Health Policy Reflections
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- Health Policy Reflections
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Some Policy Reflections
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in the context
of
a) Health Policy for Karnataka
b) Perspective Planning for
Health Services
c) Approach Document for Sth Plan.
Presented at a Dialogue of NGOs
including Community Health Cell
Team, with Director of Health
and Family Welfare Services and
Joint Director(Planning),
Directorate of Health and Family
Welfare Services, Government of
Karnataka, Bangalore.
July 1990
Bangalore
CONTENTS
1.
Introduction
2.
Perspectives in Health Policy & Strategies For The State
Of Karnataka - A response from the Community Health Cell
Bangalore. (DOCUMENT 1)
3.
A Summary of the Community Health Cell’s Response to the
Perspective Plan. (DOCUMENT 2)
4.
People’s Involvement in Planning And Implementation
Process - A Response to Planning Commission Initiative
(DOCUMENT 3)
5.
Beyond Policy Rhetoricf Statistics And Infrastructural
Development: The Tasks For The 1990s - A working paper
from Community Health Cell for the Regional Review Meeting
on Primary Health Care System Development for Southern
Zone. (DOCUMENT 4)
6*
Specific Comments on Perspective Plan For Karnataka-drawn
up for Department of Health & Family Welfare Sex-vices,
Karnataka. (DOCUMENT 5)
7.
Perspective Planning In Health - A Report of the Expert
Group of Perspective Planning, set up by the Government
of Karnataka. (DOCUMENT 6)
APPENDICES
A.
Health Policy Reflections - CHC Involvement (1984-1990).
B.
Building The New Paradigm - A Study-Reflection-Action
experiment on Community Health in India.
Towards a People-Oriented Alternative Health Care System.
C.
INTRODUCTION
The National Health Policy of 1982 strongly recommends
a collaboration of Government with non-governmental Voluntary
agencies in the Health sector to achieve the goals of the
Health Policy.
The NGO/Volag in Health is often seen by the government.
Planning Commission, and international health agencies as an
alternative service provider and at best an alternative health
team trainer. However a time has come for them to also be
recognised as awareness builders, issue raisers and alternative
planners.
The Community Health Cell, an informal study-ReflectionAction experiment in Bangalore (1984-1989) has been studying
the experiences of NGO*s/Voluntary Agencies at micro level with
a view to build up perspectives that are relevant for macro
planning. The Cell has tried to share these reflections with
health planners, policy makers, health administrators and health
service providers at various levels and at different forums
(see Appendix A, Appendix B)•
In July 1988 at the invitation of Sri.L.C.Jain, Chairman
of the Expert Group on Perspective Plan for Karnataka,
(Appendix C) we participated in a discussion on 'Perspectives in
Health Policy and Strategy'(Document 6). Following this meeting
we sent our comments (Document 5) on a Perspective Plan,
submitted to the Committee from the Health and Planning section
of the Department of Health and Family Welfare Services of the
Government of Karnataka. Later on further request we also
submitted an additional paper on Perspectives in Health Policy
and Strategies for the State of Karnataka (Document 1 & 2).
..2
2.
In October 1989, the Planning Commission initiated a
dialogue on 'People's involvement in Planning and
Implementation Process' to which we sent a paper responding
to the various questions (Appendix D) sent by the Adviser
to the Commission (Document 3). At the request of the
Assistant Director General, Health Administration, DGHS,
New Delhi, we also presented a working paper entitled
'Beyond Policy Rhetoric Statistics and Infrastructural
Development - the tasks for the 1990s at a Regional Review
Meeting on Primary Health Care Systems Development for
Southern Zone organised by Government of India and World Health
Organisation (Document 4).
Dr.Prasanna Kumar (Additional Director of Health and
Family Welfare Services, DHS Karnataka) wrote to the Cell
after persuing these papers and requested for an informal
dialogue with him and the Joint Director(Planning). The
matter was also brought up at a meeting of the sub committee
on Health of the Consultative Committee on Rural Development
held in Dr.Prasanna Kumar's Chamber on 21st June 1990.
This compilation of papers is a background for this
Dialogue.
DOCUMENT 1
*
COMW.Tf rALTH CZLL
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•PERSPECTIVES IN HE Al.TH POLICY AND STRATEGIES"
FOR THE STATE OF KARNATAKA
—a response from the Ccnaounlty Health Cell*
Bangalore
A, GENERAL PERSPECTIVE
1, As a background It la Important to keep in
mind that the health of people and populations
is largely determined by broader factors such as*
employment!
adequate Incone and purchasing power*
adequate food* housing and clothing*
availability of aanltatlon facilities and
safe water*
education and opportunity for skill development*
accessible and effective health care services.
This is exemplified by the documented experience
of several developed countries there mjor public
health problems like tuberculosis* leprosy* cholera
and other diseases were on the decline prior to
the isedical ora of antibiotics and vaccines, Xt is
accepted that this change was duo to general socio*
economic developnent.
>• At an operational level* acceptance of the
above ideas call for effective intersectoral
linkages in terns of planning and coordination
between the Departments of Health* Kducatlon*
Water Supply and Sanitation* • Housing* Town and
Country Planning* Agriculture and industries*
• • • *1
2
Keeping In wind the decentralised system adopted by
the State, this planning and coordination could be done
at the Zllla Parishad level.
3.
Regional Health Planning
At present, in the health sector, we have national
health policies, program?es enS targets for the country
as a whole, while overall policies and thrusts are
impoxtant, keeping in wind the vastness and diversity
of the country and even within single States, health
prograrares and plans need to be evolved at a core local
level—at District level to start with. Two iroportant
factors tc consider in thia are»
the special needs of certain groups, who are
socially and economically marginalised—
dallts, tribals, slum dwellers, women and
children, the handicapped,
b.
the dynamic nature of th© health status of
populations which keeps changing in response to
factort in society—eg., environmental, economic,
cultu al changes, life style changes etc.
we are faced simultaneously with the diseases
of poverty for large sections of the population,
vie., malnutrition, tuberculosis, leprosy, water
related diseases etc., and diseases resulting
from industrialisation and modernisation—eg.,
cancers, cardlo-vascular diseases and ill-defined
rev symptom complexes that are presenting in
arras of environmental pollution.
• •• .3
3
Health planning needs to move from a rather adhoc*
central!sea, top down method to a nore scientific basis.
For this* it is necessary to have good quality health
information* collected on an ongoing basis from different
geographical* social and economic strata of society.
Presently health statistics are largely compilations
from various administrative reports. Greater emphasis
needs to be given to quality of information* its validity
and analytical interpretation of the data, quantitative
or hard data reflect some of the physical factcrr but
an interactive, participatory approach with people would
indicate the live scclal/human processes taking piece.
There are presently inore than 400 voluntary agencies
working in the field of health In the State* Involving
their in planning exercises would provide a * window* to
what is ha pening at the crass root level. Involving
members of gram sabhas, mandal panchayats and cilia
pari shads would play the same role—they would in the
process get better equipped to monitor the functioning
of the heelth cere servicea.
The bydeetary allocation for heelth. education and
welfare services n>-eds to be critically analysed
in the context of the health needs of the people* This
could also be the subject of wider debate at various
levels—State. District* Zilla Parishad* Mandal Panchayat*
Gram Sabha etc.
4.
Broadly there could be—
a.
a larger allocation to health •
6-854
4
4
b.
a reducation in the present urban/rural
bias in health expenJiture—eg®, Rs®30000
spent on drug purchases per annum,per
C <.- • >• I primary health/presently covering e population
of 60—80000 (orcven the prescribed 30p00
population) is grossly Inadequate® In
contrast the annual budgets of specialised,
elite institutions at State and District
head quarters is excessive®
The Indian Fystems of Medicine (Aurvede*
Slddha, Unani, Yoga etc«t) and other systems
like homeopathy ere widely prevalent throughout the
country® They are culturally more acceptable and
economically and geographically more accessible®
Though official recognition has now been given to
them, they are very marginalised in terms of State
financial resources and in Involvement with health
planning® By recognising them as partners, we would
increase the health infrastructure many fold®
5*
During the past decade and particularly so in
the past 4-5 years, there is a very rapidly
increasing trend towards prlviticatlon of medical
services®
Corporate sector business houses are
getting involved with the running of diagnostic
centres, hospitals and even with medical education®
Though conducted under the name of Increasing
accessibility tc the latest in medical care and of
self-reliance etc®, the basic logic is one of making
profits® Unfortunately, they are also receiving State
6.
• • • ••S
5
encourogeroent. It is resulting in the conncrcIali^at<on
tnedlcjne with the ♦Belling' of high technology
diegnostic and therapeutic cervices not all of which
arc beneficial end some of which are positively
hasardous and harmful tc health.
B.
SPECIFIC If-SUES/iSTRATSGIES
1,
Public health anproach/traininq
Over the years, there has been a gradual erosion
in the role played by public health spedillsts in the
sphere of health planning. The discipline Itself has
unfortunately elid into disrepute and has not been
attractingthe best. This is in contrast to the
increasing role being played by such trained
specialists in health planning and Organization and
evaluation of health services In several other countries to
their benefit. This situation needs to be rectified by
providing better training facilities and Job opportunities.
Xt would be beneficial if all Govt. Medical Officers
could undergo sane basic training in practical public
health (more than that in the undergraduate course),
Bsanag stent, tear work etc., es in their future role, they
are also expected to function as team leaders and planners.
Xn the absence of such e -etaff college- type training,
they in effect offer only curative services to those who
manage to reach their clinics.
•
»6
6
At the primary health centre level, ♦team training*
orienting all members es one group to the overall
objectives of the work, programmes, team functioning
Itself could be given. This could be followed by regular
meetings for sharing and feed back of experiences,
problem solving, t<am building and continuing education.
At present these exercises are wore of a beaurocratlc,
policing nature mainly checking cut on target coverages.
2,
As mentioned earlier, regional plan’ Ing for health
based on a knowledge of the regional patterns of
health indicators is necessary*
3.
There is e great need for continuing education
for doctors, nurses and paramedical staff on an
organized basis* Teaching and research institutes
from different disciplines including sociology,
management, eccncmics etc., could be involved. This
should be a two-way dialogue--much feed back from the field
level is necessary to suitably modify teaching curriculum
and research priorities*
These experiments are also going on in teaching
institutions an<5 coordinating bodies among voluntary
agencies involved with health, teaching, service and
research*
4.
Recently, there is a trend emphasising vertical
health progterares • eg., immunization, oral
rehydretlon, child survival, leprosy etc., as time
bound, targettea efforts. This is going full circle
back to the days of malaria eradication and unipurpose
7
7
workers. India, infact has historically contributed
the concept of an integrated community baged
health care approach and the wisdem of this should
not be lost right of in spite of professional and
other pressures iron national and international bodies.
5.
There ic an urgent necessity to evolve a
drug poljcy. This would ensure an adequate supply
of essential drugs to meet the health needs of people and
in fact would also help conserve scarce resources.
6.
The system of medical education itself needs
critical reappraisal. Several governmental
committees have given very relevant rccomr.endetlons
r gardlng this aspect of health personnel training. But
as yet no major dent has been made on the system.
In Karnataka, private enterprise in medical education
is placing a questionable role. These money oriented
practices ere detrimental to a profession which is
so closely associated with life and health of people.
Studies (some in Karnataka as well) have reported
PQPr utllizatlon of government health services.
Xn the face of this a mere expansion of structures and
numbers will not yield results. There is a need to
consolidate and strengthen the qualitative aspects of the
service.
7.
As in many other spheres, there is corruption at
many levels of the health service. This factor has
to be addressed seriously by all concerned if the goal of
public service is to be realized.
8.
--- xx
DOCUMENT 2
“PERSPECTIVES IN HEALTH POLICY AND STRATEGIES” FOR THE STATE
OF KARNATAKA
A SUMMARY
A. Perspective Planning in Karnataka for health services
must keep in mind the goal for ‘HEALTH FOR ALL BY
2000 A.D.‘ and in this context reorient its focus:
a. From HEALTH as a medicalized PROVISION of
curative Services to Health as an enabling/
empowering process in the community increasing
individual, family and community’s autonomy
over health related means, opportunities,
knowledge and structure.
b. From Health Policy as infrastructural development
to Health Policy as 'quality of life' and
•quality of care' development.
c. From Health Planning as a top down bureaucratized
procedure to a participatory, community based,
bottoms up exercise. This is particularly
relevant in the context of the decentralised
system of Panchayat Raj ushered into the State.
B. In keeping with the overall perspectives of the Ministry
of Health & Family Welfare Services outlined in their
March 1988 Perspective Plan and the discussions with
Sri.L.C.Jain, we wish to highlight the following key
issues:
1. Health Policy must be closely interlinked with
policy of socio-economic development.
2. Health Policy must explore multi-sectoral
linkages.
3. Health Policy must evolve regionally from local
level upwards taking into account—
a. Special needs of certain groups - dalits,
tribals and slum dwellers;
b. Changing status of health, environment,
socio-economic status;
c. Reliable and good quality health information
d. Interaction with community perceptions and
needs.
4. Health budgets should be increased substantially and
rural urban disparity tackled seriously.
..2
2.
5. All systems of Medicines and existing alternatives
and options available to the community must be
involved and included in an attempt to create an
integrated Indian System of Medicine and Health
Policy.
6. Privatization and commercialisation of medicine must
be curbed and the State must continue to bear the
major responsibility to providing people with
affordable and accepsible services, NGO, Volags and
the private sector must be welcomed to complement
the services but not replace it.
7ay Public Health reorientation of all medical staff is
an important strategy organized through a staff
college process and oriented to team training and
participatory approaches.
71}; Continuing Education programmes for doctors, nurses
and para-medicals based on multi-disciplinary and
participatory approaches are crucial investments
for the future. A community/social reorientation
of medical education and all existing health
manpower training programme is important.
8. Stress on integrated community based health care
approaches and movement away from vertical
unipurpose health programmes is necessary.
9;/A Rational Drug and Technology Policy needs to be
outlined and implemented.
10^/Health Practice Research geared to important basic
issues such as:
a. Poor utilisation of government health services;
b. Corruption in health services; and
c. Participatory approaches in planning/management
should be organised.
DOCUMENT 3
PEOPLE'S INVOLVEMENT IN PLANNING AND IMPLEMENTATION PROCESS (PIP.)
(This response to a Planning Canmission, Initiative
from the Community Health Cell (CHC) Team in
Bangalore is based primarily on the experience of
the Health Sector which is the main focus of CHC’s
activities. However our conviction, that ‘Health
action*is an important and integral part of
development has led us to interact with a large
number of development groups, who may or may not
have 'health* as an important focus of their
activity and the general comments and wider issues
raised arise out of this larger interaction)
1. People1 involvement in Planning and Implementation Process
(PIP) is not really a new concept.
Firstly by participating in a democratic process of electing
the Government, (which then plans a development strategy)
the people have indirectly participated in PIP from the time
of independence.
Secondly the ‘Community Development* plans of the 1950s did
stress the involvemtnt of people particularly at implementation
level and village based consultation committees and involvement
of community based organisations was accepted in the programme
as relevant strategy. However this process was often controlled
and dominated by the bureaucrats and technocrats and quite
a large extent by the leadership ofthe dominant and priviliged
sectors of the community. So ’People's participation* got a
skewed orientation and often degenerated into a concept that
was paid lipservice to, only in documents and important
occasions.
• •2
/
2.
The concept of Decentralised Panchayat Raj has also been
all along discussed though no action, till very recently,
was taken at the political decision making level, and
where it was attempted it soon became neutralised by the
wider socio-political dynamics.
2. The new interest in People' involvement in PIP apart from
being part ofthe growing populist rhetoric also stems from
a) The evaluated experience of the last few decades where
official programmes failed inspite of technological
and managerial innovations because of lack of
involvement/participation of the people; and
b) From the increasing number of reports of micro-level
voluntary agency/NGO initiative where this dimension
was seriously attempted in diverse ways and programme
implementation met with relatively greater success.
In the NGO sector 'people's participation' was made
an important part of decision making by many projects
and taken beyond the level ofimplementation.
This explains why 'people's involvement' or community
participation is often used synonymously in government policy
papers as involvement of voluntary agencies though these are
related but different concepts.
3. While studying/evaluating these micro-level positive
experiences there is a trend in official policy documents
to concentrate on What was done — 'action', 'programmes',
'projects' and these are then integrated into policy options
and some operational guidelines and financial sanctions
enunciated. However very little emphasis is given to How it
was done and the 'process' dimensions or innovations are
ignored. If the planners interested in People's involvement
in PIP have to learn from the rich and diverse experience of
Voluntarism/NGO action in the country, they have to seriously
• •3
3.
study, adapt, integrate and accept a new 'Development culture'
where people are not seen as 'benificiaries' or 'targets of
programmes' but are seen as 'participants' as well.
4. If 'people* have to participate in the plinning and
implementation process as 'participants' in the true sense
then planners and decision makers as well as implementors at all
levels of the government's planning and implementation
heirarchy have to reorient their understanding of the
dynamics and culture of Development in many other dimensions
as well. e.g.,
A Social Analysis And crossectional feedback
a)
b)
'People' are not a homogenous/amorphous mass who can
be represented by a few formal leaders but are a
, heterogenous group stralified by income land ownership,
education, caste, culture, gender and other factors.
The stratified groups dominate and participate and
utilise services more than others. People's
representatives for dialogue must be sought from all
strata, and groups and positive discrimination towards
those groups who do not benefit from existing programmes
must be a clearly indicated policy option.
People's perception/experience given weiqhtaqe
The People's perception of the working of projects and
programmes or their own responses to problems must be
seen as equally important as statistical/professional/
technical situation analysis. This perception must
be sought by informal focus group discussions rather than
formal surveys. This calls for an attitude of learning
from the people and a growing confidence that people
who experience problems evolve their own responses that
need to be evaluated and literacy or technical skill/
knowledge is not necessarily a pre-condition for local
innovation.
..4
4.
c) Feedback from those closer to people
Feedback from lower level functionaries within the
government system, who are closer to the people and who
can more easily identify with their culture and
aspirations must be given greater importance by
higher level supervisors and decision makers.
d) Promotion of Integrated/holistic problem analysis
Integration, inter-sectoral coordination and holistic
view of a situation or problem must be stressed and
the 'orthodox’ governmental classification into
sectors/departments/ministries, projects/programmes
must be countered at the peripheral level especially
since people experience life in a holistic way and
find bureaucratic compartmentalisation hard to
comprehend.
e) Evaluation - interactive and qualitative as well
Evaluation and Monitoring has to be seen as a 'problem
solving' or solution finding exercise and not 'policing*
or 'blame fixing' procedure. Rather than basing it on
a routinised form/register filing exercise which is
not used at the level it is collected but basically
collected for someone else at a higher, more remote
level-the exercise should be moreinteractive both within
the team of funcationaries and with the formal/informal
leadership among the people and qualitative aspects
given as much importance as quantitative indicators.
f) Diversity of options and flexibility of approaches
Finally since people are in different situations and each
village, tribal area, slum, region or district is so
diverse in its historical experience, socio-cultural
reality and development experience, people's involvement
in PIP presupposes the acceptance of Diversity of responses
and flexibility of approaches in the evolving nature of
• •5
5*
projects/programmes. Models thrust top-down through
centre/state sponsorship which do not allow diversity
or flexibility are counter-productive to the whole concept.
While this may sound theoretical to the macro planner
preoccupied with measurable goals and targets and macro
programme and project guidelines - they arise out of a
deeper understanding ofthe realities at the grassroots
and of the problems in the interphase between government
development efforts and the people. It is at this
interphase the present system has been constantly breaking
down.
Managerial innovation in planning has to be beyond
orthodox project formulation and management to the crucial
process formulation i.e. not only what to do but how to do
it? If we are serious about making a change in the
situation, we cannot overlook or ignore these dimensions
any longer.
Moving on to the more specific questions outlined in
the letter-our response would be as follows
5, The Lessons from 7th Plan experience
The positive lessons are:
a. The involvement of an increasingly wider cross section
of 'development experience' in PIP has been a positive
development. This not only means greater involvement
of Volags/NGOs who are considered closer to the people
but also the acceptance of wider consultations of
formulation stage with people at all levels outside
the 'government* including at the grassroots and the
training of village based cadres.
b. This interaction between the Government and NGO system
and between the system and the people has opened up
the closed Government System of earlier years to ideas
generated outside the system and the increasing feedback
• .6
6.
to government often negative has led to some
introspection and concern for accountability.
c. In areas or sectors where NGO/Volag partners are not
available certain ministries and departments
particularly Human Resource Development, Social
Welfare and Education have experimented with Government
sponsored semi-autonomous units, e.g., the Samakhya
programme of Women’s education which have tried to
emulate ’Volag’ organisational structured and styles of
functioning. This experience is new and needs a serieus
evaluation.
The negative experiences are:
a. There is a growing misunderstanding among decision n
makers and administrators that involving people in
PIP through
i.the involvement of NGO/Volags among the people, or
ii.the trained village selected health/development
animators means that those who have been hither-to
considered outside the system, will now become
government sponsored functionaries. Due to this
development bureaucratic red-tape and other
problems of the existing systems are beginning to
make inroads into this new ’interphase’.
b. NGOs/Volags or people’s representatives on committees or
community based workers are also seen only as associates
for implementation of programmes. Their role as issue
raisers, monitors, evaluators, demand creators and exen
trainers has been mostly ignored.
c. Top-down planning, model generation and operation
guidelines still continue to stifle innovation and
creativity and still refuse to accept adequately the
differences in local social reality, past development
experience and diversity of approaches.
d. There is a growing tendency to ’lionise’ the NGO/Volags
or the people’s representatives sometimes putting demands
. .7
7.
and pressures on thQm beyond their own capabilities
or resources. The number, outreach and availability
of NGOs/Volags is also somewhat over-estimated. They
still form a very small part of the total system
inspite of their apparently increasing numbers.
The need to tone up, the existing government system and
to bring greater accountability as well as qualitative
improvement in services is theit ignored. Corruption,
inefficiency, political interference and mismanagement
continue to hold sway in the established infrastructure
while the NGOs, the people and now more surprisingly
the Private Sector are supposed to deliver/takeover/
provide better services to the people.
e. The bureaucracy and official technocracy still refuse to
discuss process levels of the established infrastructure
but continue to be preoccupied by somehow getting things
done. Scaling up of action is seen as more important
than seriously studying structural constraints and
deficiencies or facing squarely the socio-politicalcultural realities. The people’s organisations and NGDs/
Volags are seen as ’alternatives’ and there is the constant
pressure on NGOs to scale up their operations and spread
over larger areas often at the cost of quality.
f. There has been no dialogue/education process down the line
in the existing infrastructure about change in the planners/
decision makers/ government's perception about people
working outside the system (NGOs^Volags) or about 'people's
participation’ in planning and implementation of programmes.
The changed perception if at all is at the IAS cadre
levels on the top and among some of the DCs at the periphery.
The rest of the existing functionaries continue to perceive
the situation as they have in the last few decades. Such a
reorientation is long overdue.
g. The key to success in involving people in PIP is the
ability to keep them adequately informed about:
i.the evolving programmes and guidelines
ii*expert recommendations;
iii.alternate possibilities
• •8
8.
on the one hand while on the other hand constantly
interacting with them to ascertain their own responses
and experiences of problems etc. This is the weakest
link ofthe present system, there is heardly any
information available to people about the whys and hows
of each programme, much less a discussion with them to
explore ideas of how to do them better. This is an area
where NGOs have something to offer not only in ways of
•interaction with the community* but in 'creative low
cost communication' as well. Both of which have been
ignored. Information to people would probably be the
most important/credible step for the 8th plan.
6. The Health Sector:
The Health Sector planning efforts need serious reconsideration
if the concept of people's involvement in planning and
implementation process is to be supported.
i. Inspite of all the populist rhetoric and the empirical
holism outlined in the Health Policy especially since
the SOS, Health continues to be a top-down,target
oriented vertical programme concentrating on Family
Planning excessively, to the point of ignoring the other
health needs and programmes. Of late immunization
programmes are being thrust with the same orientation.
It is not at all surprising that our gains in Family
Planning are so meagre compared to the Investments and
probably the highly advertised technology missions in
immunization will meet the same fate, failing miserably
at the interphase between the programme and the people.
ii. There is a growing concern that th< s exclusive base-level
orientation towards family planning and immunization
(selective, top-down Primary Health Care) at the cost of
more comprehensive Primary Health Care, responses to
regional and situational diversity is becoming counter
productive to 'Health' itself. If the bureaucrats and
technocrats in the Health Ministry and directorates would
care to listen to the feedback from the PHC doctors, the
PHC health staff and the people, this would have been
obvious. They are waiting to be asked but the coercive,
• •9
9.
disincentive oriented top-down targetted pressure
disallows negative feedback and ignores the statistical
adjustment and mis-information that is taking place at
all levels of the record keeping procedures.
iii. If people's involvement is seen as necessary than the
health sector needs a major change in orientation, The
thousands of village health workers trained are no
longer health animators or educators of the people but
•lackeys' of the system demanding more salaries etc.,
and getting pre-occupied with the local politics.
The levels of motivation of health staff is at a very
low ebb. The levels of institutionalised corruption
in drugs and supplies and their diversion to private
practice of government staff is high. There is no
concept of problem 'solving' training or continuing
education.
Health planners are busy with infrastructural development
and analysing and quoting statistics from a record
keeping system which is highly questionable and invalid.
iv. At the people's level the image of the PHC and the
government health staff is very very poor. People are
unhappy with the functioning/attitudes and quality of
services of PHC staff. Accountability is a major need
in the health services but any change in orientation
towards involving NGO/Volags and people's representatives
in health care planning/implementation would be seen as
very threatening to the existing staff,. Ateady in
Karnataka this accountability factor is beginning to
result in Panchayat Raj institutions raising issues
about PHC service quality, corruption of doctors etc.,
v. If people's involvement in planning and implementation
process has to have an increasing role then the health
sector, more than any other sector has to accept a
radical departure from old styles of functioning and
acceptance of new forms of planning processes. At the
level of the Health Secretaries in the Ministries and
C C)
I
/if
'/
f (/■'.'
CO
r./''i ?)* 10
ic.
among some top technocrats the realities of the
situation and the challenges ahead are not unknown.
But a very concerted effort is required to move from
the existing style to a new approach and it will
need more than rhetoric.
vi. In this context the Health Sector needs to dialogue with
the NGO/Volag sector in a whole host of common areas of
interest - Community Health approaches, village level
training, health education, health awareness building,
community participation. The efforts begun early in
January 1988 to set up an expert committee for dialogue
within NGOs and Health Sector at the Central level has
has not taken off as yet due to various bureaucratic
reasons. In other sectors through such dialogue forums
and consultative committees much headway has already
been made. The Health Sector has had dialogue with NGOs
in the past for family planning efforts and now for
immunization but the NGOs have always been seen as
alternative implementors. True dialogue will require
that alternative policies, grassroot level feedback,
accountability and alternative pedagogy for training is
also explored together. The NGOs role as an issue raiser,
community educator, organiser and mobiliser has also to
be recognised. Otherwise this interaction will lead to
counterproductive confrontation.
vii. In the last two plans there has been a massive preoccupation
with infrastructural development. The number of PHCs and
subcentres have been increased substantially. Apart from
the fact that this exercise may have succeeded moreon
paper rather than in ‘brick and mortar* terms, what is
irrefutable is the fact that the quality of health care
h&cs
which was not very good to begin with the deteriorated
rapidly. This is a serious development. The Sth plan
should predominantly concentrate on quality development
of the existing infrastructure-focussing on quality of
... 11
11.
supplies^ manpower and training. If this urgent
matter is ignored, by the end of the 8th plan we will
have a concrete shell ofhealth care, promoting a
coercive family planning programme supplemented by a
top-down immunization programme with impotent vaccines
and the whole concept of ’Health for All’ will
degenerate into a farce inspite of all the UNICEF and
Technology Mission supported rhetoric. The situation
is serious because we have the pedagogocal/technological/
managerial expertise in the country to provide a
meaningful health care but what is lacking is the
socio-political will to tackle the realities at the
grass roots.
viii. For too long the Health Sector has ignored the local
health culture and traditional system of medicine and
health care because of its western allopathic origins.
Integrated policy for this plural situation is an urgent
necessity not only from the economical point of view
but also in the context ofinvolving people in their
health care. In recent years there is a upsurge in the
interest but this seems to be tinted with romanticism and
nationalism rather than ’level headed policy research’.
The 8th plan should earmark definite policy research
funds andmake a serious study of the existing situation
to evolve a more comprehensive integration policy for
the future.
Some General Issues
7. Political interference at various levels of the infrastructure
and corruption involving diversion of resources for private
use are two hallmarks of the present system. Even planning
Commission documents and reports accept this reality though
couched in ’acceptable Jargon’. At the level of the people
this is a daily experience and any involvement of people in
PIP will have to accept this feedback and be ready to
modify the situation. The people are a ready to provide the
feedback but the system is not yet ready. These issues should
• •12
12.
more objectively studied and the role more clearly documented.
The ICSSR could undertake investigative research in these
areas. Preventive programmes can be planned only if the
problem analysis is thorough.
8. While co-operative efforts have been promoted by Government
primarily as an income generating/economic activity# the
co-operative culture has not yet taken adequate roots because
of the politicisation of the process. This needs to be
strengthened and diversified.
Serious attempts should be made to link/or involve existing
functioning co-operatives to ’health' and 'education*
programmes. Not only is a link between economic development
and human resource development (health and education) thus
established, but health and education activities give time
and space, for co-operative culture to be accepted. The needs
in health and education are also relatively more homogenous
and thus conflicting interests within rural, urban slum or
tribal situations is less. There is also need to build up
the culture of ’cooperative benefits' rather than
individualised benefits and here again Health and education
lend themselves to promoting this dimension.
9. In Tribal areas there is a serious need to restructure many
of the development programmes to 'cooperative ownership*and
•cooperative benefits*. The individual 'farmer* or 'villager
oriented programme which may be realistic in a caste/class
stratified culture ofthe villages, is not always relevant to
tribal societies. Development workers are becoming
increasingly concerned about the destruction of the pre-existing
cooperative culture in tribal areas through the development
process. Sub plans for tribal area development must take
into account this reality and allow flexibility for 'group
ownership* and 'group beneficiary* orientation.
10. With the phenomenal degree of urbanisation and rapid industrial
development - a group that needs immediate and urgent focus
is the 'construction worker*. Migrancy, exploitation by
• •13
13.
contractors, unjust wages and inadequate basic facilities are
making life inhuman for a larger and larger population of
migrants to city. The 8th Plan needs to focus on them more
substantially. The NGO sector has a lot of experience to share
in this area.
To Summarise therefore
If people's involvement in PIP has to move beyong 'populist
rhetoric' to the 'core' of national planning then the 8th plan
document must include 'processes^ that enhance
i
ay Information transfer and awareness building programme for
for the people.
b. Reorientation programmes for staff at all levels of the
existing infrastructure about this alternate concept of
people as participants and not beneficiaries.
c. Monitoring and record keeping systems that are not only
quantitative but also qualitative and allow feedback from
people and from lower level functionaries of the system
who are in closer w contact with the people.
d^Increasing involvement of Volags/NGO sector in the role of
monitors, evaluators, issue raisers, demand creators and
trainers and not just 'programme implementors’
e. Positive discrimination towards those groups who do not
participate in local decision making processes supplemented
by Health / Education efforts that could strengthen the
overall community building aspects.
f. Move away from top-down, centralised, models to development
planning that reflects local socio-economic-politicalcultural realities and allows diversity of options and
flexibility of a approaches learning from the existing
positive and negative experiences of both government/NGO
development efforts especially since the 1979s.
-xxxxxxxxxxxxxxxxxxx -
DOCUMENT 4
PEYOND POLICY RHETORICF STATISTICS AND INFRASTRUCTURAL DEVELOPMENT:
The Tasks For The 1990s
(A working paper from Community Health Cell,
Bangalore, for the Regional Review Meeting
on Primary Health Care System Development
for Southern Zone. (Government of India) )
22-23 February 1990«
CONTENTS:
1. Introduction
2. Distortions in Primary Health Care
3. Some Problems of Primary Health Care in India
4. Beyond Problems : Towards Creative Solutions
5. Attitudinal Change in the Health Delivery System
6. Additional Reading
Note; This background paper responds to the aims of the meeting
as well as the tentative agenda outlined in the letter
circulated by Assistant Director General (HA) D*D.No.
3/RRM/89-90 dated 6th February 1990.
It brings together a •grass roots' public health
perspective developed from
i . A Study-Reflection-Action experiment with voluntary
efforts in Community Health in Southern India;
li. A decades experience of community oriented health
manpower development from a medical college;
iii. Participation in the evolving perspectives of
networks like medico friend circle. Voluntary Health
Association of India, Catholic Hospital Association
of India, All India Drug Action Network and Asian
Community Health Action Network.
!• INTRODUCTION
The Alma Ata Declaration, 1978 established Primary Health
Care as.
’’Essential health care made universally accessible to
individuals and acceptable to them, through their full
participation and at a cost the community and country
can afford”
The four principles stressed in the declaration were:
i. Equitable distribution
ii. Community Participation
iii. Multi-sectoral approach
iv* Appropriate Technology.
The most important development was the recognition of a
’Social Process’ dimension in health care including community
organisation, Community participation and a move towards
social equity.
India has been an enthusiastic signatory and promoter of
the Declaration and Primary Health Care policy.
!
In the decade following Alqpa Ata, we in India concentrated
on infrastructural development and manpower training to
operationalise this concept building further on the
established Primary Health centre concept with its three
tier structure of Doctors and health supervisors, Multipurpose
workers and CHW and TBAs. The Primary Health ^are(PHC)
approach supplanted the Basic Health Services approach, and
the National Health Policy statements of the 1980s tfsau a
’conscious shift from hospital-based urban medical care to
’community oriented rural health care’.
We are now at the threshhold of the 1990s - the final decade
before the goal of Health For All — 2000 AD. This Regional
Review Meeting will consider reports by the seven Southern
States on ’infrastructural developments, health manpower,
...•2
2
training facilities, community participation, self-care, coverage
of areas of health education, awareness, immunization and so on.
This working paper would like to move the discussion beyond Policy
Rhetoric,
and Infrastructural Development.
First it would like to list out the distortions that are emerging
in the comprehensive community oriented exhortations of Alma Ata
on Primary Health Care. Does our own National, Regional, State
or District level experience symbolise these distortions?
Secondly it would like to list out some of the problems that are
emerging in the policy and delivery system of Primary Health Care
in India.
Thirdly it would list out creative approaches to be explored in
the 1990s towards surmounting the distortions and problems mentioned
ment above.
Finally it would list out the dimensions of a neu development
culture which have to be developed i^ PHC policy has to move
towards Health For All - 2000 AD. Infact this i^the most crucial
test of our commitment to PHC.
2. DISTORTIONS IN PRIMARY HEALTH CARE
In the recent years we have been gradually witnessing a shift of
emphasis and a multi-dimensional distortion of the concept of PHC.
Is our experience similar?
PHC was meant to be a bottoms—up community evolved programme.
It has become a top-down community imposed programme.
* PHC was meant to be a comprehensive programme of locally evolved
activities' It has become a selective package of distrbution
services*
*
PHC was meant to be a social process stressing community
empowerment and demystification of health. It has become an
over-technologised, over-managed, over-professionalised service.
* PHC was meant to be a locally created programme appreciative of
regional diversity. It has become a monotonous model thrust from
the Centre.
3
*
PHC uas meant to be a socially promoted programme, proposed by
community involvement in a participatory managed programme*
It
has become a ’socially marketed plan’ by health ministries coerced
by National and International health resources agencies.
*
PHC was meant to be a process stressing educational, organisational,
awareness building and empowering approaches.
It has become a
medicalised programme selling or distributing industrially
produced short-term alternatives and options.
* PHC
began by learning from creative experiences of voluntary agencies
and health ministries committed to social justice in health care.
It now draws sustenances from top-down, managed, health research
projects that stress targets, quantifiable indicators and
measurable
objectives, overlooking the process factor and the
qualitative dimension.
*
PHC had a vision that was even relevant ultimately to secondary
and tertiary health care.
This dimension has been blunted by the
co-option of the concept and principles by the Medical System
which has a vested interest in the ’abundance of ill-health’.
The
medical system has internalised the rhetoric but lost the spirit.
3. SOME PROBLEMS OF PRIMARY HEALTH CARE IN INDIA
In reality in India this has meant that the comprehensive health
care concept and vision of the Bhore Committee and the numerous
committees thereafter has now been watered down in spite of the
impetous of ’Alma Ata Declaration* to top-down vertical programmes
of sterilization, contraceptive distribution, immunization, ORT
package distribution anc/some focussed TB and leprosy control.
Converting some of these to technology missions or placing them
on the Prime Minister’s 20 point programme has not necessarily
meant a move towards greater efficiency.
* Apart from the selectivisation of the package (comprehensive
to selective PHC) a host of inter-related problems in the
existing PHC delivery system further reflect the growing dis
tortions.
4
* There is a growing concern at all levels that the over-preoccupation
with Family Planning and Immunization is at the cost of basic and
comprehensive health care.
* The coercive disincentive oriented top-down targetted pressures
disallows relevant feedback and ignores statistical adjustment
and mis-information that is taking place at all levels.
* Staff motivation is at low ebb with monitoring processes being
fait-finding oriented rather than problem solving oriented,
morale is low and insecurity level is high.
*
Levels of institutionalised corruption in drugs and supplies and
diversion to private pockets or private practice is high, but
fails to be taken seriously by planners or administrators.
* The PHC process still ignores the local health culture
and
traditional systems of medicine and health care, where it is
accepted it is mostly ’lip-service’ or at best rather paternalistic
support.
No attempt at a meaningful integration has been made.
* Training programmes
are inadequate and both basic training and
continuing education faculty in its pedagogical orientation, So
that manpower still work ’for people’ not ’with people’.
* Awareness building and
demand creation processes are the most
badly neglected because of ’telling people’ or ’talking down to
them’ rather than exploring health issues with them and
empowering them through informal/non-formal education approaches.
4. BEYOND PROBLEMS: TOUARDS CREATIVE SOLUTIONS
Though the above features outlined may seem mostly critical of the
existing system, this criticism stems from a close touch with grass
roots reality#
However this paper would not like to stop at critical introspection.
There is today at both micro-level NGO/voluntary agency health
project experience as well as in many district level government
programme experience
all over India - the experience of meaningful
alternative options in handling the above problems and moving
towards<theVPHC movement a more creative and ’equitous’ response in
the 1990s.
....5
5
While it is not possible in this paper to highlight the project/
process experiences all over India, the key issues/alternatives
are listed out for consifbration by planners in the years to come.
A reference list at the end of the paper gives details of larger
papers/reports where further substantiation is available.
*
PHC Policy must be interlinked with socio-economic development.
*
PHC Policy must explore multi-sectoral linkages actively.
* PHC Policy must evolve regionally from local level upwards taking
into account:
a« special
needs of certain groups - dalits, tribals and slum-
dwellers•
b. changing local health environment and socio-economic status.
c. reliable and good quality health information.
d. interaction with community perceptions and needs.
*
Budgets for operationalising PHC must be increased substantially
and rural-urban disparity tackled seriously.
* All systems of medicine and existing alternatives and options
available to the community must be involved and included in an
attempt to create an integrated Indian System of Medicine and
Health Policy.
* Privatization and commercialisation of medicine must be curbed and
the State must continue to bear the major responsibility to providing
, people with affordable and accessible services,
NGO, Volags and the
private sector must be welcomed to complement the service but not
replace it.
* PHC re-orientation of all medical staff is an important strategy
organised through a staff college process and oriented to team
training and participatory approaches.
* Continuing Education programme for doctors, nurses and para-medicals
based on multi-disciplinary and participatory approaches are crucial
investments for the future. A PHC/Community/Social reorientation
of medical education and all existing health manpower training
programme is important.
6
*
Stress on integrated community based PHC approaches and movement
away from vertical unipurpose health programmes is necessary.
*
A Rational Drug and Technology Policy needs to be outlined and
implemented to support the PHC Policy.
*
Health Practice Research geared to important basic issues in
PHC:
a. poor utilisation of government health services;
b. corruption in health services; and
c. participatory approaches in planning/management should be
organised•
d. Appropriate Technology for
community based response.
5. ATTITUDINAL CHANGE IN THE HEALTH DELIVERY SYSTEM
The above creative solution^fcan emerge
and be supported by the
Health Delivery System only if there is a complete change in
attitude among planners* decision makers and health service providers.
This attitudinal change is the most crucial task of the 1990s.
At all levels of the system a new ’culture’ has to be actively
promoted and developed. The six dimensions of this culture are:
a. A Social Analysis and Cross-sectional Feedback
’People1 are not a homogenous/amorphous mass who can be
represented by a few formal leaders but are a heterogenous
group stratified by income, land ownership, education, caste,
culture, gender and other factors. The stratified groups have
conflicting/competing interests. Some groups dominate and
participate and utilise services more than others.
People’s
representatives for dialogue must be sought from all strata
and groups and positive discrimination towards those groups
who do not benefit from existing programmes must be clearly
indicated policy option.
b•
er ience_2iven__ weight a^e
The People’s perception of the working of projects and programme s
or their own responses to problems must be seen as equally
....7
7
important as statistical/professional/technical situation
analysis.
This perception must be sought by informal focus
group discussions rather than formal surveys.
This calls
for an attitude of learning from the people and a growing
confidence that people who experience problems evolve their
own responses that need to be evaluated and literacy or
technical skill/knowledge is not necessarily a pre-condition
for local innovation.
c» Feedback from those closer to geople
Feedback from lower level functionaries within the government
system, who are closer to the people and who can more easily
identify with their culture and aspirations must be given
greater importance by higher level supervisors and decision
makers•
d. Promotion_of_integrated/holistic_problem_analysis
Integration, inter-sectoral coordiration and holistic view
of a situation or problem must be stressed and the ’orthodox*
governmental classification into sectors/departments/ministries,
projects/programmes must be countered at the peripheral level
especially since people experience life in a holistic way and
find bureaucratic compartmentalisation hard to comprehend.
e. Evaluation — interacti.ve_and_gualitative as well
Evaluation and Monitoring has to be seen as a ’problem solving’
or solution finding exercise and not ’policing’ or ’blame fixing’
procedure. Rather than basing it on a routinised form/register
filling exercise which is not used at the level it is collected
but basically collected foi/someone else at a higher, more remote
level - the exercise should be more interactive both within the
team or functionaries and with the formal/informal leadership
among the people and qualitative aspects given as much
8
importance as quantitative indicators.
f. Diversity of
tions^and^flexibility^of^apgroaches
Finally since people are in different situations and each
village, tribal area, slum, region or district is so diverse
in its historical experience, socio-cultural reality and
development experience, people’s
involvement in Planning
and Implementation process pre-supposes the acceptance
Diversity of responses and flexibility of approaches in
the evolving nature of projects/programmes. Models thrust
top-down through centre/state sponsorship which do not allow
diversity or flexibility are counter-productive to the whole
concept•
While this may sound theoretical to the macro planner preoccupied
with measurable goals and targets and macro-programmes and
project guidelines — they arise out of a deeper understanding
of the realities at the grass roots and of the problems in
the interphase between government development efforts and the
It is at this interphase the present system has been
people•
constantly breaking doun.
Managerial innovation in planning has to go beyond orthodox
project formulation and management to the crucial process
formulation i^e not only what to do but how to do it. If ue
are serious about making a change in the situation, we cannot
overlook or ignore these dimensions
any longer.
6> ADDITIONAL READING
This working paper is based on five key papers of Community
Health Cell which are available on request for all those who
wish to explore these ideas further.
1. Community Health in India (Cover Story)
•Health Action} Vol 2, No 7, Duly 1989
(18)
...•9
9
2. Towards a Paradigm Shift
’LINK’ (Newsletter of ACHAN)
Vol 7, No 2, Aug-Sept 1988
(4)
3. Perspectives in Health Policy and Strategies
for the State of Karnataka
A Community Health Cell response 1988
(10)
4. People’s Involvement in Planning and
Implementation Process
A re^Donse to a Planning Commission process by
Community Health Cell, 1989
(14)
5. Towards a People Oriented Alternative Health
Care System*
Social Action, Vol 39, July-Sept 1989
e
(Numbers in brackets indicate pages)
Please write to author
C/o Community Health Cell
No 47/1 St Mark’s Road
Bangalore 560 001
(14)
DOCUMENT 5
i
SPECIFIC COMMENTS ON PERSPECTIVE PLAN FOR KARNATAKA
(Dept of Health and Family Welfare Services), March 1988.
In keeping with the main points raised earlier the
following specific additional comments are offered in
the context Of specific recommendations of the
Government Department.
(Paragraph numbers correspond to specific
numbers in the departmental document)
1.
"Encouraging dependence” is very different from
exploring complementarity and partnership.
Government should never depend on sources
outside government but explore links, support,
mutual dialogue etc. Government should remain
main provider/enabler supplementing its services
with other non-governmental initiatives.
Undue dependence will fuel ’privatization*.
1.3 We fully endorse the need for simplifying
procedures and reduction in red-tape.
1.4 Volags/^lGOs are operating on a no profit no loss
basis. Since it is the government’s responsibility
to provide health infrastructure they should
provide genuine volags/NGOs with mobile units
and volags could bear running costs.
...2
2
1.5
This Committee*s orientation must be built on
mutual dialogue, flexibility and appr< elation of
diversity in approaches. Otherwise the suggestion
to ’devise plans*, •supervise*t ’direct* or
•implement* could be the starting of an equally
bureaucratic procedure. Supervision should be
supportive not •policing*.
2.1-2.4
While infrastructural development is
important it should not become an end by itself
and a play with numbers on paper. PHC/pHtTs are
not functioning due to a host of reasons including
rampant corruption in the services. It is accountability
of the health team and structures to the local
community that is most important.
2.5
The drug budget of Rs.30000 per annum for a PHC is
Inadequate (less than 40p. per person), while the
suggestion to base it on population norm is most
welcome the rural/urban disparity must be severely
reversed and higher and more realistic estimates
should be made.
3.1—3.8
The focus is too much on curative services/
referral servlces/speciallst services. While a
good referral services link is a must and needs to be
well established the main effort should be on
reorienting all PHC staff including specialists towards
Public Health/Community Health orientation in their
knowledge, attitudes and practices. Public Health/Primary
3
3
Health Care and Community Health are primarily
attitudes of mind and basic skills not specialization.
A staff college training for all grades particularly
medical officers is more important than focussing on
•Specialist presence*.
4.2
Resource Mobilization
It is important to remember thatja socialist
democracy, it is the government’s primary responsibility
to provide basic health services to people irrespective
of their ability to pay. Mobilization of resources to
supplement tax payers money is a good idea only if it
is supplementary and through a process of accountability,
otherwise ’charging patients’ as a policy would lead
to keeping out the majority of the poor who need the
cervices the most.
Government knows that there is a hike in
construction materials! pay scales etc. Therefore
30-40 lacs for construction of a CMC is not "luxury".
The problem is more of the siphoning of resources
from the existing budgets by corrupt contracting
practices. In addition. Appropriate Technology efforts
in identifying suitable low cost building materials
and building plans should be explored with Science/
Technology institutions.
4.3
....4
4
4.4
Strengthening of existing health institution^
alone will not solve the problem of under
utilization of health services. The causes
for this under-utilization must be explored
through health practice research.
4.6
Why should the community take the burden of
paying incentives to the staff? The amount
mobilised should solely be used for the
improvement of services inside the health
centre—for eg., purchase of drugs, health
education materials etc.
si
DOCUMENT 6
PERSPECTIVE PLANNI\G IN HEALTH
- A Report At the invitation of Sri L C Jain, G-hairman
of the Expert Group of Perspective Planning set up by
the Govt of Karnataka, a meeting was held at ’Krishna’,
the home office of the Cldrf Fiinister on 18/7/88 for
a discussion on the ’perspectives in health policy and
strategy’ .
Members present at the meeting were:
1 . Sri L C Jain
2. Smt Vatsala Wat sa, Registrar of Co-operative
Societies & Nember—Sec retary
Expert Group on Perspective Plan
3. Dr H Sudharshan, VGKK, B R Hills
4. Dr Dara S Amar, Prof & Head of Community Medicine
St John’s Medical College
5. Dr Gopal Dabade, Convenor, Drug'Action Forum-Karnataka
6. Dr Ravi Narayan, Community Health Cell
7. Dr Thelma Narayan, Community Health Cell
8. Dr Vanaj a Ramprasad.
The following points arose as a result of the group
discussion.
Sri Jain explained the objective of this discussion and
highlighted the fact that due to the process of decent ral i satior>
greater decision mMng
powers now lie in the hands of the
people through the Gramsabha, the Mandal Panchayat and the
Zilla Parishad system in Karnataka.
In order to utilise the full
benefit of this decentralised system to bring about
greater
accountability in the functioning of the
v
2
Govt health services the resources available at the
community must be tapped^
In this process, it is
important to pay attention particularly to Human
Resources available in the community*
Two major means
of approach to creating greater awareness and in
mobilising community resources are a) through health services
b) through education
The Infant Mortality Rate is a parameter which
indicates the health status of the community and thereby
the progress made in health activities*
While attempting
to reduce the Infant Mortality Rate, literally every aspect
I
of health education and development will have to be covered^
Based on a study in Kerala, it was recalled that female
literacy by itself constituted an important parameter for
I
measuring the health status of the community*
The ensuing discussion brought up the fact that
in order to initiate any form of Community Action or even
i
to identify priorities in health needs and approaches,
a •Health Rap« of the state would be of prime importance*
It is important to identify regional differences in health
status as well as differences in class, caste, age and
sex groups*
An important aspect of creating such a
•Health Rap11 for the state would be the fact that the Govt
health statistics would have to be relied upon to a major
extent*
The members however, felt that the availability
of and access to these Govt statistics is not aneasy
task
-
CO
oI bb
) >
i \
o**
j
3
and perhaps the NGOs would have to be aided in this
matter in order to strengthen the verasity of such a
•'Health flap1’'.
The validity and reliability of such
statistics was also in question.
It would be very
important that all health organisations would have to
provide factual data of their own communities which
they serve.
However, this throws up the; fact that
there is a disparity in the distribution of health
services coverage by voluntary agencies in the state.
It was opined by the members that whereas Bangalore,
flysore and Dakshina Karnataka areas were adequately
covered by various voluntary health organisations, the
northern districts of Qidar, Bijapur etc. were inadequately
covered.
zones.
Yet the major health needs are in these northern
In order to collect any form of information in
these health service deficit areas of the north. it is
imperative that the present Glovt machinery be geared to
supply the information as they alone have a uniform
distribution of geographically placed services in the
state.
In terms of any form of Community Action, it
was felt that the untapped resources in the community
were the rural women.
This is especially so when we
consider the fact that atleast 25>> of the representatives
at the Zilla Parlshad levels are women.
Keeping in
i
4
view, the health and education approach to motivate human
resources, it was felt that the rural women had an instinctive realisation of the importance of children’s education
and children’s health.
Therefore, women representatives
can constitute an extremely powerful lobby fir pursuing
better health care and educational services for the
community.
It is obvious that the present planning for
health is budget-oriented
and not objective-oriented.
This has created a culture which stresses importance on
expending the allotted budget within a given time period
irrespective of the quality of work done.
Pdrhaps the
biggest lacuna here is the need to evolve measurable
parameters for quality of health care#
This has also
resulted in thd use of targets for measuring health
service progress#
However, the use of the target method
of evolving health services has resulted in the target
being central to all other activities#
fulfillment of
targets becomes the prime function* of health projects#
This maintains the vicious chain of target setting and
achievement of the same by any means including manipulation
of records#
Experience of the members suggested that
questioning the people themselves regarding health
performance, elicited a qualitative type of assessment
for health services#
Although the judgement was
qualitativs, it reflected the truth regarding need-ful
fillment which was in contrast to the target oriented
5
results in the same area,
In short, the use of targets
has reached a point of abuse*
Planning at central levels may be convenient*
However, central planning always leeds to mathematical
equality of resources versus population.
Aspects of
geographic distribution, physical accessibility, social
norms, cultural and traditional barriers, new prioriti
sations and actual community needs are not considered*
In this form of central planning, all resources are
distributed irrespective of the need for the same*
The
group felt that local/regional planning at Zilla Parishad
level would reverse this procedure and give practical
relevance to the process of planning*
In this manner.
accountability for performance will also be at the local
Zilla Parishad level*
It was felt that an inter active type of
planning was called for wherein community level leaders
would have to atleast express their felt needs which could
then be given a final shape at the central level*
This
would prevent the projection of centrally perceived needs
on the community by the planning authorities*
This fact
is often overlooked due to the inbuilt bias that such an
inter active type of planning with the community would be
very chaotic and unmanagable«
Yet, the strength of the
NGO activities always lies in the community level inter
active micro planning which has resulted in yielding better
and more meaningful results rather than mere target
fulfillments*
6
Ao a measure of understanding the manner in
which many of the NGOs have brought about localised changes
in the field of community health, it was felt that an audio
visual aid be prepared to highlight certain selected and
important projects in health adopted by the NGOs*
This
envisages that members of the Voluntary Health Association
of Karnataka, to begin with, would formulate an itinery
for the visit of a video taping team to each of their
project areas*
Certain processes and inter active behaviour
with the community as also innovative approaches in health
would then be filmed for each of the health centres*
It
was suggested that a number of Governmental health centres
were also doing excellent inter active planning and community
level quality work*
The work of these Governmental agencies
would also be included in this audio visual aid project*
A
final software would be used to edit the various sequences
filmed*
Copies of this film could then be circulated and
distributed through the Govt publicity net work*
The idea
is not to highlight any particular organisation’s
achievements, but to share ideas visually in order to
stimulate and modify further innovation in community health
approaches*
$
The role in health care played by the Indian or
traditional systems of medicine was highlighted*
These
ranged from home remedies and folk healers like bone
setters, dais etc* to practitioners of Ayurveda, Siddha,
Unani, Homeopathy etc*
At present, though they do have
official recognition and have their own councils etc* the
7
importance given to them in h©a1th planning and resource
This situation needs to be
allocation is still marginal*
rectified*
In the planning and implementation of health
programmes, there is a trend of going back to the ^vertical
programme’1 approach as against the integrated community
based approach*
Recent examples of these are theimmunization
programme, Bral fiehydration Therapy
programme, etc*
These
are detrimental to the general health services and also
in terms of financial input, time spent by health personnel
and most especially from the point of view of the community
in whose daily experience, health problems cannot be
dissected
one from another*
The change of $ands in decision
making from public health physicians to clinicians and
professional managers could be partly responsible for this.
The immense potential (as yet largely untapped)
of school health programmes, health education and child to
child programmes was discussed*
There is also a need to
reach children who do not attend schools or drop out of
school*
These often come from families who are the most
in need.
Innovative and nonformal methods would be needed to
reach them*
There is a need to understand and respond
adequately to the special needs of the tribal population
in Karnataka, who constitute about 4% of the total population
of the State*
This was to be done in a separate session*
It was expressed that there was a need to evolve a
8
rational drug policy.
The example of the Govt of Andhra
Pradesh was referred to»
They have recently drawn up a
list of essentiel drugs to be used in Govt health institutions
and have banned the use of certain hazardous drugs.
During the afternoon* the discussion uas confined
to discussing the perspectives in the family planning
programme of India.
It uas felt that* to begin with* the entire
family planning programme has been viewed from mainly a
demographic point of view.
The planning has bean geared
mainly to reduce the birth rate.
In this manner* the
various other facets of family planning, namely maternal
and child health aspects, have been given second priority.
Further* the aim of family planning uas again
target oriented in terms of the number of birth limitation
operatloas done*
Thusf •Human* aspects of the decision to
adopt family psil planning has been ignored*
Rather than
involve the family as a unit* individuals appear to matter
more for the family planning officials.
Even among the
individuals, the target group are women rather than men*
In the race to limit the number of births*
legalisation of abortion has been resorted to in a aery
indirect manner under the hTP Act by suggesting that one
of the provision of that act is "failure of contraceptive"*
Thus the aspect of respecting life has also been neglected.
The members further felt that there has been a vulgarisation
of the family planning programme through the use of crude
9
incentives for people accepting sterilisetion*
Thus, the
respect fo ’‘Family11 in the family planning is grossly
missing.
It should be explained that child survival is
more important than birth limitations.
It is common
knowledge that if couples are given a guarantee regarding
the survival of their children, the couple themselves decide
on a small family norm without further motivation.
Therefore ,
the stress should be on child health and prevention of
infant mortality rather than birth limitations.
The priority
that family planning enjoys in terms of budget allotment
must ba used for promoting child health schemes and maternal
health schemes.
This will ensure that the quality of the
surviving population will be of a high order rather than
merely have managable quantities of population as per
cold demographic norms.
As regards the interest of developed countries
in Family Planning in India, it was clearly brought out
that the developed countries are more interested in
protecting their own resources which they do not wish to
share with an expanding populetion from the third world
countries.
It should also be noted that these resources of
developed countries had also been built up by exploiting
develops countries through an unjust economic order and
tradition trade-aid relations.
In addition developed
countries population used more of the world’s resources
than those in developing countries.
Therefore, it is
w
imperative that decisions regarding family welfare projects
be taken irrespective of the western countries norms and
dictation.
In order to achieve the above. Family Planning
must be made as an integral part of health care delivery
rather than give it any form of separate priority.
The
provision of primary health care to the people should gain
more importance than family limitation^.
There should be
a realisation that a lot of progress needs to be achieved
on the economic front in order to ensure child survival.
The important factor to actively promote is the need to
raise female literacy which in itself will ensure small
f amilies.
There is *a need to create parameters for
measuring the progress in family planning measures.
These
parameters should not be merely the number of sterilisations
or the number of users of family limitation devices.
In
c,
fat, greatest stress should be laid to measure the para
meters relating to the progress made in child health as <
measure of the quality of the present family planning
programmes.
Health education for family health should be
more important than propaganda for family planning devices.
For more effective planning, it is imperative that the family
planning field workers themselves be involved in the planning
of the health strategy as they have a rich knowledge of grass
root experience.
?:•
The involvement of peripheral workers
in any planning proceas is central to its success and this
holds good for family planning as well.
11
The whole day’s session has been conducted
in the form of a ’‘brain storming* for ideas rather than
any form of recommending solutions.
It is a collection of
ideas of the perspectives in health and family planning
and not a collection of solutions.
/////
APPENDIX 'A'
HEALTH POLICY REFLECTIONS
CHC INVOLVEMENT
The National Health Policy of 1982 strongly recommends a
collaboration of Government with Non-Governmental Voluntary
Agencies in the Health sector to achieve the goals of the
health policy.
The Community Health Cell, an informal study-ReflectionAction experiment in Bangalore (1984-1989) has been studying
the experiences of NGOs/Voluntary Agencies at micro level
with a view to build up perspectives that are relevant for
macro-planning and which can be shared with health planners,
policy makers, health administrators and health service
providers at various levels and at different forums.
Since 1984 many such opportunities have been utilised
for such a continuing dialogue. The key among them have been:
*
A Dialogue with the Director and other officials of the
Health Directorate in Karnataka, as part of the Annual Meeting
of the Voluntary Health Association of Karnataka on the theme
•Government - Voluntary Agency Collaboration1 in March 1984.
*
A two week consultancy with UNICEF, New Delhi, to
explore approaches to enhancing Government - Voluntary Agency
Collaboration in child survival programmes in 1984-1989 phase
in September 1984.
*
A Two-day seminar on Involving Voluntary Agencies in
the implementation of Government Programme, organised by the
Consultative Committee on Rural Development in July 1985.
*
A meeting with Sri.L.C.Jain, Member, Perspective Plan
Committee of Karnataka Government to discuss perspectives on
Health and Family Welfare in July 1988.
*
A response from Community Health Cell on Perspectives
• •2
2.
in Health Policy and Strategies for the State of Karnataka*
submitted to the above Committee in July 1988.
*
Some comments on the Perspective Plan for Karnataka
drawn up by Department of Health and Family Welfare,
Karnataka, was also sent in July 1988.
★
A paper on 'People's Involvement in Planning and
Implementation Process' which was a response from the
Community Health Cell to a dialogue initiated by Sri.Bunker Roy
Adviser, Planning Commission on evolving concrete policy
guidelines on this issue for the 8th Plan in November 1989.
★
Participation in the Regional Review Meeting on
Primary Health Care Systems Development for Southern Zone
organised by Government of India and World Health Organisation
held in Bangalore (February 1990). A working paper entitled
'Beyond Policy Rhetoric, Statistics And Infrastructural
Development - The Tasks for the 1990s, was also circulated.
Participation in a Dialogue with NGOs, on Health
Policy - issues and perspectives at the Planning Commission,
New Delhi, in March 1990.
★
-xxxxxxxxxxxxxxxxxxxxxxx-
APPENDIX 1B*
BUILDING THE NEU PARADIGM
A Stud^-Reflection-Action experiment on Community Health
In India
Community Health Cell
4?/l St Mark’e Road
Bangalore 560 001
The Community Health Cell (CHC) is a Study-Reflection-Action
experiment drawing upon the rich and varied experience in
Community Health Care from all over our country. In the •
initial phase, two members of the existing team travelled
aLjLover the country interacting with Health and Development
projects. The team now continues interactions from its
base at Bangalore, Karnataka.
The Study-Reflection-Action experiment has been based on
interactions which are open-ended, non-formal, non-threatening
and a reflective exploration of past experiences and future
plans.
The purpose of the CHC experiment has been to build a
framework for an alternative approach to health care,
based on a diversity of micro-level experiences. The
attempt has been to look at philosophical assumptions,
goals, methodologies, successes and failures, strengths
and weaknesses, opportunities and threats in order to
build the comoonents of a new paradigm.
A necessary first step of this approach has been the
experimentation within the team with a non-hierarchical,
participatory, mutually supportive effort in its working.
This has led to democratic decision making which has a
team-sustaining effect and smoother function. The team has
a few full timers,9 while the part-timers contribute at
... .2
2
their convenience, such that their participation has a
flexibility ranging from half-a-day contribution,
through alternate day work, to even alternate week
contributions to the team. In addition, there ar^a number
of associates on the CHC network, coming together off
and on.
The catalyst process has generated activity for the CHC
team, ranging from participatory reflections, perspective planning,
exp.loration , issue-raising, networking, documentation,
inputs into training programmes, workshops, seminars and
Action research on Community Health related issues.
The CMC team participates with individuals, whether health
professionals or otherwise, field based project groups,
Resource and Co-ordinating groups and Government agencies
interested in exploring Community Health Action in its
various dimension.
The topic range spans Rational Drug ^herapy, Alternative
community health training,
medical education,/environmental health issues, Health
Policy matters, Medical Pluralism and Integration of
Traditional Systems of Medicine in Health Care and so on.
In short, anything of relevance to Community Health.
The definition that is emerging from our interactions
over six years is that
“Community Health is a process of enabling
people to exercise collectively their
responsibility to their own health and to
demand health as their right. It involves the
increasing of the individual, family and
community autonomy over health and over
organisations, means, opportunities, knowledge,
skills and supportive structure that make
health possible“
. . . .3
3
To make Community Health a reality, the? present health
superstructure has to be:
*
more ’people oriented’
-x more ’ community’ oriented
*
more socio-epidemiologically oriented
-x more democratic and participatory
and
9
*
more accountable.
The paradigm shift is to be in our thinking of health and
health care from the orthodox medical model of health to
■ 0
( >
/
understanding, appreciating and practicing a social model
that uill tackle health problems at its deeper roots.
This shift of emphasis should take place at all levels
and at all dimensions of existing health care planning
and management.
The Technological/Managerial components of the new
Paradigm include:
1
•K-
*
Appropriate Technology for Health
-X-
Community organisation and participation in Health
•x- Community/Village Health Workers
•Ji-
*
Involvement of Traditional Healers, Dai s
and indigenous system
Education for Health
Health with Integrated Development
< 0
< /
G
(
(✓
(/
< /
t?
<,
(
< /
< >
(?
■
>
- ;
( r
(>
x- Community support to Health Care — financial/
resources♦
. . . .4
6
Ref erences
This working paper is based on five key papers of
Community Health Cell which are available on request for
all those who wish to explore these ideas further.
1 . Community Health in India (cover story)
’Health Action’, Vol 2, No 7, July 1989
2. Towards a Paradigm Shift
’LINK1 (Newsletter of ACHAN)
Vol 7, No 2, Aug-Sept 1988
(18)
I
*
(4)
3. Perspective in Health Policy and
Strategies for the State of Karnataka
A Community Health Cell response, 1988
4. People’s Involvement in Planning and
Implementation Process
A response to a Planning Commission process
by Community Health Cell, 1989
5. Towards a People Oriented Alternative
Health Care System.
Social Action, Vol 39, July-Sept 1989
Numbers in brackets indicate pages.
Please write to author
C/o:Community Health Cell
No 47/1 St Mark’s Road
Bangalore 560 001.
* '
(10)
i
(14)
I
(14)
I
4
(i
4
4 *
4 *
x *
*>
s >
i>
* >
* >
•
•
k•
APPENDIX •€•
I
■
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i
Towards a People-oriented Alternative
Health Care System
Ravi Narayan
A ‘People-oriented’ alternative health care system cannot be
just a new package of actions, or a new technology fix. It has to
be a new vision of health care, a new attitude of mind, a new
value orientation in health action intertwined closely with
efforts to build an alternative socio-political-economic-cuhu!al
system in which health can become a reality for all people.
' i
It has been the field experience of many that the existing health
care system in India does not meet the needs of the large majority of
the people in the country. There are many reasons for this situation.
Firstly, the present model based on the ‘western-technologicalinstitutional model’ of health care is too costly and efforts to duplicate
it have meant that we can develop much less of it with our constraints
on resources.
Secondly, the present model relies too heavily on expensively
trained doctors and nurses and other para-professional workers, who
by the very nature and culture of their training are the least likely to
work in disadvantaged areas, be they rural, urban slums, or tribal
regions where most of the people reside. Hence there is a continued
shortage of humanpower in situations which need them the most.
Thirdly, the system is too closely linked to a rapidly growing
medicaljindustry of drugs, equipment, technology which, because of its
preoccupation with growth and profits, has developed a vested interest
in ‘the abundance of ill health’ and in the medicalisation of health it
self. The proliferation of drugs, capitation fees—medical colleges, high
technology, private diagnostic centres, corporate sector hospitals are all
indications of this trend.
Dr. Revi Narayan is Coordinator of the Community Health Cell,
Bangalore.
c
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230
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SOCIAL ACTION VOL 39 JULY-SEPTEMBER 1989
Fourthly, the system, having developed in a different historical
and socio-cultural milieu, is cut off from the health culture of the
people. It looks upon traditional healers and birth attendants, herbal
and home remedies, indigenous systems of medicines and their
practitioners and the folk medical culture of the people, as superstitious
remnants of an earlier era, waiting to be replaced by the so-called
‘rational scientific western system’.
Fifthly, the system looks at health in a very myopic way,
concentrating on the physical and biological dimensions, paying
lip service to the mental/psychological dimension and mostly ignoring
the social, cultural, political, economic and ecological dimensions. The
focus is on ‘diseases’ and ‘syndromes’ rather than on the way of life
or social processes in the community that cause ill health. The system
also has a built-in prejudice of looking at problems in an individual
istic sense rather than analysing them in a community and collective
context.
Sixthly, the system is highly professionalised and mystified with
its knowledge being compartmentalised in specialities and fully under
the control of professionals. There is a built-in resistance to transfer
of knowledge and skills down the line within the hierarchy of the
health team itself.
Seventhly, the medical system undermines the autonomy of
individuals, groups and communities by not increasing the common
knowledge of health and by promoting an ‘economy of created needs’.
In addition, the planners of the system thrust top-down, vertical
package of services, be they curative, preventive or promotive in nature,
on the community.
Finally, the people who use the system are seen primarily as
beneficiaries and consumers rather than as participants of a joint
effort (by professionals and patients) to build health.
When such a ‘health system’ with the built-in contradictions
outlined above is transplanted and developed in an inequitous social
system such as ours, in which class, caste, money and power determine
accessibility, availability and affordability of services, then it is not
surprising that the large majority of the people who are either
marginalised or disadvantaged, live below the poverty line—dalit or
tribal groups—are left out of it. Not having control over the means,
opportunities, knowledge, organisations and supportive services that
■ make health possible, the large majority of the people do not utilise or
participate in such a system. It is in this sense that the existing system
is not people-oriented. What then is an alternative?
»
!
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PEOPLE-ORIENTED HEALTH CARE SYSTEM
231
Towards an alternative: The Search
j
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Since the late 1960s a large number of initiatives and projects
have emerged outside the governmental system by individuals and
groups keen to adapt ‘orthodox health care’ to our very different social
realities. Doctors, nurses, health and development activists, social
workers and others pioneered micro-level community-based projects
that gradually moved beyond medical care to a host of activities and
programmes that were geared to making health care more relevant to
people’s needs. These individuals and groups, in fact this whole
‘movement* if it can be called such, is marked by its diversity in
ideology, background social analysis and perception of the develop
mental process, funding, conceptions of their individual roles and their
knowledge of medicine/health itself. However there were many
common perceptions as well engendered by the situation in India;
—All of them were aware of the inadequate reach of the existing
services, so they reached out their offorts to more peripheral
areas.
—All of them moved beyond the ‘orthodoxy’ of pill distribution
by doctors and nurses to a wide range of health actions in
which para-medicals, health auxiliaries and community-based
health workers were involved.
—In all these projects much of the health action was invariably
planned at the community level involving existing leadership
and community organisations of the village and most sections
of the people.
—Invariably most of them added preventive and promotive
dimensions to their health work and some went further on to
integrate health with developmental programmes focusing on
agriculture, income generation, water supply and formal and
non-formal education.
However, since each of them were creatively responding to
the special situation and issues relevant to their area be it a
caste village, a tribal region or an urban slum, they also
developed and explored other components of health action.
Towards an Alternative: The Evolving Perspectives
Some of us have been spending the last few years informally
studying these experiences, programmes and approaches, trying to
understand their dynamics and trying to build a new perspective,
emerging from the collectivity of the experience and basing it on the
successes and failures of these, numerous, micro-level health action
*
I
232
SOCIAL ACTION VOL 39 JULY-SEPTEMBER 1989
projects. Our study reflections have led to the identification of the
following ‘action’ components of the emerging alternative.
I
Integrating health action with developmental welfare and educational
activities: some examples
I
Banwasi Seva Ashram (Govindpur, Uttar Pradesh) had a
health and family planning programme which is integrated with its
other programmes which include agricultural extension, dairy, village
industries, education, gram kosh (revolving village fund) and social
justice programmes.
RUHSA Project (Kavanur, Tamilnadu) has developed a compiehensive health and family welfare project along with adult education,
vocational training, community organisation, income generation,
agricultural development and agro-support services.
VGKK Project (B.R. Hills, Karnataka) evolved a programme
of health care along with programmes of community organisation,
education, cottage industries, vocational training and adult education
for the Soliga tribals of that region.
Streehitakarini (Bombay, Maharashtra) working in the slums
of Bombay included among its activities maternal and child health and
family welfare, non-formal education, female literacy programme,
income generation programmes, creches for under fives and small
savings schemes.
Integrating curative with preventive^ promotive
activities in health action: some examples
and rehabilitative
The VHS Project (Adyar, Tamilnadu) evolved the mini-health
centre scheme which included maternity services, child welfare,
nutrition, family welfare, minor ailment treatment, communicable
disease control and health records and data system.
AWARE (Telengana, Andhra Pradesh) has a health programme
which includes maternal and child health and nutrition, health
education, environmental sanitation, disease control and a floating
health centre catering to 300 villages along the banks of the Godavari.
Rangbelia Health Project (24 Parganas, West Bengal) has a
maternal and child health care programme along with minor ailment
treatment, and programmes for family welfare, housing, safe drinking
water, sanitation, communicable disease control and health education.
Though most projects developed a ‘health package’ not very
different from the Primary Health Centre package of the Government
of India, the main difference was that, in these projects there was
activity in all the components and they were not pre-occupied with the
I
I
PEOPLE-ORIENTED HEALTH CARE SYSTEM
il
233
Family Planning component as the government health centres are
doing today. There was also a qualitative difference in the type of
services;
Experimentation and development of low-cost appropriate technology
I
J
— Many projects evolved simple kits for traditional birth atten
dants to ensure that they were able to conduct hygienic home
deliveries.
. ,
,
—Many projects evolved simple, locally produced health education
materials using local ideas and art skills. Others evolved simple
record keeping materials that could be used even by illiterate
village workers using simple diagrams and signs.
—The promotion and incorporation of herbal and home remedies
was a common response.
—Preparation of local food mixes and home-based oral rehydration
solutions are additional examples of this search for ‘technolo
gical appropriateness’.
Recognition, promotion and utilisation of local health resources; some
examples
*
■'
■
j
Miraj Project (Maharashtra) trained indigenous dais, village
health aides and established liaison with untrained practitioners
of Ayurvedic medicine, bone setters and registered medical practitioners
without formal training working in the area.
VGKK (BR Hills, Karnataka) worked not only with dais but
explored the use of traditional herbal medicines as well.
Tilonia Project (Rajasthan) involved indigenous medical practi
tioners and dais in implementing their programme along with village
health workers.
Deenabandhu Project (Tamilnadu) incorporated the use of herbal
remedies, acupressure and massage in their health care programme
and have been one of the enthusiastic proponents of this dimension.
I
Training of village based health cadres
Jamkhed Project (Maharashtra) pioneered the training of
village health workers—local, illiterate, middle aged women—who
became the front liners of their programmes which included maternal
and child health, nutrition, immunisation, family welfare services,
control of communicable diseases, safe water and health education.
The Rehbar-I-Sehat Programme (Korbhalwal, Jammu & Kashmir)
trained teachers of village schools as primary health care guides.
!
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SOCIAL ACTION VOL 39 JULY-SEPTEMBER 1989
trained iD most Pr°Jects and they took
several interesting names e.g.,
Swasthya Mithras (Banawasi Sewa Ashram, UP)
Link Workers (CLWS Scheme, UPASI, Coonoor)
Lay first aiders (VHS, Adyar, Tamilnadu)
Community Health Volunteers (SEWA-RuraJ, Gujarat)
Familv c5' 'y0! ^ndo’h)utch Pr°ject, Somajiguda, Andhra)
Family Care Volunteers (RUHSA, Tamilnadu)
i
Organising and involving community organisations
Mandals and Farmers' Associations
like MahiJa
Child-in-Need Institute (Daulatpur, West Bengal) organised its
MMh Mandals^ heal>h pr°grammes and balwadis by involving
Cakmta
(W
* aSSOC,ations)
the slums and villages of
I
ed th K°,lar Cc'nm^y ^alth Project (Kottar, Tamilnadu) initiatMahd^M
‘z pr°sranime in conjunction with the evolution of
2a™ Sro"u7,(W°men S °r8anisations) which have taken gradual
charge through an ongoing programme of decentralisation Over a
hundred registered village women’s organisations pay and support over
two hundred village health guides and animators
clubs i/T*V^ahar?htra) eV0‘Ved and invoIved y°ung far“ers’
clubs in the planning and organisation of services
adult P^°tkhOni PrOJ'ec^Of'^ solved its programmes of health,
adult education, grain bank, savings scheme, goat rearing non-formal
seho.1 for oMdre. „e. .I.b the p.niciX o7X%7sS“J
(men s orgamsat.on) and Mahila Sangha (women’s organisation)
Community participation in decision making
Most of the projects involved existing and or newly evolved
ommunity organisations or representative health/development com
mit ees in their organisation and planning exercises. The village
health committee was an important component
8
impose ideas from outside. Different projects have evolved this dimension to different extents depending3 on their ability to handle the above
two problems.
PEOPLE-ORIENTBD HEALTH CARE SYSTEM
235
While many of them have involved the community at various
levels of the planning cycle, decisions about funding and evaluation
are two dimensions still not generally decentralised.
Tapping local financial, manpower and other resources
The Wallur Dairy Cooperative (Karnataka) supported its health
project through a health cess on production of milk, generating
adequate resources to pay for the health team and most of the health
care supplies. Over the years the cooperative established a health
endowment scheme which paid for the basic services.
The RAH A Projects (Madhya Pradesh) developed a medical
insurance scheme which provided medical. cover through a network of
three base haspitals and 47 rural health centres.
The Kottar Project (Tamilnadu) built up a local contribution
from the beneficiaries to support village health guides scheme. Other
forms of local support apart from direct payment for services included
health savings scheme, festival donations, grain banks, accommodation
for clinics and programmes, voluntary labour and building materials,
services by volunteers, village health fund and so on.
Would these Eight ‘Action Components’ Taken Together Constitute a
People-oriented Health Care System?
Many alternative health care enthusiasts and activists would
have us think so? The ICMR organised two meetings on alternative
health care approaches, to identify new perspectives from the Indian
experience. The list of components that emerged in these meetings
were not dissimilar.
The ‘Social Process* Dimension
Our study reflections show however that these are important
components of the alternative people-oriented health care system but
are basically in the category of technical and managerial innovations.
There is another whole set of issues and dimensions which can be
called ‘social process’ components which help the above approach to
become more people-oriented. Often these issues are neglected or ill
understood by health action initiators so that even though the goal of
the initiated process is to build a health system with the participation
of all, this objective gets somewhat derailed in the ongoing process.
To understand these process components, one has to first understand
some important characteristics of our social reality as well as of the
health care system that is existing and dominant.
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An unequal society
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Firstly in the present inequitous and stratified social system
there is no community in the real sense of the word. The community
is divided by factors of caste, class, religion, land ownership, power,
education and status; Even the so-called ‘community of the poor’ has
internalised these divisions. The ‘haves’ consisting of the landed, rich,
educated, upper caste groups dominate decision making processes and
invariably participate, utilise and monopolise any services—health or
otherwise—or development in the community. The poor do not
participate at all or marginally in the process. Building a peopleoriented health system in such a situation would invariably require
two added components:
(1) Increasing the organisation, involvement and participation
of large sections of the community who do not participate
adequately in any development process today. Such
attempts will invariably be opposed by the *status quo9
forces and all who draw greater advantage from the present
system.
(2) Efforts to imbibe and improve the concept and spirit of
community and to improve group dymamics and group
interrelationships by enhancing the collective dimension
of action and the cooperative spirit.
New value system
Secondly the existing health care system is overmedicalised and
characterised by certain values which are inherent components of the
organisational ethos as well as of the professional and para-professional teams working in them. These values described in the beginning
reflect our social system and have been internalised even by those who
set out to build a more people-oriented system. Therefore, health
action initiators have to constantly
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(1) Confront these values in their action and approaches and
try and evolve new attitudes, skills and approaches that are
more people and community-oriented and place medicine,
professional skills and technology in their right and limited
context.
(2) They need to empower the people to counter these trends
in the health superstructure to make it more democractic,
accountable and relevant to people’s life.
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If we wish to build a health system with the partnership, of
all people including the illiterate and dispossessed, then health team
members need to have experienced some features of this new ethos in
their own team functioning itself. Building democratic, decentralised,
participatory and non-hierarchical decision-making processes within
the health team become as important as introducing these elements in
the interaction between the health team and the people.
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Learning from local knowledge
Thirdly, there is need to recognise that there are numerous
cross-cultural conflicts inherent in transplanting a western medical
model on a non-western culture and hence exploring integration of
medical traditions and cultures in a spirit of dialogue is very important.
This means often; more than involving the local dai or healer in the
health programme. It means learning from their knowledge and
experience and cross fertilising it with what is already known in the
more dominant and rational medicine. In this process, however, one
should also not allow a sense of romanticism about traditional or
indigenous systems of medicine making us uncritical of some of their
inherent values which may be similar to those of the dominant allo
pathic system. The relevance to the life of the poor must be an
important criterion in the dialogue and integration process. It also
means looking at the dominant western model with a more critical
focus rejecting all that is non-science and or anti-people in it.
Understanding societal processes
Finally, a people-oriented health system would help the people
to understand and appreciate the deeper links that ill health has with
societal processes so that health action could move towards wider
social issues and movements to enable people to demand health as
their right as well as to increase their autonomy —both individual and
collective—over health and organisations, means, opportunities, skills,
knowledge and supportive structures that make health possible. A
people-oriented health system would therefore have a strong dimension
of empowerment.
Is this Social Process Dimension and Value Orientation in Health
Action being Taken Seriously Today?
Our study-reflections show that this awareness is gradually
evolving as serious groups and committed project initiators subject
their action to a critical evaluation in the context of an ongoing social
analysis. For example,
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SOCIAL ACTION VOL 39 JULY-SEPTEMBER 1989
★The Deenabandhu Project (Tamilnadu) reports two emerging policy
changes in their project which symbolise the recognition of these
dimensions.
(i) A shift of the programme from its initial focus on total
community—rich and poor alike to a focus on the target
group of the powerless—the landless and the dalits.
(ii) Introduction of a comprehensive account of the nature of
poverty and its relationship to ill health, the unjust distribu
tion of land, oppression in the name of religion and other
factors in the women village health workers* training
programme to instill in their mind the class nature of ill
health.
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★ARCH Mangrol (Gujarat) records its experience of working among
the marginalised poor in the eastern belt of Gujarat and the movement
of their efforts from health of women and poor children to organising
the poor tribal villagers to challenge the unjust rehabilitation pro
gramme for villagers losing their homelands due to the Narmada dam
project.
★The Bodokhoni Project (Ganjam, Orissa) records the journey of its
health animators in helping the people to move from a magical under
standing of their problems to a critical one so that they can strike at
the root causes. Diarrhoea is not treated only with ORT but the
villagers marched to the block development office to demand a well as
a right of the citizens of India and then, when materials and resources
were made available, dug collectively their own well as a symbol of
their unity and mutual concern.
★Community Health Programme (Pachod, Maharashtra) records its
efforts in participatory management which emplies a redistribution of
power to take decisions and is convinced that this process can increase
health awareness, effect community reflection and increase demand on
health services apart from contributing to social change.
★Miraj Project (Maharashtra) records that due to its efforts in training
all health workers of various religions and castes together and with
taking their meals together, the age-old caste system is breaking down
and the dais from the dalits (low caste) are called upon by upper caste
Hindu women to conduct deliveries.
♦TAe Medico-Friends Circle, a national network of doctois and health
activists stands for the demystification of medicine, democratic
decentralised team functioning, active community participation, medical
practice built on humane values and equality and firmly opposes the
negative unhealthy values of our society whidh include glorification of
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PEOPLE-ORIENTED HEALTH CARE SYSTEM
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money and power, division of labour into manual and intellectual
workers, domination of men over women, urban over rural, foreign
over Indian.
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*The Community Health Training Team of the Catholic Hospital
Association of India (Secunderabad) defines community health as ‘a
process of enabling people to exercise collectively their responsibilities
to maintain their health and to demand health as their right’. Thus it
goes beyond mere distribution of medicines, prevention of sickness and
income generating programmes. Its training programmes for middle
level workers are therefore based on this perspective.
*The 'Mandwa Project' (Maharashtra) recounts that its experiment of
training semi-literate village women as health workers was opposed
by local powerful rich leaders and the government health personnel
since they demonstrated results superior to those of the professionals,
demystified health and reduced people’s dependency. This resulted in
loss of practice in the private sector, created surveillance and brought
accountability in a normally unaccountable public sector. The power
ful leaders were fearful of an alternative power structure developing
through the project.
All these examples taken together show that this social process
dimension is beginning to be taken seriously by many groups and there
is a move away from developing isolated models to locating the
initiative in a local socio-political cultural context.
It mus be recognised at this stage that most of the health-action
initiators in the NGO/Voluntary sector do not set out in their explora
tion of an alternative health care process after a thorough societal
analysis or a critical analysis of the political economy of existing health
and health care services. Much of the innovation and creativity is
therefore of an ad hoc nature, action and ideas evolving by trial and
error. There is, on the other nand, a lot of aberrations as well due to
this initial lack of understanding of ‘health in society*. This aberration
manifests itself in many ways.
(1) A gradual conversion from focus on the poor and indigent
to a preferential option for the well-to-do and paying
patient.
(2) A promotion of a distribution service and not the evolution
of an enabling empowering service.
(3) Increase in size, bureaucracy, compartmentalisation, overprofessionalisation and hierarchical decision-making cut off
from the lives of the poor.
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SOCIAL ACTION VOL 39 JULY-SEPTEMBER 1989
240
(4) A
‘
preoccupation with targets and records, numbers,
“die. «f
com™.
.h.« .
»
P.«ieip.ti«n, qu.l.ty uf «™e« •"'>
health abilities of the local people.
This is inevitable when health action is not located in a wider
a re-orientation become pre-requisites though not always easy.
Conclusion
This short exploration higHipMs
«( the action
of th. search for a people-ori.nted health
‘“to
I
highlights some of the social
that the project/process
recognised by health action m‘tiat°r
ople.orientation
that evolves through their effort does n
P0
somewhere along the way.
The examples given are a small selection
exoerience and reflections emerging m the country
Z” The main p>« of this paper »
“X 5
oriented health system must not become a quest
P
actions or a new technology fix.
It has to be a new vision, a new attitude of mind and a new
value-orientation in health action intertwined doseb' with efforts
to build an alternative socio-political-economic-cultural system
in which health can become a reality for all people.
A movement not a project
A MEANS NOT AN END
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PHOPLt-ORIBNTBD HBALTH CAM ««««
REFERENCES
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|
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- Media
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