease or infirmity,* its programmatic aim is somewhat
narrow- * the attainment by all peoples of the world by the
year 2000, of a level of health that will permit them to
lead a socially and eCPngmically productive life. * (my enphasis) •
Thus those who are not socially or economically productive
( e.g. the old people) have been excluded from the strategy
of health for all. In capitalism,1 socially and economically
productive life* means that activity which directly er indi
rectly benefits the Capitalists. women are specially important
to the Capitalists in so far as they are mothers who give birth
to the toilers of tomorrow, ^hat is why the Mother & Child
Health Programme. If the MCH programme derives its rationale
because problems of motherhood and child-health are quite
common, the problems like leucorrhoea ( white discharge )
dysemorrhoea ( painful menstruation ) are also universal.
But they do not kill women and hence do not become worthy of
a National programme 1 If motherhood and childhood are
biologically vulnerable states, so is old age. Thus the real
rationale of choosing problems of motherhood and childhood
for National Programmes is not only their epidemiological
characteristics but also the element of how important are these
health tissues for the needs of Capital Accumulation.
•••
/
I
• 4.
This climb-down from comprehensive to Primary Health
Care was felt necessary by the ruling class because the progra
mme of * Comprehensive Health Care
was found to be clearly
beyond their capacity* Por examples in India, compared to
the Bhore-Committee Recommendations, the achievements In
setting up of PHCs, training of doctors, nurses, midwives by
1978, was, 16^, ^6%, 5%, 30% respectively* ^he kind of deve
lopment generated by Modem imperialism is econcxnically and
ecologically so demanding on the resources and is socially so
inefficient that it invariably leads to islands of unviable
developmental models and vast tracts of underdeveloped, deprived
sectors* But for these deprived, exploited sectors, some kind
of health-care had to be offered to avoid political dissent
and to get fresh, healthy labour power from those sectors.
There was thus the need for a cheap and efficient health-care
system, meant for the rural masses* Hence the slogan of i
M Health-for All** The programme of ’Health for All* is in
the long term interests of the capitalist class as a whole*
But capitalist class is not a homogenous entity, The myopic
interests of one of its factions— the medical industrial
complex-demands that resources be spent in catering to its
growth. Hence in the essentially chaotic, unplanned capitalist
society, * H
ealth-f>r all *” was not goihg to be implemented
Health-fftr
as axunified
xxujiifiedt an all-inportant programme. It was naive to expect
a unified political commitment to this programme from the
ruling—class* It could not have curbed the interests of the
exploitative, wasteful activities of the medical-industrial
complex without a powerful pressure from below. Such a
pressure was lacking*
The principles of organization of health-care in
the programme of ^rimary-Health—Care are quite rational and
when used properly, ttey have yielded good results in some health
care projects ^pd in post-revolutionary societies like: China,
Vietnam, Mozambique* Primary Health Care includes at least s
• 5.
education concerning prevailing health problems and the.
methods of preventing and controlling them?, promotion of
food supply and proper nutrition: an adequate supply of
saffe water and basic sanitation; maternal and child health
care, including family planning; immunization against the
major infectious diseases; prevention and control of locally
endemic diseases; appropriate treatment of common diseases
and injuries; and provision of essential drugs;-
V)
go
o
©
«s
a
ow
I
g
d
(D
XI
ft)
5
*
The prcmotion of food supply and proper nutrition;
adequate supply of safe water and basic sanitation are a
far cry in backward capitalist countries. There is no wonder
th it diseases due to sanitation and malnutrition dominate/^ Given
the logic of capital accumulation is these countries, it
was quite naive to expect even these basiB/pexquisites being
fulfilled. This is especially true in the current period of
world economic crisis with rising unemployment, inflation,
budgetary deficit with less and less funds for social deve
lopment. Thus the aim of “ Health for all “ was doomed
right from the word ’go' in view of the sinking economies
of these backward capitalist countries. To merely talk about
• good princii les,’ without pointing out towards the economic
and social crisis, is to mislead the people.
It may be noted in the passing that the above
minimum programme of Primary Health Care does not say a word
about occupational health. Secondly, one wonders as to where
would programmes like: Goitre Control Progr imme oX Leprosy
Control Programme fit into this Scheme of Primary Health Care;
there being no specific mention of control of communicable
diseases nor of nationally endemic diseases.
(ctd.••.
/
p[ I
.6.
To conclude, it is thus not enouah for us Leftists
to say that Primary Health Care approach can not be brought,
into practice under Capitalism. The very concept has to be
seen in a historical perspective, and its limitations and
blindspots need to be pointed out; its politics is to be
grasped. It is only then can we adequately, scientifically
answer the question * " What went wrong t " and plan for
a socialist alternative•
•0 •
OM
$
r
COMMENTS
A Decade After - >Health for ^11*
What went Wrong?
1. Health for All was only a slogan. In planning terms it means
more specific goals and we need to recognise it and evaluate
achievements against those specific goals. We shall always
i
be far from the broader goal of ’Health for All’ since it is
an ’idealistic utopia’ which even the socialist bloc have not
been able to move towards adequately (parfe 1 page l)
2. The sentence in the second paragraph (page 1)
health care’ is confusing.
’The clear....
Needs a better formulation.
3. What do you mean by stating Hihat sidetracking of these problems
lead to undue expectations ’, (page 2 para l) May be ’blurring
of deeper/social dimensions of health’ could be an alternative
f ormulation.
4. While in India we may not consider PHC an entirely new
formulation because of the ’Shore report’ this cannot be
generalised for the international context. Even in the socialist
block the ’involvement of people/community’ has been neglected
and the whole process has been ’top-down’ (page 2 para 2)
5. Mention where you got this quotation that ’comprehensive
Health Care’ was to be ’complete, continuous, competent and
compassionate’. While it is an interesting reference, it does
not clarify whether ’comprehensive’ would involve facilities
at all levels - Primary, Secondary and tertiary.
6. You have listed out 6 criteria of Shore Committee (text mentions five)
7. In Shore Committee criteria (c) mentions ’cooperation’ of the
people not ’full participation’. This is a qualitative difference.
8. I do not understcind the difference you make between comprehensive
health care and PHC - hence the step backward is not clear, Unless
of course you are meaning that ’comprehensive ’ focussed on
Primary/Secondary and tertiary health care.
....2
Actually if you go back to the definition mentioned in page 1
there are many dimensions of the formulation which are ’new*
eg. Social acceptability of methods/technology
Universal accessibility
Cost a community/country can af ford’J
self-reliance and self-determination
This accepts diversity and flexibility and not a universal
acceptance of a western-high technology institutional model.
You have ignored all these dimensions^
10. Page 3 para 2
The paragraph starts out by raising the issue of difference
between ’well being’ and productivity but then only mentions
I
MCH as an example and here confuses ’mortality’ and ’morbidity’
issues in priority setting apart from raising the capitalist
bias issue. I think MCH is important not only because they
support capital accumalation but for other reasons of vulnerability
as well.
Which rationale is more ’real’ in the selection is hence
only a matter of opinion
11. Cheap and effieicnt health care (page 4 para 1) is not only a
scaling down to serve capitalist interests to avoid dissent even
though it could be used for that purpose. A search for Lowcost
but efficient health care is also a ’subversive alternative’ to
k
the dominant ’western high tech institutional health care’ the
further expansion of which is in the interest of the capitalists#
Even the socialist bloc have endorsed ’Health for AH’ and infact
it is examples like Cuba, China, Vietnam etc that give us the
confidence that much can be achieved at lower cost.
So your
analysis is partial and somewhat biased.
12. The point about the absence of ’powerful oressure from below’
is important and the ’issue raising demand creating - accountability
raising process from the people’ has been overlooked in the PHC
formulation. Another important dimension overlooked is the
.. ..3
♦3
•stratification’ and ’diversity of interests’ among the ’people’
and the community* Hence the process of struggle/conflicts of
interests/control is overlooked and working ’with people’ is
presented as a ’naive’ generalisation*
13.You have not mentioned any where the growing tensions and ’dissonance’
in the health car© systems of the socialist bloc itself. The
socialist alternative does not exist there either. My visit to
Poland was most disappointing in this regard. It may not have
been the best example of the socialist bloc but the professionals
I met at all levels of the health care were not concerned about
socialist alternatives. While you attack capitalist countries
rightly lets not idealise the socialist bloc atleast not their
health services unless there is definite information of ’alternatives,
(page 5 para 2) Even China is backtracking nowadays rapidly.
14. Page 5 para 3
Goitre and Leprosy get included in ’prevailing health problems’ as
uell as ’prevention and control of locally endemic diseases*.
Infact your quotation on page 5 para 1 itself mentions it*
So what is the point you are makingl
15.Actually your editorial was a bit disappointing - somewhat sketchy
considering the long time you have been mulling over the matter.
One had expected that you would have made a more thorough analysis
of *the very concept’ and ’historical perspectives and its limitations
and blind spots’. However since this is only an editorial, I
hope the other articles explore this more adequately.
3
J Lval
Lc
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A<-h
IaIvV]
"at tWL
■C I -zn
v
«r
f
I
CfW) H S
.
come nts
A Decade After - ’Health for ^11’
What went Wrong?
1. Health for All was only a slogan. In planning terms it means
more specific goals and we need to recognise it and evaluate
achievements against those specific goals. We shall always
be far from the broader goal of ’Health for All1 since it is
an ’idealistic utopia’ which even the socialist bloc have not
been able to move towards adequately (parfc 1 page 1)
2. The sentence in the second paragraph (page 1) ’The clear....
health care’ is confusing.
Needs a better fornulation.
3* What do you mean by stating *that sidetracking of these problems
lead to undue expectations ’, (page 2 para 1) May be ’blurring
of deeper/social dimensions of health’ could be an alternative
formulation*
4. While in India we may not consider PHC an entirely new
formulation because of the ’Shore report’ this cannot be
generalised for the international context. Even in the socialist
block the ’involvement of people/community’ has been neglected
and the whole process has been ’top-down’ (page 2 para 2)
5* Mention where you got this quotation that ’comprehensive
Health Care’ was to be ’complete, continuous, competent and
compassionate’. While it is an interesting reference, it does
not clarify whether ’comprehensive’ would involve facilities
at all levels - Primary, Secondary and tertiary.
6. You have listed out 6 criteria of Shore Committee (text mentions five)
7. In Shore Committee criteria (c) mentions ’cooperation’ of the
people not ’full participation’.
This is a qualitative difference.
8. I do not understand the difference you make between comprehensive
health care and PHC - hence the step backward is not clear. Unless
of course you are meaning that ’comprehensive* focussed on
Primary/Secondary and tertiary health care.
-
2
5. Actually if you go back to the definition mentioned in page 1
there are many dimensions of the formulation which are ’new’
eg. Social acceptability of methods/technology
Universal accessibility
Cost a community/country can afford
self-reliance and self-determination
This accepts diversity and flexibility and not a universal
acceptance of a western-high technology institutional model.
You have ignored all these dimensions.
10. Page 3 para 2
The paragraph starts out by raising the issue of difference
between ’well being* and productivity but then only mentions
PICH as an example and here confuses ’mortality’ and ’morbidity’
issues in priority setting apart from raising the capitalist
bias issue. I think MCH is important not only because they
support capital accumalation but for other reasons of vulnerability
as well.
Which rationale is more ’real’ in the selection is hence
only a matter of opinion
11. Cheap and effieicnt health care (page 4 para l) is not only a
scaling down to serve capitalist interests to avoid dissent even
though it could be used for that purpose. A search for Lowcost
but efficient health care is also a ’subversive alternative’ to
the dominant ’western high tech institutional health care’ the
further expansion of which is in the interest of the capitalists.
Even the socialist bloc have endorsed ’Health for All* and infact
it is examples like Cuba, China, Vietnam etc that give us the
confidence that much can be achieved at lower cost.
So your
analysis is partial and somewhat biased.
12. The point about the absence of ’powerful pressure from below’
is important and the ’issue raising demand creating - accountability
raising process from the oeople’ has been overlooked in the PHC
formulation. Another important dimension overlooked is the
.. ..3
3
*’ stratification’ and ’diversity of interests’ among the ’people’
and the community, Hence the process of struggle/conflicts of
interests/control is overlooked and working ’with people’ is
presented as a ’naive’ generalisation^
13.You have not mentioned any where the growing tensions and ’ dissonance’
in the health care systems of the socialist bloc itself, The
socialist alternative does not exist there either. 1*1 y visit to
Poland was 'Lmo^t disappointing in this regard, It m&y not have
been the best example of the socialist bloc but the professionals
I met at all levels of the health care were not concerned about
socialist alternatives. While you attack capitalist countries
i
rightly lets not idealise the socialist bloc atleast not their
health services unless there is definite information of ’alternatives,
(page 5 para 2) Even China is backtracking nowadays rapidly.
14. Page 5 para 3
Goitre and Leprosy get included in ’prevailing health problems’ as
well as ’prevention and control of locally endemic diseases’.
Infact your quotation on page 5 para 1 itself mentions it.
So what is the point you are makingI
15.Actually your editorial was a bit disappointing - somewhat sketchy
considering the long time you have been mulling over the matter.
One had expected that you wodld have made a more thorough analysis
of 'the very concept’ and ’historical perspectives and its limitations
and blind spots’. However since this is only an editorial, I
hope the other articles explore this more adequately.
Jud'
- Ixvt-I
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V
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S -h 'vvi^Llax
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Cvy
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5
VCZaZ? "1 UzHl
(o
C La "2>->
r
r
COMMENTS
A Qoqado After — tHoalth for *111
Uhat wont ^ronq?
1e Health for All was only a slogan. In planning terms it means
more specific goals and we need to recognise it and evaluate
achievements against those specific goals. We shall always
be far from the broader goal of •Health for All* since it is
an idealistic utopia9 which even the socialist bloc have not
been able to move towards adequately (park 1 page 1)
2. The sentence in the second paragraph (page 1) 9The clear....
health care9 is confusing. Needs a better foreulation.
3. Uhat do you mean by stating ihat sidetracking of these problems
lead to undue expectations9, (page 2 para 1) May be ’blurring
of doeper/social dimensions of health9 could be an alternative
formulation.
4. While in India we may not consider PHC an entirely new
formulation because of the 9Bhore report9 this cannot be
generaljsecj for the international context. Even in the socialist
block the ’involvement of people/community9 has been neglected
and the whole process has been ’top-down9 (page 2 para 2)
5. Mention where you got this quotation that ’comprehensive
Health Care’ was to be ’completet continuoust competent and
compassionate’. While it is an interesting referencet it does
not clarify whether ’comprehensive’ would involve facilities
at all levels - Primary* Secondary and tertiary.
6. You have listed out 6 criteria of Shore Committee (text mentions five)
7. In Shore Committee criteria (c) mentions ’cooperation9 of the
people not ’full participation9. This is a qualitative difference.
8. I do not understand the difference you make between comprehensive
health care and PHC - hence the step backward is not clear. Unless
of course you are meaning that ’comprehensive’ focussed on
Primary/Secondary and tertiary health care.
.2
.2^
9, Actually if you go back to the definition mentioned in pafee 1
there are many dimensions of the formulation which are ’new*
eg. Social acceptability of methods/technology
Universal accessibility
Cost a community/country can afford
self-reliance and self-determination
This accepts diversity and flexibility and not a universal
acceptance of a western-high technology institutional model.
You have ignored all these dimensions.
10, Page 3 para 2
The paragraph starts out by raising the issue of difference
between ’well being* and productivity but then only mentions
l*!CH as an example and here confuses ’mortality’ and ’morbidity’
issues in priority setting apart from raising the capitalist
bias issue. I think flCH is important not only because they
support capital accumalation but for other reasons of vulnerability
as well. Which rationale is more ’real’ in the selection is hence
only a matter of opinion
11. Cheap and efficient health care (page 4 para 1) is not only a
scaling down to serve capitalist interests to avoid dissent even
tnough it could be used for that purpose. A search for Lowcost
but efficient health care is also a ’subversive alternative’ to
the dominant ’western high tech institutional health care’ the
further expansion of which is in the interest of the capitalists.
Even the socialist bloc have endorsed ’Health for AH’ and infact
it is examples like Cuba, China, Vietnam etc that give us the
confidence that much can be achieved at lower cost. -o your
analysis is partial and somewhat biased.
12. The point about the absence of ’oowerful pressure from below’
is important and the ’issue raising demand creating - accountability
raising process from the people’ has been overlooked in the PHC
formulation. Another important dimension overlooked is the
3
stratification’ and ’diversity of interests’ among the ’people’
and the community. Hence the process of struggle/conflicts of
interests/control is overlooked and working ’with people’ is
presented as a ’naive’ generalisation.
13.You have not mentioned any where the growing tensions and ’dissonance’
in the health care systems of the socialist bloc itself. The
socialist alternative does not exist there either. My visit to
Poland was . most disappointing in this regard. It may not have
been the best example of the socialist bloc but the professionals
I met at all levels of the health care were not concerned about
socialist alternatives. While you attack capitalist countries
rightly lets not idealise the socialist bloc atleast not their
health services unless there is definite information of ’alternatives,
(page 5 para 2) Even China is backtracking nowadays rapidly.
14. Page 5 para 3
Goitre and Leprosy get included in ’prevailing health problems’ as
well as ’prevention and control of locally endemic diseases’.
Infact your quotation on page 5 para 1 itself mentions it.
So what is the point you are makingl
15.Actually your editorial was a bit disappointing - somewhat sketchy
considering the long time you have been mulling over the matter.
One had expected that you would have made a more thorough analysis
of *the very concept’ and ’historical perspectives and its limitations
and blind spots’. However since this is only an editorial, I
hope the other articles explore this more adequately.
/I
A. yR tie '
izv Jv'6^ •
va © I'
c
Lo
VWAAytT </vLt
11A4-
Cvn-A M 3>S :
A. INTRODUCTION
1. What is health?
Health la defined' by
the .World
ba!n9
‘ < the
World Health
physical,
infirmity. This implies
as a state of complete physica.,
I
not
merely
the
absence
of
disease
or
in i
;ociety.
and
,„I\.
,
'
i
health
for
each
a goal of
S’ •1B° lnC1Uded
India had suggested that ■ .
in this definition.
A KJ
i •
’
1
~
to try to
?hishdef;inition. Here we . would
J-°^ing at the^levels^^^
□ f health of the population as.anU^1®i^ the many stratifiof individuals. However, keeping in mind
<t ..£n Indian
cations of class, caste and gender that are p^
society today, it would be e-ua y
^^ppgrent sub-qroups
understand the health, statu
he differences according
of th, PObulatloh, There would al=ohb, d6^”Dulatlon3
uah need
'
"tnTrrsultino fr» their oun p.^eul.r
Soe^-econondc-politloal-dulturel ertu.tron,
2. How do
a^sure_hea 11h9_.
•
p Hpfinition -it is rather difficult to
Given the above
>’-’uhTr
di"
measure tii^oertoi, ibdio.terSoh.veai-.mam
b,.d
a
dev^b
:d^ohh9can
the years certain indicators have b^en
some estimate of thedifferent
levels u.populations and t° monitor
be used to compare u population over t ime .. -Some of_,,he.
changes
are Ii>c ine the
pe samey ?
*11 he pxolain ed as*we go along. For'
life expectancy,
rote etc. These
t.r.f «1 J
Sise.se K-d
These terms
specific diseases ue
Ih’rpoSuiabcn’by their Incidence end prssal.nc
qood health
information collection
health information
Thsre needs to bej a gooa
y
- --> to do this there
. And
‘; (out
system to work
-- - these indicators.
health
service systemi which
needs to be a.well spread out I — - efficiently
works relatively u■ -- and
most people use, which various health and disease events
regarding
where records
i--well
ma
intained
0
are
development of the health infrastructure,
In India, though the
the government, in terms of
throughout sGb-centres-.nd
the country, by pr
’— y.heelt^centres eet.bllshed
number of
—
has
and number of health personnel trained
functional efficacy of these
quantum increase, the level o
.
facilities leaves much to be desired, It is also an accepted
centres is of
fact that the data colle ted at the
these
census, the National Sample
questionable quality. However,
j and data from
Surveys, studies by research institutions
with useful
some voluntary health projects do prov'ide us mentioned above.
indicators
information regarding the'health
t..~
2
2
3^ Some background f actor s t o^. cons ider
When we try and understand the health status of the people
of India it is important to keep in mind the magnitude of
our country—the geographic size and even more its.population.
We are second only to China in population size, there being
850 million of us. This is equal to the population of USSR,
USA and Japan put together. It is said we add an Australia
to our population every year.
Our vast population is also very diverse:for instance
people in very different geographic ar as from the snowy
Himalayas, the deserts of Rajasthan, the great river valleys 9
the hilly regions and coastal belts; there are different
ethnic background, a variety of language growns, religions,
and Cultures; levels of socio-economic development, education
and political consciousness' also vary a great deal. All these
factors affect health in numerous ways; hence, talking about
the health status of the people of India as a whole is.a
very broad generalization. The average figures given ih the
tables hide diff fences that occur from place to place and
group to group. Within Karnataka itself, there are differences
in the health indicators between urban and rural areas and
from district to district. It would be revealing to know
the breakup by income level, caste/tribe, age and sex.
Another factor to consider is that the health of individuals,
communities ^and populations is a dynamic state, changing
over time, responding to a number of factors which have
a relationship with it. It has been observed in populations
that as certain diseases decline, others may become apparent
or develop anew. This has been termed the onion-peel effect.
4-
or -health gjzojD 1 ems _in Jl nd i^a
Keeping
Keeping in
in mind all the above factors it can be said
broadly that in India people'suffer from the diseases of poverty
' • the diseases$ of modernization. The 30-40% of the
alongside
population under the poverty line (about 230—300 million)
and also the lower middle cla s continue
l._,,---- to
_ bear the burden
_
of malnutrition which takes its greatest toll from children
and mothers. They also suffer-from the lack of clean water,
and sanitation, adequate housing and clothing all of which
result in various communicable or infectious diseases:eg.,
tuberculosis, leprosy, gastroenteritis, typhoid, cholera,
jaundice, diarrhoeas, malaria filaria etc., This ill health
affects the working and earning capacity of people.and often
results in disability and even unnecessary and early death.
The tragedy is that most of those diseases are preventable,
by an overall equitable development process and also by public
health measures.
...3
J
TA3LE 1
Percentage of population below the poverty line
1983-84 (Provisional)’
Rural
Combined
Urban
,.u j-c,-..
‘■* *
*'’■
_ir -..■MT.
—
-
Karnataka
37.5
29'. 2
35.0
26.1
30.1
26.8
Kerala
All India
40.4
28.1
37.4
Dept.
Source”. Status Report 1988-89’9 Govt of Karnataka 9
of Health
I.--- - & Family Welfare
and urbanization have
Modernizat ion, industrialization
There ar? many specific
brought along their own ills. aod
invir^ram^ntal pollution
oceup'stional' health problems
.
.
y
problems associated with the various industries. In
agriculture also there is extensive use. of chemicals
fertilizers and pesticides^uhich en er
Specially the
affecting the total populau 10f'j
Rurai urban migration has
sprayers and agricultural workers.
fl.nges of ^itiss>
‘Jive in -hvLnlzed conditions reauiting
in many social health problems in a
<
poverty eg., broken rli.., alcobr
itUtibn”
JU
gambling .etc. Rapidly growing
traffic accidents,
?n their basic services, air pollution, .traffiercer
housing problems and alienation
psychiatric problems,
accompanying host of psychol q
P Y
reiated disorders
Ca*««r3, cardiovascular diseases ano stress
are on the increase.
B.
FOCUSSING 0M KftRNATAKft
Karnataka i, better than tn- natlenal’
in.
the health in^icat°r3,coming secon
^rief overview
not he given
91van hlbhXlbhttng
hiqhliqhting
only the more Important aspects.
The populatioj^. and its distribution
27. 1 million (1901 census') ,
.
37.1
With a population of5.42%
of India's population, ranking
Karnataka accounts for terms of population size. With
8th among the States in
density is
an area of 191,791 sq kms the ocopulation
.Estimates of the population
194/sq km (all India 2*16/sq km),
in 1990 are 44.48 million.
1.
4
4
The following table gives some of the features of the
distribution of the pooulation in Karnataka*
Table 2
Population distribution in Karnataka (1981)
(T = Total;
T otal; R = Rural; UL = Urban)
Males
F emales
Sex%Urban
R a t io_ P o pul at ion
Area in Km
Popula-.
t ion
T
191,791
37135714 1R922627 18213087
963
R
188108.2
26406108 13352400 13053708
978
U
3682.8
5159379
926
10729606
5570227
28.89
Source: Health Information of India, 1987, CRHI, DGHS, NeuDelhi
(a) The sex-rat io is the number of f emales per 1000 males.
In most countries of the world this is in favour of females.
However in India (and Pakistan, Bangladesh, Afpanistan etc
it is the reverse and more importantly has been steadily
decreasing since the turn of the century,even post-independence.
The decline has come to a halt only in the last'census (19
The only two’States in India to have a positive sex ratio
are Kerala and Goa. Within Karnataka, Dakshin Kannada Dist
also has a positive ratio. Otherwise it varies in the
different States and Districts. The adverse sexratio has
been ascribed as being due to various casues--hiqh maternal
mortality following early marriage and repeated pregnancies,
poor educational status of women, low utilisation of health
services by women—the underlying reason being the inferior
status of women in society*
Table 3
Conditions of children and women in India
Indicator
1 . Infant Mortality
(deaths)
(per 1000 live
births per year)
India
Developing
countries
Developed
countries
1 25
96
20
18
9
60
20
400
20
2. % of new borns
weing less than
27.5
2.5 kg
3. % of anaemia among
70
pregnant women
4. Maternal mortality
per 100,000 live
418
births/per year
Source: Health Cara in Ihcl’ia, 19733, 'Jo'seph G et al.
CSA, Bangalore
5
5
(b) The age distribution of the population in
Karnataka is as follows (1981 census
0-14 ysars
: 39.6%
15—59 years
: 53.8%
6.6%
60 + years
’ This is very s.invilar to the all India pattern. With almost
40% of the population being children, ours is predominantly a
young population.
(c) Though the indicators ofchild health have shown
™ the ■■'years '^I’t'^stfll remains a matter
some improvement over
«,
of serious concern. As
/.- shown
---- in Table 3, the infant mortality
which is the number of children who die before they reach
the age?of one year still remains unacceptably high. About
30% of newborn babies have a low birthweight (less than
2.5 kg). These babies are b-hree times more likely to die in
infancy than babies of normal weight at birth. The under 5
or toddler d^ath rate is also very high.
Table 4
Estimated Infant Mortality Rates, 1985
Rural
Urban
Combined
105
57
95
Uttar Pradesh 152
77
140
Karnataka
80
41
71
Kerala
32
30
31
India
Source: Registrar General, I ndia
As can be seen, Karnat ka is on the lower side of the range
of IflR’s among the States.Having reached thus far it would bo
useful to have a more detailed district wise and population
groun wise break up of IMR. Perhaps Volags in Karnataka
could study this measure in their respective areas as.it is
an acceptable and good indicator of the standard of life
of a given population.
Table 5
Other childhood death rates -All India, 1983
,-o - rii-wiin-L
Age Specific
death rate
■ i-TB-
-•** —y— f '“I - -
Rural Male
r
t li-
- •«- ■
~7~’~Urban Male
Rural Female
Urban Female
■ 0-4 year
40.5
43.1
21.1
21.7
5-8 years
3.4
4.0
2.0
1.8
10-14 years
1 .7
2.0
0.9
1.2
Source: Health Information of India, 1987, CRHI, DGHS, Mew Delhi
6
6
*
In India, deaths of children still account for about- 40% of
the total deaths that occur—28.8% in Karnataka. A very
large number of these are preventable- and we need to make
h? Tul
specific efforts to allow these numerous children, tthe
full1
bloom of their lives.
(d) The urbjan population of Karnataka has been growing
and is high C28.9%) compared to the all India figure of
23.31%. It is necessary to find out what percentage of
the urban population are slum dwellers. A large chunk —30% of the urban population--are in Bangalore, the remaining
being spread over 281 towns.
Urban areas monopolise much of the health care and other
social service facilities. These include finances available
from both the government and private sector, highly trained
health personnel, sophisticated capital intensive equipment
and medical facilities.
In the village and hamlets, medical facilities are scarce
and nof poor quality. There is a shortage of basic essential
drugs and vaccines. Ther • are poorly trained staff in charge
of large areas and basic public health measures of safe
water supply and facilities for sanitation very inadequate.
The disparities of income and living conditions along: with
the abo e factors is revealed in the striking difference in
health indicators between urban and rural areas.
Table 6
Urban/Rural inequalities (%) in India
Urban
Rural
Population (19B1)
23.7
76.3
2» Doctors (196T-71)
70-80
20-30
3. Nurs'es/ANMs (1971)
60
40
4. Hospitals (1981)
73.9
26.1
5. Dispensaries (1981)
20.2
69.8
6. Hospitals/dispensary
bfeds (1981)
83
17
1.
Source: Health Care in India, Joseph 0 et al, 1983,
CSA, Bangalore
7
'I
si
7
Table 7
Urban/Rur al Health indicato.
I ndia
Karnataka
Urban
R u r al_
’UTban
1 . B irth rate
(1986)
26.8
29.9
27.1
34.2
2. Death Rate
( 1986)
6o8
9.4
7.6
12.2
3. Infant
mortality
rate (1986)
47
82
62
105
4. Expectation
of life at
birth (19761980)
64
53.9
60.1
50.6
Dept of
Source: Status
status Report
Keport 1988-89
i^oo-o^. Govt of Karnataka,
Health & Family Welfare , Bangalore
2.
Birth and Death Rates
The crude birth rate is the number of births
population per year. Amongst the States, joa an
uoiF3rP
Save the lowest birth rates. The goalfamily welfar.
nroqramme is to reduce the crude birth rate to 2 /
population by 2000 AD (it is already 19.1/1000 populati
in Goa). These targets and the Programme are not applicab1.
to tribal populations.
In Karnataka it is 29/1000 (
The crude death rate is the number of deaths per 1000
population per year. Karnataka has already reached the nat
1
goal of a crude death rate of 9/1000 population to be ach.eve
by 2000AD.
C.h a n g e s in health indicators over time
• ) health indicators that
A brief picture of the change in
since
Independence
is as follows:
have occurred in India j---- -
3.
Table 8
Birth rate
Death rate
Infant
Mortality
Rate
Life expectancy
at birth
1941-51
39.9
27.4
134
32.1
1951-61
41.7
22.8
146
41.3
1961-71
41.2
19.0
138
45.6
Y ea??
52.1
127
12.4
33.3
1980
Bangalore
Source: Health Care in India 9 Joseph 0 31 al, OSA,
....... 8
8
4.
Grouth Rate
Since Independence the death rate in India has declined
compared to the birth rat^ which deer ased only
more steeply
J___ ,__y -■ 1 rate
-'-- ••J-h an enormous
gradually. Hence we have a •••
high growth
with
from
361
million
in 1951 to
increase in total population
estimated
to
be
840
million now.
685 million in 1981. Ue are
In Karnataka^ the increase in population has been from
million in 1951 to 37 million in 1981.
Here one must mention the experience of some Volags
working with defined population groups who state.that there
is an under-enumeration of the total population in their
area: eg.
eg., in tribal regions. It would be important to have
an estimate of the extent to which this occurs as it would
have serious implications.
Only some health indicators have been highlighted in
the Section above to present a general idea of the health
situation prevailing in India and particularly in Karnataka.
C.
NUTRITION .LEVELS
The nutritional status of individuals is closely linked
to their health status, determining to a large extent their
resistance to disease. The optimal growth and development
of children is also dependent on good nutrition. There.are
also specific nutrition deficiency diseases like protein
calorie malnutrition, iron deficiency, anaemia, Vit. A
deficiency, Vit 3 4 D deficiency etc.
Some statistics
India level are:
regarding child malnutrition at an all
1. % of infants with low birth weight
2. % of malnourished children
(mode rate/severe)
3. Children affect.ed by iron
deficiency anaemia
4. Number of children turning
blind each year mainly due to
Vite A deficiency (estimate)
(Sourc e:
:30%
:around 40%
c
around 50%
40,000
Future-Development Perspective- on Children,
UNICEF (Based mainly on government statistics
relating mostly to 1986).
The National Nutrition Monitoring Bureau systematically
collects information on a representative stratified sample
of households in rural and urban areas in 10 States of the
country, of which Karnataka is one. Every fifth rural household
does not eat adequately and among children below 4 years of
age, one in 3 consumes less food than recommended.
9
*
to
9
Family income and land ownership are critical
determinants of food intake. Those who own more than 10
acres of land have a mean intake of 3100 calories per day,
those who own less than 5 acres ate 2600 calories per day
while landless labourers consumed 2300 calories on an average.
Protein intake showed a similar trend. Overall the calorie
intake in Karnataka is higher than in neighbouring States
like Andhra and Flaharashtra.
Fluoro sis caused by excess fluorine in the water, has
been reported to be a public he 1th problem in some areas,
affecting the bony skeleton, teeth, sometimes causing
knock knees. High levels of fluoride (5-* 11 ppm) in open well
water has been reported in villages of Chitradurga, Tumkur
and Bellary districts. Dental fluorisis affected 75.76% of
individuals surveyed in flundargi Taluk of Dharward Dist
where the fluoride content of water was 3-7.6ppm. Fluorosis
has also been reported in some areas close to dams with the
possible causal factor being ecological changes caused by
construction of dams.
D.
DISEASE PROFILES IN KARNATAKA
An understanding of the quantum load of different
diseases in a population also gives an idea of the level of
health of the peculation. However, this is mor? easily said
than done particularly in India. Some of the difficulties
in measuring disease have been mentioned in the earlier part
of the note." The situation is even more complex because
several systems of medicine/healinn practices are actively
present here, each with their own approaches to disease/
symptom complexes. Hence government health services cannot
be the base used to measure disease in the community as only,
part of a population may use that service. The only alternative
is to conduct community based surveys which are very expensive
and cumbersome undertakings. Given the scant resources in.
the health sector it has not been possible to conduct nation
wide sample surveys to measure different diseases. Flore
complete information is available about some diseases: eg.,
leprosy and tuberculosis for which there are National Health
programmes with active case detection.
Available information on some of the diseases in Karnataka
Karnataka
as given in the Status Report 1988-89, Government of Karnataka,
will
now
be
given.
Dept of-Health and Family Welfare, u
Tabla 9
___
_1_987 _ _ \
Cases
Deaths
A . Respiratory
diseases
1. Tuberculosis 103006
2 . i .Acute
Respiratory
infect ion
.Pneumonia
1140
1988 (Provisional)
Cases
Deaths
125303
1172
192127
6599
contd...
75
84
. .10
10
Table 9 (contd..)
19 88 ( Pr o v i s i□ nal)
1987
E
Cases
Deaths
543944
91
Cases
____ -
..
.M.
••
Zt.
Deaths
■
- •
....
Gastro
intestinal
diseases
3. Dysentry
(all forms)
4. Acute
diarrhoeal
diseases
205161
237
5. Gastroenteritis
85393
524
14091
639
6. Cholera
1918
87
2167
70
7. Infectious
hepatitis
7774
122
5413
60 ’
8. Typhoid
17941
28
15406
36
C.
9. Malaria: total
positive cases
88505
127008
Plasmodium
falciparum
cases
29582
37667
2457
11870
10 .Filar ia
11.Lepro sy
D. Vaccine
preventable
childhood
diseases
12 .Diphther ia
2223
16
550
12
13 .Measles
8522
25
4481
25
14.Whooping cough
4928
14
7113
12
15.Poliomyelitis
2456
30
759
22
16.T etanus
1517
314
4841
299
17.1nfluenza
339827
8
16.Chickenpox
2387
4
19 . Oapanese
encephalitis
132
43
81
27
20.Kyasanur
Forest Disease
51
10
56
6
11
E. Others
•**
1'1
Table 9 (contd. • /
1987
Cases
19 88 £Provisioial)
Deaths '“■“Cases'
Deaths
.. __ _
~
21.Rabies
3486
46
3997
36
22. flen ingicoccal
inf ect io n
523
73
118
12
23.Syphilis
5375
2
5749
1
24.Gonococcal
infection
5036
25.Encephalitis
1347
26.Haemorrhagic
f ever
53
27.Guinea worm
990
28.All other
diseases
S
ss
=
7927329
7620
190
13991
7683977
10045
• T**
=
of tnose
those patients/cases who reported
These .figures are of
he'lth
services. They do not represent the
to the government
actual incidence of the diseasej in the community. A survey
that 77% of the
in fhiraioaon Rlocks Varanasi sshowed
■>
.
pSpuJaJion never urnd the primary hpalih d.ntte^ervrcesad
only 10.4% of illnesses in that community Mere amended to
at th= primary health centre. The number of deaths due to the
different disoa.es given in the Table also do not represent
d aease ™rtalr?y rata but probably are the "Umb" who
died out of those who reported. Hence, it would be unwise
to draw too many inferences from this data.
peoo!rSlOthaJhonerlDn^aya?s
interactions with several
bar?uberculosi| is st Hl *
major public health problem more than 40 v.ar. a,t orimePof
causing much suffering, disability and du..
- ,
life If is a disease'that affects children and young adults
esoecially males. All development workers should be aware
P
National Tuberculosis programme and create an awar-n
of the
about the facilities provided under this.
Uhen trying to work out the percentage P^^^lfthf
tuberculosis from figures given in the abova.report all he
districts, except Kolar, had a surprising uniformity p
the
third decimal point! The prevalence rate jas 2.12 p;r
population. This is rather surprising and raises questions
about the basic validity of the data.
12
*
12
L3P-T93y* The av rage prevalence rate for the entire
State is given as 3/1D0D
3/1D00 population in 1989. However,
However
there are large regional differences. The districts with
high prevalence rates (per 1000 population'? are.
Ra ichur
8.8
Gulbarga
8.6
Rallary
6.9
8 idar
5.7
8 i j aour
5.3
Mysore
3,9
Mandya
3.6
Kolar
3.6
G.c,i.Q_e_ ,PT6vgritable diseases in childhood
uiL9.
—
- - ----- ---- i are
diphtheria, whooping cough, tetanus, poliomyelitis, measles
and tuberculosis. Great emphasis is being oiven to immunization
programmes by the government, sponsored by UNIGEF, through
the Universal Immunization Programme (iJIP) and the Technology
Mission. Unfortunately it is being converted into a verticalised 9
top-down, target-oriented programme during the past few years.
The history of our own health services and programmes has
shown that an integrated health service at the level of the
community works best, is most cost-effective and acceptable
to the people. But this lesson seems to have b?en lost under
various pressures and compulsions working at an international
and national level.
Malaria which had declined consi 'erably in the 601s
has shown a resurgence in the 70’s due to various reasons.
Greater recognition is now being 'iven to environmental and
biological measures for the control of mosquitoes, instead
of relying only on insecticides as there hasbeen growing
resistance in the mosquitoes to the latter.
ka.ber and food borne diseases or the gastro-intestinal
IL3 3 a 533
h o 1 e r a, g a a t r o eTiT e r i t i s, d ysen tr y V'^cTTa Frh o'e a s’,
viral hepatitis, typhoid) are a me-jor cause of ill health
in India and Karnataka. Facilities for safe water suoply and
proper sanitation are still inadequate especially in rural
areas. There is a continuinq need for t'-is to be a major
area of focus as a preventive he 1th measure even though a
water and sanitation ..decade has dr-ady gone by.
KY.a.?anur For.!?st Disease
(KPO)
is a v'_
1 _‘l____
viral
disease
transmitted
by ticks to man. It 'was Tirst reported in 1956-57 in Kyasanur
Forest in Shimog.a district. It also affects adjoining a r ? a s
of Uttar Kannada, Chickmagalur and Dakshin Kannada districts.
KFD is associated with the felling of forests and clearing
of land for agricultural use. Those at greatest risk of
infection are cu:ltivators visiting the forest accompanied by
their animals or for cutting wood.
2'IP g n 3 S e E n c e p h a 1 i t j^s (JE) is also a viral disease
transmitted by mosquitoes, Nandya and Kolar districts are the
most affected.
This is a brief overview of some of the communicable
diseases. Non-communicable diseases including cancers,
cardiovascular diseases, diabetes, mental ill health have
not been discussed.
13
______
13
E.
CONCLUSION
Causation of disease and
Concepts regarding the causation of disease or
ill-health have evolved From miasmic theories (factors
relating mainly to the environment) to germ theories (discovery
of bacteria, parasites, viruses etc) to multifactorial theories .
(a number of factors including both the above) in the West.
In India, our own ancient systems understood the health o
individuals to be the result of a comoosite of physical,
mental and spiritual factors and the importance of hood,
cleanliness, good housing and a disciplined way of life were
accepted as necessary for good health. Whether social, economi
and political factors were recognised is a debatable issue.
of the
Ptessntly 5 however, it is accepted that some
population
are:
basic determinants of the health status of a
i. adequate and equitable distribution of
income, food, shelter and clothing;
ii. accessibility to safe water supoly
supnly, sanitation
education
and
employment:
facilities,
iii. a healthy environment: and
iv. healthy social rnlationshios and life styles.
The role played by the health care services is
secondary to theseo
It has been shown by the histories of the developed
countries that communicable diseases like tuberculosis^
leprosy and gastrointestinal diseases declined.before the
era of antibiotics and vaccines followinn the improvement
of the socio-economic condition of the pooulation and by
implementation of basic measures of sanitation.
L__J with rural development work, education 9
Thus groups involved
all contribute
awareness building, conscientization
c^..the
health
status of people.
significantly to improving
REFERENCES
1. Central Bureau of Health Intelligence, Health Infg,rmaction
of India, 1987, DGHS., Govt of India, New Delhi
2. Bureau of Health Intelligence, Status_Repo_rtx__1.988^8_9
Dept of Health & Family Welfare, Govt of Karnataka, (Bangalore
3. Joseph G et al, Hea 1th^r^ifL-India^JlB?. , Centre for
Social Action (CSAY, Bangalore
Agricultural Development
4. Narayan R, Health, Nutrition and
Karnataka
)
(an exploration focussing on Karnataka ’State
State),
Bangalore
Community Health Cell, CNF.CE.,
5. Park JE and Park K 9 LeXJ, k°2.k 0r Pr®ntive and _SocLal
Bhanot, Jabalpur•
Fled i cine. 1976, Bansrsidas
L_
April 9, 1990
HEALTH CARE SERVICES!
KNOWLEDGE, TECHNOLOGY .AND^PFLI.CAIigN
KNOWLEDGE
A)
There is a direct relationship between rise in living
standards and improvement in health indices as shown by the health
history of industrialized nations.
B)
However, relatively high level* of health are attainable even
by a country with limited resources like ours and these levels can
be attained within a relatively short span of time.
This is
passible through Primary Health Care approach utilizing readily
available biomedical technologies^- - Lt is not necessar y to wait
for comparable economic growth to take place first.
The task is
not utopian.
C)
The strategy to achieve this has been well charted in various
documents like the Bhore Committee report,
"Health for Alls
ICMR-ICSSR report on
An Alternative Strategy” and the National Health
Policy and has employed effectively by several micro level
experiments in our country.
D)
The state of Kerala in our own country, Sri Lanka, Taiwan,
China and Cuba have also shown how good health care can be
provided at low cost.
E)
While infections, infestations, communicable diseases and
deficiency disorders from a major proportion of our morbidity
load, degenerative disorders, coronary heart diseases, stroke and
cancers have also emerged in considerable proportions making it a
-
double burden o-F morbidity.
I&^CJdNOL.OGY.l.
A. Highly effective yet simple, cheap and safe technology
applicable even at field level is available to tackle most of our
problems.
Examples:
1.
iodine deficiency diseases including endemic goiter are the
easiest and cheapest of all diseases to prevent through the
provision of iodized salt.
No more new knowledge or technologies
are required.
2.
Iron deficiency anaemia can be controlled by daily
administration of one of the cheapest of the drugs - ferrous
sulphate.
3.
Nutritional blindness can be controlled through massive
dosing of vitamin A once in every 6 months.
4.
Effective immunizations are available against several killing
and maiming diseases like tetanus, polio, whooping cough.
diphtheria and measles.
5.
Oral rehydration therapy can avert hundreds of thousands of
deaths due to dehydrating diarrhoeas.
Advances in chemotherapy of tuberculosis and leprosy have
made it possible to treat patients in their own homes till
complete cure is achieved. even without continuous attention of a
doctor.
-z B.
Experience of industrailized countries has demonstrated that
interven tions with available high technology has proved not only
prohibitively expensive but also had no s i gn i f ican t impact on
morbidity due to non-communicable diseases like heart stroke.
cancers etc.
Even here the major thrust has to be on education,
effective changes in behaviour.
life styles and better
surroundings.
APPLICATIONe
The problem is ths widening gap between available knowledge
and technologies and their being put to optimal use.
It is in the
application of what we know that we are failing even more than in
the mere discovery of new knowledge.
The solution lies in
reaching the benefit of available science and technology to the
people?.
There have been a number of micro level, small scale
experiments and pilot innovations, several of them in our own
country j, which have been highly successful in the extension
technologies, in enlarging the outreach of services to rural areas
and in bringing about an improvement in health indices to the
level that we are expecting to reach nationally by the end of this
century.
We are now in a transition from the first to the second
generation of technology application which implies a big jump from
the micro level experiments to mass application of well proved
me t hod s.
This requires an entirely new form of organization.
In
this ths psopls thsmsslvss hsvs to play the dominant role instead
of being passive recipients.
The success of this bottom-up rather than the top-down
approach will depend chiefly on our social commitment and a strong
political will with the people at the center o-f the stage..
The role of the health services will have to change from the
present appropriative to a supportive nature.
__U. ..
CO'
SEvACARfrj
Guidelines for state health care delivery system
Suggestipns frpn field experience of voluntary sector
Aiirt-
To provide health care services equitably accessible to poor
Structure:For each vlllage/Ward of a city- Door-step services through village/
community health worker and Dai
For a cluster of Vlllages/city- Cottage hospital services of primary
helth care.
At a district level- Raferal hospital preferebly attached to the
Medical college ( If available)
At a state level Superspeciality hoppltal accessible strictly
on referal baMs.
How for the cottage hospital be ?
Ideally on 1/2 an hour’s reachable distance from the village
by the fastest transport ( on foot, by bullock cart by deep). The
pliable approach roads and quick communication system( Phone)
is requisite minimum if ambulance of cottage hospital is suppossed
to cater emergencies. With ready ambulance service and good
roads one expects to cater 25 k.m. radius area around.
How far the referal hospital be ?
Preferebly within 1/2 an hour’s distance by ambulance of
cottage hospital. The referal hospital is thus expected to cater
50 k.m. radius area.
How much the cottage hospital be equipped ?
The minimum must that cottage hospital should cater is1) Curative care
a) indoor emergency care for the problems where
patient is not transportable to referal hospital
eg:- Forcep/Ventouse delivery9 breach delivery, PPH,incomplete
abortion ( OB & Gyn)
-Resuscitation of new born, Dehyderaticn, lower respiratory
tract infections, convulsing child, PEM with complications,
Kerosene/Dature posolning, Dipthfia (paed)
A
-Snake bite. Tetanus, insecticide poisoning, severe
hypertension, actute LVF . COAD ( General Medicine)
-Epistaxis9 tracheostomy9 colic (Surgery)
...2
L
»
• • 2..
b)curative services for illnesses which
referal hospital
need not come to
eg, Convron Ailments attending Gyn/JMcd/Medicine O.P.D,
(including T.B. & Leprosy)
-Extraction of loose tooth
-Acute otitis media, wax in ear, otomycosis, safe ■
Maggots
i
CSOMr
-Minor burns, abscesses, suturing, dressing, splints.
-Conjunctivitis
-Normal delivery
2)
Preventive and promotlve services at door-step by out-reach
programme organised from cottage hospital:
What should be minimum manpower requirement of a cottage hospital:
-A postgraduate in Paediatrics
-A postgraduate in OB 6c GYtf
-A Postgraduate in community medicine
A A separate inwe^fking tralna?of all these doctors in elementary
anaethesla, orthopedics, dentistry ENT, opthalmology will have
to be undertaken to equip them to run O.P,D* effieently,)
-Two ANMs for hospital
-Two ANMs for cutreach health services
-Two social workers for cutreach programme
-A dresser cum dispenser cum registration clerk
-Two attendants for hospital
-To attendents for cutreach programme
driver for ambulance
-A 8 dhobi1 on contract basis for the hospital.
The role of referal hospital
~^o cater all specialities (like General surgery,General
Medicine, General Paediatrics, orthopedics, ENT, opthalmology,
CB & Gyn, Dentistry b Corrnunity medicine) strictly on referal basis
either from private sec ctor or from cottage hospital.
• Documentation of local events
* Appropriate research
• Teaching students if attached to a medical college :
• •3
B
-3
learnings from Sevagram experiment
Expected indoor load- 1 pjer 11 people
Expected average hospital stay- 7.5 days
expected bed requirement- 2 beds per 1000 population C 100% bed
occupancy
Expected indoor recurring cost (1989 figures)- 68Rs./day/bed
(Salary, drug . food 9 mentainance all
inclusive)
Expected out-reach recurring
expenditure (1989 figures)
- 510 Rs./admission
46RVper caplta/per year
-3.5 fc/capita/year for village
drug kit and for hiring
mobile health team
-2fc/capita/year for Vi*/+Dai
Bemuneration
Expected out door attendance - 1 ^er per sen/per year
Blind lanes-
What can be average out door expenditure of running
O*P*D<Service ?
What should be the numerical relationship between total
O•P.D.attendance/indoor admissions and number of doctors/paramidical
staff needed to run the cottage hospital ?
The above mentioned information will guide in
deciding population that can be catered and the catchment area
for a cottage hospital in more concrete terms. The cost economic
feasibility of employing skilled manpower at the cottage hospital
can also then be calculated
The strategy for out reach services« Annual cluster (pulse) isiuunisatlon strategy
(4 vislts/village/year)
-MCH services (3 vislts/village/year)
—Health education C Slide shows/comsnunity meetings
-Supervisory role to be shouldered by postgraduate doctor in community
Midic ine
How to assure availability of skilled manpower ?
-Mandatory 5 year interpreunership on completing post
graduation study before obtaining post grudate degree.
-If a medical College is available nearby
The district refera1
hospital be obligatorily run by medical college staff.
How can privatisation be checked ?
Free and good quality of accessible health service from
government sector can check privatisation, All government employees
must Join state health insurance scheme and no reimbursement be
allowed for hospital care obtained from private sector.
... A5ML .
f
• •4 • •
How to Incorporate people*s participation and their control ?
For state health services to be responsibe to people’s
need, empowering people by promoting their participation and
by controlling at least a pjart of financial resources id
obligatory.
The decentralisation process must be initiated.
In
the present situation, the control can not be totally decentralised
as professional wisdom is not necessarily identied to felt
demands of the people eg. the demand of tonic bottles and pricks
can not be justified by professional wiadom.t® ba kukkIuLxk
There must be scop>e in the system for professional wisdom to be as
sertive en^ough when required. As it is important that health
professionals are not required to dance at the tune of peoplefs
mind, it is also imperative that people be empxxwered to the extent
that they can conmand an efficient and quality health care delivery
system.
The following strategy is suggested- The state should
extend health services through health insurance scheme. The smallest
participatory unit wguld be a village or a ward of a town(depending
on population) The population size of the participating.
Cdmrnunity can be around 1000. The area to be catered by
• district level referal hospital and cottage hospitals would be
predefined. The decision to participate in the state hel&th
Insurance scheme will be taken by Gram Sabha with at least 75%
majority9
that means health insurance scheme would be voluntary.
The people’s pjarticipxation in management of services would
occur by co-opting a representative from each p>articip>ating^ unit.
The management body so formed with the hospita 1/state co-ordinators
would enjoy maximum MMXra
and implementation.
autonomy in local planning, budgeting,
Out of expected recurring expenditure, state would handover say
75% amount in advance with district hospital and 2 5% balance amount
would be distributed to participating unit according to p>er capita
calculations. This year marked amount will thus be deposited with
Gram-panchayat/Minleipa 1ity/Corporation and would go back to
hospital in form of health Insurance contribution^, provided
beneficiaries by atleast 75% majority approve it.
In the event of
non-participation in state health insurance scheme, the money would
go back to the state.
The financial control will serve three objectives
1.
The professional and management body of the health
system would be responsive to people’s demand in terms of efficiency,
outreach and quality since they seek for 25% budgetary allocation
from the people.
• ••5
mi.
X
/
i
.. 5..
2.
Since the 75% of funds are assured, the professional
and management staff would not be that insecure so 4s to
compromise on misdirected people's demand.
3.
The autonomy in planning, budgetory allocation and
implementation would pave way for creative involverement of
managerial staff and the people.
The superspeciality health care will be provided by
state run hospital stricly on referal basis.
For a purposeful link between people and health service
delivery staff, it is essential that village based and
village level staff is controlled more Intensely by the people
I suggest the following strategyThe village based staff (VW & Dai) would be paid
ha norar ium by Gram Sabha. The year marked amount would be made
available with Gram-Panchayat by the state (2Rs. per capita per
year ) The powers to hire (by *^5%
majority) or fire (by atleast
35% beneficiary) village based functionary will rest with Gram-sabha.
To get satisfactory performance report from Gram-sabha would be
requisite minimum for doctors /ANty/Social workers before they
entitle for increments or promotions. The obligatory minimum for
unsatisfactory performance would be protest lodged by at least,
35% of beneficiary population.
It is believed that direct control on village based
staff and indirect control on village level staff will pay
its dividents in incfeasing responsiveness to the people.
What is the proposed financial layout ?
(based on Sevagram experience)
Money with the State for
health delivery system expendituee- 80fh.(?) per capita
per year (1989 figure)
Allocation to the District hospital System -36Rs.per capita
(75% of 48 Rs.)
Allocation to Gram Panchayat for
VHW remuneration
Allocation to Gram Panchayat
for health insurance contributiont
-2 Rs. / per capita
- 12Rse / per capita
Balance money with state government for
•running supprspeciality hospital
-To meet non-recurring expenses of
cottage & district hospitals
-For state sponsored scheme
(2 5% of 48Rs.)
)
)
)
)
)
)
30Rs./cqpita
*
The role of Voflnntary Sector
-Appropriate training of paramedics (Supportive role)
-Operational Research*
-An obligatory participant in evaluation
of health system performance (Watch dog)
-Search for alternatives (Reformist/revolutionary role)
Rolle of Village based swkerst
David Warner in 'Vb®* lackey of1 liberator’ has
brought out comparison of doctor and village health worker* The
oppropriate future role of a doctor* according to the author is
on a tap ( not on top)* as an auxiliary to the VHW* helping to teach
hin/her more medical skills and of attending referals at the VfW* s
request for 2-3% of cases that are beyond WHW’s limit* VbW has
been recognised as the key mentoer of the health team* is the doctor’
equal and one who assumes leadership of health care activities
in the village* but reliee on advice* support and referal assistance
from the the doctor when he/she need it*
Sevagram field experience distillate the following
a) The role
VHW can not be doctor’s equal in curative services
(The felt need of the people) beacuse VbH can not command faith
of an expert healer* Though people do approach VW for symptom
relief of common self limiting illnesses because of easy
accessibllity* the credibility that VHW enjoys depends on efficiency
and quality of hospital system that stands behind* VIX is regarded
as a link between system and the people* The power equationVHW for poor villagers and superspeciality hospitals for urban elites
is sefen by rural poor as double standrads and glaring discrimination*
To be instrumental in development activities and cons cient is at ion
process, VllW has wide scope* In propeople milieu their leadership
skills can be nurtured* One does not expect government system to
the hopes lie with voluntary sector •
provide such milieu
Looking at the hard realities * in the present government health
system.
VHW can be a lackey and not the liberator.
b) The selectioni-
For VW to be answerable to the community* it is often quoted
that VHW should be selected by the community* However precise
structure of conmunity in never realised* In a Gram Sabha* few
vocal affluents dominate the platform whose opinion
can not be
considered vox populi. All meirbers of a village (Community)
neven turn up for meeting. The partisan nature of selection can not be
considered that of silent majority*
..
..7
Apart from answerability to the community. VW has to meet
the minimum quality expected by the health system from hin\/her
to function^ as an efficient link. The directions of where
how
to go a is known better to the professional wisdom in technical
matters•
To meet both requirements, Sevagram experience suggests the
following stategyLet the maximum numbers of candidates be suggested by
Gram sabha by at least 75% majorty^ The proper person would be
selected among them by the mobile health team members on the
basis of following guidelines1)
The VHW should preferebly come from a family which is not
desperate in meeting two ends. The poor class remains engrossed
in earning one’s bread and hardly can think beyond.
ir,
The VFW be preferably acceptable to all factions of the
conrnunity*
in)
The scope of developing leadership qualities In VFW
should always be learking in the mind.
Av)
It is obligatory that VFW can read and write in local language*
v)
The selected candidate should be such who is likely to stay
permanently in the village.
1°
Sevagram experience, it was not easy to get voluntary
offers fcrcm ViX’s responsibility in sufficient numbers. Quite
often the health team had to persuade a person in whom leadership
qualities have been observed. The occasions where non-performing
was to be dropped, were not infrequent.
c) Male or Female
The choice depands on the kind ofJob expected and the
availability. A lady VHW is preferable if she meets the minimum
quality expectations. We found it difficult to get appropriate
lady candidates who fulfil technical expectations and also perform
socially with competence.
d)The incentive
The Incentive of putting one’s soul in an endeavour can
be money, material, prestige, power and enjoyment of creativity.
The first two become the ^ajor concern of a poor & low caste
FFX who is struggling to find out his/her identity. The prestige
and power attract those whose minimal basic necessities are
satisfied. The creativity bXm satisfies only few already conscientised
individuals.
..8..
By selecting Vf*J from middle class one tries to tap a candidate
who may not be attracted merely by monetary consideration. By
effective implementation of health»progranme the credibility of
the health system can be transmitted to this vital link. By
nurturing leadership skills through informal partipatory education
one hopes that the creativity incentive will superveve.
el. The cojitypl «
VHW has to be responsive to people’s need at the same time
be guided by village health team* The twin control can be
established by providing financial support through Gram Sabha and
performance evaluation by the health team.
Decvr
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14
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a
Tibetan Experience With PHC & NGOs
By Kesang Y. 1'akla
It has been ten years since the
International Conference on Primary
Health Care was held in Alma Ata,
USSR in 1978. I would like to share
the experiences that the over 110,000
Tibetan
refugees arc
undergoing
and how we are endeavoring to play
our part in advocating Health tor
All through the provision of Primary
Health Care (PHC) with the assistan
ce of non-governmental organisati
ons (NGOs).
In the early sixties,
when the various departments of
the Tibetan Government started
to carry out their respective pro
grammes, and as the Council for
Home and Rehabilitation Affairs
progressed with their work, help
was sought from the Government
of India and voluntary organisations.
The Government of India provided
land
and co-operation to start
housing projects in Tibetan refugee
various
settlements in
various parts of
In
the
process,
funding
India.
up five
organisations also set
hospitals and about a dozen dispensaries in these settlements. The
voluntary agencies provided both
resource and expertise to run these
health services. In a few cases
local expertise was also
used.
However, these services were all
local
Indian
Tibetan
authorities.
were
refugees
As the
without
funds and sufficient medical exper
tise, the whole health issue became
most frustrating.
Health
care
suffered severely.
The lack
of
of the Tibetans in
services management
involvement
the health
process and
the lack of a gradual handover of
the health programmes,
and training,
made
planning
the
whole
situation a most difficult one. This
is a good example of the shortfalls
of
developmental
programmes
without active involvement of the
target community. This situation
becomes frustrating for both the
voluntary agencies and the target
group. This also proves that short
term emergency medical services
for refugees do not solve the problem
fully. Health problems are conti
nuous and, therefore, the target
groups need to be involved in the
whole planning and management
process,
so that even after the
funding agencies withdraw their aid,
the whole health programme does
Under these
some
conditions, in
not faulter so badly.
frustrating
refugees.
But as the years passed
settlements
the
Tibetans
were
forced to go to the nearest Indian
health centre.
Lack of trans
portation, language barriers and
by and
most
economic constraints further contri
curative and oriented to meet the
emergency medical needs of the
of the
voluntary
organisations gradually withdrew
their support, the health services
became
less functional. In fact
some of the centres were at the verge
of having to close down, whilst a
few centres were taken over by
Mrs. Kesaiiff
buted to
the
crowded living
problem, whilst
conditions, poor
sanitation, nutrition and hygiene
in the settlements aggravated the
worsening health problems of the
Tibetans.
Incidence of tuberculosis
Tukla is director oj the Department uj ilea'th.
among libetans is higher when
compared with Indians and Nepalese.
The average ratio is 2 1/2 times,
and prevalence rate about 35.38 in
1985 in our Control Project Areas.
We also continue to have other
common diseases such as diarrhoea,
skin problems, worm infestations,
malaria, malnutrition, and over all
poor health conditions.
Health
problems are severe in under
developed countries like India and
Nepal, where the Tibetans are
exposed to and living in refugee
conditions.
In the face of severe health
problems and lack of appropriate
resources and services, possibilities
for Tibetans taking active participa
tion in the long-term planning,
organisation and running of health
services in the various Tibetan
settlements were discussed. Sugges
tions also came forth from some
outside friends.
The urgent need
for a central office to look into all
aspects of health planning, resources
and expertise needed by the Tibetan
community was felt.
Subsequently,
in
1981, the Department
was established.
December
of Health
The groundwork
for a health development infrastruc
ture was laid at Delek hospital in
Dharamsala in 1980, when
the
Primary Health Care approach and
I B Control
Programme
were
initiated.
This was followed by
Community Health Workers training
programme in 1981. Emphasis on
changing the roles of the volunteer
medical personnel from running
This paper was presented at the 15th annual conference uj the National
Council for Internaiiona/ Health in l^ashiiigion. DC held from May l{t i(/ 2!. IvKS.
12
i'lbeian Bulluiin
curative programmes to teaching the
newly recruited Tibetan staff was
encouraged. The Tibetan staff were
urged to take more responsibilities
in the day-to-day management of
health programmes, whilst the con
cept ol health education and pre
ventive measures were introduced.
During this time, the health
strategies of the World Health Orga
nisation, UNICEF,and the Govern
ment ot India’s National Health
Programme were studied with the
objective of adopting their experience
into our health planning process.
Being refugees, we come across
several constraints : No access to
international aid through bilateral
agreements: Lack of experience in
health planning and services; Uncer
tain financial resources making over
all programme planning and budget
ing difficult; Lack of skilled perso
nnel and training facilities; The
scattered locations of the various
Tibetan settlements made centralised
planning difficult and required a
disproportionately high cost and
number of manpower; International
expertise cannot be invited into the
Tibetan settlements due to restrict
ions by the host country.
Despite these, Primary Health
Care was established as our goal.
Services were provided through the
existing 14 health centres and
hospitals, whilst 32 more health
centres were started in India and
Nepal. However, we still have a
few areas where no health services
are yet available.
For organising all these, we
are solely dependent on the co-opera
tion and support of NGOs. The
involvement and help of NGOs in
the development of our health
services is a very good example of
how NGO support is actively
contributing to effective local health
development programmes.
With
this experience
an example of
how international
NGOs can
actively contribute toward achiev
ing the objectives of Primary Health
Care by reaching out to the more
deprived section of society. It is
unfortunate that the government
agencies who could do more in this
are heavily weighed down by politi
cal obligations,, which override the
humanitarian need of the world’s
most needy. This certainly slows
down and prevents us all from
reaching the goal of “Health for
All by the year 2000”. At the end
of the year 2000, when the whole
effect of the Primary Health Care
approach would be evaluated and
reviewed, I hope serious and due
consideration will be given to the
need to set politics aside when it
comes to providing health to people
especially those who are less
privileged through no fault of their
own.
I may add here that at (he
grass-root levels in the settlements,
we also receive good co-operation
from the Government of India’s
health centres, whilst many local
Indians who reside near some
of our health services also come to
us for help. Regardless of race,
we happily share what we have
with any one who is needy. In
achieving health for all we need
this kind of co-operation and uni
versal humanitarianism amongst
people as well as governments.
As refugees, here is an example
of how we are left out of the inter
national health care system .*
In the process of organising
PHC services for the Tibetan
refugees, we felt, urgent need
to have a
well
organised
system of imparting health educa
tion.
Therefore, in 1984, we
prepared a five year project pro
posal for initiating a health edu
cation programme
amongst the
Tibetan refugees. This proposal
mainly covered costs of (raining,
production of teaching aid materials
in 1 ibetan language and drawing,
and services of relevant expertise.
As the chances of getting the total
budget from NGOs appeared slim,
and as we are not in aposition to get
direct assistance from International
funding agencies, we submitted
the proposal to the Indian Ministry
of Health and Family Welfare in
New Delhi, with a request to sponsor
this proposal from their budget or
to recommend it to the WHO. The
project proposal was appreciated and
finally recommended to the WHO
for considerations uuder its inter
country budget. When this was
discussed with the WHO authorities
in their South East Asia Regions
headquarters in New Delhi, we were
told that our proposal was commend
able and deserving; but unless the
the Indian Government is willing
and able to give us help from their
share of WHO fund, they cannot
help us directly.
Under these
circumstances, where is the effort
to encourage participation of ail
communities and how can all
sections of people be reached ?
In the meanwhile, the education
programme is being implemented
in a limited way to the best of our
abilities out of our meagre resources.
As this is a very important and
urgently needed service within our
community, we will strive to do
our best to organise a more effec
tive health education programme
that will undoubtedly go a long
way to promoting primary health
goals.
Aug.—Sepi., /9d\S’
13
When
health
programmes
are initiated in the settlements, the
community is actively involved and
made to feel responsible. In some
of the more established settlements,
the people are contributing about
30% of the operating expenses
whilst in most settlements the
contribution is only around 10 to
15%.
For valid reasons, the
the funding agencies emphasise the
need to make self-reliant projects.
Wc are woking towards this, but
for practical reasons and severe
economic limitations, the process of
achieving complete self-reliance is
going to be very gradual and
difficult. For example, tuberculosis
is in high proportion amongst our
refugees. The treatment is long
and the cost of drugs is high,
specially for those patients who do
not respond to first line regimes.
In order to treat these patients,
large sums of money are required
(e.g., costs of 1st. line treatmentRs. 462 or S 36. 2nd line treatment
SI 16 and 3rd. line treatment-$492).
The majority of the patients are
naturally unable to pay and so we
have to find the means to help
the control and prevent the spread
of this disease. Therfore, we have
to continue to look for funds, at
least at this stage, when the people
simply cannot afford it.
In the few years of its existence,
the Department of Health has made
progress in ensuring more equitable
distribution of our limited resources
and expertise, reinforcement of
coordination
and collaboration
training of Community Health
Workers, control of TB, essential
drugs, health education, immunisa
tion and promotion of Tibetan
traditional
medicine.
Here I
might also add, apart from the 46
Primary Health Centres and Hospi14
tals, we also have 2K
hbetans
traditional medicine centres in
the various settlements. In Dharamsala where we have the main
Tibetan
Medical
&
Astro
Institute, we have a college training
young Tibetans and Pharmacy for
production of medicines. Efforts
are also being made in using
the best of the two systems of medi
cines for the maximum benefit of
the people.
We still feel the need to streng- '
than our management process, but
much depends on the resources that
will be provided for future activities.
At present the administrative
budget for running the department
at the central level is only about
1.6% of the total budget. The
remainder is spent on implementing
health care in the settlements at the
grass-root level.
Despite several limiting factors,
with the active participation and
support of NGOs, we have made
encouraging progress in providing
PHC services in the Tibetan refugee
communities. More people are
now' conscious of health care and
the health services; Immunisation
is more acceptable to the people
although poor availability of the
vaccines and other resources inter
rupt the success of the immunisa
tion programme;
mothers are
more interested in learning about
better child care, immunization and
nutrition; more people are aware
that TB can be cured: and people
are more receptive to health edu
cation and health messages.
While we have had some success
it is also true that these achieve
ments are greatly overshadowed
by the fact that the majority of the
Tibetans in Tibet, under China’s
oppression, are being deprived of
health care as well as all their basic
human rights. These Tibetans are
under constant fear, humiliation,
imprisonment, mental and physical
tortures, and without freedom of
speech or thought. Talking about
health is far fetched luxury in light
of their deprivations. This again
makes one wonder about the irony
of advocating “Health For All by
the year 2000." It is tragic that
even now hospitals in Tibet are
being used by the Chinese as a
convenient means of eliminating
Tibetans under pretext of doing
what they officially term “necessary
operations.”
This abuse
also
includes well documented cases of
forced abortions and sterilisations
of Tibetan women. For the Tibtans in Tibet, the hospitals are the
very facilities that cause their
deaths. Under such circumstances,
how is the goal of health for all
going to be achieved ? How many
of the world populations are
sulfering under similar conditions
and what are world answers to these
questions.
As the health conditions of the
six million Tibetans are greatly
affected by the political conditions
that we are forced into today and
as the Primary Health Care goal
is intended for all peoples of the
world, wc cannot ignore this aspect
and so I feel obligated to bring your
attention to it.
Lookingal the situation on a
broader sense, our experience also
indicates that if we are to achieve
the Primary Health Care goals,
there is an urgent need for all
agencies, specially the Government
agencies, to be more humane in
reaching to the needy sections of
our society for the sake of health
for all.
As lor the Tibetans, we believe
in Buddha’s teachings of love and
care for beings. Therefore, we will
continue to do what we can for
contributing towards health for all.
At this juncture of our history, we
need the world’s understanding and
support. Those who advocate the
goals set out in Alma Ata should be
human enough to reach out to all,
specially to those who are deprived
for no fault of their own !
1 il'cian Hullciin
Coyi >t ’• 3 ST' 1
ORGANISATION OF HEALTH SERVICES
Term 1
1 s2
3,4
5
In troductory
Development of tropical health services
Importance and effects of culture
Behavioural sciences
Term 2
The Organisa t i on of He a 11 h S e r vi c es
(10.00 and 11.15 except Feb.19th and 20th at 14.00)
Jan ua ry
9th 1973
1 7th
1 8th
23rd
2 5 th
February 8th
19th
20th
March
9th
1. The character!’sti cs of underdevelopment
2. Basic health services
3. The health team
4. Auxiliaries: nature and function
'5. Referal systems and medical care delivery
(Mobile teams, health centres, flying
doctor services)
6. Voluntary agencies
7. National health patterns worldwide (Seminar)
8. National Health Service (U.K.) - (Prof.Pearson)
9.
Seminar on international aid (Prof.
Drs Southgate and Schram)
Bruce-Chwatt
Medical Administration Course
(Prof. R.F.L. Logan, Prof. B. Abel •’Smi th,
Drs J. Ashley, E. Wheeler, D.A.T. Griffiths
and others)
py
February 1st
14.00 The evolution of services
15.15 Practical:
6 th
Political implications
Information systems
14.00 The use of services and other resources
15.15 Practical:
1 3th
Science in planning
14.00 The development of measures of efficiency
and effectiveness of services
15.00 The economics of medical
15th
r4o
14.00 The estimation of need for services and
factors leading to demand
15.15 Practical:
8th
mic, S
care
14.00
Seminar on priorities ano forces which
1 5.00
i n fluence choice
Example:
KTirilja dam (occupational, socio
political, n utrition al5 commonicab 1e
disease and economic factors)
2
Term 3
The Organisation of Hea 11h
Services
(Dr Schram 1-12 and 18
Dr Barton 13-17)*
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11 .
12.
1 3.
14.
15.
16.
17.
18.
Maternal and child health
School health and student health services
Occupational health services (industry, mining,
agriculture, public services)
Military services and expeditions
Rehabilitation of disabled, blind, deaf
Health of immigrants, refugees and prisoners
Urban slum dwellers and mental health services
Retirement and tropical geriatrics
Public administration and committee management
Principles of management (selection, training
and methods)
Manpower studies
Medical education and education of health team
members
Health planning principles
Systems analysis
Operational research
Evaluation ofservices
Planning of legislation
Revis i on
i
•k
Suggested arrangement - to be confirmed
Covn H-
Self-Sufficiency in Financing Community Health Programmes; Rhetoric or Reality?
The idea of self-sufficiency has been a critical part of the development
of the concept of community health during the past decader.. This is so because
the new concern for community health is based on the need to get health care
to the poor and under-privileged. Self-sufficiency focuses attention on both
the search for additional resources and on the demands for social justice for
the poverty-stricken.
Self-sufficiency is important it is argued for a number of reasons.
Firstly, self-sufficiency provides an incentive to mobilize untapped community
resources. It gives proof that a community is committed to allocate heretofore
untapped money, materials and manpower to meet its own needs and to make health
care available to those who mostly have done without.
Secondly, self-sufficiency breaks the "charity" mentality of both the
donor and recipient. By supporting its own programmes, the community no longer
feels like a beggar re-enforcing the patronizing attitudes of the donor.
Rather pride and self-confidence is restored to a previously mentally and
physically down-trodden people. They can meet donors on a basis of equality.
Thirdly, self-sufficiency is important to break the dependency of poor
communities upon the rich. Especially in programmes which recieve funds from
overseas donors, community people often feel fettered by the donor relation
ship. Self-sufficiency place the power both in terms of money and decision
making back into the hands of those whom the programme serves.
Self-sufficiency does not mean isolated autarkic development. Rather
it means the creation, most often with outside help, of indigenous infra
structures which can be supported and maintained by community contributions
and committment. Many non-government organizations in community health in
Asia have taken self-suggiciency as one of their basic goals. They have done
so because they believe that only through self-sufficiency can the aspirations
of the poor be realized and the potential of the poor be developed.
The ideal of self-sufficiency brings into focus both in theory and
practice a number of critical issues for people involved in community health
programmes. Among them are: How do communities become self-sufficient?
What defines self-sufficiency at an operational level? Does donor money help
or hinder self-sufficiency? Is self-sufficiency a realistic goal for those
who are marginalized by the existing social, political and economic system?
Many people involved in non-government programmes in Asia have had
both thoughts about and experiences■with many of these issues. Their pro
grammes often are poised on the horns of a dilemma which demands selfsufficiency for the "liberation" of poor community people but needs outside
support to provide resources unavailable in poor communities. A review of
their ideas and experiences is timely as international aid becomes more
difficult to provide and many community health planners become aware of the
need to re-evaluate their programmes in light of the experiences of the 10
years.
I
I
•*
2
In order to explore this issue in some depth by utilizing the ex
periences of a wide range of people involved in community health programmes
in Asia, ACHAN is holding this workshop. Its objectives are:
1. to clarify the concept of self-sufficiency;
2. to identify, articulate and examine issues arising from this concept;
3. to create a dialogue among participants about how this concept should
be pursued in the future.
To do this, a number of people from both Asian community health pro
grammes and overseas donor agencies have been invited to discuss this topic.
The framework of discussions will be built upon short presentations of about
7 papers consisting of overall views of the concept of self-sufficiency,
reflections and personnel experiences, case studies and views’* from donor
agencies. It is hoped that an open and frank exchange will take place with
people sharing both successes and failures.
A publication of the proceedings is forseen.
.M-.
. ■
I
I
it^ii
C^yv\ H 3> <T •
GOmBUn FINANCING OF HEALTH .HlCJgCTS. IN
DEVELOPING COUNTRIES? SEVA.WMCXNUIA) aXIWX^££
JAJ009 U.N.*
THE SETTING
The Kasturba Hospital, Sevagras, Wardha has helped to initiate
an outreach health progranrae to the villages nearby.
The health
insurance scheme has evolved to its present fom tlirough a series
of changes and adoptations which were largely based on the
@xperiences(1) of past approaches and their failure.
The realisation that blind charity corrupts the people,
compelled the organisers to develop a strategy that attempts towards
cofi^mlty involvement, which at present expresses in form of
financial contribution from the community, people’s participation in
decision making and supervision of village health worker’s (VhV,-)
performance.
The contributions towards health insurance are made mostly
in kind because it is easy for the villagers to contribute Jawar-
Sorghum- at the harvesting time.
This makes in to a village fund,
to be utilised to support outreach health prograBBae, and other
development activities,
^he fund acts as a prepayBent^schvaie,
subscription entitleaents include free primary level health care
and subsidised referral care.
The observation that village is not a homogenous community
and 'that mere availability of haaLth care facility does not
necessarily make it accessible to the poorest section5 paved the
way for collecting health insurance contribution according to
xmx
*
capacity though services offered .vere accoruing co
contd..,
e
INCHaRGE, Health Insuraace Scheme &
Assoc.professor of Medicine,
MG IMS; Sevagrao,Wardh£(KS).-442 102
INDIA
3
r
the need.
_
The purpose of collecting village fund was not to raise
the financial support to the outroach progrijaae but to inculcate and
generate demand for a qualitative service since they have paid for it.
In fact, it was a tradition among villagers to collect voluntary
contributions graded according tc capacity may that be for a temple,
a religious village function or a sport competition.
At present the
health insurance contribution from lowest income group(landless
labourers) is 8 Payali of dorghus per family per year(equivalent to
Rs,16/- at the current market rate).
The land owners contribute in
addition 2 Payali per acre of land holding.
The collection is done
by village health worker at a preselected site and on a preinfonaed
day.
-i-faose who fall to enroll themselves on the said day, can not
avail the health insurance facility for that year.
The village fund covers the following expenses: drug cost of the
village kit, transportation cost of the mobile health team and
remaining balance goes to VH>* for his/her resameratioa.
The hospital adopts these villages only if 75/o of the poor
coiwrunity agreed 'to participate. If the mesbership dropped below 75>
■?
in a village in any one year then the scheme was withdrawn.
It was
experienced that project withdrawal due to lackof support usually had
the effect of motivating the cossmunity to reorganise and in most
cases reinstate the insurance scheme.
To the insured persons, the hospital offers free referral treat
ment for unexpected illness and 75^ subsidy for planned/expected
episode of illhealth such as nornal pregnancy, cataract, hernia etc.
The non-nembers are free to avail aedicr.1 facilities but at the full
hospital charge.
contd ® ®*s/—
...4/-
ThE ACHl£V£i-ANlS;
1) The health insurance sc hem has found acceptance ox the poor
people (see % of coverage of the population? Table—1)e
2) There is no vaccine preventable illness(masles? poliomyelitis s
diphtheria? whooping’cough? tetanus) reported in children and in
mothers after mass iwnunisation by cluster(pul^e) approach was
undertaken.
3) There is no maternal death reported in last 5 years©
4) The community survey undertaken in the insured villages reveal
that but for unexpected and compelling reasons? all indoor hospit.
sations invariably^ occur in Kasturba Hospital,
It speaks of the
accessibility and the credibility in regards to quality care that
the hospital envoys.
5) The health team having earned credibility is now placed in a
privileged position to be regarded as guide^councellor for wider
dimensions of health which deal with priority needs of people.
COMMUNITY FINANCING OF 1EALTH PROJECT s-
Econoaies of health care has gained special attention in recen
years.
Traditionally health care has belonged to the social servi
sector and therefore mist be administered by the state as a welfar
measure.
As a result of unprecedented developments in the health
care sex-vice sector, ^specially with regards to the new medical
technology, the corporate interests in health care haw been gro^^i
rapidly in last few years.
These developments have made interest
in issues of health finance most urgents because the burden of hex
holds in capitalist economies in making direct payments(or throt^t
contd.. .
.JU.
^3A
A village weting(Gram ^abha) is held every year before Jawar
collection.
xhe meeting is coordinated by the doctor Incharge and
attended by ANM, Social Worker and VHW(the saoblle ho al.th team members)*
It is an occasions to reflect upon performance of health delivery
system*
The we ting •of ten stormy—serves dual purpose of evaluating
performance of health structui'e and also enacting disciplinary action
on irregularties committed by villagers themselves*
The village
meeting helps to facilitate communication between health tea^ and
beneficiaries on one hand while on the other, it helps villagers to
command control on VHW^ and thehealth team*
At occasions* people
have decided to change the VHW and selected a more appropriate person^
The VHW provides symptomatic drug treatment^ offers preventive
and promote cure with the help of visiting health team members* refers
ho spi tails able paiients and acts as a link between the hospital
and the comnnmity for other village—development activities*
The ANM with the social worker organises peripheral visits for
vaccination and also provides maternal^ child health care*
They
are the ones who follow all indoor admissions and sea to it that the
commitments are fulfilled*
The doctor incharge has the role of supervision. treatment of
patients in hospital* conducting health education slide-shows,
coordinating village we tings late in the evening for health/non-
health development activities and training VHW as per need*
The location of hospital and its approachability(by roadway
service in our area)* we found, is an important consideratim in
peopleSs view point*
radius*
It did not matter for villages within 5 kms
For a distant village we received offers of village adoption
only if there was regular roadvzay service plying to Sevagram*
contd* * *4/«»
s 5 2
insurance) for health care services is going to be more heavier
than ever before* In India$ the state has been an important provider
of free health care services*
investment by the state health
care has increased rapidly in seventies*
The state therefore
has been rethinkin^bout health finance and has been taking of
alternatives* One of the alterr-atiws since the 6th plan has been
the state’s open support to the private health sector«>
Another
has been the privatisation of public previsions(handing over
public institutions to private bodies* permitting government
doctors to Indulge in private practice)*
And the more recent
one(in Maharashtra) being” fee for services* in govemmeM health
institutions*
All this is keeping with interr
' ^1
trend in
health finance(2)*
Howeverthere is no concern expressed to correct gross inequali
ties in the distribution of state health sector^
The trends are
disturbings
The Micro-experimant of the kind in Sevagram was set up in
search of alternatives^ not merely for health financing but
primrily towards wre ^ust heelth Care- one that caters preferen
tially *Have h'ots*1 It was this minimsi zrust that we considered
obligatory before the financial aspects could be spelt out*
xhe dole of ©galitarean health care by an abow down approach,
is not and should not be the philosophy of primary health care.
The people should own 'their health services*
Of course^ given
the prevailing modes of product!on, structure of society and
distribution of political power& such declarations sound very urrefil e
The micro’-experiment like tht in beV< gram therefore can not boast
to create an oasis wherein the right to health can be exercised
contd.
sy«*
•6/**
froni below
Within the given social limi ent ions # it has attempted
to raise a model wherein irore and more com:.unity involvement
commmity control can be inculcated.
1'he financing of health project
in Bevagram should be viewed in this background. It was ai^ed to
raise a replicable model provided there is enough political will
do SO.
Before health finance at Sevagraffi project is calculated
the
following must be kept in rsind:-
i) lhe referral hospital for this project is a 500 bedded
medical college hospital which gets 75% recurring expenses
from government while collection of 25% amount is the responsi
bility of Kasturba Health Society that runs this college and
hospital*
Since its a medical college—hospitalt all norss in
regards to staff pattern and facilities laid down by Medical
Council of India for teaching and research are to be followed*
The cost of running this hospital is therefore much more than what
one will expect from a service oriented hospital draining a
project area.
ii) ^he hospital billing pattern is not based on system/atia
cost analysis but follows the rough estimates of the market
value
Hospital bill therefore can not be relied upon for the
health financing calculations*
ill) All out door saediceJ. consultations
reach Sevagrafifc
the project area do not
Many of them prefer to go to local practitioners
or practitioners in Wardha tow to get a tonic prick/bottle of
their choice• '^he outdoor consultation cost borne by a village
family thus can not be counted*
contd...?/-
: 7 s
iv) The hospital administration does not calculate outdoor and.
indoor hospital cost separately.
xhe ±3ai outdoor attendance
of Sevagraa Hospital is 9 tims the indoor admission rate.
This
outdoor cost is lumped with Indoor expenditure when we have
calculated hospital expenses per indoor adMsslon.
v) -he cost on outreach health services depends significantly
the kind of manpower employed and the methodology adopted for
outreach service.
We adopt cluster(pulse) immunisation strategy(3)
for aass ianamisatiosi.
*e have only one ANM and a Social Worker
who look after 23 villages and effectively cover them for imtnmd-.
zation, antenatal and postnatal care with the help of village
health worker of every village.
year.
visits a year,
We overall require 7 village
-'he routine outreach services do not require the
doctor.
THS FACTS
a) FOr the average hospital stay of 9 days with the annual bed
occupancy of 75^» Kasturba Hospital^Sevagras spends(year 1988-89) on
an average it.944 per Indoor admission(Table-2).
The proportional
expenditure incurred on various categories include fc.JO/- on diet
(3.19%), &.125/- on drugs(13.16%), fe.30/- on maintenance(3.^%),
&.304/- on non-doctor staff salary(32.2%) and &.307/- on doctor
staff salary(32.52»).
The approximate cost incurred per indoor
patlmt per day amounts to &.105/-. This is an ovo-restiiaation. because'
it includes cost incurred on 9 outdoor patients( say by Rs.27/-(fe.3/-
per outdoor patient per day),
-ha approximate indoor cost thus works
out to be &.7S/- per day per pc.tient or Rs.702/- per indoor admission.
contd a a « b
. .8/-
The staff shares the chunk this expense i»e.87^(43*7^ for doctor
staff and 43.3% for non-doctor staff).
For a service oriented
hospital after deducting additional expenses of teaching staff
salaries $ the projected cost works out to be Bs.612/- per indoor
adiaission or Rs.68/- per day*
b) ^he expenditure (Year 1990) on outreach health services at
It
Sevagra& project works out to be fc.5*28 per capita per year,
includes &.0.70 drugs9 &.O.33 on transportation ox health teais^
Fs.1.85 on salary of health teas senbers and Rs.2*40 on VHW’s
remuneration.
xhe ^evagram project could collect .1.3*45 per cap!
per year as health insurance contrlbution(year 1990) and Rs. 1.41 per
capita(Year 1988) from indoor hospital bill i..e.total Rs.486 per
capita per year which is 92% of outreach health service expenditure
(See Table 3A, 3B).
c) £4
£or a health project serving rural population,one can extra
polate the hospital load, kinds ofhospitalisation and recurring
expense from Sevagra® experience.
The data of last 5 years reveal 'the following:—
i) 'The indoor admission rate is 1 per 11 people in the insured
category*
The maximum indoor admissions expected are 91 per
year per 1 $000 popitLationa
ii) Out of the total indoor admissions, planned Illnesses like
hydrocele, hernia, cataract,
cataract$ normal delivery etc.share l/3rd
load* while tharest 2/3rd is due to unexpected illness episodes.
ill) For the average hospital stay of 7*5 days (analysed data froi
project area), one will require 2 beds per 1^000 population for
a service oriented toc*pital and the average cost of indoor
contd,
•»®
/ **
•9/“
admission to a service orimted hospital would be fc,68 per day
&®510 per hospitalisation and &.4S per capita/ per year*.
THS WISDOMtWe find that coasminity financing:
- Increases accessibility of basic health services and pronotes
greater concerns for health in coimmity*
ensures that services are acceptable and respond to the priori*
ties as fudged by the coMimity*
— generates the concept oi right to demand a qualita'tlw health
care by the beneficiaries and keeps service providers oa the
toes®
- bffers an alternative payment mechanise to persons
med
service but ar© unable to pay i.e-risk sharings
- holds the potential to take away clients from private services,
and be more cost effective to both*
- stiaulates self confidence, organisational ability and so paves
the way for other developamt activities through ccasmmity
iwolvememt.
?he literature(4 & 5) however
raises few cautions in approach
t,o community financing which we found
'
being inapplicable in our
settSag>
£au.tic>n.a in approach to
financln#
I e Does little to prosaote equity^
can place great burden on the
poor/slck and suffers fro&
’adverse selection.’
Our exporiencQ
principle of contribu
tion according to capacity
out services according to
need developed an egalitarean system which does not
suffer from’adverse sele
ction \
contde>.. 10/-
*.10/-
2. ‘The desirability and afford
2. Lacks stability of revenue
ability of the scheme offered
and needs a high degree of
stability of revenue and
external support to aobilise
willing comimity involvement
and sustain conrnunity efforts
on sustainable basis.
3 * Favours creation o£ those kinds 3.Since hospital has to raise
25^ of expenditure from a
of health facilities for which
highly subsidised or free
there is high local demand
indoor servicesf high tech
rather than meeting profemedicine * unless cost effec
ssionally perceived needs.
tive^ can not be the profess
ional choice.
4. Is not easy to ‘sell
poor people.
4. If the scheme evolves froi
the peopiec does no **
require to be sold.
5. Covers ssall proportion
of cost
5
6. Benefits the cowamity
more than individuals,
there nay bo reluctance to
partic1pate.
6. Our insurance acheme bene
fits individuals more by
sharing risk and thus fix
no reluctance to participate
7. Carries danger of excessive
use of facilities.
7. The facilities are priaaarilj
controlled by professionals
and not by the people thus
avoids their excessive use.
The primary health care is
the constitutional right of
every citizen. To recover th
entire cost from the cominity should never be the
primary concern of propeople
schemes.
author wants to highlight that insurance system evolved
at bevagram was a tool to develop an e galltare an and just health
care delivery system and not an attempt towards sell reliance«
coatd,. .-j
..11/-
Those who preach, of self reliance in health care should first
answer the following questions:
i) *hat is the niniwa financial need to raise a ^ust aad
quality primary health care prograrm^?
iiO What percentage of poor nan’s incosse should be spent on
prlaary health care?
ili) What proportion of total expenditure should coae froa state/
individual resources?
Pesrcent coverage of population under healthInsuraace Scheme
Year
No. of Total popu- ‘
villa lation
ges
Health insurance percent covers^!
Total
Socio-economic^ ^oc io-econoid.c
grade
grade 1V+ V
1988
21
16305
61.50
53.16
68. 2S
1989
18
13932
64.95
56.06
71.82
1990
23
19457
74.45
65.51
79.13
Socio-econouic grading:
Grade—I
Family who employ labourers on a yearly contractual
basis £or Agricultural work called •SAWAR*
Grade—iI
Families who m irrigated land but do not employ
8ALDARtt
Grade-X xx
Families who own dry land and a pair of bullocks
Grade—IV
Families who own dry land but do not have bullocks.
Grade-V&
landless labourers
Recurring Expenditure per Indoor admission
Kasturba Hospital> Sevagraa
B@ds» 500
Wwriii.OTaufluiui„. hi ■ir.ii ■ niit—
Year
r> n—r- ■:wnwrpwiwwM.rjr.—Mm
Average Average
hospital hospital
bed occu-stay per
pancy(%) pt.(days)
Recurring
Total Diet
Expenditure
per
indoor
admission ( fe.)
Drugs
Maintenance
Non-doctor Teaching
staff
doctor
staff
Residential
doctor sta
ff
1986-87
67.4
9.1
587
30.94 102.51
326.25
205.19
69.18
24.77
1987-88
75.7
9
604
28.74
98.35
289,26
196.00
91.00
42.19
1988-89
76.4
8.9
637
30.15
124.23
303.95
217.00
90.00
30.85
-I
t
TABLE- 3 A?
Incom-expenditwx of outreach heal'th services
(^evagraa Project )
Year
Villages
1990
23
Population
Xnsuyed population
14390
19457
INCOME
-Contribution towardshealxh insurance scheme:
(converted to rupees at the rate of
fc.150/- per quintal of Jowar)
Rs.67^028.00
KXIENDIIURS
1. Drug kit*
(fc-600 per village/year)
ts.13s800.00
2. transportation by diescllsed Oeep(20 km/day for
23 days a month,total 7
visits per year per vill
age at the rate fc.2/ ksa).
fc.20,240.00
..balance(villge fund including VHW’s
resauneration)
•«
is. 46 ,788. 00
(average Ss.2835/yea?/per
-K~
= Excluding Vaccine cost
)
■
TABLh>?B$ Income «*exjwidlture on outreach services
(Kasturba Hospltal^Sevagras )
Year
1988-89
I-k>3ulg,tioa. covered
villages
21
16305
INCOMS;
Hospital Bill Recovery
a) from patients receiving
75% subsidy
(337 admissions ^fe.35.90 )
Rs«11
b) ^foes non*insured hospitalisation
(176 admissions at the ratebi Rs.123.90)
te.21,730.00
i'otsi
«00
te.33,154.00
EssasEsssssstfisazaEssss: 3—jaxssriM
SXESNDITURS :
ANM’s salary
(Rs. 1800 per soonth)
fc.21,600.00
Helper *s salary
(Rs.1200 per month)
&.14,400.00
Total...
fe.36,000.00
sanra ssi «S3ETaswsssc asxrKaacar os ns
1. Ja^oo U.K; When, ths Search
; ^UG.X.tL.S , Sevagraia; Dr.
Nayar J.; 1984.
2. Duggal R. & Anin S.; Co at of health care, a household survey
in an Indjah district; ^cundation for Research in CoEunmlty
health, Bonbay; 1989*
3. Ja^oo U.N.et alj z‘amal clusters pulse) laauaization experience
In villages near Sevagraa* India; Journal oi ^rcpical
& Hygiene 88: 277-280(1985).
4
Brain A.B, & Bua A.; Coffi-junity financing in developing countrie
the potential for the health sector; Health tclicy and planning
5(2), 95-108, 1988.
5. Btinson «.; ^osmnity financing of Prissary *$ealth Dare,
ton ^.4.; Anerican Public Health Association; 1982.
ANALYSIS OF THE PRESENT HEALTH CARE DELiyEOT^SYSTEM IN INDIAt
Forty years after independence India on the road to development
is now facing a serious crisesf. India’s population continues to
grow at an alarming rate and the health conditions of the masses
remain distressingly loWc. Our health services are manifestedly
inadequate and ineffective? especially in rural areas and iail
to cover 70 to 8CP/^ of our population
India is the 11th poorest country in the world with the 2nd
highest population of 762 crores (1936)0 India’s infant mortali y
rate is still a deplorable 105/1000. 1.5 million children lives
are taken by diarrhoea alone. There are more than.oO million
children in India who are malnourished; four million cases oi
leprosy of which 15% are children less than 14 years. Tuberculosis
amounts for 9 - 10 million cases of which 2-3 million are
open cases. 50% of all lactating and pregnant mothers suffer
from anemia. Children affected by polio are on the increase;
more than120,000 are affected of which 80% are below 3 years of
age and despite the efforts towards universal immunization the
numbers keep growing. One million (11,18,948) and more of the
population is disabled due to one reason or the other. All these
are important indicators of the Health Status of the Indians.
And after 4 decades of post Independence planning we may ask
whether and how much India has progressed. Only true facts can
answer this question. Achievements and failure should be neither
magnified or played down as it is often done. The institutional
and manpower growth of
cd our health care system is impressive.
We now have a ministry of Health and Family welfare.at ‘the
centre and in the stapes, large departments of public health
and medical organisations and institutions. Excellent specialized
facilities are available for cardiac diseases, cancer and
neurological and nephrological dis ordersP A huge infrastructure^
of hospitals, dispensaries, subsidiary centres, community health
centres, Primary Health centres has been built, The number of
health professionals and paramedical workers have remarkably
increased. The number of institutions and practitioners in the
Indegenous system of medicine indicate a considerable though
less striking growth. Though many of these health, institutions
and personnel serve the upper and middle classes in todays
society, they could be put to better use. We have every right
to be proud of these achievements. Yet one must also look
at the negative side of the health situation and acknowledge
that ”our failures are even more glaring than our successes.
Inside our big hospitals and private nursing homes, we,find
modern amenities, highly qualified experts. Outside their
'/wallp, poverty and disease march bleakly over the landscape.
' /A deeper study of martality rates, disease patterns and conditions oi
1 children and women reveals a distressing situation. The poor
coverage and inbuilt inequalities of our health system are
other key elements of this deplorable and unjust situation.
Every human being possess the right to life and health,and to
the necessities of life, including proper medical services.
With its commitment to justice, liberty, equality and
fraternity, the Constitution of India clearly recognizes the
Governments1 responsibility for health.
2
The world at large and India in particular continue to experience
’’the poverty of health in the midst of scientific abundance” and
glaring inequalities in health resources. While basic health
services remain inaccessible to more than the two thirds of
humanity and millions of poor die of easily preventable diseases,
the rich enjoy even more specialized facilities. Most villages
have
p. opoi' health personnel and services, while cities are
saturated with doctors and medical centres, Health which is
claimed to be right of every individual is in reality a
privilege of the relatively few wealthy.
The Alma Ata delegates at the International conference in Sept.
1978 saw health as a fundamental human right and stated that
’’The attainment of the highest possible level of health is a
m'>st important world-wide social goal whose realization requires
the action of many other social and economic sectors in
addition to the health sector. It strongly affirmed the need
of primary health care to achieve an acceptable level of health
by all people by the year 2000 and to reduce todays gross
inequalities which are ’politically, socially and economically
unacceptable’.
According to the 1984 statistics 37*4% of India’s population is
below the poverty line, unofficial calculations however suggest
a much higher figure. Dr. Mahler gave the call ’’Health for all by
the year 2000 A.D.” at the 1977 TOC. According to him ’the
present realities of the 3rd world are simply unacceptable.
There is little joy in life now nor any kind of justice for a
child condemned to disease or early death because of the accident
of birth in a developing country... There is no rationale that
can defend a system that withholds the gift of health and care
from nine tenths of a nation’s population’. ’Resources distriX bution in the medical sector is such that 80 to 90% of the resources
go to meet 10 - 15% of the health problems. Social and economic
inequalities and powerlessness prohibit the people from the
knd^O e
oni the capacity to afford the health care of their
family. In equalities exist at two levels :
1.
2.
In the distribution of the health care services
In the capacity of the people to afford to maintain good
health. These two areas make up the central theme of this
paper. We shall follow a sequence and order based on the
following points.
a.
The present health care delivery system in India and its
distribution in the rural and urban centres.
Availability of these facilities to different economic
classes and medication practices.
Manufacture and distribution of drugs.
b.
c.
Our National Health Policy :
The Government adopted a new ’’National Health Policy” in August
1983 and recomitted India to ’’the goal of ’Health for all by
2000 A.D! through the universal provision of comprehensive
Primary health care services”.
The policy confirms the trend in favour of restructuring the health
services emphasising community, preventive and promotive health
linked to a hierarchy of referral services and integrated with
human development and poverty alleviation programmes. People
must be required to take health into their own hands
3
- 3 through community health volunteers, traditional birth attendants
and practitioners :f indegenous medicine, all of them trained
and equipped to make appropriate interventions at given livels
backed up by supporting services. The efforts must be to move
from expensive hospital, drug based curative services, largely
confined to the middle and upper urban strata, to reaching
health to the people where they are and in particular, to
vumeraoie segments and backward regions
An analysis of the National Health Policy reveals some striking
difference with the ’Health for all documents’. First the
Government emphasis is much more on poverty alleviation that on
the reduction of inequalities and the organization of the
oppressed to defend their rights. The policy does not speak
even once of social justice in health and in other fields.
The essential pre requisites to attain the goal ’Health for
all’ are completely bypasses, there is no definite and far
reaching programme to promote community participation in important
matters. There is no radical change in the health budget, while
insisting on Primary Health Care, the policy is concerned with
private practice, paying clinics and the establishment of
specialist centres. The attainment of ’Health for all’ is
intimately related to the eradication of poverty, inequality
and ignorance. There can be no lasting solution to the country’s
health problems, unless and until the illnesses affecting
the society at large are tackled side by side.
Hea1th care delivery system in India :
The challenge that exists today in many countries is to reach
the whole population with adequate health care services and to
ensure their utilization. The large hospital which was chosen
for the delivery of health services has failed in the sense that
it serves only a small part of the population. Therefore it has
been aptly said that these large hospitals are more ivory
towers of disease than centres for the delivery of comprehensive
health care services.
Administrative set up at the Centre, State, and District level :
The health system in India has 3 main links i.e Central, State
and Local.
I.
At the Centre :
The official organs of the health system at the national level
consists of :
1. The Ministry of Health and Family Welfare
2. The Directorate General of Health Services
3.
The Central Council of Health and Family Welfare.
1. The union ministry of health and family welfare is headed
health
by a cabinet minister, a minister of* state and' a deputy
'
minister. There are political appointments. The union ministry
has the following departments :
ii
Department of Health
Department of Family Welfare
The functions of the Union Health Ministry :
a
International Health relations and administration of post
Gurantine.
4
- 4
b
c
d
e
f
g
H
Administration of central institutions
Promotion of research through research centres and other
bodies
Regulation and development of medical, pharmaceutical,
dental and nursing professions.
Establishment and maintenance of drug standard.
Census, collection and publication of other statistical data.
Emigration and Immunization
Coordination with states and with other ministries for
promotion of health.
It is the responsibility of both the centre and state for
8
Prevention of extension of communicable disease
Prevention of adulteration of foodstuffs
Control of drugs and poisons
Vital statistics
Labour welfare
Ports other than major
Economic and social planning
Population control and family planning
2.
Direct orate General of Health Services :
1
2
3
4
5
6
7
The director general of health service is the principal advisor
to the Union Government, in both medical and public health matters.
The General functions are surve/y, planning, coordination,
programming and appraisal of all health matters in the country.
The specific functions are :
a International health relations and quarantine
b Control of drug standards
c Medical stores depots
d Post-Graduate training
e Medical education
f Medical research
g Central Government Health Scheme
h National Health Programmes
i Central education Bureau
j Health Intelligence
k National Medical Library
3. Central Council of Health : A large number of health subjects
fall in the concurrent list which calls for c.oncurrent list which
calls for continuous consultation, understanding and cooperation
between the centre and the states.
The functions of the Central council of Health are :
a To consider and recommend broad lines of policy in regard
to matters concerning health in all its aspects.
b To make proposals for legislation in fields of activity
relating to medical and public health matters
5
M1 '' i
1
' iU '
ii'
"I1, i ii
1
Ji"
- 5 C
d
To make recommendations to the Central Government regarding
distribution of available grants-in-aid for health purposes.
To establish any organisations invested with appropriate
functions for promoting and maintaining cooueration
between the central and state health administration.
11 At_foe State Level : There are 25 states in India. In all the
states the management sector comprises the state ministry of health
and a Directorate of Health. The State Ministry of Health is
headed by a Minister of Health and Family Welfare and a Deputy
Minister. The Director of Health service is the chief technical
advisor to the State Government on all matters relating to
medicine and public Health. He is also responsible for the
organisation and direction cf all health activities. A recent
development in some states is the appointment of a Director of
Medical Education in view of the increasing number of medical
colleges.
District Level, : The principal unit of administration
ln<iia is , the district under a collector. Most districts in
India are divided into two or more subdivisions each taken, care
of by an,Assistant or Sub Collector. Each division is again
divided into taluks. Since the launching of the community
development programme in India in 1952, the rural areas of the
district have been organised into community development blocks
W^tnoag^0Xi?ately 100 villages and a population of about
HO to 1,20,000 under a block development officer. Finally
there are village panchayats which are. institutions of rural
local self-government. The urban areas of the district are
organised into the following :
Four area committee
- Municipal boards
Corporations
Under the multipurpose workers scheme, it has been suggested to
the states to have an intergrated set-up at the district level
by having a chief medical officer with three deputy GMO's.
The recent working groups on health for all by 2000 A.D.
recommended that the District Hospitals should be converted into
district health centres each centre monitoring all preventive
promotive and curative services of one million population.
The Panchayat Raj is a J tier structure of rural local self
government in India.
1 > At the village level the Panchayate Raj consists of
a The gram Sabha
b The Gram Panchayat
c The Nyaya Panchayat
2.
At the block level the Panchayate Raj consists of Panchayat
Samithi. The Panchayat Samithi consists of all Sarpanchas.
3.
The Zila Parishad is the agency of rural local self government
at the district level.
Health Care of the Community :
The frontiers of health extend beyond the narrow limits of
medical care. Health care c vers a broad spectrum of personal
health services.ranging from health education and information
through prevention of disease, early diagnosis and treatment
and rehabilitation.
6
- 6 Two major themes have emerged in recent years in the delivery of
health services s
a)
b)
Health service should be organised to meet the needs of
the entire population and not merely selected groups. Health
services should cover the full range of preventive, curative
■' ■'P litation services.
The best way to provide health care to the vast majority of
rural people and urban poor is to develop effective
Primary Health care services supported by an appropriate
referal system.
Levels of Health Care :
Primary Level.
The first level is usually the point of
concoct"between the individual and the health- system, where
primary health care or ’essential health1 is delivered. The
primary health care insitutions in rural India are the
primary health centres and their subcentres. Although there *
is a vast network of primary health centres and subcentres in
the country, experience over the past three decades has
shown that PHCs and their subcentres have not been able to^
meet effectively the minimum health need of the vast majority
of the rural population. In order to remedy this, defect,
the government of India in 1977, under its new Rural Health
Scheme, adopted an alternative strategy of delivering primary
health care through the agency of village health guides
(community health workers). The CLW is a volunteer from the
village itself and is selected by the village community. Besides
providing primary health care, the village health guide or
CLW bridges the cultural and communication gap between the
rural people and the organised health sector.
1 .
2.
Intermediate level : At this level more complex problems are
dealt with. The sub divisional/district hospitals mainly
U1AO UJL UU. oO the second level. They also provide support to
the primary health care institution.
I-'.-
3.
Central Level : This com- rises ’Tertiary Care’ or super specialist care. This is provided by the central level insti
tutions (e.g. Regional Hospitals, Medical College Hospitals)
They not only provide highly specialized care but also
sustain primary health care as part of a comprehensive
national health system.
Health Care Services :
Thehealth care system is intended to deliver the health care
services. It operates in the context of the socio economic
and political framework of the country. It is represented
by five major sectors.
1.
Public Sector
1• Rural Health Scheme
Primary Health Centres
Sub Centres.
2 Hospitals/Health Centres
Community Health Centres
Rural Hospitals
District Hospital/Health Centre
Specialist Hospitals
Teaching Hospitals
3. Health Insurance Scheme
Employees State Insurance
Central -Govt. Health Scheme
7
- 7 4. Other agencies
Defence Services
Railways
II. PRIVATE SECTOR :
Private Hospitals, Polyclinics, Nursing Homes
and Dispensaries
2. General Practitioners and Clinics.
1.
Ill Indigenous systems of medicine :
1. Ayurveda and Siddha
20 Unani and Tibbi
3. Homeopathy
4. Unregistered parctitioners
IV. Voluntary Health Agencies
V. Vertical Health Programmes.
PRIMZ.RY HEALTH CENTRE :
Health planners in India have visualised the primary health
centre and its subcentres as the minimum 'infrastructure for
the delivery of health care services to the people in rural
areas.
FUNCTIONS OF THE PHC 2
a. Medical care
b. MCH and’ Family Planning
c. Improvement of environmental sanitation with priority for
safe drinking water, disposal of human wastes.
d. -Control and surveillance of communicable diseases
e . Collection and reporting of vital statistics
f. Health education
g. National Health Programmes
h. Referral services
i. Training of village health guides, health workers and
health assistants.
Health team at PHC :
Medical ifficers'
- 2
Compounder
- 1
Sanitary Inspector
- 1
Health Inspectors
- .2
Extension Educator (FP) - 1
Computer
- d
ANM
- 1
Driver
- 1
Ancillary staff
- 2
3
•>'
•’’<i:'
- 8 At each sub.centre
Health worker (f)
Health worker (M)
Health assistant (M)
yooT-*-’-
f-
p.t (f)
- 1
- 1
- 1
- 1
The PHC thus represents a TEAM approach to the health problems
of the community.
Community Health Centres ? A few PCH’s have been upgraded to
CHC’s which has been established for coverage of- ^ne lakn
population with 30 beds, and specialized medical care services in
/z centre level may be from one of the locally
s
acceptable traditional
systems of medicine and one of them must possess public heairn
qualifications and experience.
2) HOSPITALS : Apart
Apart from
from the
the primary
primary health
health centres,
centres, the
me present
pxeocixu
orgination of health services by the Government Sectors consists
of rural hospitals, districtohospitals, specialist hospitals
and teaching institutions.
a* Rural Hospitals :
It is now proposed to upgrade the rural dispensaries (allopa
thic/traditional systems of medicine) to primary health
centres. At present a good number of PHCs are located at
tehsils/taluka head quarters which also have hospitals.
Such PHCs may be shifted to the interior rural areas.
b. District Hospitals : There arqfcroposals to convert the
districtTospitals into District health centres. Hospital differs
from a health centre in the following respects.
hospitals
Health Centre
Curative services
Preventive, promotive and
1
curative
Has a definite population 80,000
No catchment area
2
to 1,20,000 to cater to
’Mix’ of medical & Paramedical
Curative staff
3
workers.
t
-
..
«
__ __ ______ l_
O___ _4.
MCI
orwiCT CTC^
3) HEALTH INSURANCE :' There is no universal health insurance in
India .~~7,t~6resent it is limited to industrial workers and their
families. The Employment State Insurance Scheme provides compre
hensive medical care to industrial workers. The central Govt.
Health Scheme provides comprehensive medical care to central
Govt, employees. The above two schemes cover two large groups
of wage earners in the country.
4) OTHER AGENCIES ;
services have their own organization for medical care
1 Defence
xcxj-oc
lx.- xxx-l-.-jjr___ l’provide
-“ comprehensive health
to defense
personnel.
The railways
care tservices through
„ the agency
. of Railway hospitals. Health
units and clinics.
2 Private Agencies : Private practice cf medicine provides a
large share of the health services available. The general
practitioners constitute 70% of the medical profession. They
provide mainly curative services. Most of them tend to congre
gate in urban areas. The private sector of the health care
services in not organized.
9
- 9 3
4
5
Indigenous systems of medicine : The practitioners of indi
genous systems of medicine eg. Ayurveda, Siddha provide the bulk
of medical care to the rural people.
Voluntary Health Agencies : The voluntary health agencies
occupy an important place in community health programmes.
The type of service rendered by voluntary health agencies
have oeen classified as :i Supplementing the work of official agencies
ii Pioneering - new ways and means of doing new things.
Research is one form of pioneering.
Vertical Health Programmes in India :
Since India became free, several measures have been undertaken
by the government to improve the health of the people. Most
of the programmes have been aided by the International Health
Agencies such as the WHO, UNICEF, USAID, Rockefeller
Foundation etc. These vertical health programmes have been
launched for the control /eradication of communicable diseases,
improvement of environmental sanitation, nutrition and rural
health, e.g. The National Malaria eradication programme,
Diarrhoeal Diseases, Control Programme, National filaria
Control Programme, National T.B. Control Programme etc.
Availability of Health Care Facilities to the Poor
Widespread poverty, malnuturtion and ignorance, insufficient
and or unsafe water supply and many other evils still plague the
countryside. Our health services do not cover the 70 -,80% poor.
The prevalent model of health care is irrelevant for several
reasons. Instead of responding to the specific problems, needs
and aspirations of Indians and being attuned to their customs
and traditions, and taking into account their local medicines
ar.d p-^o'-'titioners, the western system mainly responds to the
socio-economic conditions and disease patterns of developed
countries; It neglects the indigenous systems of medicine and
uses, highly specialised personnel, sophisticated technology and
costly drugs.
The following table gives the quantitative aspect of available
health facilities s
Nor
No.
No.
No.
No.
No.
of hospitals
of hospital beds
of community health centresof PHC’s
of dispensaries
of subcentres
7474
535735
711
8496
26842
94918
(1986)
(1986)
(1986)
(1986)
(1986)
(1986)
This table represents the total at the all India level - besides
there has been a definite increase in number over the past 5-6
years, these do not represent the urban and rural split up, nor
does it indicate its functioning and availability to the poor
masses. Eight out of ten Indians have little or no access to
modern medicine. The number of doctors in 1984 was 2,97»228. A
WHO study-mentions that India has sufficient number of doctors.
But how equally are they distributed and how many doctors are
available to the rural population ? The doctor population ratio;
in the urban areas is 1:1;300 and in the rural 1 :20,700.
10 .
- 10 -
The rural population uho make up 80% of India’s population are
deprived of health facilities while the 20% of the urban
population ^njoys 80% of medical care and facilities. Ihis .
partially explains the widespread ill-health prevailing in the
villages. The reason for this disparity in medical facilities
may be’due to °
Lack of participation and cooperation by the people in
Government health programmes.
- Improper allocation of funds: 75% of the budget is allocated
for maintaining staff; 12% for transport; 12% drugs and 1/o
for innovative, experiments0 The budget allocated ior tne
rural areas would be even less*
Medical personnel, especially doctors are reluctant to serve
in the'rural areas for more than one reason. Most often due to.
Inadequate living conditions in the rural centres.
- Family problems, education of children etc.
- Want of social life.
Intellectual isolation and inadequate facilities for main
taining professional competence.
- Problems of political interference by local government
officials etc.
Presence .of and unhealthy professional competition by local
practitioners and those practicing indegenous systems ci
' medicine5
The present trend of privatization and commercialization of
the medical
medinal profession is too strong a temptation to the
young
young oedico.; m de v;orse by a lack of motivation for the
right values in life.
Annua'11 T“ '*2 0C0 or u 'ae fresh doctors are added to the already
exisring numoer of doctors so unequally distributed among the so c
rural and urban population. The medical profession has become
commercialised that manyayoung student would use any means,
nav any amount of capitation fees to get into medical college
with the feeling that one has got into one of the best money
making ventures of today. Ind to make matters worse the training
and motivation given in today's medical colleges is strictly
hospital based, case oriented and not patient oriented,
westernised and sophisticated. The Indian trainee doctor is not
exposed to a real understanding of the social, cultural and
religious concepts of health and disease in rural India and
the many traditional systems of medical care. The attitude
of most doctors■towards anything Indian would be,one of contempt
with unconcern for* the uneducated poor village. The motivation
given to a person depends on the content and values orientations
of the training given to them.
The private sector has an important part in the country's health care
system of which the Church's role is of significance. Initially
th«* Church launched out in caring for the health needs of the
neoole especially the poor and with funds from abroad etc. “
most often free medication and care was available to the real y
poor but through the years with increasing privatization and
commercialization of medical care with increasing price
modern drugs; higher salaries to doctors; maunte
buildings; sophisticated equipment etc. a shift in pri^r
has' J-aken place and today the Church's health care is by and
itrgen! linger for the real poor but only for those who can
afford to pay*
11
• • •»
- 11
Apart from the economic factors, the poor are also illiterate
and hence not health, conscious. Their concept of health and
disease is masked by their superstitions and wrong beliefs that
prevent them fr.m accepting and availing for themselves existing
health facilities.
Drug and the Health Care System
The drug industry in India today is like any other industry,
profit oriented, with monopolization and promotion of multi
national corporations-r The role of drugs in the eradication of
disease is limited. Modern medicines and drugs cover only a.
small minority of the people in the poor societies.- It is known
fact in India that among the marketed 60,000 drugs, more that
60% of them are either irrational, unscientific, useless, harmful
or banned.
Essential drugs, which can cope with the overwhelming problems
even in relatively sophisticated societies, number around 200.
But for the villages and the urban slum-dweller great miracles
can be achieved with fewer than 30 well chosen drugs. But this
is precisely where the interest of the drug industry wanes.
The drug industry is concerned with profits first, like any
other business, not with the health needs of the majority.
An analysis of the marketed drug formulations show that vitamin
preparations accounted for 15% of the total number of formulations
- the largest single group of drugs marketed. 9% were tonics or
deficiency drugs; 5% tranquilizers and sedatives; expectorants 5%.
All these items together are vigorously sold under popular brand
names with high pressure advertising and sales promotion campaigns.
Most of the basic ingredients required for these preparations
have to be imported egs in the case of cough syrups and tonics,
none of the basic ingredients in these formulation is produced
in India.
While anti-infections and antibiotic drugs account for 21% of
the total, their production generally falls short of the quantities
required to treat the widely prevalent diseases cured by them.
There is also a growing suspicion that the people of the third
world are infact being used as ’guinea pigs’ for extensive
testing of certain drugs which is now virtually impossible to do
in the developed countries. The.reason why these blatant mal
practices continue may be due to :
i) ineffective, inadequate and corrupt drug machinery facilitating
easy introduction of harmful drugs in the market. Every state in
India has its Food &. Drug Administration. With a few exceptions,
most of these are badly managed with poor testing facilities ani
lack of trained personnel. They are alos subject to administrative
interference and political pressure.
ii) The enormous power and influence wielded by the drugs
industry enables it to stall, tone down and even overcome the
orders and regulations proposed by several organizations, committees
and individuals.
A-
iii) The pharmaceutical industry in India does not have to face law
suits and" pay damages to the affected parties. The principal
reason for this is the poor level of consumer awareness and
absence of well organised consumer protection movements.
- 12 iv)) In a situation likethis, one would expect doctors to.play
role in controlling the excesses of.the drug firms,
a critical
<
but the close ties between the medical profession and the
pharmaceutical industry in such that they feed each others
pockets. Probably the single most important part of drug
promotion is. sampling : free samples to doctors which has been
■»
iogenerated into a rat race among manufacturers.
Sample drugs are lispensed by most CP’s and may be even charged
- through acquired free - Roomfull’s of drugs have been
acquired by some doctors and later sold to wholesalers. Doctors
also accpet substantial gifts from drug companies. Most doctors
after leaving medical college depend on medical representatives
for information about drugs. A large number of people resort to
self-medication and almost all drugs are easily available over
-the counter.
With such a situation existing in the medical world, what about
those destitutes numbering hundreds bf millions below the poverty
line probably accounting for more than half of the Indian
population ? Most likely they will simply be bypassed. But
everything will continue to be done in the name of the poor,
the deprived and the weak.
In conclusion ;
humanised
Our efforts should be towards humanized health care, humanised,
living and humanized development of people. We are a country with
the World’s third largest medical man-power. We are signitatory
to the Alma Ata Charter of 1978* We are acknowledged as a Third
World Leader - yet
.
It is here where more than half of its people live below the
poverty line5 where 80% ormore children are malnourished; where
half of the world’s T.B. patients are; one third of the world’s
leprosy patients are struggling to survive; where 1*5 million
children die of diarrhoea and 40,000 children go bling
annually due to lack of Vit A! What has gone wrong and where ?
” You know sometimes it feels like this. There I am standing by
the shore of a swiftly flowing river and I hear the cry of a
drowning man. So I jump into the river, put my arms around him,
pull him to shore and apply artificial respiration. Just when
he begins to breathe, there is another cry for help. So I jump
into the.river, reach him, pull him to shore, .apply artificial
respiration, and then just as he begins to breathe, another
cry for help. So back in the river again, reaching, pulling,
applying, breathing and then another yell. Again and again,
without end, goes the sequence. You' Know, I .am SO' bust jumping
in, pulling them to shore applying artificial respiration, that
I have not time to see who the hell is upstream pushing them
all in ” .
Irwing Zola.
23-11-87/200
Prepared toy:
Community Health Department
of the Catholic Hospital
Association
India
157/6 Staff Roa4
Secunderabad 5OV2 003
Con h 55 • ly ■
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, COMMUNITY CENTRE, S.D.A., NEW DELHI 110016
Grams : VOLHEALTH
Phones : 668071, 668072
New Delhi-110016
H-43
Fifty Universal Health Messages
I
Murray Laugesen
These are universal messages because they apply to most parts of India and’
nearby countries.
These are health messages because if they are adopted they will result in
control of diseases and improvement in health.
These messages, like telegrams, say the most important things in as few words
as possible. But like telegrams their meaning may not be clear to the receiver.
So each message has to be translated into commonly used village words and
communicated slightly differently for each area, using different arguments,
stories and jokes to suit people of that area. In some areas, special messages
for that area will have to be added. Some examples are given.
These universal health messages are meant to clarify what needs to be taught,
to state in simple words and ideas what people in villages need to know for
their own good health.
They will be found useful as check lists for all health workers, teachers and
extension workers and those writing training manuals and teaching materials.
The people who finally hear these messages are not just the women and children
of the villages, but the heads of families caste groups and villages, the people
in power. What changes are they willing for ? For each message taught,
resources should be available. If we recommend immunization, we must have
sufficient vaccine, transport and staff to immunise whole villages.
I
For a Healthier village—What the people can do for themselves
What families can do
1.
Dig a pit for rubbish.
2.
Grow a vegetable garden, using the manure from the rubbish pit, and the
waste water from the house.
Compost this rubbish into valuable manure.
(
3.
2
)
Make a better latrine that the people will like to use, especially in all new
houses.
What the village can do together
4.
By group discussion, get group decision for gro^ health actions (to begin
with, choose a problem where success is assured).
5.
6.
Clean village wells and keep them clean.
their sides.
Protect them by building up
i
Control the worst of the village pests—snakes, stray dogs, lice, flies, bed
bugs, scabies, mosquitoes, rats.
Make family planning methods known and available outside of clinics and
health workers.
8.
Plan how to feed the very thinnest of the toddler children with extra food
per day during the leanest months of the year.
9.
Arrange with the nearest health centre to immunise all the children.
10.
Get someone in the village trained in simple health care, and get her
supervised regularly. Get at least one village dai trained also.
Child Care
11.
Breast feed as long as possible.
12.
Introduce semi-solid food from five to six months.
13.
Feed young children five or six times a day.
14.
Continue giving food in illness.
15.
Use the health service available.
16.
Get children rmmunized.
17.
Keep yourself and your surroundings clean.
18.
Drink clean water.
19.
Have no more than two or three children.
20.
Have children two to three years apart.
Care of Mothers
I
21.
A woman who is pregnant or breastfeeding, should eat more food than
she normally eats. And she should eat some green leafy vegetables daily.
22.
A woman who is pregnant or breast feeding needs at least one iron tablet
daily, especially if she is tired or pale.
23. Pregnant women and women with young babies need special care,
should visit a trained health worker each month.
They
(
3
)
24.
A pregnant women should have the delivery of her baby done by a trained
health worker. A trained health worker washes her hands frequently.
This protects the mother from fever afterwards.
25.
Cut the cord of the newborn baby with a clean knife first held in the flame.
This will protect the baby from tetanus.
Care of the Eyes
26.
For healthy eyes, eat green vegetables, and plant a kitchen garden.
27.
Stop infection spreading from eye to eye. (Trachoma and pus spreads
from one eye to the next by mother’s sari, common towel, kajal or surma).
28.
See a trained health worker if a person
—cannot see clearly in both eyes
—cannot see at night
—has pain in one or both eyes.
29.
If something has got into the eye, or if it is sticky, wash out the eye
immediately with plenty of water.
30.
Then show to a trained health worker.
Cataract is curable if operation is done early enough.
only by eye doctors from well known hospitals.
Get operations done
Tuberculosis
31.
Tuberculosis is a dangerous disease if it is not treated properly.
32.
Proper treatment for tuberculosis means regular treatment for at least
a year.
33.
If the patient stops treatment as soon as he feels better, the disease will
surely return. This time cure will be difficult and very expensive.
34.
Take treatment only from trained health workers.
35.
Special foods are not necessary, but regular treatment is essential.
36.
Regular treatment soon makes the person non-infectious.
37.
Tuberculosis is a disease which is spread by sputum and cough.
38.
Stop the disease spreading. Cover the mouth when coughing. Do not spit
on the floor. Keep a special container for sputum, and burn it in the fire.
39.
If there is cought with sputum lasting more than 2 weeks, it might be
tuberculosis. Get the sputum tested at the nearest health centre. Show
any thin child with cough to the health worker; it might be tuberculosis.
40.
Protect all children from tuberculosis by BCG injection.
J
Leprosy
41.
Leprosy is not hereditary.
not a venereal disease.
It is a disease, and not a curse from God.
It is
(
42.
4
)
Do not be afraid of people with deformity.
infectious leprosy.
Usually they do not have
43.
Leprosy can be cured with regular treatment.
44.
Take treatment only from trained health workers.
45.
Start treatment as soon as possible.
46.
Patients on treatment soon become non-lnfectious.
47.
Stay on regular treatment.
48.
Deformity can be prevented with regular treatment.
49.
Deformity can often be cured with surgery.
50.
Inspect unfeeling hands and feet each day for injury or burns; wear shoes
to prevent injury to the feet.
Special Messages for Certain Areas
Here are some examples of extra messages for certain areas and local
problems, Each person knows his own areas best : the message has to be
short and clear.
Western Orissa where violent massage
is practised.
Do not massage the baby's abdomen
after birth. This is harmful to the
baby.
Many rural areas where tetanus is
common despite branding of the skin.
Do not brand the baby's abdomen
after birth. Instead brand the end
of the cord and prevent tetanus.
Areas where goitre is common as in
hill areas of Assam and Bhutan,
Iodised salt prevents
iodised salt available).
In Rajasthan where water is scarce.
Purify wells weekly with bleaching
powder.
In Assam where wood is plentiful.
Boil all drinking water.
goitre
(If
Acknowledgement
For a healthier village is radically adapted from Nine do-it-yourself health
actions by Dr. Sam Street WHO Ethiopia in UNICEF News 87/1976/1.
Child care—is from Child Care Education—basic universal messages by
Dr. Peter Greaves FAO/UNICEF Regional Adviser in Nutrition, card published
by UNICEF Information Service, New Delhi.
We are indebted to Dr. Greaves for the concept of Universal Health Messages.
Care of mothers is adapted from Simple Nutrition Messages by VHAI.
Care of Eyes, tuberculosis and leprosy sections are adapted from the relevant
patient retained health records published by VHAI, and from pamphlets on
leprosy published by Dr. R. Thangaraj, Leprosy Hospital, Salur, A.P.
Printed at J S Bros. A-3UI1, Naraina Industrial Area, Phase I, New Delhi - 110028
L
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, COMMUNITY CENTRE, S.D.A.,
NEW DELHI 110016
PHONES : 668071, 668072
GRAMS : "VOLHEALTH" New Delhi-110 016
E-18
Village Sanitation Improvement
Scheme, India
by
S. B. Watt
ITDG Water Consultant
The National Environmental Engineering Research Institute (NEERI),
Nagpur, India, has a long and successful history of developing techniques
in public health engineering appropriate to Indian conditions.
These
techniques include simple methods of large scale sewerage treatment suitable
for townships with piped and water borne wastes, but they are also trying to
find ways to help the majority of people who live in small village and
isolated hamlets.
J
Toilet facilities for many people in India are very poor anti contribute
greatly to ill health amongst the population. Modern, piped sewarage systems
are expensive and are usually outside the ability of the local users to main
tain without constant attention and advice. World wide experience with
village sanitation improvement schemes demonstrates that unless the users
of the system are involved in the planning and construction work, they will
not take responsibility for the upkeep of the installation. Engineers at NEERI
are supporting a small sanitation improvement scheme at a village near
Nagpur, called Mahalagoan. They are providing the toilet bowls and another
local organization is providing the materials to construct the toilets. The
local people have these materials free of charge, and are shown how to do
the construction work. All the work up to ground level is paid for, and the
users of the toilet then construct a hut over the base plate as and when they
have the materials or resources to do so.
It is well known that man is the reservoir of most of the diseases that
cause him to be ill, and the basic strategy of any sanitation programme is
therefore to carefully control the disease-causing bacteria in his excreta, to
prevent them from contaminating foods, drinking water etc.
Improved
sanitation is a fundamental step towards improved well being, but without
educating the users of the toilet in the need for hygiene and care, the full
benefits of any scheme will not be achieved.
(
2
There are many methods of collecting and treating excreta from simple
pit privies to large scale water borne, piped systems. The method described
below was evolved in Ceylon, and has the advanges of a water seal closet
which prevents flies and odours, low cost, and easy removal of the decompo
sed excreta. It cannot safely be used, however, in areas which are regularly
flooded, in impermeable or frozen soils, or near to wells which provide water
for drinking.
The excreta is flushed through the water seal into the soakage pit by the
1 or 2 litres of water used for anal cleansing. The liquids in the pit soak
slowly into the soil, and the solids decompose into gases and humus. The
gases diffuse slowly through the soil causing no nuisance, and every 2 or
3 years the pit is uncovered and the humus removed.
Method of construction
1.
The most important step is to convince the people who will use the toilet
of the need for improved sanitation. Without their full support the toilet
will probably be neglected and abused.
------ T
I
I
'
'
1 HUT CONSTRUCTED
i
J 0V TOILETOWNER
I
I
I
I
1 METRE DIAMETER
2 METRE DEEP
5 cm THICK CONCRETE
SLAB COVERED By SOIL
I
I
I
I
CONCRETEI
slab
SOAKAGE PIT
_
«0cmTHICK^^^
I
T
(J pOp o o
.L-r
Imx Im S<juarg0 R.
PIPE
WATER SEAL TRAP
BRICK LINING
LAID with GftPS
CROSS SECTION
THROUGH toilet
GdsEs ESCAPE
BY DIFFUSING
INTO SOIL
DECOMPOSING _
WfiSTE
LIQUIDS PERCOLATE IHVO SOIL
L
(
3
)
2.
Choose the site very carefully. It should be located in a convenient
position to the household who are to use it, and the soakage pit should
be easy tp empty. Check most carefully that the infiltrating liquids from
the soakage pit do not percolate into any nearby water wells. The toilet
must always be downhill of the well, and at least 15m away. If the rock
or soil around the well is fissured or broken, take special care that the
liquids from the soakage pit do not reach the well water before they have
purified in the soil.
3.
Excavate the hole for the soakage pit adjacent to the site that the user
has chosen for his toilet. Clear the ground for privy slab, excavate for
i
the water seal trap, and dig a trench for the pipe which connects the
water seal trap to the soakage pit.
4.
The water seal trap must be pre-cast from sand/cement mortar. A
specially prepared mould is needed for this, but it is not a difficult job to
do. Full and lengthy instructions on how to make the water seal trap
maybe obtained from VITA publictations—the address is given at the
end of this article. To help prevent debris and rubbish from blocking
the water seal and pipe, design the narrowest dart of the toilet to be
next to the bowl.
5.
Well up the inside of the soakage pit with bricks, leaving small gaps
between the bricks for the liquids to escape. Lay and join the pipe bet
ween the soakage pit and the water seal trap. Connect the water seal
trap to the pipe, and fill around the trap with weak concrete to hold the
trap steady in position.
6.
Cast the privy base slab around the water seal trap, and trowel the sur
face smooth. Build up the footrests, and make sure that all washing
water will run into the trap. Alternatively if several privies are to be
built, construct a simple mould to precast the slabs.
7.
Lay the pre-cast cement cover over the soakage pit and cover this with
soil. The cover is made from mortar (1 cement, 4 sand) at least 5 cms.
thick. Include steel reinforcement if this is available.
8.
The toilet is now ready for use, and the owner may use any materials
that he has available to construct a hut around the squatting plate.
9.
Stress the importance of correct maintenance. If too much water is
used, the pit will flood. Debris and garbage will block the water seal
and will be difficult to remove. When the pit is full, it should be allowed
to stand unused for 1 or 2 months to kill the bacteria, before it is
(
4
)
emptied. During this period, the toilet user will need to arrange for his
family to share a neighbours privy. The excreta that has decomposed
will then be safe to use as fertiliser.
Like all toilet facilities, the water seal privy needs careful use and regular
cleaning. It is absolutely essential that education in hygiene is considered
to be part of the toilet construction programme.
Preferably, hygiene
education should come first, leading to a demand for improved sanitation.
For further information :
1.
The National Environmental Engineering Research Institute, Nagpur 440020
Maharashtra State, India, have many excellent publications on low cost
water and sewage treatment methods.
2.
VITA publications: 3706 Rhode Island Avenue, Mt. Rainier, Maryland,
USA 20822. For instructions and drawings of water seal traps etc.
3.
Excreta Disposal for Rural Areas and Small Communities, by E.G. Wanger
and J.N. Lanoix. World Health Organisation Monograph Series No. 39.
WHO SEARO, 36 Ring Road, New Delhi -110001. One of the best books
available on low cost sanitation.
4.
Guide to Simple Sanitary Measures for the Control of Enteric Diseases
S. Rajagopalan, MA Shiftman, WHO, 1974. Describes low cost sanitary
measures that can be implemented with limited resources to control
enteric diseases.
5.
Water Treatment and Sanitation H. Mann and D. Williamson. Rev. ed.
1976. Intermediate Technology Publications, 9 King Street, London
WC2E 8HN, U.K.
Acknowledgement
We are grateful for permission to reproduce this article from Appropriate
Technology 2, 4 p. 15-16, 1976.
VOLUNTARY HEALTH ASSOCIATION OF INDIA
I
C-14, COMMUNITY CENTRE, S.D.A.,
NEW DELHI 110016
PHONES : 668071, 668072
GRAM : "VOLHEALTH'' New Delhi-110 016
C-11
Journal of Christian Medical Association of India
November 1973 pp. 468-472
How much of a hospital's work could
be done by paramedical workers ?
HELEN GIDEON, md
Christian Medical Commission,
World Council of Churches
1211 Geneva 20, Switzerland.
Paper from Bangalore Workshop conducted in April 1973
for the Orientation of Medical Officers & Nursing Superin
tendents for Community Health Care.)
Summary
Analysis of 1032 outpatientsand 681 inpatients for eight mission hos
pitals in six States in India showed that 48% of outpatients and 44% of in
patients would probably not have needed to come to the hospital if they had
been treated or advised earlier by a paramedical worker.
Material and Method
Hospital sending delegates to a community health workshop were asked
to send a list of inpatients for one week and 1,000 consecutive first attendance
outpatients by age, sex and diagnosis. The object was to get the participants
of the workshop to analyse these data to get an idea of what percentage of
1
patients need not have been admitted to the hospital if health education,
advice, preventive care or simple treatment could have been given to them
earlier. Also, what percentage attendance at OPDs was really necessary
either for prevention or treatment.
It was decided that the patients be categorised into ‘Preventive’ (P) and
‘Non-Preventable’ (NP). Preventable, where admission and OPD attendance
could have been prevented if care had been given and accepted earlier. NonPreventable, where admission or OPD attendance was required for treatment.
Before this exercise could be given to the participants, the workshop leaders
(
2
)
did a‘test’ analysis. A careful look at the lists soon made it clear that
patients could not be divided into these two categories. For instance, how
would one categorize those who came for FTND (full-term normal delivery) or
‘New Born’ ? or cases marked NYD (not yet diagnosed) ? or those who came
for tubectomy ? Could a threatened abortion, febile convulsion, eclampsia
have been prevented ? Unless a decision could be made on such diagnosis,
could not proceed.
I
Consideration had also to be given to the inconsistencies that were
bound to occur with each participant’s interpretation of what could be called
•P’ or ‘NP’.
With this very real problem it was decided to have a third category which
was termed ‘Special’. This category included all doubtful diagnosis, FTND,
new born, etc. Three leading physicians took the lists and marked each
patient ‘P’, ‘NP’ or ‘S’. Careful attention was paid not to overweigh the pre
ventable cases. For the OPD lists it was decided that every fifth case out of
1,000 be analysed. The following list serves as an example of the classifica
tion in each category :
INPATIENTS
Admission avoidable,
Obstetrical and other
had simple care been
given earlier
'P1
unclassifiable
Upper Respiratory
Infection
Full-term normal
delivery
Pneumonia
Septic Abortion
Abortion
Asthma & Bronchitis
Abscess
New Born
Heart Diseases
Parasites
T ubectomy
Pyelonephritis
Pulmonary Tuberculosis
NYD
Diabetes
Amoebiasis
Delivery requiring
Caesarean or forceps
Hansen’s Diseases
needing admission
Typhoid Fever and
immunizable diseases
Gastroenteritis
Antepartum
Haemorrhage
Malnutrition and anaemia
and related infections
Admission probably
unavoidable
•NP’
Cancers
diagnoses
Accidents & Fractures
i
(
3
)
OUTPATIENTS
Hospital outpatient attendance,
avoidable had early community
care given
_________ ‘P[__________________
‘NP’_____________
Hospital outpatient
attendance, probably
unavoidable
Obstetrical
unclassifiable
___ _____
Diabetes
Kwashiorkor, Malnutrition
and associated infections
Antenatal
Cancers
Fractures
Sterility
Hypertension
Abrasions
Anaemias & general weakness
Check-up
Allergies
Epilepsy
Patients and Surgery
Urinary Infections
Myalgia
Gastroenteritis and Diarrhoea
Hookworm and other Parasites
Discharging Ear
Upper Respiratory Infection
Hyperacidity, Immunizable
Diseases Scabies
The following table lists the hospitals from where data was obtained.
TABLE 1
Name, location and size of hospital; number of one-week inpatients;
number and percentage of patients analysed.
1
Beds
Admission
date
No. of
patients
(1 week)
No.
analysed
No. not
included in
analysis ‘S’
Holdsworth Memorial
Hospital, Mysore City
280
1-8 Sep.
1972
138
68
IQ
CSI Hospital
Banglore
200
140
79
31
CSI Hospital, Woriur
Tiruchy 3, Tamilnadu
52
11-17 Feb.
1973
30
21
9
Mohulpahari Christian
Hospital, P.O. Mohul
pahari, Bihar
120
19-25 March
52
30
22
Holy Cross Hospital
Kottayam, Quilon
Kerala
Creighton-Freeman
Christian Hospital
Mathura, U.P.
250
?
196
163
33
160
3-11 Feb.
1973
52
26
26
115
20 March
1973
17-23 Feb.
1973
192
141
51
189
153
36
Total________________
959
681
Percentage___________
* One day only.
** Not by age and sex, included only in totals.
100
71
278
31
’’'Holy Family Hospital
Delhi
**St. Joseph Hospital
Dindigul, Tamilnadu
1973
i
350
(
4
)
Participants worked in pairs, analysing the material by age, sex, ‘preven
table’, ‘non-preventable’ and ‘special’. As each pair completed the analysis,
the information was called out and recorded on a blackboard and percentages
were calculated.
The bed strength of these hospitals varies from 52 to 350 beds; the total
number of inpatients for one week for each hospital (except Holy Family,
Delhi) was 959, 681 or 71% of these have been analysed.
1
TABLE 2
Analysis of 681 patients (by age and sex) admitted during one week for
conditions defined as ‘preventable’ and ‘non-preventable’ (‘P’ & ‘NP’)
2.1
UNDERFIVES
Males
No.
%
Females
No.
%
No.
%
• p.
19
63.3
16
72.7
35
‘NP’
11
36.7
6
27.3
17
67.3
32.7
Total
30
100.0
22
100 0
52
100.0
2.3
15-44 years
5-14 years
2.2
Males
No.
%
‘P’
18
48.6
‘P’
‘NP’
19
51.4
Total
37
100.0
2.4
45 + YEARS
Total
Females
Total
No.
%
No.
%
No.
%
54.8
45.2
61
‘NP’
34
28
66
48 0
52.0
95
94
50.0
50.0
Total
62
100.0
127
100.0
189
100.0
2.5
SUMMARY ANALYSIS
Irrespective of age, sex
No.
%
‘P’
28
81
25.4
74.6
‘P’
•NP’
Total
109
100.0
No.*
%
‘NP’
301
380
44.0
56.0
Total
681
100.0
* Total analysis includes 153 patients of the Holy Family Hospital in Delhi and 191 of
St. Joseph’s in Dindigul, as data from these hospitals were not available by aqe
and sex.
Note.
As a result of some corrections, these figures vary slightly from the
handouts at the workshop.
r
(
Summary of Table 2
►
)
5
Of 681 inpatients.
67.3% of patients under five years were preventable admissions
48.6% of patients 5-14 years were preventable admissions
50.0% of patients 15-44 years were preventable admissions
25.0% of patients over 45 years were preventable admmissions
44.0% of total patients, regardless of age, were preventable admisssions
These figures would have been considerably higher if more information
had been available in the diagnosis as was listed.
OUTPATIENTS
Of the eight hospitals, only four sent lists of 1,000 consecutive firstattendance outpatients by age and sex and diagnosis. Three hospitals sent
grouped diagnosis which were difficult to analyse. In all, it was possible to
analyse 4,331 outpatients; of these, every fifth case was considered. The
results were as follows :
TABLE 3
Analysis of selected 1,032 outpatients from hospitals by age and sex and
by conditions defined as ‘preventable’ and ‘non-preventable (‘P’ and 'NP')
3.1
UNDER-FIVES
Males
.p.
53
80.3
41
00.4
‘NP’
13
19.7
10
19.6
94
23
Total
66
100.0
51
100.0
117
3.2
1
Total
No.
. Females
No.________%_
No.
5-14 years
No.
33
15-44 years
Male
.
%
Female
No.
%
80.4
19.6
100.0
Total
No.
%
No.
%
‘P’
‘NP’
49
.p.
131
49.9
92
21
70
30
•NP’
132
50.1
155
37.3
62.7
287
43.7
100.0
Total
70
100
Total
263
100.0
247
100.0
510
100.0
3.4
15+YEARS
No.
SUMMARY ANALYSIS (OP)
3.5
‘P’
‘NP’
24
81
%
23-0
77.0
Total
105
100.0
223
Irrespective of age and sex
No.________ %
.p.
495
48.0
‘NP’
537
52.0
Total
1,032
100.0
* For one hospital, data by age and sex was not available. These 60 patients have been
included in the total.
(
Summary of Table 3
6
)
Of 1,032 outpatients :
80.3% of patients under five did not need hospital OPD care
70.0% of patients 5-14 years did not need hospital OPD care
43.7% of patients 15-45 years did not need hospital OPD care
22.8% of patients over 45 years did not need hospital OPD care
48.0% of total patients, regardless of age, need not have attended OPD
CONCLUSION
I
These data should not mean that hospitals can be done away with. The
figures are presented with the hope that hospitals may find it possible to
reorganise their services, so that highly experienced doctors, specialists, and
sisters are not forced to waste their time on work that can be done by others.
If auxiliaries could be trained, given simple standing instructions on what
to treat, what drugs to use, what to refer, then almost half the hospital work
load could be reduced. If auxiliaries are not available, it may be possible to
train and use school teachers or girls with a high school education to work
in their own villages, with supervision from the hospital staff.
Such reorganisation will :
a)
give the doctors and specialists more time;
b)
save hospital funds, facilities, beds, drugs and the time of the
supporting staff;
c)
develop responsible paramedical staff;
d)
make it possible to serve greater numbers of people, as time of
personnel and funds will become available;
e)
save family disruption caused by admissions that could be prevented;
f)
save the time spent at outpatients, which patients can use to earn a
livelihood.
The advantage listed seem obvious. At the same time-one can visualise
the problems associated with reorganizing services, e.g. for a while the
hospital income will drop due to prevented admissions. It may be that
admissions will increase again as patients needing treatment are diagnosed
in the community. There will be problems of retraining the staff to fit into
the changed pattern of service. Problems such as these and many others
will arise, but if the value of reorganization is realised and accepted, the
challenge of change will not seem insurmoun table.
June 1973
Further copies can be obtained from :
Voluntary Health Association of India
C-14, Community Centre, S.D.A.
New Delhi - 110016
Ptinted at J S Bros. A-3011, Naraina Industrial Area, Phase I, New Delhi-110028
r
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, COMMUNITY CENTRE, S.D.A.,
NEW DELHI 110 016
PHONES : 652007, 652008
GRAM : "VOLHEALTH" New Delhi-110016
H-6
Health Education and Community
Health Behaviour
By
D. BAN ER J I
Chairman & Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru University
New Delhi - 1 1 0057
Theory and Practic of Health Education
Health educators have taken great pains in asserting that health education is
fundamentally different from propaganda or high pressure salesmanship; they
also do not consider it to be synonymous with mass communication. Health
education, according to them, seeks to bring about changes within a person
in relation to his individual and community health goals.
Every community, responding to the health problems faced by it, formulates
its own health goals which determine the pattern of its health behaviour.
Changes in the health goals of a community and of individuals are required
when there is a gap between the pre-existing health goals and the goals they
ought to have in the context of the current knowledge concerning the health
problems and the accessibility and availability to the community of services
that are based on such knowledge.
Three considerations emerge from the above approach to health education :
Firstly, as it involves persuading individuals and communities to shift
from some of the pre-existing health goals to newer health goals that
the health educators consider to be more desirable forthem, it involves
value considerations. There is thus always a danger of health edu
cators becoming, unwittingly or otherwise, instrumental in imposing
certain preconceived values which may not necessarily be in the best
interests of the individuals or of the community.
Secondly, as there are almost constant changes in the nature of health
problems, changes in the body of the knowledge for dealing with them
and changes in the services that are made accessible and available to
the people, health education has to be a continuous process.
(
2
)
Thirdly, as almost al) health practices have been developed in the cul
tural, social, political and economic settings of western countries,
which are often diametrically opposite of what are prevailing in a deve
loping country like India, health educators in such countries have to
take an extra precaution of ensuring that the natural science essentials
of health practices are separated from what are called the social, cul
tural and political overcoatings which these practices have acquired in
the course of their development in the western countries. It is the res
ponsibility of the health educators to ensure that the natural science
essentials of the health practices are inserted into a new “envelope”
or “coating” that will harmonise better with the social, cultural and
economic environment of India.
Because of the above considerations, a sound understanding of the response
of communities to their health problems and their response to the various
services that are made available to them is of crucial importance for formula
ting a strategy of health education. Unfortunately, this cardinal principle—the
principle of basing a health education strategy on community diagnosis—has
not received due attention in the actual practice of health education in India.
For instance, health educators in India very willingly and actively participated
on a massive scale in “selling” family planning to the masses—to a hungry
and poverty stricken population with very poor health status (particularly of
mothers and children) and with extensive unemployment, social exploitation
and illiteracy!. Neither the health educators in India nor the numerous health
education consultants from abroad made any significant efforts to base the
family planning health education strategy on sound community diagnosis.
Again, in the case of practice of health education in the Indian tuberculosis
programme, instead of making community diagnosis, health educators chose
the easier and much more “rewarding” path of imitating their western coun
terparts and kept on the refrain of “educating the ignorant, superstitious and
illiterate” public of India about tuberculosis. Later on, a community dia
gnosis, which was made for some other purpose, revealed that because of
weaknesses in the services, a very large number of tuberculosis cases, who
were actively seeking help, were not even being diagnosed as cases of tuber
culosis and are being turned back with a bottle of useless cough mixture2.
These findings indicated that much more than the tuberculosis patients, it
was the organisers of tuberculosis services who ought to have been
“educated”. Similarly, studies of treatment default in tuberculosis pro
grammes indicated that organisational, managerial and technological lapses,
rather than lapses on the part of patients account for the bulk of the problem.
Yet health educators kept the focus only on the lapses of the patients and
were thus instrumental in diverting attention from the far more serious lapses
in the services.
(
(
3
)
Health educators in India have a tendency of imitating the approaches that
have been developed in western countries and of almost blindly rushing in
to take upon themselves the task of rectifying the “faults” of the community,
without fully questioning the adequacy of the services that are being provided.
In considering health services to be something sacred, something which is to
be accepted without question, health educators in India have taken a very
untenable value position. Findings from a recent study of health behaviour of
rural populations in India3 appear to be very relevant in the context of the
*
present crisis in the practice of health education in India. This effective study
has provided data for developing a more effective framework for the practice
of health education in India.
Health Behaviour of Rural Populations in India
Considering the activities of a primary health centre as a purposive interven
tion to change for the better some aspects of the pre-existing health culture
of the community served by it, a research study was designed to examine the
current status and the nature of this interaction between the health services
that are introduced through the PHCs and the pre-existing culture of rural
population in India. A report on this study has been published elsewhere3.
Only a broad outline of the study design and the principal findings are being
summarised here.
In order to get data on health behaviour of rural populations under relatively
more favourable conditions, a deliberate effort was made to select, in the first
instance, primary health centres and villages which are much above the
average. The study has been completed in 19 villages, 11 of which also serve
as the headquarter village of a Primary Health Centre. These primary health
centres are from seven states of the country which belong to the different
region^.
Considerable care was taken to develop a methodological approach that was
specially tailored for studying the health behaviour of villagers (including
their behaviour in relation to the primary health centre services) against the
background of the total village culture. Research investigators lived in these
villages for three to five months. Apart from making special efforts to get
themselves accepted by all the segments of the village community and collec
ting data through village informants, the investigators identified informants
and some “ordinary” members from each segment of the village community
and made observations and conducted depth interviews to understand the
health culture of each segment of the village against the background of its
total culture. They also prepared case reports to provide a deeper insight in
to the response of the different segments to health problems in the fields of
medical care, family planning, maternal and child health, communicable
diseases, environmental sanitation, etc. Work instructions, checklistsand
other documents had been prepared to enable all the investigators to cover
uniformly all the major areas in relation to these problems.
(
4
)
The investigators’ stay in the village also enabled them to make direct obser
vations, followed by depth interviews, of the actual behaviour of the villagers
when they encountered certain specific health problems. They could also
study the interaction between the primary health centre personnel and the
villagers, both when the former visited the village and when the villagers
visited the primary health centre, Apart from these efforts to ensure that indepth qualitative data are obtained from all the segments of the entire village
community according to well defined work procedures and check lists and
that they were, as far as possible, checked and cross-checked, a quantitative
dimension was given to the main qualitative data by framing an unstructured
interview schedule on the basis of these data and administering it to a twenty
percent stratified random sample of the village households.
As an additional safeguard, after completion of the field work in the villages
of a primary health centre, some of the data concerning the health behaviour
of the community were cross-checkd with the personnel of the primary health
centre and the concerned personnel at the level of the corresponding seven
state directorates of health services. An additional four states were added to
the original seven to examine how far the findings from these seven were
applicable to the others. These eleven states covered over 80 percent of the
population of the country. Recognising that the complex nature of the
problem for this study calls for a new and rather exacting methodological
approach, an effective monitoring system was developed by the research
director to ensure that the data collected by all the investigators were of a
minimum accepted quality.
Taking into account the social and economic status of the people, the epide
miology of health problems and the nature of the health services available, it
was not surprising that problems of medical care should be by far the most
urgent concern among the health problems in rural populations. But the
surprising finding was that the response to the major medical care problems
was very much in favour of western (allopathic) system of medicine, irrespective
of social, economic, occupational and regional considerations. Accessibility
of such services and capacity of patients to meet the expenses were the two
major constraining factors. These findings seriously call into question the
prevailing views of social scientists and health educators on this subject.
On the whole, the dispensary of the primary health centre projected a very
unflattering image. Because of this and because of its limited capacity, it
was unable to satisfy a very substantial proportion of the demand of the
villagers for medical care services. This enormous unmet felt need for
medical care services has been the main motive force in the creation of a very
large number of the so-called Registered Medical Practitioners (RMPs) or
“quacks”. The RMPs are thus in effect created as a result of the inability of
the physicians of the primary health centre dispensary of other qualified
(
5
)
practitioners of western medicine in the villages to meet the demands for
medical care services in the villages. Without taking these basic issues into
consideration, health educators in India have promptly condemned the
villagers for patronising such “quacks". It is worth noting that almost all
these RMPs use allopathic medicines rather than aurvedic or unani medicines.
When these RMPs prove ineffective, depending on the economic status of the
individuals and the gravity of his illness, villagers actively sought help from
government and private medical agencies in the adjoining (or even distant)
towns and cities.
There were, however, numerous instances of adoption of healing practices
from qualified or non-qualified practitioners of the different Indian systems
of medicine and homoeopathy and from other non-professional healers. This
aspect of health behaviour has received much more than its due share of
attention from health educators and social scientists. In their preoccupation
with writing in details about some of the “exotic" aspects of health behaviour,
they seem to have over-looked the fact that among those who suffer from
major illnesses, only a very tiny fraction preferentially adopted these practices,
by positively rejecting facilities of the western system of medicine which are
more efficatious and which are easily accessible and available to them. Usually
these practices and home remedies were adopted : (i) side by side with wes
tern medicine; (ii) after western medicine failed to give relief; (iii) when
western medical services were not accessible or available to them due to
various reasons; and (iv) most frequently, when the illness was of minor
nature.
Another very significant finding of this study is that the family planning pro
gramme had ended up in projecting an image which was just the opposite of
what was actually intended by health educatorsand social scientists. The
image of the family planning workers in rural areas was that of persons who
use coercion and other kinds of pressure tactics and who offer bribes to
entice people into accepting vasectomy or tubectomy. Because of this
approach to family planning and failure of family planning workers to develop
a rapport with the villagers, sometimes the villagers were unable to meet their
needs for family planning services. There were several instances of mothers
who, failing to get suitable family planning services from the primary health
centre, took recourse to induced abortions to get rid of unwanted pregnancies.
This not only pointed to the failure of the programme to meet felt need of
individuals for family planning services but it also draws attention to the
failure of the programme to offer suitable abortion services to mothers with
unwanted pregnancies, despite the passage of the abortion bill. Ironically,
services of health educators and social scientists had been mobilised
on a very large scale to provide “support" for such a family planning
programme.
(
6
)
Another significant finding of this study is that there was considerable unmet
felt need for services of the Auxiliary Nurse Midwife (ANM) at the time of
child birth. Villagers were keen to have the ANM’s services because they
considered her to be more skilled than the traditional dai. Wherever the
ANMs provided the services the dai’s role had become less significant. How
ever, the overall image of the ANM in villages, particularly in north India, was
that of a person who is distant from them—meant only for special people or
for those who can pay for her services. She is not for the poor. She can be
called only when there are complications and then also she should be paid.
Because of the inability of the ANMs, the majority of the deliveries even in
the villages where the primary health centre is located were conducted by
dais and relatives and neighbours. In villages with no primary health centre,
their sway was almost complete.
As in the case of the Registered Medical Practitioners, confinement by rela
tives and friends and by indigenous dais was popular among the villagers not
because of their intrinsic merits but in the absence of suitable services from
the ANM/Lady Doctors, they were compelled to settle for something which
they considered to be inferior but which was all that was accessible to them.
The only two programmes which can be stated to have reached the grass
roots level in the villages were those concerning malaria and smallpox. Des
pite several complaints regarding the sincerity of these workers, there was
almost a universal agreement among the villagers that these workers did pay
visits to them. A significant finding was that these workers did not encounter
any major obstacle in getting participation of the community in these pro
grammes. Except when there were understandable compulsions, such as
prospect of a poverty stricken mother losing wages for 4-5 days at the peak
agricultural season due to the child's vaccination reactions, and some cases
of orthodoxy, their was general acceptance of smallpox vaccination in village
communities. The number of children who were left unvaccinated due to
lapses of the parents appear to be a very small fraction of those who remai
ned unvaccinated due to lapses of the vaccinators and their supervisors.
Patients suffering from tuberculosis, leprosy and trachoma got very little
services from the corresponding national programme. It was remarkable that
despite this, these patients actively sought help from elsewhere—from the
nearby towns or even big cities. Such help was not only much more ex
pensive and bothersome but it was also much less efficacious, both clinically
as well as epidemiologically. Other preventive measures for these diseases,
of course, were almost non-existent.
Although, by far the great majority of the villagers still went to the fields for
defecatior; significantly, impelled by sheer felt need, a number of them had
incurred considerable expenditure to get latrines of various types installed
in their homes. They got little encouragement or help in any form from the
e
(
7
)
primary health centre. This was another instance of the health institutions
falling behind even the already existing felt need for preventive services in
the community.
There were no sustained efforts to deal with such diseases as cholera, dip
htheria and guineaworm and bookworm infestations as public health problems.
When, however, epidemics of cholera and diphtheria struck separately three
of the study villages when the field work was going on, the primary health
centre and the district health authorities encountered little difficulty in getting
community participation in the anti-epidemic measures. There were also
instances of villagers, on their own, seeking triple antigen immunization from
the primary health centre. Very often even this need was not met by the
primary health centre.
Extensive prevalence of adjectpoverty, as a result of which more than half of
the population was unable to meet even the minimum dietetic calorie needs,
and appalling conditions of sanitation, water supply, housing and education
presented an ecological setting which was conducive to a widespread pre
valence to various types of health problems in the community. These health
problems formed only a component of the overall gloomy picture of the way
of life in Indian villages. Ignorance, superstition, suspicion, apathy and
fatalism should thrive in such a milieu. It is, therefore, a tribute to the
strength of the culture of the rural populations in India, that despite these
overwhelming odds, their health behaviour has retained so much of rationality.
It is doubly unfortunate that health educators overlooked these obvious
realities and uncritically set out to “educate” the people of the country at the
behest of equally uninformed health administrators.
As in the country as a whole, as indeed in the international fields, in the
villages also, the conditions of acute poverty and helplessness was associated
with a political system which was dominated by a tiny group of highly privile
ged persons. This political power, in turn, vested this group with additional
power to further exploit the weaker sections. Over and above, they got
support and sustenance from similar power elites higher up in the hierarchy
which extended right into the international arena. Each one of the villages
studied thus presented a picture of a rather stable equilibrium in which a
vast majority of the village population was kept effectively subdued by a small
privileged group which had acquired political power by controlling land,
trade, cooperatives, industry, money lending, education and the law and order
and the judicial systems. Experience had taught the persons belonging these
weaker sections that efforts to stand up to the prevailing order would invite
very deterrent punishment. They had thus learnt to live with the system, thus
giving it the appearance of “stability”.
Health Education professionals
allowed themselves to become an instrument of the power elites for main
taining such an inequitous stability.
(
8
)
Because of their urban orientation, it was observed that workers of rural
health and other developmental agencies generally had a strong distaste for
rural life. This distaste was for the entire way of life and not simply for the
very poor facilities available there. Health workers, including health educa
tors, tended to keep a distance fromjhe rural population as a whole. How
ever as they were required to work for rural populations, they took advantage
of the village power structure and confined themselves, as far as possible, to
satisfying the privileged gentry of the village. In doing so they (a) won app
robations and rewards from the so-called community leaders who had the
ear of their superior officers and of the political leaders at the higher scales;
(b) dealt with the least disagreeable segment of the village community; and
(c) got a free hand to “tackle” the rest of the community.
The findings of this study brought out a number of key issues which are of
far reaching significance for the future development of a sound strategy for
the practice of health education in the country :
1.
It brings out clearly that there is no significant cultural resistance to
acceptance of modern medicine as long as they are efficacious and
they are accessible and available to them. This finding, therefore,
seriously calls into question the belief of a very significant sector of
health administrators, social scientists and health educators that there
is considerable cultural resistance to the acceptance of modern medical
practices in rural populations in India;
2.
That the existing health services are working at a grossly low level of
efficiency, which has led to considerable under-utilisation of these
services. Priority should, therefore, be given to ensuring that this
problem is overcome;
3.
4.
There is also considerable scope for bringing about qualitative
improvements in the existing health services and bringing it more in
tune with the social and cultural setting of the village communities; and
Finally, after ensuring a reasonable level of utilisation of the existing
capacities and after bringing about the required qualitative changes,
there is a case for making quantitative expansion of the health services
to meet the requirements of rural populations. This will imply rectifica
tion of the existing imbalance in allocation of resources : this will imply
a shift in providing services from the privileged to the underprivileged.
Basis for an Alternate Approach to Health Education
The findings from this study raise a number of issues which should have
important bearing on the entire field of health education in India—on
education, training, practice and research : in Health Education in India.
(
9
)
1. There is clear evidence that individuals and groups belonging to all
the segments of rural populations from the different regions of the
country have, on their own, brought about significant changes in their
health behaviour in curative, preventive as well as promotive fields
when the health services that were available to them had fallen far
short of the requirements.
2.
These remarkable shifts in health goals of the community and of
individuals had been brought about without any intervention of health
educators. If anything, health educatorshave to take the blame for
being instrumental in diverting attention awap from the central issues
of community diagnosis by raising issues which are peripheral, if not
blatantly counter-productive and irrelevant.
3.
The most urgent task before health educators in India will, therefore,
be to "catch up" with the already accepted individual and community
health goals by emphasising that the needed
available to them.
services be made
4. As more effective health services are made available on a larger scale,
health educators will be called upon to motivate people to make more
effective use of these services. Motivating patients of tuberculosis
and leprosy to take the medicines regularly, dispelling rumours con
cerning alleged illeffects of contraceptives and ensuring adequate
coverage of the different immunisation programmes, are instances of
such fields of action.
5.
As additional resources are made available to the people, health
educators will be required to promote more effective participation in
the more extensive programmes that are developed in such fields as
maternal and child health services, environmental sanitation and control
of communicable diseases.
j
6. These changes in the role of health educators will require fundamental
changes in the entire field of health education in India—in developing
the content of health education and in the fields of education, training
and research. Practice of health education will no longer be confined
merely to implementing “Instructions" that are handed down by pro
gramme administrators, as has generally been the case thus far. Health
education will be an integral part of an elaborate interdisciplinary effort
for formulating and implementing effective community health services
for the country and for evaluating them. Acting as a “spokesman" for
the community, practitioners pf health education will be called upon to
marshal the relevant social science data and fit them into the bigger
process of programme formulation so that it is possible to promote
participation of the community in these programmes.
(
10
)
References
1.
Banerji, D. (1971) : Family Planning in India : A Critique and a Perspective,
New Delhi, People’s Publishing House, pp. 31-35.
2.
Banerji, D. (1971) : Tuberculosis : A Problem of Social Planning in Deve
loping Countries, NIHAE Bulletin, Vol. 4, No. 1, pp. 9-25.
3.
Banerji, D. (1974) : Health Behaviour of Rural Populations in India : Impact
of the Primary Health Centres, Economic and Political Weekly, Vol. XIII,
pp. 2261-2263.
Acknowledgement
Permission
from
Dr. Banerji to
reproduce this article
is
gratefully
acknowledged.
Printed at jsb Printing Press, A-30/1, Naraina Industrial Area, Phase-1,
New Delhi- 110028
r
SS"; I?
INTRODUCTION
If the quality of the life of people has
to improve they will have to change by adopting
better practices. But, people don't change
etfcily and quickly. Socio-cultural Factors like
tradition customs beliefs, fear of the unknown
etc., create blocks in them leading to resis
tance for change. To over come these blocks and
to lead the people to better and improved
practices,there is need of imparting them
the necessary knowledge and skills, clear
their doubts and misconceptions and develop
in them favourable attitudes leading to quickier. decisions resulting in positive actions.
One of the best channels through which these
inputs can be provided to the people is through
their local leaders. But, the leaders them
selves will have to be visited informed and
motivated. One of the methods adopted for
informing the leaders and involving them
in the social change was conducted Orientation
Training Camps for them.
The concept of Orientation Training Camps
for leaders is not new to our country. As early
as in 1953 OTCs formed the basic method and
tool for community education and for involving
local leaders in the developmental activities
in rural areas under the Community Development
Blocks and National Extension Services. Realis
ing the importance and utility of OTCs, the
same were included in the family planning
programme also right from the inception of
the programme. Each OTC was of 3 days duration.
Later the duration of the OTCs was reduced
to one day.
With the passage of time there is a
greater reliance on OTCs as could be seen
from the increase in the number of OTCs allotted
and conducted each year. These have been
2
given the pride of place in IPP-III, Karnataka.
The implementation Volume of IPP-III States
as follows
Community Education : Orientation Training
Camps'*.
Orientation Training Camps (OTCs) are
rapidly coming to be regarded as the linch
pin of community Education for Health and
Family Welfare in India. OTCs are small gather
ings at which family welfare policies and
programmes are presented and participants
have an opportunity to raise questions, ex
press their own concerns, enlarge their under
standing of family welfare and lend their
support to the movement. The invitees, in
addition to formal *and informal 'community
leaders, include village level officers,
teachers, women and private Medical Practiti oners. Until recently., OTCs were held
for three days, but is now felt that programmes
are better attended and more effective if
they are shorter, more practical and generate
greater group participation1’.
"B.
When the recent introduction of the
Zilla Pari shads and Mandal Panchayat Systems
in Karnataka conducting OTCs for leaders
takes added significance.
Why OTCs for Leader ?
Man is gregarious by nature i.e., lives
always in groups with other fellow-men. Man
is also said is a social animal, having mutual
interaction with other people. Each person
will be influencing the others and in turn
will be influenced by the others-influencing
in thoughts, opinions, decision actions in
manners, perceptions in knowledge, attitude
and behaviour.
3
A leader has been defined as the person
who influence the others more than being
influenced himself by them.
It has also been observed that majority
of the people want to be given the lead and
led by some one. When time comes, they consult
somebody in whom they have faith.
It is these qualities of leaders vis-avis their people which makes those incharge
of developmental activities look for them
to influence the people to lead them to give
the opinion, to help them form utilities
and in idecision making, The local leaders
do these much better than others because
they are local people know the imoods and
temperaments of the people^, their customs,
beliefs
they can speak to the people in
their own dialect and language, they can
do these when people are available and free.
They can communicate better. They can also
adopt new practices in their own lives and
thus demonstrate to the people the advantages
of such new practices, i.e., they act as
change agents andi sustain the change. They
in mobilising local resources for
also help
I
programmes and activities. When there is
shortage of personnel to reach out for all
people, the local leaders will do that job
for the authorities incharge of development
activities, provided they are themselves
exposed to and convinced about the new practices
to be adopted through OTCs and similar educa
tional activities.
Scope of OTCs :
OTCs are to be conducted at Village
Level, Community Health Centre Level, PNC
Level, Sub-divisional Level, District Level,
Divisional Level and State Level.
4
OTCs can be conducted in general including
all types of people from all walks of life or
they can be specific for specific groups
like OTCs exclusively for women, for slum,
dwellers for village people or -cfor
-- urban
for Social Workers for Teachers,
people, for
Youth Leaders for Govt, servants etc.
Objectives of OTCs :
The main objective of OTCs i s the same
the overall active and sustained
support
and co-operation of the leaders of the area
in the Educational and Motivational efforts
for the promotion of the family welfare programme and other Health activities among
the people of area.
The Specific Objectives :
1.
To provide interface between the
community as represented by its leaders and
the Health and Family Welfare personnel.
2. To provide a forum for free and
frank discussions between the leaders and
programme officials to clear any doubts and
mi sconceptions, about the Health and FW Programmes.
3.To provide to the participants simple
scientific knowledge about various Health
and Family Welfare Programmes and activities
with special emphasis on FW aspects like
relation between population growth and socio
economic aspects, process of conception and
various methods of contraception.
4. To provide to the participants know
ledge about sources of various types of services
provided.
X
5
5. To inform the participants about
the inter relationship between Family Welfare,
Health, Nutrition, Education and their cumula
tive effect on the improvement of the quality
of life of the people.
6. To make the participants aware of
their own potentialities in leading the people
towards adoption of better Health and FW
practices through individuals and
voluntary
organisations^ local bodies, Health Committees
etc.
Planning OTCs :
The success or failure and the degree
of success or failure of each OTC depends
upon the amount of planning that has gone
in arranging it, the manner in which it has
been implemented and the manner in which post
camp followup is carried out. The OTCs fail
and create bad impression in the participants,
if the organisers are not sincere in their
efforts or if they organise the OTCs in a
very casual manner.
The following aspects have to be attended
to in the planning part of the OTCs.
1. Knowledge about the No. of OTCs
to be conducted during a particular year,
the level at which OTCs are to be conducted,
the budget allotted to each type of OTCand
latest instructions from higher offices regarding
conducting the OTCs.
2. Knowledge about objectives, contents,
methodology to be
adopted in conducting
OTCs.
6
3. Proper selection of leaders and
participants in sufficient numbers, wel 1
in advance-
4. Spatial distribution of OTCs during
the previous years and probable spatial dis
tribution during the current year.
5.
Timing of OTCs.
6.
Venue <of OTCs
ments.
7.
8.
Agenda.
9.
10.
11.
1.
and physical
arrange-
Speakers, Resource Persons, Organiser
incharge.
Educational materials and Aids.
Food and refreshments for participants.
Certificates, Mementos etc., for
participants.
Knowledge about the No. of OTCs to be
conducted;budget etc :
Apart from general instructions there
will be circular instructions from higher
offices each year intimating the No. 'of OTCs
to be conducted by each PHC, Sub-division
and district at different levels; the budget
Such
allotted etc.,
circulars should
be carefully filed in chronological order.
A small note has to be prepared out of these
circulars giving ready information. The expendi
ture will have to be limited to the budget
allotted to each type of OTC.
Circular instructions showing the pattern
of allotment of OTCs under MEM Wing and IPP11I(K) along with buildings are enclosed
( Annexure-I and Annexure-II A and II B
as examples.)
I
7
2.
Knowledge about objectives, contents
be adopted in conducting OTCs :
etc., to"
1
This manual provides the above information
in detail. These are also Guidelines issued
by Ministry of Health and FW, Govt, of India.
Health & FW activities are not static
within a given fixed frame work >these wi 11
be changed through years. To effectively
fulfil the needs in the light of these changes
there will be circular instructions from
time to time from higher offices. These have
to be kept in ^iew while planning OTCs. The
MO and his staff may also feel the need of
including certain items having local importance.
3.
Proper selection of leaders and partici
pants of OTCs :
This is the most crucial aspect in plann
ing the OTCs. Hectic efforts to select partici
pants at short notice will only lead to wast
age of efforts, funds and poor achievement
of the objective of OTCs.
OTCs are part of educational activities
under FW Programme each year and will continue
to be so in the near future also. Further
the help of local leaders will be required
in connection with other activities also,
Hence, it is necessary to have a permanent
exhaustive list of leaders for the entire
PHC area, arranged sub centerwise and village
wise& brought upto date from which the list
of participants can be drawn up for each
OTC.
The list of leaders should arrange from
the lowest level, giving due importance to
the suggestions of Health workers (Male and
8
Female),local Dais and Community Health Volun
teers, gradual building up Jto include PHC
Level, Taluk Level, district “Level and State
Level Leaders also.
X
As stated earlier, a leader is a person
wno can influence the ideas, thoughts^ opinions
attitudes and actions of a number of people.
Opinion Leaders are those leaders whose opinion
is sought by people on different aspects
and thus they influence their opinions.
There will be some leaders who influence
a small group of people only like their neigh
bours or their relatives, where
there
will be some who influence large groups of
people. Both types of leaders are important
for Health and FW Activities.
When the Word Leader is said^ the mind
immediately thinks of MLAs, MPs, Panchayat
Chairman and MemberSj Zilla Pari shed Members^
etc. These leaders are called "Formal Leaders"
i.e., leaders who command respect of people
because of their official positions
The
local teachers, postmaster, Doctors and even
the Health workers come under the group of
Formal Leaders.
There will also be some people who don't
have any officially given position like the
formal leaders, but still influence other
people. Such leaders are called "Informal
Leaders”. The local priest or Swamiji of
Math, the money lender, the landlord, the
barber, the Dai,are examples Of
of "Informal
Leaders". Further informal leaders can become
formal leaders and formal leaders can become
informal leaders.
9
While some people are already leaders,
there will be some who are not leaders but
have the capability of potential^ to become
leaders ,if a suitable opportunity or occassion
arises.
It is necessary to identify these leaders
the persons who have got the potential
to become leaders. It is necessary to involve
not only the big leaders who can influence
a large number of people but also the innumer
able small leaders who can influence their
immediate neighbours, relatives or co-workers.
and
It is easy to identify the formal leaders.
If an enquiry is made in a village as to
who are the teachers, postmaster and other
Govt. Officials, Bank Officials, V.P. Chairman
and Members etc., a list of such leaders
can be prepared. But it needs some effort
to identify the Informal Leaders.
Methods of Identifying the Leaders :
There are certain tested methods of
identifying the leaders by which the leaders
and potenti
potential
al
leaders can be identified.
1.
Discussion method :
While discussing with the community
during their routine work the Health workers
may find that some of the persons take keen
interest in discussions and in Health work
and to be initiative. The namei and particulars
of such persons may be noted immediately
by the concerned Health Worker and a list
of such persons may be prepared.
10
2.
Observation method :
In this method the concerned Health
worker will keep his/her eyes and ears open,
and closely and carefully observej to detect
persons who arevery
veryactive,
active, enthusiastic,
andco-operative and
service
minded
who can influence others.
others, Particulars of
3
have
to
be noted down then and
such persons
by
the
worker
and
after observing over
there I
*; areas, a list
period
of
time
in
different
a |
of such persons can be prepared.
3.
I
Socio-metric method
group method :
or
selective
This is a scientific method. In
this method (a) The concerned Health Workers
will together enquire in the community about
the formal leaders in that community like
the Government officials., V.P. members and
the known in<
Chairman etc., and also about
;
1 leaders like priests, barbers, dias
formal
etc., and make a list of them with full parti
culars.
(b) Contact each of the leaders so listed
whom they
and enquire from each of them, r*
consider as leaders, by putting the following
questions to them.
i)
Whom do you consider as the most
influential person or as leader in your
locality/vi11 age.
ii)
Why do you consider him/her as an
ii)
influential person /Leader.
iii)
Who helps the community and people
at times of crisis or development.
iv)
Whom do the people consult and seek
iv)
advise from regarding their problems relating
to agriculture, health, litigation etc.
11
c) Make a list of persons whom the
leaders contacted and have told answer to
their questions.
d) Mark against the name of each persons
1isted as in (c) above, how many people
have referred their name in answer to the
question.
The persons whose names have been referred
by many people, can be taken as the leaders.
4.
Systematic sampling method :
This method is followed in villages
having more than 800 population.
In this method the concerned Health
workers will visit every 5th house or 10th
house (depending on the size of the population)
and put the head of the family or in his
absence^ any responsible adult member of that
family,the same questions as put in the socio
metric method and record the answers.
The persons who were referred most by
these people are to be considered as leaders.
By using these methods? especially the
Sociometric Method and Systematic Sampling
Method, the real leaders can be identified
in each village and locality and their lists
can be maintained. There is the possibility
of the leaders of the minority groups being
left out, when a list for the entire village
is prepared^ since the leaders of the majority
groups will be referred by large number,
of people as compared to those of minority
groups of women. As such it will be necessary
to listout the leaders, locality-wise and
groupwise.
12
Whenever an OTC has toi be organi sed
the leaders can be selected ■from the lists
prepared as above, provided it is kept upto
date.
The participants of
OTC in the rural
areas are to be selected from the concerned
area only.
only, The leaders of minority groups
have to be specifically selected. OTCs for
specific groups can also be considered.
For the OTCs at district level, the
participants can be selected from amongst
the ZiIla Parished
Pari shed Members^ Mandal Panchayat
Members, Members of the Taluk Level Committees,
eminent Social Workers and a few opinion
leaders of village level who had the opprtunity to attend OTCs at village PHC/SHC Level
and did participate well in them and also
those who did good work in family welfare,
at the rate of one or two from each PHC Area.
For the state level and or Divisional
Level OTCs which is to be held towards the
end of the year, prominent leaders from dit
ferent fields are to be invited at the rate
of two per district.
The number of participants to be selected
for each OTC, irrespective of whether it
i s village-level PHC Level, Sub-division
Level, District Level, Division/State Level
is 40. The ideal number of participants would
be not less than 20 and not more than 40.
Though officials of the Health and FW
Department and those of other Departments
will have to take part in the OTCs, care will
13
have to be taken that they donot form majority
among the participants unless it is a special
group OTC especially for them.
The persons selected <as participants
Xo a particular OTC will have to be intimated
well in advance about their• selection and
' ‘ '. This wi 11 ensure
their willingness obtained.
that if some^of those selected are not willing
to attend, some other may be selected and
the full sanctioned strength of participants
is obtained.
4.
Spatial Distribution of OTCs :
All areas of the district and of the
PHCs should have equal opportunity to have
OTCs. Lopsided loading of OTCs in one part
of the district to the exclusion of other
parts of the area is to be avoided. For this
purpose it is necessary to have a chronologi
cally ordered list of OTCs conducted so for
during the previous years.
The tendency to conduct OTCs repeatedly
in the same place in view of Convenience
has to be avoided.
5.
Timing of OTCs :
OTCs will be successful only if the
required number of participants attend them
and are free from other restrictions during
the duration of OTCs. Farmers will be busy
during the agricultural season. Many people
will not be fr£e, during fairs and festivals.
During rainy seasbn transport may be disrupted
in some places. Hence, it is necessary to
take into> consideration the local weather
c1imatic conditions, agricultural and sociocultural factors, before fixing an OTC on
a specific day.
&
i
14
6.
Venue of the OTCs :
A suitable place for conducting the
OTC will have to be selected well in advance.
It should not only provide adequate space
for the deliberations of not only 40 partici
pants but also for the other officials from
the organiser's team, for arranging exhibition
and filmshows and for arranging food and
refreshments. A village panchayat may be
an eminently suitable place for the OTC but
it may discourage female participants due
to the association of the building with politi
cal activities of men folk. A medical officer
may feel that the annexe of his PHC or hospital
is excellent for OTC, but a PHC or Hospital
is mentally associated with sickness, opera
tions and injections and the participants
moods and deliberations will be affected
by these factors. A big vacant food godown
of another agency may be readily and freely
avai lable ,but it may be so big that the group
of participants may feel very uncomfortable
in its vast emptiness. Squatting on Floor
may lead to better discussion as compared
to sitting on school chairs.
Hence, lot of thinking and discussion
has to go injwhile selecting a suitable venue
for OTC that generates warm human relationships
and exchange. Banners’ and posters have to
be displayed at the venue.
7.
Preparing an advance calender for OTCs:
An calender for conducting OTCs for
one financial year has to be operated well
six aspects,
in advance based on the above
Viz., (1) No. of OTCs to be conducted and
4
15
budget allotted for the same, (2) Knowledge
about the objective, contents etc., of OTCs,
(3) Proper selection of leaders and partici
distribution of
pants of OTCs,
C"‘ , (4)
' *' Spatial
and
(6) Venue cf
OTCs
OTCs, (5) Timing of
after
delibrations
with the
and
due
OTCs
officers andI officials of the department and
those of other departments with representative
of local bodies and voluntary organisation:
Responsibilities have to be fixed, meticulous
records have to be maintained and those given
responsibilities should be held accountable.
8.
Agenda for the OTC :
An agenda or programme schedule.^ guides
the activities that are to follow and helps
in addressing to the fixed path without wander
ing away to unconnected areas and thus fritter
ing away time.
Therefore, a well
planned agenda or programme schedule has
to be prepared in advance after due discussions
and after taking into consideration the time
available for the OTC* the topics required
to be covered^ the particulars of the particiare
available
pants, the lecturers who
and such other factors., The usual tendency
to prepare the agenda just a few minutes
earlier to the start of the OTC or at the
time of inauguration of the OTC will have
to be desisted.
The coverage of topics in an OTC camp
for school teachers will have to be different
from what it has to be for a group of farmers.
The method and contents of coverage of topics
for participants who have already attended
such orientation camps earlier, will have
to be different from that planned for partici
pants attending the OTC for the first time.
The pattern of Agenda for OTCs prepared five
to ten years ago will have to be modified
4
16
suitably so as to include the latest programme
requirements like EPI, ORT, Multidrug Therapy
in Leprosy Eradication Programme etc.
The time of starting and ending the
OTC will have to depend local conditions,
but certainly on the convenience of the partici
pants.
The Agenda will have to be circulated
among, the participants, guest speakers and
connected higher officers j well in advance.
The pattern of Agenda usually followed
in OTCs is as follows :
9-00 AM to
10-00 AM
10-30 AM to
11-15 AM to
AM Registration
Welcome, inauguration
11-15 AM Chief Guests talk
Presidents address.
11-25 -AM Break
10-00
BUSINESS SESSION
11-25 AM to
11-50 AM Quality
11-50 AM to
12-20
P.M.
of
1i f ewhat it is; Attempts
to
i mprove
improve
it: role
of Health & FW Acti
vities in improving
it, Universal Immuni-,
sation
Progr amme;
Nutrition;
Talk
and
discussion.
FW
Programme-smal
I
1
family normi - A brief
talk covering popula
Explosi on-tal k
tion
discussion.
and
Com h
THE VILLAGE HEALTH WORKER LACKEY OR LIBERATOR?
David Werner
964 Hamilton Avenue
Palo Alto, California 94301, USA
Prepared for:
International Hospital Federation Congress
Sessions on Health Auxiliaries and the Health Team
Tokyo,Japan
22-27 May, 1977
THE VILLAGE HEALTH WORKER -LACKEY OR LIBERATOR?
— David Werner —
1977
Throughout Latin America, the programmed use of health auxiliaries has, in recent years,
become an important part of the new international push of 'community oriented' health care.
But in Latin America village health workers are far from new. Various religious groups and
non-govemment agencies have been training promotores de salud or health promoters for
decades. And to a large (but diminishing) extent, villagers still rely, as they always have, on
their local curanderos, herb doctors, bone setters, traditional midwives and spiritual healers.
More recently, the medico practicante or empirical doctor has assumed in the villages the
same role of self-made practitioner and prescriber of drugs that the neighborhood pharmacist
has assumed in larger towns and cities.
Until recently, however, the respective Health Departments of Latin America have either
ignored or tried to stamp out this motley work force of nonprofessional healers. Yet the
Health Departments have had trouble coming up with viable alternatives. Their Western-style,
city-bred and city-trained M.D.s not only proved uneconomical in terms of cost effectiveness;
they flatly refused to serve in the rural area.
The first official attempt at a solution was, of course, to produce more doctors. In Mexico the
National University began to recruit 5000 new medical students per year (and still does so).
The result was a surplus of poorly trained doctors who stayed in the cities.
I
The next attempt was through compulsory social service. Graduating medical students were
required (unless they bought their way off) to spend a year in a rural health center before
receiving their licenses. The young doctors were unprepared either by training or disposition
to cope with the health needs in the rural area, With discouraging frequency they became
resentful, irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed miserably. They created dependency
and expectation without providing continuity of service. The net result was to undermine the
people's capacity for self care.
It was becoming increasingly clear that provision of health care in the rural area could never
be accomplished by professionals alone. But the medical establishment was-and still isreluctant to crack its legal monopoly.
At long last, and with considerable financial cajoling from foreign and international health
and development agencies, the various health departments have begun to train and utilize
auxiliaries. Today, in countries where they have been given half a chance, auxiliaries play an
important role in the health care of rural and periurban communities. And if given a whole
chance, their impact could be far greater. But, to a large extent, politics and the medical
establishment still stand in the way.
* * * * *
My own experience in rural health care has mostly been in a remote mountainous sector of
Western Mexico, where, for the past 12 years I have been involved in training local village
health workers, and in helping foster a primary health care network, run by the villagers
themselves. As the villagers have taken over full responsibility for the management and
planning of their program, I have been phasing out my own participation to the point where I
am now only an intermittent advisor. This has given me time to look more closely at what is
happening in rural health care in other parts of Latin America.
Last year a group of my co-workers and I visited nearly 40 rural health projects, both
government and non-government, in nine Latin American countries (Mexico, Guatemala,
Honduras, El Salvador, Nicaragua, Costa Rica, Venezuela, Colombia and Ecuador). Our
objective has been to encourage a dialogue among the various groups, as well as to try to draw
together many respective approaches, methods, insights and problems into a sort of field
guide for health planners and educators, so we can all learn from each other's experience. We
specifically chose to visit projects or programs which were making significant use of local,
modestly trained health workers or which were reportedly trying to involve people more
effectively in their own health care.
We were inspired by some of the things we saw, and profoundly disturbed by others. While in
some of the projects we visited, people were in fact regarded as a resource to control disease,
in others we had the sickening impression that disease was being used as a resource to control
people. We began to look at different programs, and functions, in terms of where they lay
along a continuum between two poles: community supportive and community oppressive.
Community supportive programs or functions are those which favorably influence the longrange welfare of the community, that help it stand on its own feet, that genuinely encourage
responsibility, initiative, decision making and self-reliance at the community level, that build
upon human dignity.
Community oppressive programs or functions are those which, while invariably giving lip
service to the above aspects of community input, are fundamentally authoritarian, paternalistic
or are structured and carried out in such a way that they effectively encourage greater
dependency, servility and unquestioning acceptance of outside regulations and decisions;
those which in the long run are crippling to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the programs which we found to be more
community supportive were small non-government efforts, usually operating on a shoestring
and with a more or less sub-rosa status.
As for the large regional or national programs- for all their international funding, top-ranking
foreign consultants and glossy bilingual brochures portraying community participation—we
found that when it came down to the nitty-gritty of what was going on in the field, there was
usually a minimum of effective community involvement and a maximum of dependency
creating handouts, paternalism and superimposed, initiative destroying norms.
I don’t have time to elaborate here, but anyone who is interested in a more detailed account of
community supportive and oppressive health programming may send for a copy of a paper I
presented in England last year entitled "Health Care and Human Dignity."
In our visits to the many rural health programs in Latin America, we found that primary health
workers come in a confusing array of types and titles. Generally speaking, however, they fall
into two major groups:
auxiliary nurses
or health technician
•
•
•
•
at least primary education plus 1
- 2 years training
usually from outside the
community
usually employed full time
salary usually paid by the
program
(not
by
the
community)
health promoters
or village health workers
•
•
•
•
average of 3rd grade education
plus 1 - 6 months training
usually from the community and selected
by it
often a part time health worker supported
in part by farm labor or with help from
the community
may be someone who has already been a
traditional healer
In addition to the health workers just described, many Latin American countries have
programs to provide minimal training and supervision of traditional midwives. Unfortunate!;,
Health Departments tend to refer to these programs as 'Control de Porteras Empiricas'Control of Empirical Midwives-a terminology which too often reflects an attitude. Thus to
Mosquito Control and Leprosy Control has been added Midwife Control. (Small wonder so
many midwives are reticent to participate!) Once again, we found the most promising work
with village midwives took place in small non-government programs. In one such program (in
Pinalejo, Honduras) the midwives had formed their own club and organized trips to hospital
maternity wards to increase their knowledge.
* * * * *
What skills can the village health worker perform? How well does he perform them? What are
the limiting factors that determine what he can do. These were some of our key questions
when we visited different rural health programs.
We found that the skills which village health workers actually performed varied enormously
from program to program. In some, local health workers with minimal formal education were
able to perform with remarkable competence a wide variety of skills embracing both curative
and preventive medicine as well as agricultural extension, village cooperatives and other
aspects of community education and mobilization. In other programs—often those sponsored
by Health Departments-village workers were permitted to do discouragingly little.
Safeguarding the medical profession's monopoly on curative medicine by using the standard
argument that prevention is more important than cure (which it may be to us but clearly is not
to a mother when her child is sick) instructors often taught these health workers fewer medical ■
skills than many villagers had already mastered for themselves. This sometimes so reduced
the people s respect for their health worker that he (or usually she) became less effective, even
in preventive measures.
In the majority of cases, we found that external factors, far more than intrinsic factors, proved
to be the determinants of what the primary health worker could do. (See Outline 1.) We
concluded that the great variation in range and type of skills performed by village health
workers in different programs has less to do with the personal potentials, local
conditions or available funding than it as to do with the preconceived attitudes and
biases of heath program planners, consultants and instructors. In spite of the often
repeated eulogies about "primary decision making by the communities themselves," seldom
do the villagers have much, if any, say in what their health worker is taught and told to dn.
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"PRIHAR/ DECISION MAKING BY THE COMMUNITY" -
INTERNATIONAL STYLE
The limitations and potentials of the village health worker--what he is permitted to do and,
conversely, what he could do if permitted-can best be understood if we look at his role in its
social and political context. In Latin America, as in many other parts of the world, poor
nutrition, poor hygiene, low literacy and high fertility help account for the high morbidity and
mortality of the impoverished masses. But as we all know, the underlying cause-or more
exactly, the primary disease-is inequity: inequity of wealth, of land, of educational
opportunity, of political representation and of basic human rights. Such inequities undermine
the capacity of the peasantry for self care. As a result, the political/economic powers-that-be
4-
assume an increasingly paternalistic stand, under which the rural poor become the politically
voiceless recipients of both aid and exploitation. (See Figure 3.) In spite of national, foreign
and international gestures at aid and development, in Latin America the rich continue to grow
richer and the poor poorer. As anyone who has broken bread with villagers or slum dwellers
knows only too well: health of the people is far more influenced by politics and power groups,
by distribution of land and wealth, than it is by treatment or prevention of disease.
Political factors unquestionably comprise one of the major obstacles to a community
supportive program. This can be as true for village politics as for national politics. However,
the politico-economic structure of the country must necessarily influence the extent to which
its rural health program is community supportive or not.
Let us consider the implications in the training and function of a primary health worker:
If the village health worker is taught a respectable range of skills, if he is encouraged to think,
to take initiative and to keep learning on his own, if his judgment is respected, if his limits are
determined by what he knows and can do, if his supervision is supportive and educational,
chances are he will work with energy and dedication, will make a major contribution to his
community and will win his people's confidence and love. His example will serve as a role
model to his neighbors, that they too can learn new skills and assume new responsibilities,
that self?improvement is possible. Thus the village health worker becomes an internal agentof-change, not only for health care, but for the awakening of his people to their human
potential. . . and ultimately to their human rights.
However, in countries where social and land reforms are sorely needed, where oppression of
the poor and gross disparity of wealth is taken for granted, and where the medical and
political establishments jealously covet their power, it is possible that the health worker I have
just described knows and does and thinks too much. Such men are dangerous: They are the
germ of social change.
So we find, in certain programs, a different breed of village health worker is being molded
one who is taught a pathetically limited range of skills, who is trained not to think, but to
follow a list of very specific instructions or 'norms’, who has a neat uniform, a handsome
diploma and who works in a standardized cement block health post, whose supervision is
restrictive and whose limitations are rigidly predefined. Such a health worker has a limited
impact on the health and even less on the growth of the community. He—or more usually she—
spends much of her time filling out forms.
* * * * *
In a conference I attended in Washington last December, on Appropriate Technology in
Health in Developing Countries, it was suggested that "Technology can only be considered
appropriate if it helps lead to a change in the distribution of wealth and power." If our goal is
truly to get at the root of human ills must we not also recognize that, likewise, health projects
and health workers are appropriate only if they help bring about a healthier distribution of
wealth and power?
Factors that Influence What a Primary Health Worker Can Do
Intrinsic factors
Extrinsic factors
............................................. ....................... . ...
Factors influencing personal potential Outside decisions and control
ofVHW
• attitudes, open or preconceived, as to what the
• cultural background
VHW should be taught and permitted to do
• level of literacy influencing
• length, content, quality and appropriateness of
• personal factors
training
o
compassion
• limitations of'norms' imposed on health worker
o
integrity
by outside authorities (e.g. Health Dept.)
o judgment
• ability or inability of instructors and
o
initiative
supervisors to build upon the existing
o
perceptiveness
knowledge, skills and cultural perspectives of
o
special talents
the VHW.
o
learning capacity
• available
funding
(from
outside
the
community)
Local Conditions
•
•
•
acceptance of VHW and
program by community
health priorities within the
community
available
funding
(from
within the community)
LOCAL rtEiOURCeS FOR
WiD&NG EDCXATfONAtGAP (VHfcr'S JVATVVE
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(carefully
GUARPED)
What the health worker can do is too often limited by external factors (doctors and politics)
rather than determined by his personal capabilities and potential.
Fig. 3 Too often aid and exploitation go hand in hand.
6
"WE FEEL IT OUR
MORAL DUTYTO HELP
THE POOR STAND ON
THEIR OWN FEET"
Aid
S'
COULD IT BE A
VICIOUS CIRCLE?
Increased aid
(with strings *
attached)
Stronger central power
(national, foreign,
multinational)
Weaker people
t'! 4-
Increased debt
(poor owe rich)
V,
Increased dependency
of poor on rich, or rural
community on central govt.,
and of central govt, on
foreign and multinational
agencies. k
THE
AID
CYCLE
A
Humiliation, decreased
dignity, increased
irresponsibility, sense
of futility, misdirected
anger.
Increased
exploitation
Increased outside
manipulation and control
We say prevention is more important than cure. But how far are we willing to go? Consider
diarrhea:
Each year millions of peasant children die of diarrhea. We tend to agree that most of these
deaths could be prevented. Yet diarrhea remains the number one killer of infants in Latin
America and much of the developing world. Does this mean our so?called 'preventive*
measures are merely palliative? At what point in the chain of causes which makes death from
diarrhea a global problem (see Outline #2) are we coming to grips with the real underlying
cause. Do we do it. . .
•
•
•
•
by preventing some deaths through treatment of diarrhea?
by trying to interrupt the infectious cycle through construction of latrines and water
systems?
by reducing high risk from diarrhea through better nutrition?
or by curbing land tenure inequities through land reform?
Land reform comes closest to the real problem. But the peasantry is oppressed by far more
inequities than those of land tenure. Both causing and perpetuating these crushing inequities
looms the existing power structure: local, national, foreign and multinational. It includes
political, commercial and religious power groups as well as the legal profession and the
medical establishment. In short it includes . . . ourselves.
As the ultimate link in the causal chain which leads from the hungry child with diarrhea to the
legalized inequities of those in power, we come face to face with the tragic flaw in our
otherwise human nature, namely greed.
Where, then, should prevention begin? Beyond doubt, anything we can do to minimize the
inequities perpetuated by the existing power structure will do far more to reduce high infant
mortality than all our conventional preventive measures put together. We should, perhaps,
carry on with our latrine building rituals, nutrition centers and agricultural extension projects.
But let's stop calling it prevention. We are still only treating symptoms. And unless we are
very careful, we may even be making the underlying problem worse . . . through increasing
dependency on outside aid, technology and control.
But this need not be the case. If the building of latrines brings people together and helps them
look ahead, if a nutrition center is built and run by the community and fosters self-reliance,
and if agricultural extension, rather than imposing outside technology encourages internal
growth of the people toward more effective understanding and use of their land, their
potentials and their rights . . . then, and only then, do latrines, nutrition centers and so-called
extension work begin to deal with the real causes of preventable sickness and death.
This is where the village health worker comes in. It doesn’t matter much if he spends more
time treating diarrhea than building latrines. Both are merely palliative in view of the larger
problem. What matters is that he get his people working together.
Yes, the most important role of the village health worker is preventive. But preventive in the
fullest sense, in the sense that he help put an end to oppressive inequities, in the sense that he
help his people, as individuals and as a community, liberate themselves not only from outside
exploitation and oppression, but from their own short-sightedness, futility and greed.
The chief role of the village health worker, at his best, is that of liberator. This does not mean
he is a revolutionary (although he may be pushed into that position). His interest is the welfare
of his people. And, as Latin America's blood-streaked history bears witness, revolution
without evolution too often means trading one oppressive power group for another. Clearly,
any viable answer to the abuses of man by man can only come through evolution, in all of us,
toward human relations which are no longer founded on short-sighted self-interest, but rather
on tolerance, sharing and compassion.
I know it sounds like I am dreaming. But the exciting thing in Latin America is that there
already exist a few programs that are actually working toward making these things happenwhere health care for and by the people is important, but where the main role of the primary
health worker is to assist in the humanization or, to use Paulo Freire's term, conscientizacion
of his people.
Outline #2
3
WE SAY PREVENTION IS MORE WPORTANT THAN CUREBUT WI«ESHOULD PREVENTION BEGIN?
EFFECT
4
Ne&dl&ss Suffering and Dehu ma nation
X
4*
Dis proportionately high morbidity and mortality
(especially infante, mothers,and young men)
Infections, such as diarrheas and pneumonia, xiiolence, etc.
t
Poor nutrition, poor hygiene; low literacy high fertility
Low initiative, misdirected anger
Inequity of:
Wealth
Land
Health Care
Education
Re presentation
Human Rights
t
THE
MO
CYCLE
*
t
CAUSE
Erfsting power structure
-financial power groups
-political pawergroups
-medical establishment
■legal profession
-religious power groups
\
<
J
/
Private
J Governmental
Z Foreign
Multinational
— Greed
(shortsighted
self-interest)
t
PREVENTIVE
MEASURES:
Social reform
(or revolution)
Humanization
(Evolution)
Before closing let me try to clear up some common misconceptions.
Many persons still tend to think of the primary health worker as a temporary second-best
substitute for the doctor . . . that if it were financially feasible the peasantry would be better
off with more doctors and fewer primary health workers.
I disagree. After twelve years working and learning from village health workers-and dealing
with doctors—I have come to realize that the role of the village health worker is not only very
distinct from that of the doctor, but, in terms of health and well-being of a given community,
is far more important. (See appendix.)
You may notice I have shied away from calling the primary health worker an 'auxiliary'.
Rather I think of him as the primary member of the health team. Not only is he willing to
work on the front line of health care, where the needs are greatest, but his job is more difficult
than that of the average doctor. And his skills are more varied. Whereas the doctor can limit
himself to diagnosis and treatment of individual 'cases', the health worker's concern is not only
for individuals—as people—but with the whole community. He must not only answer to his
people s immediate needs, but he must also help them look ahead, and work together to
overcome oppression and to stop sickness before it starts. His responsibility is to share rather
than hoard his knowledge, not only because informed self-care is more health conducing than
ignorance and dependence, but because the principle of sharing is basic to the well-being of
man.
Perhaps the most important difference between the village health worker and the doctor is that
the health worker's background and training, as well as his membership in and selection by the
community, help reinforce his will to serve rather than bleed his people. This is not to say that
the village health worker cannot become money-hungry and corrupt. After all, he is as human
as the rest of us. It is simply to say that for the village health worker the privilege to grow fat
off the illness and misfortune of his fellow man has still not become socially acceptable.
The primary health worker lives
and works at the level of the
people. His first job is to share his
knowledge.
(Illustration from the forthcoming
English edition of Where There is
No Doctor by David Werner)
Forgive me if I seem a little bitter, but when you live with and share the lot of Mexican
villagers for 12 years, you can't help but feel a little uncomfortable about the exploits of the
medical profession. For example, Martin, the chief village medic and coordinator of the
villager run health program I helped to start, recently had to transport his brother to the big
city for emergency surgery. His brother had been shot in the stomach. Now Martin, as a
village health worker supported through the community, earns 1,600 pesos ($80.00) a month,
which is in line with what the other villagers earn. But the surgeon charged 20,000 pesos
($1000.00) for two hours of surgery. Martin is stuck with the bill. That means he has to
forsake his position in the health program and work for two months as a wet-back in the
States—in order to pay for two hours of the surgeon's time. Now, is that fair?
* * * * *
No,
iNo, the
me village health
Health worker, at his best, is neither choreboy nor auxiliary nor doctor's
substitute. His commitment is not to assist the doctor, but to help his people.
The day must come when we look at the primary health worker as the key member of the
health team, and at the doctor as the auxiliary. The doctor, as a specialist in advanced curative
technology, would be on call as needed by the primary health worker for referrals and advice.
He would attend those 2-3% of illnesses which lie beyond the capacity of an informed people
and their health worker, and he even might, under supportive supervision, help out in the
training of the primary health worker in that narrow area of health care called Medicine.
I0
Health care will only become equitable when the skills pyramid has been tipped on its side, so
that the primary health worker takes the lead, and so that the doctor is on tap and not on top.
TIPPING THE HEALTH MANPOWER PYRAMID ON ITS SIDE
THE TYPICAL PYRAMID
THE PYRAMID AS IT SHOULD BE
The people come first
The doctor
is on top
1
-1 1
1
f
COMMU/Vr TY
j
* *
J?
■
'v
v 1
rhe
doctor
in on tap
(not on top)
COMMUNITY
The community is on the bottom of the stack.
Each level is rigidly delineated.
1 ?
The community health worker
assumes the lead role in the
health team.
Appendix
COMPARISON OF THE MEDICAL DOCTOR AND THE PRIMARY HEALTH WORKER
(Note: The medical doctor as described here is the typical Western-style M.D. as produced by
medical schools in Latin America. Clearly, there are exceptions. Most Latin American
medical schools are beginning to modify their curricula to place greater emphasis on
community health. However, not modifications but radical changes, both in selection and
training, are needed if doctors are ever to become an integrated and fully positive part of a
health team that serves all the people.)
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER (at
his best)
Class
Background
Usually upper middle class
From the peasantry.
How chosen
By
medical
school
fbr:|| By
community
for:
grade
point
average; interest, compassion, knowledge of
economic and social status.
community, etc.
Mainly institutional, 12-16
years general schooling, 4-6
years medical training.
Training concentrates on:
Preparation
•
physical and technological
aspects of medicine,
Mainly
experiential.
Limited,
key
training
appropriate to serve all the
people
in
a
given
community:
Dx
&
Rx
of important
I I
and gives low priority to
human, social, and political
aspects. (This is now
changing in some medical
schools.)
•
•
•
•
•
Qualifications
Orientation
Primary
Interest
Highly qualified to diagnose
and treat individual cases.
• Especially qualified
to
manage uncommon and
difficult diseases.
• Less qualified to deal
effectively
with
most
important diseases of most
people
in
a
given
community.
• Poorly
qualified
to
supervise and teach VHW.
(Well qualified in clinical
medicine, but not in other
more important aspects of
health care; he tends to
favor imbalance; wrong
priorities.)
Disease/Treatment/
Individual patient oriented
•
•
•
disease Preventive medicine
Community health
Teaching skills
Health care in terms of
economic
and
social
realities, and of needs (felt
and long term) of both
individuals
and
the
community.
Humanization
(conscientizacion) and group
dynamics
More qualified than doctor to
deal effectively with the
important sicknesses of most
of the people.
Non-academic qualifications
are:
o Intimate knowledge
of the community,
language, customs,
attitudes
toward
sickness and healing.
o
Willingness to work
and earn at the level
of the community,
where the needs are
greatest.
Not qualified to diagnose
and treat certain difficult and
unusual problems; must
refer.
Health/Community
oriented.
Seeks a balance between curative
and preventive. (Curative to meet
felt
needs,
preventive
to
meet
real
needs.)
Job The challenging and interesting Helping people resolve their biggest
cases. (Often
(
bored by day to day problems because he is their friend
problems.)
and neighbor.
Superior. Treats people as patients. On their level. Treats patients as
toward Turns
people
into
'cases’ people.
Underestimates people's capacity Mutual concern and interest because
for self-care.
the VHW is village selected.
Attitude of the Hold him in awe. Blind trust (or See him as a friend. Trust him as a
sick toward M.D. sometimes distrust).
person, but feel free to question him.
Attitude
the sick
I az
or VHW
Mutual concern and interest because
the VHW is village selected.
Hoards
it. Shares
it.
How does he use
Delivers 'services', discourages Encourages informed self-care,
Medical
self-care, keeps patients helpless helps the sick and family understand
knowledge?
and dependent.
and manage problems.
Accessibility
Often inaccessible, especially to Very
accessible.
poor.
Lives
right
in
village,
Preferential treatment of haves over Low
charges
for
charges
services.
have-nots.
Treats everyone equally and as his
Does some charity work.
equal.
Overcharges.
Reasonable
charges,
Expects
disproportionately Takes the person's economic
factors
high
earnings. position
into
account.
Feels it is his God-given Content (or resigned) to live at
Consideration for
right
to
live
in
luxury economic level of his people.
economic factors
while
others
hunger, Prescribes
only
useful.drugs.
Often prescribes unnecessarily Considers
cost.
costly
drugs. Encourages
effective
home
Overprescribes.
remedies.
Relative
Permanence
At most spends 1-2 years in a A permanent
rural area and then moves community.
to the city.
member
of
the
]
Visits his neighbors in their homes
Can't
follow
up
cases
because
he
to
make sure they get better and
Continuity of Care
doesn't live in the isolated areas.
learn
how
not
to
get sick again.
Too expensive to ever meet Low cost of both training and
medical needs of the poor— unless practice.
Cost Effectiveness used
as
an
auxiliary Higher effectiveness than doctor in
resource for problems not readily coping with primary problems,
managed by VHW.
Resource
Requirements
Hospital
or
health
center. Works out of home or simple
Depends on expensive, hard-to-get structure.
equipment and a large subservient People are the main resource.
staff to work at full potential.
Present Role
On
top.
the
bottom.
Directs
the
health
team. On
Often
given
minimal
responsibility,
Manages all kinds of medical
in
medicine, i
problems, easy or complex. especially
Regarded
as
an
auxiliary
Often overburdened with easily
(lackey) to the physician.
treated or preventable illness.
Impact on
Community
Relatively
low
negative).
the Sustains
class
mystification
of
dependency
on
outside
“(in
part Potentially
high.
Awakening of people to cope more
differences, effectively with health needs, human
medicine, needs, and ultimately human rights.
expensive Helps community to use resources
resources, more effectively.
Id
Drains
(money).
Appropriate
(future?) Role
resources
of
poor
On
tap
(not
on
top). Recognized as the key member of
Functions as an auxiliary to the the
health
team.
VHW, helping to teach him more Assumes leadership of health care
medical
skills and attending activities in his village, but relies on
referrals at the VHW's request. advice,
support,
and
referral
(The 2-3% of cases that are beyond assistance from the doctor when he
the
VHW's
limits.) needs
it.
He is an equal member of the He is the doctor’s equal (although
health team.
his earnings remain in line with
those of his fellow villagers).
TWO APPROACHES TO HEALTH CARE
Taking
of others
c
i
o
o
tw —
TSE LAND OF
L
ffalplhg others learn ,
to oare for theuselves ;
I
/Ltf 7^
I up A ere vAere \ A
KNOWLEDGE
"'tz
TOE PIT OF
IGNORANCE
encourages depenflenoy
and loss of fraedoRi«
5
encouragfcfi indspandsnea,
self-raHance and equality.
- Media
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