“KARNATAKA MARCHES TOWARDS HEALTH PROMOTION IN 21st CENTURY”
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- Title
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“KARNATAKA MARCHES
TOWARDS
HEALTH PROMOTION
IN 21st CENTURY” - extracted text
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“KARNATAKA MARCHES
TOWARDS
HEALTH PROMOTION •
IN 21st CENTURY”
FOCUS
ON HEALTH
PROMOTION
DRAFT FINAL REPORT
JANUARY 2001
INTERNATIONAL UNION FOR HEALTH PROMOTION AND EDUCATION
SOUTH EAST ASIA REGIONAL BUREAU
KARNATAKA CHAPTER.
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•
“KARNATAKA MARCHES
TOWARDS
HEALTH PROMOTION
IN 21st CENTURY”
FOCUS
ON HEALTH
PROMOTION
DRAFT FINAL REPORT
JANUARY 2001
INTERNATIONAL UNION FOR HEALTH PROMOTION AND EDUCATION
SOUTH EAST ASIA REGIONAL BUREAU
KARNATAKA CHAPTER.
SECTION - V
Vision and Strategy Statements
51-52
Summary of the findings, discussion and Recommendations
A. Organisation
B. Manpower
53
53-54
C. Training and professional education
54
D. Functions
55
IEC Activities
School Health Programmes
55
E. Ethics, Advocacy, partnership for Health Promotion.
56
F. Funds
57
G. Intersectoral Coordination
57
Education Department
58
Information & Broadcasting Department
58
Other Departments
Other Recommendations
59
60-61
CONTENTS
PAGES
1. Preface
i
2. Topic
ii
3. The Process
iii
SECTION -1
4. Introduction
1
5. Objectives
1
6. Materials & Methods
2
SECTION-II
Literature review
7. Need for Health Promotion
6
8. New Challenges
6-7
9. Health Promotion
8
10. Ottawa Charter
9-13
11. Health Education
13-16
12. Advocacy
16
13. Social Support
17
14. Empowerment
17
15. Factors which determine health states
and Main Actors Responsible - An
overview
16 .Health Promotion & its Benefits
Benefits from control of environment
Benefits from behaviour changes
17-19
20
20
21-23
SECTION - 111
Health Education Bureau
17. Introduction
24
18. Structure of Section - I
25-27
19. Structure of Section - 11
28
20. Functions of Section - 1
29-32
21. Functions of Section - II
33
22. School Health Programme
34-36
23. Recommendations
37-39
SECTION-IV
24. Grass root Workers
•
40-41
25. Health Supervisors
42-44
26. Health Educators
45
27. Medical Officers of Health & Senior
Health Administrators.
45a
28. Recommendations
46
29. Interaction with other health related
Department
47
30. Interaction with non-govemment
organization
47
31. Interaction with people.
48-49
PREFACE
Health promotion is defined as a process of enabling people to increase control
over the determinants of diseases and disability and improve their health by their
own efforts.
The public policy and health policy in particular should be able to help people to
acquire health and sustain it for a long time, so that they remain productive for
more number of years and do not add to the burden of diseases and disability.
Health promotional policy works in this direction.
The Task Force of Health and Family Welfare of Karnataka Government wanted
to apply these principles into the Karnataka State Health Care Services. A rapid
assessment of the State of art of Health Education process was felt necessary and
this report is related to the assessment of the extent and method of implementation
of health promotion in Karnataka State Health Care System and to find out the
modalities of application of the principles of health promotion with a view to
integrate it with health education.
Topic
The topic is “Feasibility and modalities of application of principles of Health
Promotion and its integration with Health Education.
The Process
The Research Team after receiving the orders of assignment from the Karnataka
Task force on health and Family Welfare to take up rapid assessment of the
existing situation with regard to the structure and functions of Health Education
Wing of the State Health Department, prepared a research proposal and submitted
to the Task Force. After approval of the same, the rapid assessment was taken up.
The assessment involved:
1.
Literature review on health promotion.
Field visits to 16 Primary Health Centres in 4 districts to know the state of
art of health education activities and to assess the competencies of the
health manpower at the district and Primary Health Centre levels and the
organizations strengths and weaknesses.
3. Obtained the views of senior health experts who were closely associated
with the functioning of the Health Sector and present Health Education
practitioners in and outside the State.
2.
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Some data were collected from the Health Directorate and District Health
Officers about the structure and performance of the health education wing.
The data were analysed and discussed in the Seminar Organised for the
purpose.
6. This is the final report of the assignment.
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LIST OF TABLES
1. Statement showing the Number of Respondents planned and contacted.
2. Number of LE.C. Activities conducted from 1997 - 1999.
3. Number of School Health Education Activities - Target achieved.
4. Knowledge, Attitude & Practice of Grass root level Health Workers.
5. Knowledge, Attitude & Practice of Health Supervisee
6. Knowledge, Attitude & Practice of Health Educators.
SECTION - I
A. INTRODUCTION
B. OBJECTIVES
C. METHODS & MATERIALS
Introduction and Objectives of the Study
A. INTRODUCTION
The Task Force on Health and Family Welfare, Government of Karnataka
invited the Karnataka Chapter of the South East Asia Regional Bureau of the
International Union for Health Promotion and Education to take up a rapid
assessment of
the
"FEASIBILITY
AND
MODALITIES OF
APPLICATION OF PRINCIPLES OF HEALTH PROMOTION AND
THEIR INTEGRATION WITH HEALTH EDUCATION".
The Karnataka Chapter accepted the assignment and conducted the study. The
following is the report of the study.
B. OBJECTIVES
1. To develop a vision and strategy statement on health promotion for the
Karnataka State.
2. To examine the organizational structure and functions of Health Education
Bureau of the Directorate of Health and Family Welfare Services.
3. To make a rapid assessment of capabilities of health staff to undertake
health promotional responsibilities with particular reference to
competencies of grass root level health staff and their supervisors, block
level health educators, District Health Education Officers, Medical Officers
of Health of the Primary Health Centres and District Health and Family
welfare officers.
4. To assess the existing inter-sectoral coordination related to health
promotional activities amongst the different developmental departments
and non-governmental organizations at primary Health Centre, District and
State level.
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C. MATERIALS AND METHODS
A qualitative assessment was decided upon because of the time constraint
imposed by the task Force to complete the study. Though this is a qualitative
study and based on focus group interviews and observations, care has been
taken to see that the interviews of relevant staff and observations have been
made by the experienced researchers themselves to ensure credibility and
validity of the report.
1. Literature about health promotion published in the International and
National journals and WHO documents have been reviewed. It included
global strategy for Health for All by the year 2000 and Alma Ata
Declaration of 1978 on Health for all (H F A) 2000 and primary health care
published by WHO and Ottawa Charter for health promotion (1986). And
other documents and reports Reviewed are Report of an International
Meeting on public Health (New challenges) and Ninth general Programme
of work (9GPW) published by W FI O.
2. Information about the structure and function of the Health Education
Bureau were collected from the Directorate of Health and Family Welfare
Services and the District Health and Family Welfare Offices of four
Districts who are looking after planning and implementation of health
programmes in their district. These information have been tabulated and
analysed.
3. Data was also collected by interviews and from focus group discussions
and field observations of the primary health centre and District Health staff
regarding their competencies in health promotional activities.
4. Opinion of the health administrators, health researchers and health teachers
on some aspects of health promotion and practice, its importance and
feasibility and the competencies and skills required to implement health
promotional strategies have been collected by open-ended questionnaire
and analysed. Experts from the State of Karnataka and outside the state
were included in the study.
5. For field study one district from each of the four revenue divisions of the
State was selected. Sixteen Primary Health Centres, 4 from each district
were selected for observational study. The districts are kolar from
Bangalore Division, Bijapur from Belgaum Division, Bellary from
Gulbarga Division and Kodagu from Mysore Division.
3
6. In order to know the existence and extent of intersectoral coordination and
cooperation and involvement, representatives of various development
departments and non-govemment organizations were also included in the
study.
7. Criteria used for assessing the competencies and skill of the staff to
implement health promotional activities and opinion of public Health
Experts.
Criteria used
Rank assigned
KNOWLEDGE
1.
Has a clear perception of the meaning of
health promotion. His/lier job responsibility
and that of health department
High
2.
Has vague perception
Moderate
3.
Has no perception
Low
ATTITUDE
1.
He/she is very eager to promote health and
feels worthwhile to do health promotion
work.
2.
He/she feels that it is worthwhile, but shows
indifference and not so enthusiastic about
their job.
Moderate
He/she feels rather not concerned about his
job responsibility and about health
promotion or health education
Low
OPINION ON STATEMENTS
Strongly Agree
Agree
Agree with reservation
Disagree
Consenses
Exist
Consenses
Does not exist
3.
4.
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Statements made are related to the following.
1. Need for health promotion and Education.
2. Methods of planning health promotional activities.
3. Importance of social mobilisation activities.
4. Need for involving people in the health programmes.
5. Need for inter-action with developmental departments and non
governmental organizations.
6. Need for further training of health staff.
7. Additional training for Medical Officers of Primary Health Centres.
8. Need for re-orientation of syllabus in Community Medicine in MBBS and
MD courses.
9. Need for change in the attitude of policy makers towards public health and
health promotion.
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TABLE-1
STATEMENT SHOWING THE NUMBER OF RESPONDANTS WITH
THEIR DESIGNATION, PLANNED AND CONTACTED
SI.
No.
1.
Designation
Director of Health and Family
Welfare Services
2. Additional Directors of Health &
FW Services
3. Joint Directors of Health and FW
Services
4. District Health and Family Welfare
Services
5. District Health Education Officers
6. Dy. District Health Education
Officers Block Level Health
educates
7. Medical Officers of Health of
Primary Health Centres
8. Health Supervisors, Male and
Female
9. Health Workers Male and Female
(ANMs & Jr. H. Asst.)
10 Health experts and senior Health
Administrators
11. Non-Govt. Organizations
12 Other
Government
Sector
representatives
1. Education
2. Public Health Engineering
3. Agriculture
4. Horticulture
5. Women and Child Welfare
6. Information and Publicity
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Number
planned
1
No. Contacted
4
3
6
6
4
4
4
20
4
14
16
12
32
28
64
50
98
48
8
6
1
1
1
1
1
1
1
1
1
1
1
1
262
182
1
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SECTION - II
NEED FOR HEALTH PROMOTION
According to World Health Organization the definition of Health is “a state of
complete physical mental and social well-being and not merely the absence of
disease”. Despite this definition and its widespread usage, all over the world large
majority of people view the health in the context of curative medicine, often
described perhaps presumptually - as “modem scientific medicine.” Apart from
this, there is a pervasive misconception among health planners in many countries
especially in developing countries that good health is primarily a result of medical
intervention and hospital services and there has been a growing morginalisation of
public health.
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NEW CHALLENGES
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But the evidence available is quite the contrary. Mckeown’s research has shown
that past improvement in health has been due mainly to modification of behaviour
and changes in the environment. For example, Mckeown’s analysis of mortality
trends in U.K. between 1801 - 1971 has shown that mortality from infectious
diseases such as Tuberculosis, Bronchitis, Pneumonia, Influenza etc., as well as
from water borne and food borne diseases had already begun to decline even
before effective treatment became available.(1)
(1) Mckeown suggests that communities and Governments should look into
factors (behavioural and environment) to bring further advance in health
status of their countries.
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(2) Studies have also shown that extreme poverty of some l/5th of the world
population is the greatest killer and largest cause of human suffering.
Disparity in health exists between nations and the gap is increasing.
Healthier countries are becoming more healthier and poor health countries
are becoming poorer in health status. Just like rich countries becoming rich
and poor countries becoming poor due to imbalance in the economic
development. (2)
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(3) In addition, grave disparities in health condition remain within the
countries, communities and gender. For example poorer and less educated
people suffer from higher mortality and morbidity than those who are better
educated and have higher income within the country and communities.
Women cany the triple risk of death and disease because of reproductive
burden and gender inequality and social injustice in all walks of life.
Therefore, people who are relatively poorer, less educated and women
living in rural and semiurban and slums of big cities have less access to
health care system, suffer more from inequality and social injustice.(2)
(4) The emerging fourth challenge is the resurgence of old diseases like
Malaria and Tuberculosis and new diseases like HIV/AIDS and drug
resistance of insects and bacteria are all adding to the problem of health of
developing countries.(2)
3’
(5) The fifth challenge causing alarming situation both in developing and
developed countries is the increased cost of medical care due to social and
commercialization of medicine, in the advent of advanced diagnostic and
technological knowledge. Inspite of these advances and costly treatment,
there has been no improvement of health of the people in relation to
expenditure.(2)
(6) The 6lh factor causing concern is related to alcoholism, drug addiction,
tobacco smoking and tobacco chewing.
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In the face of these challenges, the approach and strategy for maintaining and
improving the health of the people should concentrate more on the root cause of
illhealth and diseases. These root causes or determinants of health and diseases are
related to (1) income (2) Education (3) Employment (4) Nutrition (5) Housing (6)
Safe Water (7) Sanitation (8) Health environment (9) Health care infrastructure
(10) People’s participation (11) People’s awareness, and level of skill (12) Primary
health care (13) Prompt diagnostic and therapeutic services and (13) Rehabilitation
services. These are the direct causes. The indirect causes are many and they
prevail in all walks of life of governance. Some of them, are public policy, health
policy in particular, light to health, access to health care, infrastructure and health
care providers, equity and social justice etc.
In these circumstances peoples health can be improved and sustained only by
comprehensive plan of action that cuts all roots and rootlets that cause illhealth.
For this to happen, all the people and the concerned government organizations,
voluntary organizations and religious organizations, Industries should come
together and work at all levels from the top policy makers (political, social and
religious leaders) to peoples representatives.
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HEALTH PROMOTION
What is Health Promotion ?
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Health Promotion is defined broadly as a process of enabling people to increase [|
control over the determinants of illhealth and improve their health. In essence,
health promotion is Social and Political action. It seeks to empower people with
knowledge and understanding of health (health education) and creating conditions ||
conducive to healthy living and healthy life style (social support). It reaches and
involves people through the context of their every day lives, such as homes, work l|
places (Industries, offices) learning (schools and colleges), and play ground ''
recreation facilities, and eating establishments.
Health promotion takes a developmental approach to health, whereby health is
considered as the goal and is a result of the activities of all development sectors
like housing, local governments, education, industry, agriculture, transport
services etc. Development approach promotes stronger heal th programmes
characterized by greater relevance to various development sectors such as school
health, healthy cities, healthy villages, and healthy food markets etc.(3)
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In her opening address to the 5lh global conference on health promotion in Mexico
Dr. Gro Herlem Brundtland, Director General, World Health Organization stated |
that “Promoting health is about enabling people to keep their minds and bodies in
optimal condition for as long as possible. That means, that people know how to
keep healthy. It means that they live under conditions where healthy life styles are
feasible. It means that they have the power to make healthy decisions - within
them selves, community, local government and within the State. (4)
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The UNICEF “State of Health of World’s Children - 2000” (5) presents evidence
to show that India is not investing sufficiently in mother and child care despite tire
fact that infant mortality rate and under 5 mortality rate are not showing any
decline in 2000 as compared to 1998-99.
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II. OTTAWA CHARTER AND JAKARTA DECLARATION ON
HEALTH PROMOTION
Significant features of the Charter
1.
Ottawa charter define health promotion as a process of enabling people to
increase control over the determinants of illhealth and to improve their
health.
2. Health is seen as a resource for every day life and not objective of living.
3. Health promotion is not just securing of health, but goes beyond healthy
life styles to well-being.
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4.
Pre-requisite for health are: (1) income (2) food (3) shelter (4) sustainable
resources (5) social justice (6) equity (7) water supply and sanitation (8)
education. Improvement in health requires a solid and secure foundation in
all these basic needs.
5.
Political, economic, social, cultural, environmental behavioural and
biological factors can all favour health or may be harmful to it. Health
promotion action aims at making these conditions favourable to health
through advocacy.
6.
Health improvements require secure foundation in (1) a supportive
environment (2) access to information (3) development of life skills and
opportunities for making healthy choices (4) equal opportunities for all
segment of the population to get free access to health and related services
irrespective of class, creed and gender difference. Health promotion aims
at enabling people to take control of those things which determine health.
7.
Health pre-requites and health supportive accessories cannot be ensured by
health sector alone. It demands coordinated action by all concerned, by
governments, health and other social and economic sectors, by nongovernmental and voluntary organizations, by local authorities, local
communities, families and individuals. Health promotion action aims at
bringing coordination between various sections and media, between
differing interests in society for the pursuit of health.
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Based on the above principles, the Ottawa Charter suggested the following action.
1. Build Healthy Public Policy
The health promotion agenda of the policy makers in all sectors, at all levels of
government and society directs them to be aware of consequences of their
decisions and accept their responsibility towards health. Health promotion policy
combines diverse, but complementary approaches like (1) legislation (2) fiscal
measures (3) taxation and (4) organizational changes. It is the coordinated action
that increases income, foster greater equity and social justice to individual family
that counts to improve health. The health promotion policy requires the
identification of obstacles to the adoption of healthy public policy in both health
and non-health sectors and finds ways and means to remove them and thus helps
policy makers to make healthier choice.
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2. Create supportive environment
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Creation of an environment supportive and sustainable is a prerequisite for health.
Intricate links exist between people’s health and their environment and this is the
basis of socio-ecological approach to health. While conservation of natural
resources should be encouraged through out the world as a global responsibility,
the modification and creation of sustainable new resources for health should be the
responsibility of every nation and every community.
Supportive environment consists of two cortiponents. One is the physical
environment and the second is the social environment. As for as physical
environment is concerned, that every person and family must have minimum
health infrastructure and it should be easily accessible, he/she must have work and
minimum income to possess and utilize the infrastructure. The way society
organizes work would help to create a healthy environment. Health promotion n
generates living and working conditions that are safe, stimulating, satisfying and
enjoyable.
Social environment is concerned with changing old behavior pattern or adoption
of new behavior pattern is of course possible only when man or woman is
motivated and committed to behavior change. But the process of motivation and
commitment can be made easier and quicker by creating social environment which
creates critical mass in the community. That is the opinion of family, peer groups,
formal and informal leaders and religious groups should support a particular
behavior. It may be about small family norm, giving up tobacco and alcohol,
extramarital sex or age at marriage etc.
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These health promotion activities helps to create and sustain such social pressure.
The concept of supportive environment implies that action is oriented towards
determinants of the health of the population. This is used to build bridges between
sectors and professions, between theoretical concepts and practical action for an
improved environment and public health and between the developing and
developed countries,
Achieving supportive environment will require a new awareness of the
possibilities for improving health through environmental change. It will also
require a strong future orientation that links public health to sustainable
development and consequently require a new emphasis on strategic planning and
development of management skills to facilitate cooperation between sectors.
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3. Strengthen community action
Community action playt a very significant role in making people believe in what
they do and how they do and behave. It cements their belief. Therefore,
community action programme, where they plan, take decisions, implement them,
mobilizing their own resources and take control over and own them should be
encouraged. Community development draws on existing human and material
resources in the community to enhance self help and social support and to develop
flexible systems for strengthening public participation and direction of health
matters. This requires, full and continuous access to information, learning
opportunities for health as w'ell as funding support.
4. Develop personal skills
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Education for health and enhancing life skill development are important, because
they increase the options available for them to exercise more control over their
own health and their environment, which sustains health. Enabling people to learn
through out their lives, to prepare them for all stages of life and cope with the
illness and injuries are essential. This has to be facilitated in schools (school
health) home, work place (occupational health) and community setting. Health
promotional activities extends to these areas through educational, professional,
commercial and voluntary bodies,
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5. Reorient health services
Health sector and health professionals remain/ the sheet anchor of health
promotion. They must plan efficient system of primary health care service through
out the country from villages to metropolitan cities. They must involve local
governments and people to take control of them. They must move increasingly in a
health promotional direction beyond clinical and curative services. Health sector
and health professionals need to embrace an expanded mandate which is sensitive
and respects cultural needs. This mandate should support the needs of the
individual and communities for a healthier life and open channels of
communication between the health sector and broader social, political, economic
and environment components. The health sector and other sectors of government,
voluntary health organizations and other groups in the community must work
together and contribute to the pursuit of health.
Jakarta Declaration on Health Promotion into the 21st century.
The Jakarta Declaration on health promotion offers a vision and focus for health
promotion into the 21st century. Its main emphasis is to tackle health determinants
and for this, it draws upon widest range of resources from all sides. The
declaration recognizes that health promotion is an essential element for health
development. Health promotion, through its investments and actions on
determinants of health, contributes significantly for the reduction of inequalities in
health, ensure human rights and build social capital which is so important for
health and well-being of people. The ultimate goal of health promotion, as
envisaged in the declaration, is to increase in the health expectancy and to narrow
the gap in health expectancy.
The Jakarta declaration endorses all the five Ottawa Charter Strategies
Charter strategies:
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Build healthy public policy
•
Create supportive environment
•
Strengthen community action
•
Develop personal skills
•
Reorient health services
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In addition, the following five priorities for health promotion have been suggested.
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Promote social responsibility for health of decision makers.
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Increase investments for health development
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Consolidate and expand partnership for health.
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Increase community capacity and empower the individual
Secure an infrastructure for health promotion.
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The Declaration calls for action to speed up progress towards health promotion
giving priorities for the following:
1.
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Raising awareness about the changing determinants of health.
2. Supporting the development of collaboration and networks for health
development.
3. Mobilisation of resources for health promotion.
4.
Accumulating knowledge on best practices.
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Enabling shared learning.
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7.
Promoting solidarity in action.
Festering transparency and public accountability in health promotion.
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Jakarta declaration called on W.H.O. to take the lead in building a global health
promotion alliance and enabling its member States to implement the action
programmes. A key part of this role is for W.H.O to engage governments, nongovernmental organizations, development banks, U.N. agencies, inter-regional
bodies, bilateral agencies, the labour movement and cooperative as well as private
sector in advancing the action priorities for health promotion.
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III. HEALTH EDUCATION
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The widely used definition of health education is “Health Education is a process h
which affects change in the health practices of people and in the knowledge and ||
attitudes related to such changes”. (6). This definition implies that health
education is a process, it involves series of steps, it is concerned with establishing
changes in knowledge, attitude and behavior and also involves efforts by the
people. Aims of health education as formulated by W H O (7) is to (1) ensure that II
health as a valued asset to the community (2) equip people with skills, knowledge
and attitude to enable them solve their health problems by their own efforts and (3)
to promote the development and proper use of health services.
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Health education in the context of health promotion concept.
According to a position paper on health education jointly prepared by International
Union for Hygiene Education and division of health education W. H. O. Geneva with support from Centre for communicable diseases Control U.S.A. (8), health
education is the combination of planned social action and learning experiences,
designed to enable people to gain control over the determinants of health and
health behaviors and the health status of others.
Planning
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2. The people who use this data must be knowledgeable in isolating those
factors that affect health and also must possess skills to determine the
relative importance of these factors.
3. To ensure the needs and interest of the target population, they must be
involved in the planning process.
4. People’s participation assures that there is a rapport with people and a
basis for pursuing mutual efforts and partnership. It should be
characterized as doing something “with” rather than “to” the people.
Health programmes are more successful when target population perceive
the problem and solution in question to be the most important and
appropriate respectively. People are found to act on issues they judge to be
important to them.
6. Creating demand for health is an important responsibility of health
education. For example, people may not judge a given problem or i^sue to
be important simply because they are unaware of its magnitq^ p|
prospective and long-term effects
5.
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Planning must be based on the consideration of relevant information. This
information must provide multiple factors that influence the behavior and
health related outcomes of interest and must account for the needs of
interests of the target people.
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Learning experiences
7, Numerous factors influence the learning process including literacy, access
to services and media resources, readiness for change health beliefs,
environmental and social barriers and social reinforcement. Therefore, the
health education programme planning must take into consideration not
only for technical education barriers such as illiteracy, but also for social
and economic barriers.
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8. There are difference^ in the way people receive, process and act on
information. So health education programme must be prepared to offer a
variety of learning methods and strategies to maximize the probability of
attaining the desired educational and behavioral outcomes and necessary
social change.
9. Combination of health education methods are important in effective
communication. This depends upon the characteristics of the target
population, active involvement of collaborating organizations and
representatives of the community as partners, availability of resources and
competence of the persons conducting the health education programme.
10. There is no single model or method that holds universal superiority, health
education specialists, must understand a variety of educational, behavioral
and social sciences theories.
11. Those who plan health educational programmes must be capable of
adopting educational strategies for various sub populations of that
community on the basis of characteristics that may be practically
identified, such as age, sex, neighbourhood, ethnic and cultural identity.
12. Therefore, the older concept of health education is not sufficient to meet
the needs of health promotional goals. It should strive to enable people to
identify the determinants of health and take action to nullify their effects
bn health and take control over the measures to protect, preserve and
promote health. The task of improving health is not only confined to health
sector, health professionals and health communicators, but to all
developmental sectors of governments and non-govemment organizations,
religious leaders, traders, industrialists, politicians and all those concerned
with governance of the country and who matters for running the country
towards development, progress, and happiness.
Health sector, health professionals and health communicators have a
v
9 I
a "
g
9
9
special role to play. They should act as coordinators, advocates and
facilitators of health promotion.
16
Action required for individual countries or states with in the countries for
health promotion.
In order to provide action plan for promotion of health in developing countries,
W.H.O. Working Group on Health Promotion convened a meeting of senior health
administrators in the region in 1989. The group identified the following areas for
action.
1. Enhancing health knowledge and understanding is the first essential step in
health supportive action by people.
2.
Creating conditions - (social and environmental) that are conductive for
health is another essential requirement.
3. These can become a reality when there is high level of awareness for
health among policy makers, politicians, economic planners Health
Researched, and the public people.
,
;
When the awareness is transferred into policies and legislative support, favourable
resource allocation for health would follow. Thus full mobilization of all social
forces for health will be needed for health promotion. In order to achieve these
goals, three fold strategies are recommended. They are (1) Advocacy (2) Social
and Environmental support for health and (3) Empowerment of people for health.
7j *
Brief description of Advocacy Social Support and empowerment.
J
1. Advocacy:
* •
c
?
?
5
3
3>
2 •
3’
3
9
Advocacy is the process of providing evidence based knowledge to people so that
they become convinced and committed and take appropriate decision in favour of
the action required. Thus Advocacy is helpful in generating public demand and
bring about health issues in every day activities. It helps policy makers and elected
representatives to make right kind of decisions in the allocation of financial
resources for community health. It helps religious leaders to become more
committed and convinced and help spread scientific way of life to the people. It
convinces political leaders to realize the need for support people’s wishes and try
to reorient health system. Advocacy to professional people helps in creating
motivation and interest in researching problems that affect people’s health and
find scientifically based strategies to solve health problems. Finally Advocacy
helps create critical mass of interest and support positive health and makes people
to take healthier decisions.
17
Social support for health
Social support means creating and mobilizing favourable public opinion in favour
of health behaviour. This helps in legitimization of a particular action. It may be
small family noun, giving up smoking or givingHimhealthy habits and take
decision to build a sanitary latrine in the house. Public organizations and
institutions like, Youth Clubs, Mahila Mandals, Panchayats and other social
groups, are very usefull in these matter.
,
Building health infrastructure in villages and towns and cities is another social
support system. Health infrastructure like (1) protected water supply (2) sanitation
and sewerage system (3) building health centers and hospitals within the easy
reach of tire people and (4) provision of good roads and transport etc.
>
Empowerment of people for better health
> ■
,
■
‘
Empowerment of people means, providing health literacy and spread of
knowledge to all and motivate and create interest in them so that every body
become self-supporting in health. Inculcation of knowledge and helping people to
develop required skill and capacity to acquire positive health and maintain it. It
includes suitable employment to every body equitable access to health,
infrastructure and health advise and health care services.
-
Thus favourable decisions of policy makers and those who allocate resources at
the State and Central levels are crucial. Followed by proper planning, strategy,
development for health promotional activities at State and District level are
essential. Directorate of Public Health must have adequate manpower and
resources to implement the programmes effectively and monitor and evaluate and
provide feedback to the programme managers. In addition, the people should
participate in planning, implementation and management of health programmes at
grass root level in every village, town and city if health promotion is to become a
reality.
■»
..
Factors which determine health status of the population and main actors
responsible - An Overview
)
-
,
1. Individuals, Family and the Communities
2. Local, District and State level Government health Organizations
3. Sectors other than health
W
'49
U7
W
3
3
4. Central Government.
HEALTH DETERMINANTS THAT NEED ATTENTION
1. Individuals Family and Community
-
’
;
\ s
r
>
7
) '
?
s
'
?
?
g
5 f
5
5
3
2. Health Ministry (State) Health
System services, health research
community.
While genetics cannot be changed, the
person’s awareness, knowledge, skill
life style play an important role. Family
decides the way of living, nutrition
standard, home environment. Family
also decides about education, how many
children are wanted, handle family
conflicts, how to care for disabled
members. The community influence the
health of its members through safe
water supply, sanitation, education,
shelter, handling violence and un
employment.
Health
Ministry
and
health
professionals are responsible for:
a: Health legislation
b: Health policies and budgeting
c: Health education
d: Provide primary and secondary
health care.
e: Make available minimum health care
facility accessible for all.
f: Administer and manage health care
facility so that the services are actually
rendered on day to day basis.
g: Develop and maintain research health
planning,
monitoring
health
programme,
implementation
and
determining health impact of health
programmes and to provide needed
evidence to the policy makers and
allocation of health resources.
h: Training and maintaining pool of
medical and health personal of various
levels
of
expertise,
health
administration etc.
19
3. Sectors other than health
1. Government Sector
2. Non-Govt. Sectors.
Almost all sectors of economic activity
have an impact on health status of the
community through national or regional
policies and decisions. For example
Farm and Food Policies have a direct
impact on health so also water supply
and sanitation and primary education,
environmental
pollution
and
degradation due to uncontrolled
industrial pollution have indirect
impact.
Social security system for working
people and senior citizens, level of
employment, control of criminality and
violence have indirect effect.
4. Central Government
T
5
5
3
9
3
i)
3
5 ■
57
©
Rural and urban development, housing,
industry, energy and transport sectors
have both direct and indirect effect on
health, the effectiveness and efficiency
of administration and also measures to
limit corruption have additional impact
on community health.
Although Central Government is far
away from health situation of the
individual, the macro economic policies
of the government and principles of
good governance in general both have a
direct impact on health. Economic
policies and the allocation of budget
between the various ministries, the
degree of commitment of the ministries
for their mission, the efficiency and
effectiveness of administration and the
research policies pursued by the
government have all impact on health
problems.
20
Health Promotion and its benefits
A.
Benefits From the Control of ENVIRONMENT
Experience of the western countries is striking to demonstrate the vast benefits of
health promotional activities (action in the root causes) that accnie to mankind.
These countries brought down infant mortality rate from 200/1000 in 1880 to
about 70 by 1930. The morbidity and mortality due to gastro-intestinal disease
come down markedly during the same period. 60 to 70% of these improvements
are attributable to safe water supply provision of sanitation, good housing
Nutrition, education and behaviour changes like personal hygiene and practice of
small family norm by majority of the people in those countries.
v
India missed Industrial Revolution so also Sanitary revolution that brought ,vvast
improvements in the standards of health of Western Countries. India under the
foreign rule for over 200 years, with its deep entrenchment in tradition,
superstition etc. is still even in the wake of 21st century and independence is still
experiencing the very high preventable mortality, morbidity and disability. This is
because, very little attempts have been made, to act on the root causes of illhealth.
Even in the 21st century, nearly 40 to 45% of people do not have water supply
(70% do not have safe water supply) 65% do not have toilet facilities, 40% of
women between 15-49 years suffer from preventable anemia and 35 to 38% of
women have body mass index below 18.5 kg/m, and 44% of children under 3
years are underweight. These are tlie examples to show how the country’s health
system is neglecting the health promotion activities. The experience of the western
countries who are implementing some of the health promotional programmes in
their communities against chronic and behaviour related disease shown substantial
improvements in health of the population besides brining down the burden of
diseases and social costs.
The evidence that health promotional policies and actions yield substantial health
benefits is bpitfg accumulating. The experience of the western countries who have
implemented and are implementing health promotional programmes in their
communities have shown substantial improvements in health of the population
besides bringing down the burden of diseases and social costs.
21
B. Benefits from behaviour modifications
1. School Health
School health programmes in promoting better health show clear evidence of
achieving higher literacy levels, reductions in dropout rates, cassation of smoking,
reduction in substance abuse, reduction in social consequences of teenage
pregnancy. School health promotional programmes can be effective in transmitting
knowledge, developing skill and supporting positive health choices. The evidence
indicate that greatest effectiveness lies when programmes are comprehensive and
"holistic" linking the school with health services, and where adequate attention is
given for teachers training. Health promotion in schools has emerged very strongly
in the last decade in Europe and is spreading to the whole world as a mechanism to
combine a variety of elements achieving maximum health outcomes.
2. Cardiovascular diseases (CVD) and Cancer.
x
, „
There is clear cut evidence that cardiovascular diseases come down significantly
when health promotional activities like campaign against smoking change in
dietary habits, encouraging physical exercise are implemented. For example in
Finland, cardiovascular mortality has reduced by 73% since 1772 and all cause
mortality has been reduced by 50% in working age of population over the same
period. In a similar way, North Caroline experienced 71% reduction in lung cancer
mortality and 44% from all other cancers.
’
?
■:
Other studies show that programmes aimed at changing lifestyle habits bring very
positive health benefits. For example, WHO collaborative study in Belgium for
CVD prevention resulted in 25% reduction in CVD mortality. Programmes aimed
at lowering serum cholesterol through healthy diet produced an average reduction
of 15% serum levels of cholesterol among school children. One percent reduction
in serum cholesterol act ion through dietary knowledge would bring a 2 to 3%
reduction in coronary heart diseases. This was evident in Nevertheless campaign
launched by super markets.
< '•
x
^3
,
%
a.
9
3. Reduction of smoking benefits
The World Bank estimates that economic burden from smoking including health
costs and loss of productive capacity by disability or death is around 200 billion
annually. 50% of all smokers lo0se 20 years of life expectancy. Besides smokers
pollute the atmosphere in their homes and public places. Smoking habits can be
brought down by variety of health promotional measures like pricing cigarettes
and legislation. There is evidence that 10% increase in the price of cigarettes
(through taxation) leads on average to a 5% decrease in the quantity smoked and
22
the decrease in 15% among young people. Legislation restricting smoking in
working sites in Finland led 2.4% smokers quitting smoking and 14.3% reducing
the quantity consumed.
■
j
1
)
j
->
Further, smoking cessation programme in schools have resulted in 30 to 50%
fewer smokers, especially in peer groups. However, there is also evidence to show
that without follow up with multiple strands of action, these rates do not hold.
Smoking cessation programmes over a 20 year- period have yielded 13% less
mortality from coronary heart diseases, 11% less from cancer mortality. Among
pregnant women smokers cessation of smoking has resulted in lowering the risk of
low birth weight and reduction of obstetric complications. Smoking cessation is
found to be most cost effective programme. The cost per life year gained from
such programmes ranged from 2000 to 5700, whereas the cost per year gained
from treatment for mild hypertension is up to 8600 and the cost of extensive drug
treatment per life year gained is more than 192,000.
3 v
4. Mental Health and health promotional activities.
'
3
5 .
’
There is significant evidence to show that mental health promotion strategies have
reduced depression, reduced suicide rates and reduced behavioural problems.
Swedish Educational Programme have shown very positive results. For example,
there was reduction of suicide rates for 19.7 cases/100000 population to 7.1 cases
after 3 years of programme implementation. Besides there was economic benefit,
the number of inpatient days reduced by 70% and there was also savings in the
amount of tranquilizers and anti-depressant drugs used. Other mental health
promotional programmes have reduced teenage pregnancy HIV infections, 75%
reduction in pre-term delivery, reduction in low birth weight babies and babies
brain damage.
3
?s .
5. Healthy Ageing
•?
'
3
5
3
3
©
9 -
&
9 9
9
9
The real key to healthy ageing is to begin health promotional early in life.
However, there is evidence to show that application of health promotional
activities like, physical activity even at the age of 50 can bring down substantially
cardiovascular mortality and risk of falls and enhances cognitive function of the
mind. The impact on society is seen in keepin the elderly population active and
therefore productive for a longer period, reducing health and social costs. The
available evidence show that maintaining healthy life styles in old age is directly
associated with health gain.
23
’ •
6. Healthy Equity
Equity in health is gaining ground in recent years. WHO describes equity as a fair
opportunity provided for all people to enjoy health to their fullest potential. It does
not mean equal health status for every one, but it means reduction of differences
between people's health as much as possible through equal opportunity for health.
*
’ v
y
.. .
.
There is evidence to show that socio-economic conditions related to income,
education and employment are at the root causes of illhealth. Even in Europe,
substantial number of people (57 million in 1993) lived in 23 million poor
households. Even in rich countries, people with means live several years longer
and have fewer diseases and disability than people without resources.
Relative deprivation has shown to have profound effect on health rather than
absolute poverty. Relative deprivation can have poorer education, low skill
development, higher unemployment and lower capacity to deal with information
and lower material resources. There is strong evidence to show that relative
poverty is closely linked to poorer health. Many equity interventions for health are
found to have impact at community level. People can gain increased ability to
solve their problems at every stage of participation or involvement of the local
community.
Healthy cities concept of WHO's Health for All strategy with hundreds of people
participating provides a strong multi-agency framework for development. Such
programmes have shown evidence of effectiveness including generating increased
income, through work opportunities, improved community support with
counseling services and better community involvement etc.
3
Data also show that health and education are most important and powerful forces
for economic development in poorer countries. Basic investment in health and
education can produce positive economic outcomes. This kind of investment in
Trinidad, Cuba, Chile and Cost Rica has reduced poverty to less than 10% of the
?
population.
©
9
3
I
a
9
S3 A
References:
1.
McKeown T - The role of Medicine - Dream, Mirage or nemisy, Lodon
Nyffield Provincial Hospital Trust 1976.
2. New challenges for Public Health - Report of an inter-regional meeting,
Geneva, 27-30 November 1995 (Page 7 & 8) from World Health Report
1995.
3. Ottawa Charter for Health Promotion.
4. Opening address of 5th Global Conference on Health Promotion - Mexico
- 2000. Promotion and Education quarterly, 2000, Vol. VIII/3, Page -15
5. UNICEF State of World Children - 2000.
6. Society of Public Health Education (1966) Health Education Monographs
No. 21, New York.
7. W.H.O. (1954) Tech. Rep. Ser. No. 89.
8.
Extract from meeting Global Challenges - published 1UHPE Board
Meeting - Souvenir - April 2000
Page 23.
9. Development of Competency - based on University Health Promotion
courses by P. Howat, et al - Journal of Promotion and Education Vol.
VII/1, 2000 Pages 34 - 35.
10. A Practical Frame work for setting priorities in Health Research.
11. Human
Development - South Asia’s Educational Renaisance UNESCO.
12. Health Promotion in Action - Voluntary Health Association of India.
13. Health Promotion - Dr. H. Nakajima, Director-General (Retd) W.H.O.
14. Malnutrition - A South Asia Enigma - Dr. Ramalingaswamy & Jonson
& J. Rhode.
15. A call for action - promoting Health in Developing countries W.H.O.
24
SECTION - III
Health Education Bureau
1.
2.
3.
4.
5.
6.
Introduction and objectives
Structure of Section I
Structure of Section II
Functions of Section I
Functions of Section II
Recommendations
I HEALTH EDUCATION BUREAU
1. Introduction and objectives
The State Health Education Bureau (SHEB) was started in the Directorates of
Health and Family Welfare Services in the year 1930. The Bureau was reorganised
in 1965 with the assistance of Government of India, W.H.O. and UNICEF.
Stalwarts like Dr. V. Ramakrishna and others played a significant role in bringing
about the establishment of the SHEB in the Department of Public Health in the
then Mysore State. It was nurtured and enriched by many eminent Directors of
Public Health of Mysore State and latter Karnataka State ever since. World Health
Organization, Rocke-feller Foundation and other International Health
Organisations also helped the growth of the State Health Education Bureau.
The Bureau developed a sound health education policy forfhe state and exerted its
influence in improving the health status THROUGH HEALTH EDUCATION. The
Bureau laid down long term and short term objectives, structure and functions
needed to reach those objectives.
A. Long term objectives
a.
To help people to achieve health by their own actions and efforts.
b. To obtain people's active support and participation for public health
programmes and policies.
c.
To assist people to shoulder the responsibility for health.
d. To encourage people to demand more and better health services.
25
B, Short term objectives
a.
To collect baseline data of the prevailing health conditions, health
attitude, beliefs and values etc.
b.
To educate the people on health matters by various methods and
evaluate the relative effectiveness of the methods and channels of
communication.
c.
To provide in-service training in health education for all categories of
health staff.
d.
To produce health education materials and reproduce them wherever
needed.
To reach the above objectives, the Bureau laid down the following activities.
1.
Planning, organising and directing State-wide health education activities.
2.
Conducting studies regarding baseline data, health educational needs,
resources, priorities etc.
3.
Determine the appropriate channels of communication and develop
effective methods and materials for their use.
4. Training of the personnel of health and family Welfare Department
on health education methods.
5.
Assisting, organizing and conducing of seminars conferences,
family group teaching etc.
6.
Fostering cordial intra and inter-departmental coordination and
building good relationship with non-governmental organizations.
7.
Dissemination of scientific information for people, through various
channels of communication.
26
Il STRUCTURE AND FUNCTIONS
A. STRUCTURE OF THE HEALTH BUREAU - I
The State Health Education Bureau consists of two Divisions. First Division is
headed by the Project Director, Reproductive and Child Health Services and
Second Division is headed by the Additional Director, Health Education and
Training. Functionally also the first Division is concentrating on health and family
welfare and the second Division is concentrating on School Health, Training,
Nutrition etc.
SI.
No.
Category
______________________ ;
1.
2.
3.
4.
5.
6.
7.
8.
----------------------- ---------------------------Joint Director A1-1’
Deputy Director
Field Publicity Officer
Editor
Assistant Editors
Health Education Officer
Health Educator
Social Scientist
Sanctioned
Working
1
2
1
1
2
1
1
1
1
1
—
1
—
—
31
104
7
78
782
517
At State Level
1
—
At the District Level
1.
2.
District Health Education Officers
Dy. Dist. Health Education officers
At the Primary Health Centre Level
1.
Block Health Educators
Health Educators with Diploma in Health Education (DHE)
No. with
DHE
State level
Distinct level
Pry. Health Centre
Teaching Staff
Total
10
130
51
26
217
No. without
DHE
—
5
466
—
471
Total
10
135
517
26
688
£.Os
27
Comments
The strength of the staff and their qualification at the State level is adequate, but
the vacant posts should be filled up.
At the district level, 104 posts have been sanctioned for 27 districts at the rate of „
more than 3 per district. Whereas, only 782 posts of Block level Health Educators
have been sanctioned for 1685 Primary Health Centers. At the rate of one Block
Level Health Educator per primary Health Centre, still 903 posts are to be created. *
This is very difficult to achieve in the near future, because, it involves heavy
expenditure and no trained and qualified Health Educators are available for ?
recruitment.
Besides taluka level health officer posts which are sanctioned recently to
strengthen the administration and management of health programmes in rural
areas. This is a good development and this taluk level health office should be
strengthened with posts of Health educators. Therefore, there is need to reorganise
the distribution of available Block Level Health Educators between talukas and
PHCS.
<5
2
28
STRUCTURE OF THE HEALTH EDUCATION BUREAU - II
This action of State Health Education Bureau consists of the following staff.
SI No.
Category
Additional Director
Joint Director
Training Unit
1. Training Officer
2. Health Superviser
Student Health Education Unit
1. Deput)- Director
2. Assistant Director
3. Dist. Nursing Officer
Audio-Visual Unit
1. Technical Officer
2. Artist cuin-photographer
3. Artist
4. Sub-Editor
5. Projectionist
6. Craftsman
7. Silk-Screen Technician
Field Study & Demonstration Unit
1. Technical Officer
2. Health Superviser
3. Public Health Nurse
4. Home Science Assistant
5. Social Scientist
6. Teacher
Exhibition Unit
1. Technical Officer
Sanctioned
Working
1
1
1
(vacant)
1
1
1
1
1
1
1
V
1
1
1
1
1
1
1
1
1
V
V
V
1
1
V
V
1
V
1
V
1
1
1
1
1
1
1
1
V
(0 U1
FUNCTIONS
A. INTRODUCTION
<ii)
The main function of the Division 1 of Health Education Bureau is to plan,
implement and monitor health education activities pertaining to family welfare in
rural areas of the State. These activities are implemented and monitored through
the District Health and Family Welfare Officer at the District level and Medical
Officers of Health at the Primary Health Centre level under the over all
supervision and control of respective Zilla Panchayats. The bulk of the work is
carried out by the grass root level workers and Health Supervisers. Block level
Health Educator organise, the IEC activities involving grass root level workers and
local non-govemment organisations and public people. He also guides Health
Workers and Supervisers and monitors the health education activities.
<3
9
29
At the district level, the District Health Education Officer prepares a district plan
of 1EC activities. He supervises and monitors all health education activities
throughout the district. He undertakes tours and meet and discuss the health
education issues with other developmental sectors of the government and local
non-govemment organizations. He is also resource person for local NonGovemment Organisations for health education activities.
B. OBJECTIVES, STRATEGIES AND METHODS USED FOR THE IEC
ACTIVITIES.
a. Objectives:
1.
Promotion of higher age at marriage.
2.
Promotion of spacing methods.
3.
Promotion of terminal methods for those who are having more than two
children.
4. Involving people in IEC activities.
5.
Motivating people to demand Reproductive and child health services.
6.
Encouraging people's participation.
7.
Discouraging gender discrimination with respect to conception and child
care.
8.
Encouraging 100% ante-natal registration and care.
9.
Motivating and encouraging parents to care for infants and under 5
children especially in the matter of nutrition and immunization.
b. Strategies used for IEC activities
Most of the IEC activities are 100% centrally funded and sponsored. They are
planned at the State level as per guidelines given by the Government of India and
given to the districts for implementation, monitoring and reporting. The number of
activities and methods to be used are fixed depending upon the total grants
received. At the district level, the number of IEC activities are divided among
several Primary Health Centres in the district and given to the Medical Officers of
Health for implementation.
30
c. Method used
All the standard methods of health education are used. They are:
a. Mass media, Door Darshan, Radio, Press, Video films.
b. Folk media - Dramas and street plays.
c. Exhibition.
d. Personal communication by grass root level workers.
e. Group discussions:
1.
2.
3.
4.
5.
Mother Swasthya Sangha (MSS)
Atte Sose Samvada
Village Health Committee
Village Panchayat
Local S.H.G. and youth and Yuvathi Mandals
31
Table - 2
Number of IEC activities by conducted in the last 3 years
Targeted & achievement during the last 3 years
1997, 1998 and 1999
SI No.
IEC activity
Target
Achievement
% of achievement
1.
Film Shows
14400
6198
43
2.
Film strips
40500
40204
99
3.
TV & VCB
4050
2500
4.
Folk media programme
2700
2500
90
5.
Multi-media campign
-nil-
169
—
6.
Press advertisements
-nil-
979
—
7.
Press release
-ini-
4273
—
8.
Exhibition - major
14400 2
5390
37.3
9.
Dramas
32
—
10.
Healthy Baby shows
10735
9222
86
11.
Mahila Vichara Vinimaya
12615
9770
77
12.
Mother-in-law and Daugher-inlaw program
8545
6921
81
13.
Mahila Dinacharini
6320
5073
80
14.
MSS Workshops: Taluka
Districts
175
9
160
9
90
100
15.
Folk Artist Workshop (1997)
19
8
16.
Village level MSS Tmg.
programme (1997)
3215
2920
C. Budget made available for IEC activities
SI No.
1.
2.
3.
Year
1997-98
1998-99
1990-2000
Budget
75.01 lakhs
90.86 lakhs
61.48 lakhs
1
H pt - roo
90
32
E. REMARKS OF THE DIRECTOR, R.C.H.
Though IEC is the base for creating demand generation for Family Welfare and
Maternity and Child Health Services, the inadequacy of funds has become a major
barrier in the implementation of IEC strategy. On an average, Rs. 70, lakhs are
being spent on IEC per year under FW & MCH for a population of more than 5
crores in the State. This is a very meagre amount. However, there are various
thrust areas under FW & MCH which are not effectively covered.
With the introduction of Panchayathraj System in Karnataka, implementation of|j 2
IEC at district level has become very difficult. It is observed that a major portion
of amount earmarked for district levels activities remains unspent as the amount is «
either released very late or not released to District Health and Family Welfare
Officers by Zilla Panchayats.
Many posts of health education personnel are remaining vacant at all levels. Many
Primary Health Centres do not have sanctioned post of Block Health Educators
and even sanctioned, posts are not filled. 255 posts are vacant for 782 sanctioned
posts of Block Health Educators. With all these constraints, IEC activities have
played a vital role in popularising FW & MCH programme in Karnataka.
Inference on the data presented above and on the remarks of the Director.
IEC activities are planned depending upon the budget made available for health)| ?
education by the Central and State Governments. The budget allotted is too small
compared to the need. With so many eligible couple living in 27066 villages
spread over 1.92 lakh square kilometers it is impossible to reach them and create
awareness and motivate them. In fact, the progress made under RCH care
especially in promoting spacing methods is very low and so also in increasing the ?
age at marriage. Percentage achieved under film show and exhibition is only 43%
and 37% respectively. This is not encouraging.
The progress achieved so far in brinVng down birth rate and increasing the couple
protection rate (58.6%) cannot be attributed soleley for these IEC activities. Most
of the awareness about family limitation may be cumulative effect of al! the
formal and informal health education activities and public opinion and social
pressure that were going on in the State over the years. The people in the State
seems to have realised that small family norm is best for their well-being and
women in particular are coming forward for permanent method even with one girl
child. However, the present progress in couple protection rate is entirely due to
permanent method, that too female sterilization. Therefore, efforts should be made
to remove the unmet needs of nearly 11.5% of eligible couples and popularise and
motivate people to accept spacing methods to improve their health as well as
&
g
3
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33
reducing the infant and under 5 years childrens morbidity and mortality. This will
also help to bring down maternal mortality and morbidity. The male participation
is also important in the community. Another crucial and important health
promotional measure is increasing the age at marriage of girls. This is important in
the long run. Both these measures are necessary to bring about sustainable
behaviour of people for small family norm.
Further, progress in RCH is possible only by health promotional strategies of
advocacy, social support and empowerment. Therefore, the State Health Education
Bureau should gear up to tire task in coming years,
Functions of H.E.B. II
The functioning of this section of Health Education Bureau is very important to
reach the long term goals set by the Bureau. However, the functioning of this
section is not very satisfactory. This Section consists of 5 State level units with
technical and non-technical staff. These units are (1) Audio-visual Unit (2) Field
Study and Demonstration Unit (3) School Health Unit (4) Exhibition unit and (5)
Training Unit. Some units are not working because of posts sanctioned are vacant
for a long time and sufficient grants are not made available for effective
functioning. Each of these units have a definite function to perform.
For example (1) tire Audio-visual unit is concerned with (a) training different
categories of health personnel in audio-visual education and preparation of A.V.
aids (b) Designing, production and procurement of A.V. aids and other educational
materials for use in the field (c) assisting in tire evaluation of A.V. aids produced
in the Bureau. This section is not functioning because most of the key posts are
vacant for a long time.
(2) Functions of Field Study and Demonstration unit are (a) Main purpose of this
unit is to find out most suitable, effective and cost-effective methods and media of
health education (b) planning, organising and implementing and demonstrating
research-cum-action programmes (c) investigation of various health education
issues that may arise from time to time and assist in solving them. Thus this unit is
very essential for supporting health education activities technically and
scientifically. This unit also is not functioning because of the absence of the key
staff for a very long time. The existing staff do carryout some work in the field
demonstration unit, but it is negligible and Hot based on scientifically planned
studies.
34
Therefore, the staff for both these units should be found as early as possible and
these units should be energized Both these units are very important to plan and
bring out scientifically based evidence for health promotional activities and
materials they produce and use and also to bring out relative cost effectiveness of
several media they use.
(3) Exhibition unit which is very important for planning health exhibitions for the
State. It is not functioning properly because of the absence of the key staff over a
long time.
(4) Student School Health Education Unit and Training Units are however
functioning. Their performance is given below.
SCHOOL HEALTH EDUCATION PROGRAMME
'•
,
: #
School health programme is a State plan scheme and started in the 3rd year plan
period. The objectives and goals were laid down as per recommendations of Smt.
Renuka Ray Committee Report in 1965. The school health programme first
covered 30 primary Health Centres in 1965 and extended gradually to cover 35
Primary Health Centres in 1969, 103 Primary Health Centres in 1973, additional
300 Primary Health Centres in 1980, 90 Primary Health Centres in 1985, 100
Primary Health Centres in 1986, 122 Primary Health Centres in 1987, 465 Primary
Health Centres in 1998 and thus by 1989, 1245 Primary Health Centres, out of the
present 1686.
Goals and objectives
3 .
Goals:
?
5
To enhance and Promote health education of school children in every
possible manner to enable them to adopt measures to achieve and remain
healthy and develop in them a self reliance and social responsibility and
better quality of life not only as children of today, but also as adults of
tomorrow.
Objectives
1.
Promotion of positive health
2. Prevention of diseases
3. Early diagnosis, treatment and follow up of defects.
4. Awakening health consciousness in children.
5. Provision of healthful school environment
?
,
2.
i »
5
3
B
35
Activities
To reach the above goals and objectives, the following activities were planned to
be implemented.
1.
Health appraisal of school children.
2.
Remedial resources and following up.
3.
Prevention of communicable diseases including vaccine preventable
diseases.
4.
Healthfull school environment.
5.
Nutritional services.
6.
Mental Health and Dental Health and Eye Health.
7.
Health Education
8.
Health Education of the handicapped Children
9.
Teachers training
10. Proper maintenance and use of school health record.
Organisation for implementing the school health scheme
School health service is one of the basic responsibility of State Health services and
it is incorporated in the functioning of primary health Centre throughout the State.
Therefore, the entire State health organization from sub-centre at the grass root
level to the head of the Health Education Section at the State level are responsible
for implementing the scheme. The primary health centre staff plan and implement
the school health programme in their areas, district health supervisory staff District
Nursing supervisor supervises and give guidance and monitors the progress.
The District Health and Family Welfare Officer reports to the head of the Health
Education and Training section of the State Health Education Bureau at the State
level. The District Health Education Officer plans and implements the health
education activity through the Block Level Health Educator. The Medical Officer
of Health of the Primary Health Centre is responsible for medical examination and
36
follow up of the health of the school children with the help and assistance of
Health Worke under his/her control.
Performance.
1.
2.
Activities
Extent of Coverage
Health appraisal
Only medical examination is carried out.
Remedial measures and follow up
Done very superficially
3. Prevention
of
communicable Only immunisation services given to 1,
diseases
including
vaccine 4, 7Ih standard children. No other
preventable diseases
communicable diseases is detected or
treated.
4. Nutritional services
No programme
5. Health Education
Not carried out systematically
6. Teachers training
Carried out, but not sufficient.
7. Maintenance of school health Not done systematically
record
8. School environment, water supply Nothing is done
and sanitation
As shown above, the performance is patchy and all activities are not carried out
except the medical examination and immunisation of 1, 4 and 7th standard
children Teachers training is also not sufficient and the progress is not satisfactory, Ii
No attempt is made to take up any activity under school environment and P
sanitation in schools. The follow up service is very unsatisfactory. Only activity
that is carried out under the school health service is medical examination and
teachers training which is given below.
>5
5
5
J
5
9
?
5
?
•»
■
37
Table - 3
Showing performance in some activities of school health service during 19992000
Activities
1.
2.
3.
4.
Medical examination of school
children
Immunisation
1st standard
7th standard
10Ih standard
Teachers training
Medical defective found
Percentage of target achieved 1999,
2000
. . .
80%
83.8%
100%
73.54%
69.55%
17.63%
As per the records furnished by the Health Education and Training (HET) of the
State Health Education Bureau, only school medical examination teachers training
and immunizations service is monitored at the State level. The performance of
each district is scrutinised and progress noted. The districts which lag behind are
noted and remarks sent to the respective District Health and Family Welfare
Officers. Though the physical targets achieved are above 80%, the quality of
service appears to be v£ry_poor. During our visit to about 8 Primary Health
Centres in 4 districts, we had a chance to look into the school health records and to
discuss the matter with school head masters. Medical examination is done mostlyl
by Health Assistants and not by the Medical Officers except in Kodagu District./!
There is no follow up services. The quality of training of teachers is not
satisfactory according to most of the teachers. Teachers also feel that it is an
additional job and many of them are burdened with other school regular curricular
activities. Health education in schools is not carried out regularly and it is very
unsatisfactory. The Education Department is not sufficiently collaborating with the
health staff.
Recommendations
School health service is one of the most important health promotional activity.
Though it is a regular activity of the Health Department and Medical Officer of
Health of Primary Health Centre is responsible for at least medical examination of
school children, it is not done properly.
3
)
3
38
Medical Officers of Health should be activated to take up school medical
examinations seriously and the performance monitored by the District Health and
Family welfare officers and the MOHs who are lagging behind should be
reprimanded.
Health Education activity should be planned and every school in the Primary
Health Centre area should be covered. The Health Supervisors at the PHC level
must be made responsible and the District Nursing Supervisor and the District
Health Education Officers should monitor the programme and report to the
District Health and Family Welfare Officers.
There is no attempt to improve school environment. Water supply and toilet
facilities should be provided to every school. This should be taken up as a priority.
This involves substantial investment and efforts should be made to raise donations
in the villages by giving equal contribution from the Government. This may be
taken up on a phased manner.
Teachers training should be intensified and quality of training improved. There
should be at least one trained teacher in every school in the State by the end of
2002.
The furniture, flooring in most of the schools is very poor and should be improved.
Though this programme a combined responsibility of Health and Education
Departments, the Education Deptt., is not evencing sufficient interest in the
programme. District Health and Family Welfare Officers must start advocacy
programme for District Education Officers and Zilla Panachayat President and the
District Executive Officer. The Additional Director of Health and Family Welfare
Services should meet his counter part at the State level and bring pressure on the
District Education Officers. The District School Health
Councils and State Health Councils should meet periodically and hold discussions
on the performance of school health activities.
The government and Zilla Panchayats should be persuaded to invest in providing
toilet facilities all schools in the State.
The vacant posts in Field Study and Demonstration Unit, Audio-Visual Unit,
Exhibition Unit should be filled up urgently and these units should be made
functional and energised.
39
Question of bringing all 1EC activities under the Health Education Bureau should t
be closely examined because the health education work in there programmes I
should not suffer when it is most needed. The programme directors know when
they should launch health education campaign and where. It is his responsibility to
achieve completion of the control programme. (Disease/Epideinic)
The routine health education programme covering all the areas of public health
should be the responsibility of State Health Health Education Bureau and special
health education campaign should be left to the respective programme Directors.
Recommendations on repositioning of Health Educators.
One BLE post may be sanctioned for every PEIC in the State in a phased manner at II ■'
the rate of at least 200 posts every year for the next 5 years.
All the BLHEs should be deputed to acquire DHE qualification at the rate of at II
least 50 every year.
The District level health educational staff at the rate of one DHEO and two 11 Q
DDHEOs per district may be retained and the excess staff may be posted to taluka 1'1
health office.
Taluka level health offices which are newly created should be provided with
Deputy Health Education Officers at the rate of 1 DHEO per taluk. This will /j ?
strengthen the taluka level health organization and he will have sufficient
population strength and monitory resources to plan and carryout 1EC activities. All
the taluka level Health Educators should be assisted to own two wheelers and the
fuel charges may be sanctioned. This will help him to tour the area and implement
the new strategies under health promotion.
The Health Task Force may suggest to the Govt, to allocate at least 5 to 10% of 1^
the health budget for health education purposes as approved by Central Health
Council.
40
SECTION - IV
1.
2.
3.
4.
Grass Root Level Workers
Health Supervisors.
Health Educators.
Interaction with other Health Related Departments.
5. Interaction with Non-Governmental Organisations.
6. Interaction with People.
1. GRASS ROOT LEVEL WORKERS
Total of 50 workers from 4 Districts posted to 16 Primary Health Centres were
interviewed and they were questioned about their knowledge and practice of
health education and observed their attitude towards the subject of health
education.
Competency
Most of them are aware of their responsibilities (80%) and felt that health
education is one of their most important and frequently undertaken job. Most of
them (85%) showed strong positive attitude towards the job. In fact many
expressed, they are able to do their job because of their health knowledge and their
ability to talk to them and convince them about the health benefits of their action.
About 75% of them know various methods of health education and social
mobilisation techniqus. However, they are not making any effort to get the
cooperation of the Village Health Committee members and local people. The
people's participation in conducting health programme at the grass root level is not
much appreciated by the field workers and their efforts to involve them is almost
absent. Participation by members of the Mother Swasthya Sangha (MSS) is
however appreciated by all the workers. Most of them expressed they must have
frequent meetings involving mother-in-laws and daughter-in-laws and other
elders, where they can discuss common health problems and remove some doubts
and misunderstandings, superstition about child birth and child care.
Interaction with other Sectors.
Grass root level workers get the maximum cooperation and help from the
Community Development Departments through Anganwadi Workers. Inter
sectoral cooperation from other sectors is not appreciable except Revenue
Department from whom they get pregnancy allowance sanctioned to their clients.
41
Table - 4
Grass root level workers, their level of knowledge and attitude on various
aspects of Health Promotion and Education Interviewed
SI
Percentage
High
Moderate
Low
Total Number
Responded
80
16
4
50
No.
1.
Awareness
responsibility
2.
Knowledge
80
12
4
50
3.
Attitude
75
14
6
50
4.
Need assessment capacity
76
14
10
50
5.
Knowledge about Health
Education methods
80
12
8
50
60
30
10
50
the
and
70
10
20
50
Need for Inter-sectoral
Coordination.
80
16
4
50
Advocacy
20
40
40
50
Social support
10
30
60
50
Empowerment
10
20
70
50
of
6.
Social mobilisation
tactics
7.
Knowledge about
State of people
N.G.O participation
8.
9.
job
Methods to be used in
Health Promotion
42
Inference and recommendations
1 he knowledge, attitude and practice of grass root level workers with regard to
health education as one of their prime duties and its importance in implementing
any health prog5ramme is satisfactory. However, they are not in a position to
appreciate and involve the local people in either planning or implementing the
health programme in the villages. Though they understand the need and
advantages of involving local leaders in conducting health programmes, they do
not have the skill to do so. Therefore, there is a great need for training the grass
root level workers in development of skill as to how to involve the local people in s
the health programmes. People participation in health activities under the primary
health care strategy is one of the main function of the Primary Health Centre as
recommended by the Alma Ata Declaration. It has also been realised throughout
the world both in developed and developing countries that people's participation is
sine qua non for the success of any health programme, and it (people's
participation) should assumes greater significance in health promotion strategy.
*
.
■>
■J
'■
;•
(
■?
•
•
:
Mother Swasthya Sangha (M.S.S.) activities were appreciated by all. This
programme should be strengthened and frequently arranged, but such programmes
will have to be monitored and supervised by the Health Supervisors. These
meetings and contacts are conducted only once in a way or whenever the money
for it is released. This should not be the case. The programme should be a routine
duty of health workers Health Workers male and female in every sub-centre
should plan their contact meetings and conduct them as planned at least once per
week so that they can hold at least one meeting per month in every village.
IEC activities in each village should be planned and conducted by making use of
local school children, teachers, retired people and other public spirited social
workers. Both male and female people should be encouraged to participate.
Organised community activities have better impact in creating awareness.
Health Supervisers
?.
9-
3 *
g
9
9
A total of 28 Health supervisers staff from 4 districts were interviewed. As shown ]/
in table 5 All of them are aware of their over all responsibilities and they know h
that health education is one of their duties. Conversation with them revealed that
they have good knowledge about supervision and guidance. They undertake
frequent tours of their area and help the grass rootx health workers in difficult
cases of refusals of advice and resistant cases towards family limitation. Their
knowledge of supervision and guidance is only with reference to normal, routine
personal health education to the individuals. However, they also participate^ in
group education like M.S.S. activities and jathas and video sows and baby shows.
43
In many places, Health Supervisors and resource persons for local NGO for their
education campaign. However they need training in health promotion strategies.
Problems of Health Supervisors.
Many of them are quite senior people with 15 to 20 years of service. They do not
have promotional opportunities, because only few of them get a District1
Supervisory position. This aspect has lead them to feel frustrated and have become
less enthusiastic in their job. This should be halted by appropriate remedy. Most of
the health work at the grass root level is carried out by the grass root level workers
and their supervisors. The Department is illoffered to neglect their services,
especially in the field of health education. In fact, in many PHCs, it is the senior
Health Supervisor who manages the PHC activities because the Medical Officer of
Health is either absent or attends only to clinical work.
3
3
3
5
3 o
3
3'
3
5
©
3
44
Table - 4
Health Supervisees, their level of knowledge, attitude on various aspects of
health promotion.
SI
Percentage
High
Moderate
Low
Total Number
Responded
1.
Awareness of job
responsibility
80
15
5
28
2.
Knowledge
70
20
2
28
3.
Attitude
80
16
4
28
4.
Knowledge and ability in
need assessment
80
10
10
28
No.
5.
Ability to supervise and
guide
78
12
10
28
6.
Social mobilisation
capacity
75
.15
10
28
7.
Knowledge about the
need and role of peoples
participation
80
18
2
28
65
15
20
28
Advocacy
20
Social support
18
60
70
20
12
28
28
Empowerment
15
60
25
28
8.
Inter-sectoral
coordination
9.
Knowledge on health
promotional strategies
45
Inference:
Though Health Supervisors are important at PHCs level, health education
programmes, there seems to be complacency in their attitude and practice. This
may be due to the (1) presence of Block level Health Educator, who is responsible
for implementing the organised health education or 1EC activities at the PHC level
and (2) also the Medical Officers of Health are not taking any interest in
administrative affairs of the PHC and leave everything to the Health Supervisors.
Health Education as an activity at PHC level is suffering from these two
constraints. Both these constraints must be attended to by Medical Officers. They
must be made to take more interest in administration and management of health
programmes including health education at the PHC level.
There is need to be proper supervision and monitoring of PHC performance from
the District Health Officers.
Recommendations
The Health Supervisors must be made responsible for all health education
activities at the PHC level. The administration should activate these people. More
particularly the Medical Officer of Health must be made to take interest in
administration and management. This is possible by frequents visit of the District
Health and Family Welfare Officers to the PHCs and arranging seminars and
symposium at District level for all Medical Officers of Health.
Block level Health Educators, District Health Education Officers and Deputy
District Health Education Officers.
14 Block level Health Educators working at the Primary Health Centres, 4 District
Health Education Officers and 4 Deputy District Health Education Officers
working at District level were interviewed and participated in focus group
discussions.
Competency
As shown in table 6 most of them are aware of their job responsibilities and know
the job well. They have the right kind of attitude and appeared enthusiastic in their
job. They have sufficient skill to develop education programmes. However, they
are not making use of their skill in social mobilisation work and involving people
in health education activities. For example, 90% of them have sufficient
knowledge about the need for inter-sectoral co-ordination and N.G.O.
46
involvement, but only 30% of them are making efforts. When asked why it was so,
many of them expressed that they are a neglected lot. There contribution is not
recognised by superior officers. Only 50% of them have right kind of
communication skill and 40% of them are capable of talking to people on any
subject. Their knowledge about advocacy is satisfactory, but their ability to
practice is doubtfull. They do not have sufficient knowledge about social support
and empowerment. Except 5 District Health Education Officers, all others need
intensive training in the principles and strategies of health promotion.
,
.
Recommendations
Long Term
■
'•
?
’$'
The Health Educator at the Taluk and Primary Health Centre level and the District
Health Education Officers and the Deputy District Health Education Officers at
the District level are the key persons for planning and implementing 1EC
activities. They should have sufficient knowledge about the community and
community leaders and should be enthusiastic and committed for tire task of
spreading scientific knowledge to people and involve them in health programmes.
In fact, part of the reason for tardy progress of health education programmes is
attributable to non-involvement and half hearted participation of the people. This
is the case in all health programmes. It may be improper Malaria Eradication, Poor
Tuberculosis Control low couple protection rate etc. Therefore, training and re
training of the Health Educators in social mobalisation methods and in various
modem Communication Technology is urgently’required. Most of them take their
job very casually and do things very slowly. This may be due to lack of
Administrative Pressure form the Districts.
Short term
Immediately, there is great need to arrange training programme for all the Health
Educators on health promotion. A programme of reorientation for District Health
Education Officers and the Deputy District Health Education Officers and those
possessing DHE qualification may be organised at the State level in two or three
batches. The course may be of one week duration.
y
j
•?
For those BLHEs without DHE qualification, a two weeks training programme
may be organised at the Divisional level so that all the Health Educators are
trained and equipped with skills to plan and implement IEC activities under health
promotion strategies as recommended by the Ottawa Conference on Health
promotion. More specifically they need training in group dynamics, motivation,
communication, interpersonal relationship, intersectoral coordination and social
mobilisation. They should also be trained in modem electronic media and
utilization of computers.
5
■>5
...
?
>
*•
J
9
5
Table - 6
Block Level Health Educators. Distrit Health EDUCATION Officers and the
Deputy Ditrict Health Education Officers their level of knowledge and
attitude and ability.
High
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Percentages
Medium
Awareness of job responsibility
Knowledge
Attitude
Skill of collecting and analyzing
health need assessment
Knowledge about health education
methods
Social mobilisation tactics
Knowledge about the local leaders,
religious groups and need to
involve them in health education
activities
Need for inter-sectoral co
operation and NGO involvement
80
90
95
65
15
7
4
20
5
3
1
15
80
10
10
70
60
20
25
10
15
Knowledge
Practice
90
30
50
40
5
30
25
40
5
40
40
20
40
40
20
40
20
60
20
40
20
45
20
30
30
30
40
15
60
10
50
30
40
Communication ability
Ability to write, press release and
talk to lay people
Knowledge about health
promotional activities
Knowledge about advocacy
practice of advocacy
13.
Knowledge about social support
practice of social support
14.
Knowledge about empowerment
practice of empowerment
measures
Low
L+& A
MEDICAL OFFICERS OF HEALTH
v
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5
s
?
5
TX
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»
Twelve Medical Offices of Health from 4 districts participated in the discussions.
Opinion and their response to various issues is given below. Many of them know
the importance of health education and the need for extensive health education
efforts. They also know that health education is one of their duties, but they did
not show any enthusiasm and interest in health education activities. However, not
all of them are indifferent towards health activities. Those who do not have much
clinical practice do well in all health programmes including health education and
those having good clinical work say that they do not have enough time to do so
much of non clinical work including health education. In fact, Medical Offices
who have good clinical practice take the help of health workers to assist^ him.
Doing clinical work is good for the people, because many patients need not go for
distant places for primary medical care. Therefore, the clinical practice should not
be disturbed. The principle of integrating clinical practice with non clinical work
like administration and management of health programmes has been a failure.
Now Taluka Health officers have been established and Taluka Health Officers
must be made Administrator of Health Services in the taluk and all the health
workers including Medical Officers of PHCs should come under his administrative
control.
HIE MEDICAL OFFICERS WERE QUESTIONED AND THEIR OPINION WAS
COLLECTED. THE RESULTS OF THE ANLYSIS IS AS FOLLOWS:
3
■»>
AREAS EXAMINED
REMARKS
1.
THE NEED FOR HEALTH PROMOTION.
ALL AGREED VERY STRONGLY.
2.
METHODS
OF
PLANNING
PROMOTIONAL ACTIVITIES
HEALTH
ALL AGREED, BUT THEY DO NOT
WANT TO
MAKE
PART, IN
PLANNING PROGRAMMES
3.
IMIp^QTANCE OF SOCIAL MOBILISATION
MANY DO NOT HAVE ANY IDEA OF
SOCIAL MOBILISATION STRATEGY
4.
NEED FOR INVOLVING
HEALTH PROGRAMMES
PEOPLE
IN
50% AGREED, BUT ANOTHER 50%
SAID
PEOPLE
DO
NOT
COOPERATE.
5.
NIlD FOR FURTHER
HEALTH STAFF
TRAINING
OF
ALL AGREED THAT HEALTH
WORKERS SHOULD BE TRAINED
AND NOT THEMSELVES.
6.
QUALIFICATION
REQUIRED
HEALTH EDUCATERS
FOR
ALL AGREED THAT THEY SHOULD
HAVE DUE QUALIFICATION.
7.
ADDITIONAL TRAINING FOR MEDICAL
OFFICERS OF HEALTH
MAY BE USE FULL. ONCE IN 3
YEARS
FOR
UPDATING
THE
RECENT ADVANCES
8.
NEED FOR ORIENTATION OF SYLLABUS
OF COMMUNITY MEDICINE IN MBBS
COURSE
ALL AGREED THAT THEY MUST
BE EXPOSED MORE AND MORE
TO THE
COMMUNITY.
AND
ALL
NATIONAL
HEALTH
PROGRAMMES
SHOULD
BE
DEMONSTRATED TO THEM IN
MORE DETAIL.
9.
NEED FOR CHANGE IN THE ATTITUDE OF THEY AGREED THAT PUBLIC
POLICY-MAKERS
TOWARDS
PUBLIC HEALTH
WORKER
IS
NOT
HEALTH
APPRECIATED BY MANY DOCTORS
AND
MUCH
LESS
THE
ADMINISTRATORS. IT IS RARELY
THAT GOOD HEALTH WORKER
(DOCTOR)
IS
APPRECIATED,
WHERE AS GOOD CLINICIAN IS
APPRECIATED
BY
ADMINISTRATORS
AND
POLITICAL LEADERS, ALIKE
OPINIONS ON PUBLIC HEALTH EXPERTS ON SOME ISSUES OF
HEALTH PROMOTION
Health promotion is a pan and parcel of Public Health. In fact the goal of public
health is to create the environment conducive, and mould the behaviour of all
people favourable to positive health. Health Promotion comes even before the
primary level of prevention. It is also called primordial prevention. Therefore
Health Promotion is not something different from the main stream of public
Health Philosophy and Public Health Actions.
Opinion of public health experts was sought about some aspect of health
promotion. 98 people were approached in and out of the state and 48 people
responded. Their opinion is given below. Opinion expressed by experts is
overwhelmingly in favour of application of principles of Health Promotion in the
Public Health Action Programmes most of them also express that public health in
recent years is being neglected by policy makers and due status is not given to the
public health & public health experts. This will have to be over come by
appropriate advocacy programme for top level policy makers.
OPINION OF PUBLIC HEALTH EXPERTS
AGREED OR NOT (PERCENTAGE)
STATEMENTS RELATED TO
STRONGLY
1.
2.
3.
4.
5.
6.
7.
8.
THE
NEED
FOR
HEALTH
PROMOTIONAL STRATEGIES AND
THE RATIONALE AND POSSIBILITIES
OF
IMPLEMENTATION
IN
DEVELOPING COUNTRIES
AGREED
DISAGREED
20
80
-NIL-
10
90
-NIL-
5
90
5
NEED FOR INVOLVING PEOPLE IN
HEALTH PROMOTION PROGRAMME
3
90
7
NEED FOR TRAINING FOR MEDICAL
OFFICERS OF HEALTH, & DISTRICT
HEALTH AND FAMILY WELFARE
OFFICERS ON HEALTH PROMOTION
10
90
-NIL
DESIRABILITY
OF
DUE
QUALIFICATION
FOR
HEALTH
EDUCATOR
AND
DPI!
QUALIFICATION FOR HEALTH &
FAMILY WELFARE OFFICERS
5
90
5
3
90
7
3
95
2
METHODS
OF
PLANNING
IMPLEMENTATION
IMPORTANCE
MOBILISATION.
OF
AND
SOCIAL
NEED
FOR
STRENGTHENING
SYLLABUS
IN
COMMUNITY
MEDICINE FOR MBBS AND DPH
NEED
FOR
CHANGE
IN
THE
ATTITUDE OF POLICY MAKERS,
POLITICIANS
TOWARDS
PUBLIC
HEALTH
t) & £
OPINION ON SOME OF THE IMPORTANT STATEMENTS ON PUBLIC
HEALTH POLICY
STATEMENTS
1.
2,
3.
4.
5.
6.
7.
8.
9.
THE CONCEPT, PRACTICE AND IMPORTANCE GIVEN FOR
PUBLIC HEALTH BY HIGHEST DECISION MAKING
PEOPLE ARE 1MOPORTANT FOR IMPLEMENTATION OF
HEALTH PROMOTIONAL STRATEGIES.
ONE OF THE MAJOR BARRIERS FOR IMPLEMENTING OF
THE HEALTH PROMOTIONAL STRATEGIES IS THE LACK
OF PROPERLY TRAINED PUBLIC HEALTH EXPERTS AT
THE HIGHEST DECISION MAKING LEVEL AND AT THE
MIDDLE PLANNING AND IMPLEMENTATION LEVEL.
PUBLIC HEALTH RESEARCH IS NOT MAKING THE
NECESSARY CONTRIBUTION TO PUBLIC POLICY,
BECAUSE OF ITS TENDENCY TO WANT TO BE SEEN AS
EXCELLENT RATHER THAN ANY RELEVANCE TO THE
NEEDS OF PUBLIC POLICY.
MOST PUBLIC HEALTH PROFESSIONAL AND CLINICAL
PROFESSIONALS
WORKING
IN
PUBLIC
HEALTH
POSITIONS IN THE COUNTRY HAVE LITTLE TRAINING IN
WIDER ASPECTS OF HEALTH. THEIR EXPOSURE TO
RELEVANT SOCIAL SCIENCES AND HAVE HAD LITLE
OPPORTUNITY TO LEARN FROM ROLE MODEL HOW TO
ADDRESS THE SOCIAL, ECONOMIC AND POLITICAL
FORCES AFFECTING HEALTH.
POLICY MAKERS IN PUBLIC HEALTH AND HEALTH
PROFES1ON.AL SHOULD MEET REGULARLY TO REVIEW
THE HEALTH PROBLEMS AND RESEARCH EVIDENCE
AVAILABLE FOR THEIR DECISION MAKING.
IN ADDITION, THE PUBLIC HEALTH SPECIALIST NEEDS
SKILLS IN COMMUNICATION, PUBLIC POLICY ANALYSIS
AND DEVELOPMENT.
SOCIAL PRORAMMES (THIS INCLUDES HEALTH) ARE
OPERATING
UNDER
EVER
TIGHTER
RESOURCE
CONSTRAINTS. THEREFORE, THE CONTRIBUTION OF
GOOD HEALTH TO SOCIO-ECONOMIC DEVELOPMENT
MUST BE CONVICINGLY DEMONSTRATED IF ADEQUATE
AND SUSTAINABLE RESOURCES ARE TO FLOW TO THE
HEALTH SECTOR.
RESOURCE ALLOCATION FOR PUBLIC HEALTH MUST BE
MORE
EQUITABLE
CONSISTENT
WITH
ITS
CONTRIBUTION TO SOCIAL DEVELOPMENT AND NEW
RESOURCES SHOULD BE MOBILIZED.
THE GOVERNMENTS SHOULD FIND WAYS AND MEANS TO
ENHANCE THE STATUS AND IMAGE OF PUBLIC HEALTH
CARE PROFESSIONALS CONSISTENT WITH THEIR
CRUCIAL ROLE IN HEALTH OF THE NATION.
PERCENTAGES
AGREED
DISAGREED
100%
-NIL-
98%
2
70%
30%
60%
40%
100%
-NIL-
90%
10%
100%
-NIL
100%
-NIL-
100%
-NIL-
47
4. Inter Action with other Health Related Departments
•
•
Findings
,
Intersectoral coordination of all developmental departments of the Government is
important for speedier and effective implementation of health promotional
programme. In this connection, the representatives of the following departments
were contacted and information collected by using structured questionnaire. They
are Education, public Health Engineering, Information and Broadcasting,
Agriculture and Horticulture Departments. Most of them agreed that there is need
for cooperation and coordination between Health Department and their
Departments but expect that the health department to take initiative in the matter
because health is the business and concern of health sector. Many of them are not
happy about the attitude of doctors towards them.
:•
> '
t
Recommendations
First of all there is need to educate other departments to impress on them, that
health of the people is their concern also and if there is cooperation and
coordination, the health promotional programmes can be implemented smoothly
and quickly. Moreover, the proper and successful implementation of health
programmes would also help other non health related programme substantially,
because people take more and keen interest if the programme is health related.
Therefore, there is need for organising advocacy programmes for managers and
policy makers of other developmental departments at the State level, they should
be identified and educated. A programme for people can be effectively and
efficiently implemented, if all departments extend^ support and participate. For
example, the success of Family Welfare Programme to some extent is due to the
extensive intersectoral coordination and cooperation. The benefits that flow from
intersectoral coordination is much more than the benefits that accrue when
departments work separately.
This is the fruit of interaction and this does not cost any thing instead strengthen
interposal and Interdepartmental bonds and helps cohesion and purpose in
government institutions. This is very important because people are loosing
confidence in government run programmes.
5. iteraction with Non-Governmental Organisations
>’
35 if
J '
J
5
Eight non-govemment organizations in 4 Districts implementing some health
education activities were contracted. All of them are veiy much enthusiastic to do
health work and help people to improve their health. But most of them are
dependent on government for funds and projects. The projects managed by the
48
NGOs are better organized and people are satisfied by the services. Some of them
engage full time staff These workers seem to be more serious about their
responsibility and duty and they have better rapport with the local people
performance of NGO seems to be better than government organisation but the
budget of NGOs is very high compared to government organization.
>
In the long run it may be better to involve more and more NGOs in health related
work and a mechanism has to be found to identify real social service minded
NGOs and try to encourage them. Unless socially spirited people come forward to
manage non-govemment organisations and if they are allowed to work only with
full time employees and work like any other profit oriented organizations, they
would become very soon as government run institutions. Therefore, careful
verification of non-govemment organisations and the staff composition and the
background of people who run such organisations is required before entrusting any
health related projects to them.
6. Interaction with the People
>
It was possible to meet some people in the villages in all the 8 Primary Health
Centres of 4 Districts. Both women and men in their homes and in public places
were interacted to understand whether they know the health education and other
health programmes and
whether they are getting adequate information about
health.
Findings
, .
Most of the respondents showed indifference to our questions. On probing further,
they revealed that the health worker come and talk to them on health matters
sometimes on family planning and antenatal care. Mothers expressed that AN Ms
are advising them on diet and child care. They are not aware of any other Health
Education Campaign on other Health activities except Aids/HIV.
>
;
Many villagers are not satisfied by the services they receive when they go for the
Primary Health Centre for treatment, except immunization services.
;
Nevertheless, it is surprising to know that many of the villagers have understood
the rationale of small family norm and they do not have much gender
discrimination and coming to sterilization camps even with one girl child. But
many are not for male sterilisation.
T-
Most people want water supply at their doors through taps and some of them are
also willing to bear the expenditure on it, but they do not know why they want
piped water supply. They do not know the importance of sanitation and are not
interested to have toilet facilities in their homes.
K
•s'
$
9
3
"
49
Recommendations
.
5
J
9
3
§
3
3
3
a
■J ‘
2
3
>
•J
J
55 •
3*
S
§
I
Therefore, there is need to launch health education programme (edocacy)
systematically and continuously by the government. The television media and
radio should be used more fr equently to reach large number of needy people. The
messages should be transmitted instead of scholarly talks through media. Prime
time should be chosen for telecasting messages and slogans. These programmes
should be supplemented by Health Workers in the field by way of clarification etc.
51
SECTION - V
1. Vision and Strategy Statement.
2. Summary of the findings discussion and recommendations.
1. A vision and strategy statement for improving the health status of
Karnataka State in 21s1 Century.
India including Karnataka State is facing a triple burden of diseases and
disability even after 50 years of development after attaining political
independence. The first burden is that many preventable diseases and disability
still persist as public health problems. This is due Jrf partly, to administrative and
technical problems in the control of infectious and nutritional diseases and partly
due to failure in public health policy.
In addition, due to demographic transition and increase in expectation of life,
people are surviving longer. Unfortunately they survive to suffer from chronic
diagnostic facilities, costly drugs and longer hospital stay. Relatively, more
health budget is being spent on elderly people than young and middleaged
people. This is the 2nd burden.
The third burden is the emergence of new diseases like HIV/AIDS, Alcoholism,
and Drug abuse.
These challenges together with higher infant mortality rate (70/1000), higher
proportion, low birth weight babies (30%) and higher mortality among under 5
children all pose a formidable disease burden to the State.
In the face of these challenges, the health care system in the State is not that
efficient as revealed by slowing down of decline of IMR and under 5 year
mortality, is recent years in the incidence of malaria, tuberculosis and
HIV/AIDS.
Therefore, there is clear indication that the present and past public health policies
and strategies are not sufficient to lessen the burden of disease and disability in
the state in has lead the state spend more and more for curative services and get
less and less in terms of Health gain to the population. The experiences of
western countries from 1801 to 1971 has shown a similar trend.
*
»•z «■
5
5
>
52
Ottawa charter after consider all the above, factors has suggested to all countries
apply the principles of Health Promotion in their health policy. The Karnataka
State would do well to implement these strategies to achieve maximum benefits
in terms of improved health. These strategies would help the people and
government to reach the determinants of illhealth and destroy the roots. Even
though, this is a long, arduous and expensive task, it is the only way left for
reducing the burden of disease and disability.
The 5 strategies suggested by the Charter are:
1.
2.
3.
4.
5.
Build healthy public policy.
Create supportive environment.
Strengthen community action.
Develop personnel skills.
Reorient health services.
Major areas of concent which should be adequately addressed are:
❖
❖
❖
❖
Development of human Resources.
Sustained action to build supportive environment for all people.
Fostering intersectoral action for health.
Forging partnership between non-govennnent organism and government
health sector.
With the application of principles of health promotion and hopefully improved,
health administration, the State may hope to improve health status of people of
Karnataka, sufficient enough to live a healthy, useful and productive lives at least
by 2015 in the 21st century.
2. Summary of the Findings, Discussion and Recommendations.
The study reveals that the Karnataka State Health Department has required
organizational infrastructure, manpower and skill to launch Health Promotional
activities in the direction as suggested by the World Health Organization’s 9lh
General Programme of work. However, some minor deficiencies and weak
linkages have been found in the study and they are discussed below and remedial
measures suggested in the way of recommendations.
53
A. ORGANIZATIONAL STRUCTURE
The existing organizational structure in the State to take up health promotional
activities at the State, District, Taluka and Primary Health Centre level is
adequate and no additions or modifications are required. The name of the State
Health Education Bureau may be renamed as Health Promotion and Education
Bureau. All the Health Education staff may be brought under one head.
B. MANPOWER
State Level
Some posts of Technical Officers of the Health Education Bureau at the State
level are vacant for a long time. This has led to the disfunctining of these Units
and State Health Education Bureau is very much handicapped without these
Units. For example, the Audio-Visual Unit is essential for pre-testing all IEC
materials before they are produced in large numbers to be cost effectiveness.
Like wise the Field study and Demonstration Unit is essential because the health
promotional activities are field tested for their applicability to the population and
the cost effectiveness is determined before they are applied to a larger area.
Therefore, the vacant posts in Audio-Visual, Field Demonstration and Exhibition
Units may be filled up urgently.
District Level
At the District level, no addition is required. The posts of the District Health
Education Officer and one Deputy District Health Education Officer may be
continued.
Both of them should have DHE qualification (the State has sufficient number of
DHE qualified Health Educators) Their designation may be changed as District
Health Promotion and Education Officer and Deputy District Health Promotion
and Education Officer.
Taluka Level
At Taluka level, there are no Health Educators post are sanctioned at present.
Therefore, one Health Educator post may be sanctioned for every taluka. The
State has sufficient number of Health Educators for 175 talukas these post must
be filled with D.H.E. qualified Health Educators.
54
Primary Health Centre Level
The State has 1685 Primary Health Centres (this may go up also) and there are
782 Health Educators. Therefore, there is shortage of nearly 900 posts. It is very
necessary that each Primary Health Centre should have one Health Educator and
therefore additional posts may be created in a phased manner at the rate of 200
per year for the next 5 years.
C. TRAINING AND PROFESSIONAL EDUCATION
Training
The Study reveals that the Health Educators and Medical Officers need training
in the health promotional aspect. Short term training courses may be arranged for
District Health Education Officers, Deputy District Health Education Officers
and the Medical Officers of health of all Primary Health Centres at the State level
and at Divisional level. The training may be of one week duration.
The Health Educators without DHE qualification may be sent for acquiring DHE
qualification at Gandhigram in a phased manner.
Professional Education
The Medical Officers of Health of Primary Health Centre or Health
Administrators at District and State level should have right kind of attitude and
interest in health promotion, because they are the kingpins in health care delivery
system. Therefore, their attitude and interest in health promotional activities are
important and essentional.
Since the medical students are moulded in the philosophy of medical and health
practice and service at graduate level and it is here they form attitude and team
and develop skills, for right kind of attitude and practices. The syllabus in
Community Medicine in MBBS and DPH and MD courses must be adjusted to
include Health Promotional aspect of health care in a substantial way. The
Community Medicine Department must have infrastructure to demonstrate the
operational aspect of Health Promotional activities. The Rajeev Gandhi
University of Health Sciences may be requested to issue guidelines and modify
the syllabus in Community Medicine for both at undergraduate, diploma and
degree courses.
55
D. FUNCTIONS
1EC activities
Information, Education and Communication activities are very important and
essential for creating awareness of health and its importance in the minds of
people. This is the Is1 essential step in any health education programme to enable
people to take control of determinants of illhealth in the community. At the
present moment, there are no sufficient routine IEC activities in the State except
centrally funded programmes. The State health sector should plan and carryout
Health Education Programmes as a routine function of the Department and
sufficient resources should be earmarked for this in the annual health budget.
Sponsored programmes are also very few and they will not reach the people and
their impact is negligible.
School Health Programmes
This programme is very important in inculcating the health knowledge, moulding
childrens health attitude and develop right kind of healthy life style favorable for
healthy living. A comprehensive health programme which is already in existence
should be implemented in all the schools in the State. Therefore, the Government
may be requested to issue orders to activate interdepartmental committee and
implement comprehensive school health programme. This programme should
include (1) health appraisal and follow up including medical examination (2)
teaches"Training (3) providing good clean and well ventilated class room (4) safe
drinking water and toilet facilities to all schools and colleges in the state.
Further a comprehensive health education curriculum may be framed and taught
covering all aspects of health promotion in a graded manner to the 1 standard to
XII Standard students as is being done in Europe, Australia and USA. The
curriculum should include environment, air pollution, green house gases which
are causes of illhealth. Healthy life style, population elements, family welfare
and sex education HIV/AIDS etc. Health promotional measures required to be
cultivated and practice by the individual, family and community and their social
responsibility towards the health of others is very essential, for health promotion
of the population.
The Subject of health promotion may be made a compulsory curricular subject in
schools and appropriate educational material may be produced by State Health
Education Bureau in collaboration with Health, Health Education and
Educational Experts.
56
E. ETHICS. ADVOCACY, HEALTH RESEARCH AND PARTNERSHIP EOR
HEALTH PROMOTION.
Ethics
Bioethics cannot be limited to medical practice and organ transplant. Bioethics
is, in broader sense, includes all interventions upon human being whether in a
group setting or individual. Health Promotion and Health Education are
undoubtedly a type of intervention, functioning type of the person, type of life
style, attitudes, desires, wishes and way of life. Health promotion also covers
inequity and injustice meted out to some section of society. In fact the rationale
of application of health promotional measures is to uphold the dignity tke=drgnrty
of human being, affirmation of human right and the freedom to empower himself
to protect and promote health. So ethically also the health promotional principles
are sound and the human right demands the application of these measures in civil
society.
Advocacy:
■ ,
.
For successful implementation of health promotional policies and activities, the
health sector should develop strategies for Advocacy at various .levels. It should
be armed with solid evidence that health promotion works and^worthwhile. The
health department should have a strong support and useful partnership with
industry and other non-govemment organizations.
*
•-
Advocacy is required at all levels of governance. At the top level to policy
makers, legislature and decision makers (specially resource allocators). Health
administrators at the top level must be able to take strong leadership and plead
with policy makers and exert pressure on them to change the directions of policy
wherever it is not favourable for health promotion. For this to succeed, the health
administrators should have solid and convincing evidence Health Research and
Partnership.
How and where convincing evidence is available. The scientific evidence can
come only by health research. The Stale has vast potential for collaborative
research in health research. There are 23 medical colleges with well equipped
fully staffed, community medicine departments. The Government should foster
partnership between Medical Colleges and the District Health Administrators for
producing scientific evidence about the benefits of health, Promotional activities.
x
» •>
jV
I ’
I
X
57
Collaborative research is cheaper and more usefull because it gives feed back to
the health programme manager to change the directions if required. This is a
highly potential area to develop and the Government can insist upon this while
handing over 3 PHCs to the Medical Colleges as contemplated recently.
Funds
The funds for 1EC activities, Advocacy programmes and social mobilisation
programmes should be granted by the Government. It should be remembered that
money spent on health promotion activities can bring 10 times more devidend
than the money spent on drugs and purchase of sophisticated equipment. The
Government should proceed in the direction of allocating more and more
taxfunds for attracting root causes of diseases than trenting diseases for cosmetic
purposes.
The Central Health Council has already given guidelines to allot 5 to 10% of
health budget for health promotion. This should exclude the investment on water
supply and sanitation.
Intersectoral Coordination
It is very clear and apparent from literature and a decade of experience that
health promotional areas overlap between many developmental departments.
And the health promotion is possible only by developmental approach.
Moreover, health promotion is essentially a social and political action and
therefore, the health promotion goes beyond health sector and embraces all other
developmental sector of Government. Therefore, intersectoral cooperation and
coordination becomes very necessary and crucial for successfully
implementation of health promotional activities. Many case studies and opinion
of experts show that comprehensive multi-disciplineiy health promotional
programme yield better results than solo sector.
The study reveals that there is no strong linkage between health sector and other
development sectors both at the top and the bottom levels. Therefore, modalities
should be found out and experimented to secure firm coordination and
cooperation amongst all developmental departments at the Ministerial, Secretary',
Directors level at the District level and at the grass root level. Health promotional
committee may be formed with the State Health Council with the Chief Secretary'
as the Chairman to oversee the policy directions, and matters of intersectoral
cooperation between various sectors. Developmental sectors which are very
important and whose activities comprise^ many health promotional components
are:
58
*
*
*
■
■
■
■
Education Department.
Intonnation and Broadcasting Department.
Community Development Department.
Agriculture Department.
Department of Industry
Social Welfare Department and
Public Health Engineering Department.
1. Education Department
The Study reveals that there is no strong linkage between Health and Education
Departments in the State. A close liason is veiy much needed between these two
Departments because one of the most important health promotional programme
in the long run is the School Health Programme (SHP). For successful
implementation of School Health Programm very close collaboration is essential.
Already existing committees at state & District levels may be given sufficient
responsibility & powers.
2. ^information & Broadcasting Department
This sector is very much relevant to day than ever before. Because of the
explosing of information on health promotion an multitude of media telecasting
such information. Many TV Stations in their enthusiasm to make T.V. shows
attractive especially by the youths include scenes and actions that actually
convey unhealthy life styles. Therefore, there must be a Watchdog Committee to
watch out such shows and bring it to the notice of controlling authority in the
State. Such a Committee should include public people also.
For purposes of telecasting health promotional activities by the governmental
media, a plan of telecasts has to be prepared by the Information and Broadcasting
Department and the health experts either from the Department of Health or from
non-govemment organizations doing health promotion work to be consulted
before telecasting.
Health Promotion and Education Bureau should prepare their own TV scripts and
request the Information and Broadcasting Department to telecast periodically.
Details may be worked out jointly by the two Departments. The Health
Department should gather public opinions about the television shows that have
health implications and bring this negative telecasts if any to the notice of the
Information and Broadcasting Department. Health Department through its health
59
promotion and education wing should identify the health promotional elements in
the programmes of these sectors and discuss with the respective authorities.
Similarly, the directions by the Government may be issued to all development
oriented Departments to have a close liason with the Health Sector.
3. Collaboration with Non-Government Organisations
Health promotional activities are carried out mostly at the level of people, in the
families, community, villages and slums. Proper understanding and cooperation
of local non government organizations are very usefull and essential. At present
there is no formal collaboration with the Non Government Organizations. The
Government may issue directions to the health sector to establish firm and
sustainable relationship with local non-govermnent organizations for
implementation of health promotional activities. These organizations are very
essential for social mobilisation, people’s contact and people’s participation in
the programme.
Go
OTHER RECOMMENDATIONS
1. Recommend to the government to give directions and support to the Health
Sector and other development departments in line with the
recommendations in W.H.O. 9lh general programme of work.
2. Request the government to include public health experts in the top policy
making bodies.
3. Request government resource allocators to take long term view of benefits
of Health Promotion & Education before deciding the financial allocating
to various ministries.
4. Request the government and non government organization to look into the
question of equity and social justice in providing health care services.
5. Request the government and philonthropic organizations and non
governmental organizations to support provision of Water Supply and
Toilet facilities to all villages and toxyns.
6. Request the government to issue guide lines to Education and Health
departments to take up comprehensive. School Health Education and
Promotion activities and allocate required financial and other resources.
7. Request the government to take urgent steps to prepare a model for
communication strategy for Health and Innovative Methods and approaches
to effective communications.
8. Appeal to the public to participate in Health Promotion & Education
activities to gain control over the determinants of illhealth.
61
9. Request the government to reverse its decision on qualification required for
administrative posts at District and higher levels. All higher administrative
posts in the health department should be filled up with public health
qualified people only.
10. Policy Makers in Public Health and health Professional Should meet
regularly to review the Health Problems and Research Evidence available
for their decision making.
11. Social Programmes (this includes health) are operating under ever Tighter
Resource constraints. Therefore, the contribution of Good Health to SocioEconomic Development must be convincingly demonstrated if adequate
and sustainable resources are to flow to the health sector.
12. Resource allocation for public health must be more equitable consistent
with its contribution to social development and new resources should be
mobilized.
13. The government should find ways and means to enhance the status and
image of public health care professionals consistent with their crucial role
in health of the nation.
i til-SI DENT
uHE/SEARB - Karnataka Chaptar
.'iroctorata ot Health Servicas ComplsxAnanda Rao Circls, Bang'alor0‘5tiO 009
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