COMMUNITY HEALTH IN INDIA
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- Title
- COMMUNITY HEALTH IN INDIA
- extracted text
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RF_COM_H_56_PART_1_SUDHA
TRAINING FOR COMMUNITY HEALTH CARE
- DR DARA S AMAR
- The aim-of— t+rrs-pTES’entation—is—to highlights some of the var-i-ous-attempts
f'lr. cU /-c-1
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made in St. Sohn's to orient Health Workers, including Medical students,
towards Community Health Care.
--Whi-le—feh-eors—aJiE_jiO—se-lutignsj. The attempts
fe-bese-eluss. have provided invaluable insights into this important goal.
Being a Mt-dical College, St. Sohn's aims at providing the training component in
the formation of health teams, j
„
Health Team Training8
St. Sohn's Medical College is in a unique situation to train el-1--t-h-e
members of a*" health team under one roof. f T+ri-s create^ a better understanding
y^of each other's role’r-at44e4R-b4wa-d?+re~-i-8<riated~-/e-rfli—of—fe-saimfl-g—available^
-rts^whe<,«^£eT^eaeh^cafregerry—ofu-hca-ltetT.woPkeT'S-»
students, Community Health Workers, Deacons,
Medical students. Nursing
School teachers, village
mothers etc. are the various health team members who get their training at
,'Aj2_
yz.
St-. Sohn 's.
St-fto-u all 'I'l're-t-rai-e-ing—is—deue—b-y—t-he—same—Laci.il t-y.,—i.t.'-treeamgs
Concentration on healthi
J&Kr^s Medical/College has an entire/facuity of medical doctors who
can devote full
it is only
ime to the health aspect of community development. Therefore,
gical that the training at—St-.—Sohn's for the health team
should concentrate mainly on-healt *^fhis training is complemented by the
training in developments
ork given by other organisations.
Use of-local language;
Majority of\the graining programmes for. the health team is corrupted, as
far as possible, in\he local language of Kannada.
This is an important
aspect since expression^/ thought is best achieved Through the usV of
local language by the health team trainees.
Since the trainees come from
different parts of the country", the training programmes here provides
facilities for translation of several languages.
In fact, the department
has already published an entire book on Food Hygiene Practice in Kannada
Participatory—processs
fhe main objective of the^varieus’'health programmes of St—■ John-^s aims—nt a
. LcSp
I' <4 <x
.
participatory process wherein the villagers themselves •partic-ipobo in-
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f inancing^healtli care, supply of materials and manpower jst-er
This is
particularly exemplified by the Mallur Health Cooperative Centre,—whi-ch now - <>-
p-vrai eud"
-bas--d±-s—ew—hes^irt-^i-bij-i-id-i-ng-et=e?-y-t-hTo-tigh—the-tt'caith-Cocrpcr-a-b-i-ve Movement
,whi-eh- the-colleg-e initiated in 1973.
Village Health Committees have been
formed at each of the rural health centres and -arti decisions nrc participatory
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in mature.
A large part of the organisation of -ourgieo-1—ond othor speciality
rural camps- are also done by the villagers.
youth groups and Mahila Manfials.
This is through their village
Even the training of. the various cat.pnnri.xs-
-&f- health workers, including medical students, is-done-through—teachers
dr-a-wn—f-peffl—the village leaders thems-el-vesE-r?
c~-o
Coordination with other agencies;
VM
Tt is—rmpe-rtafTte—te-hob 3f<.=3ehR-!-s work in coordination with governmental and
non-governmental health institutions.
Clinics,
Programmes such as the Rural Mobile
Universal Immunization Programmes,
Integrated Child Development
Scheme, Notional Social Service and Rural Internship Training are examples
of such coordinated efforts.
faculty
T-bsxt caching faculty-err-tr also drawn—eb guest
various sister institutions
Integrated Hea-l-bft—Ga-re—T-ra-i-nj-ng2
Villagers in India often resort to indigeneous systems of medicine.
The
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p* 0'^training at St-r-febn1 a fur—Um various catugrrries—health workers including
our medical students, includes training in Herbal Medicine, Herbo Mineral
Medicine, Acupressure, Homeopathy and Yoga.
Many of our graduate doctors
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working in remote rural areas, have substantiated the fact that there is
J:his need to' inte-cgrogo Vj-i-l-opat hie—msd-j-cine with >th-e other systems of medicines
as is being attempted at St. -Je-hn-'-s. c
Health
-------. Education ae a priority?
.
It has—been—rfcal-ised-at_Sts. Sohn's that~over the years of experience in
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training health team members for the villagers, there is a greater need to pay
attention to health education <net-h.-,do. Tin' the long run, it is the health
education programme that have paid off the maximum dividends.
With this in
view, health education receives a top priority in the training programmes
conducted at St.’John's.
'Innovative methodologies such as Child to Child .
health education, rural mothers motivation programmes^ rural school teachers
health education training programmes ore some of the important -hc^-lt-h
Ixy Zip. Otficww. .
.edwootion- programmes^den-e-by St-»—^SehFPs . The health education methodologies
include the development of -Indi gonrj&us. audio-visual aids in the form of
simplified demonstration models using local materials rather than sophisticated
charts, photos, films etc.
The materials for most health education sessions
are prepared by the village school children and village school teachers.
-Health cduoation-in the—field—of ^/utrition^ involves teaching the village
mothers to use their oun traditional recipes in a nutritionally correct
manner.
The aim here is to strengthen the existing traditional diets which
are^nutritionally far superior to the imported diet from the urban areas.
Thornfnrt , greeter stress is laid on the use of local cereals, pulses etc.
along with promotion of breast feeding as well as local weaning diots for/fcjj
-village children.
Sensitisation to the rural mil/iou;
In order that all the trainees at St. John's, including medical students
and nursing students, must understand the -rural- dynamics ofzlifo, special
training programmes are organised on a res id ential-t r-alniog basis at our
rural health centres.
These rural residential training programmes stress
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on understanding the various factors which govern rural life and in turn the
health of the people.
Areas such as agriculture, animal husbandry, small
scale industry, customs and traditions, housing and environment, role of
women in society, food practices etc., are all studied through field projects
by the various groups of trainees.
The training programmes are thus oriented
to sensitize the health worker to the various aspects of rural life and how
each of these aspects are related to the. health of the villagers.
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T.his has
already paid off in tcrrris' of th^. practical ad&i^p given by outxQladuate
doctors even in the hospital promises.
Reaching outfe
Considering the resources and facilities^-available for health care at St. John’s,
it is quite natural to try and reach out to thcundcrscrvcd areas using -all the
available resources for health care. Rural sergiaol camps in the field of.-2-^ecu>>. fc,z
Qph4-.hr. i mg in y- Mf, ncrm14ningy| him*< n»
—Pa udtra tries and General Surgery
etGs-^. arc conducted in the villages.
Methodologies have been evolved at
tno village level to ensure asepsis and follow-up for post operative care
through the use of trained school teachers, youth volunteers^traditional
healers ettr;
itself.
Specialist surgical care, is thus made available at the village
In the bargain, the faculty have gained confidence tnat it is
possible to reach out with even oophiofrieotcd health care to the villages.
Those exercises have also proved to be an important force of cohesion,
among the various hospital departments and Community Medicine Department.'
The rural mobile clinics further carry the health care facilities to over
12 health
centres, spread through three Community Development Blocks
covering over 300 villages.
In this process of rendering services to the
unreached, our trainees (through the participation in such programmes)
gain invaluable experience.
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Understanding health and disease holistically^
In order that our health team trainees dn not dichotomise health care into
various compartments, the training programmes -include giving health rare to
families rather than individuals.
Through programmes such as the Clinico-
sociel ease study and field family health care projects, the ggi'ioris eet-egorics -tff trainees are
made to understand the cause and consequence
of disease in terms of multiple factors rather than^clinical signs and
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symptoms of the^bedy.
during thia training ppegrommcc, temphasis is laid on
the planning and management of health care at minimal cost.
Our graduates
-in-the—futUP-&T. would also be cost conscious and make their programmes financially
self perpetuating in the village communities rather than make the people dependent
on charities.
Serving the urban under-privileged^
Urban slums in and around Bangalore, are also served by St. Johfi-'o Medical
College.
Health programmes such as immunization Coverage against the major
killer diseases for children, maternal and child health clinics for expectant
mothersschool health programmes, are some of the urban based health
acti vities „o-f—St. Johrr'-s.
In addition, the Medico-social Unit also aids
in counselling for alcoholism, drug addiction, juvenile deliquency etc.
various gro0as of health^team t rainces^at-'SE. John's^ttjus'get an opportunity
to learn
serve thc^undcr privilegcxfin all aspects of health care.
Continuing educations
Although basic training in health care is imparted to various categories
of health workers, it is important that a follow-up is done on the
utilisation of the knowledge gained at St. John's,
several methods are followed.
for this purpose,
At the professional level, doctors can
seek elective posting in selected specialities for further skill
enhancement.
Regional Colloquia arc organised for sharing professional
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experience among Community Health Workers and Rural doctors.
an opportunity for learning from each other,
Leeturca—atg-,.
This provides
it—io more important than-
Continuing education is also provided by St. John’s for
health agencies from afar.
The United Planters .Health Association of
Southern India (UPASI) works in collaboration with the Department faculty
to train their Medical Officers, Nursos, Compounders and even their Estate
Managers in the field of health care and health management.
Periodical
newsletters also act as a means of net working/ graduates and Community Health
Workers working-in various parts of the country.
Development as part of health5
Extension training in agriculture, water resources and veterinary care for
village youth, are part of field training programmes given in rural health
centres.
The stress is on youth motivation and training in these areas,
especially among the rural unemployed youttys,
Functional literacy programmes
and vocational guidance arc some of the other services rendered in the
villages.
Our health trainees, including our medical students, participate in
these developmental programmes under their National Social Service activities,
which is coordinated by the department faculty.
At—th-fa. Sonclusionit may bo o.totcd-fe+ia^^ll the above programmes are
dynamic in nutrore since they a-re updated constantly, depending on the feed
back received of their effectiveness and efficiency.
The umphasis is Hws-
on training and health education rather than merel^iiie provision of
multiple services.
This ensures that whatever have been the programme
inputs, the results will be long lasting, self perpetuating and effective.
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A REPORT ERCM KERALA
BASIC HEALTH COMUNITIES
—Fr Edwin MJ*
We read and hear a lot about community health these
deys. But strangely we find thee the proponents often fail
to speak about the most im ortant component of a community
health programme, ie., communities ther.iselves.
“t would seem obvious that, we need to nave communities
to have community health. But unfortunately this is not so.
Building communities is pet to become an integral
part of the mental concept of a good many of our community
health wdrkers.
..'hat is a community?
Or: What are the characteristics
that make a mass of people into a community?
We need, to have
consensus of what we mean by community when we speak of
community health. Some of the guiding principles of a
community are:
1. A community is not a crowd.
It is not a transient aggregation of passersby.
Community has certain amount of permanency.
2. A community presupposes commitment to one another.
And this commitment is actually the most identifying
factor.
3. A community has a shared vision.
Consensus on objectives holds the community together.
In this sense a community “works together".
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♦Director
Xavier Pastoral Centre
PB 17, Nagercoil 629001
2
4. A community means its members feel with one another.
A community, devoid of feelings, is not yet a community
It may be just a task force.
Community members "weep with those who weep and
laugh with those who laugh".
5. A community celebrates together.
It brings imagination, feelings and art to play in
the collective affirmation of persons and events
and mysteries of life.
6. A healing community heals not only by the explicitly
therapeutic programmes but also by its process of
affirmation and the strength of the relationships.
Community is an antidote against alienation,
loneliness, insecurities and the resultant
psychosomatic problems.
7. A liberating community, const' uently a healing
community is a participating community.
Participation in decision making is what makes a
mass into a people. When people decide together they
become conscious of their dignity as partners in
progress, as subjects and equals and not just
objects and the ruled.
8. A community that is empowering, hence liberating
and healing, makes its members not only to decide
on the choice of various solutions proposed
but also to see the problems together.
Knowledge is power. A community that has been enabled
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to identify the problems and constantly to
evaluate them is an empowered community.
Few will dare to exploit that community.
9« A community that is effective is necessarily small.
This follows from our earlier principles. A
big community can neither offer powerful relationships
nor scope for participation.
Only a fellow
ith a big voice can make himself
heard in a big village. Small men feel too small
to speak up in bigger structures.
10. A community that intends to have wider macro
level im-pact ensures linkage with other similar
communities through representative structures at
various levels. This ensures both the smallness
of the community and the wider level effective
action with effective grass-root participation.
11. A healing community takes a holistic view of
health that includes the various social, economic,
environmental and other factors effecting health.
Do we have such communities?
Such structures or
infrastructures that would make community health action
more sustained and more participatory at grass-roots?
Until we have such communities whatever we call
corm: unity heel th programme may at the most be a rural
extension programme and not real community health action.
Community health is not jus? a programme for the
people* it is also something of the people and by the people.
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They say examples speak louder. Let me share with you an
attempt where we try to integrate the community structure
aspect or the infrastructure aspect# into community health
action.
We call this project Basic Holistic Health Communities.
BASIC HOLISTIC HEALTH CCh? UhlTIEfl
Our first step here is to start organising basic
communities of thirty houses each. We have altogether
170 such basic communities now.
These communities arc geogra-hical, ensuring that
nobody is left out. This geo graphical aspect ensures also
a permanent identity "or the communities. As long as
the houses are in a given geographies 1 area the communities
are also there. Even if for some reason or other seme communities
or all the communities in a village remain dormant for sometime
the day somebody wakes them up they come alive and ready
to jump into action.
These communities meet once a week or twice a week
or even of saner as the case ma\ bn. Those meetings are
either for prayer# or for celebration, or for nonformal
ecucation or for discussions on problems affecting them and
so on.
Five representatives from each community make the
representative general body of the villa c. One representative
from each community makes the executive body of the village.
Representatives from the villages make the zonal
representative bodies, the general body having a representative
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each from the communities and executive committee having
village representatives at the ratio of one representative
for five communities. What is discussed below that is
at grass root communities# each up to the top through
their representatives at various levels and what is
discussed at the top is reported back to the basic
communities.
Our system of handling finance in one of these villages
called Kodimunai# will make this accountability to the
grass roots clearer. Here the Treasurer is
free to spend on his own discretion upto Rs.50,00 for
emergency expenses. When the President and the Treasurer
decide together they can spend upto Rs.10:.00. The Executive
Committee of the village can spend upto Rs.500.00.
The
representative general body of the village having five
representatives each from the communities can spend upto
Rs,1000,00.
If it is more than Rs.1000,00 the representative
general body of the village makes the decision and sends
it for referendum among the basic communities. The decision
is not carried if more than half the number of the
communities fail to support the decision.
This type of two way communication helps for sustained
action. It is enough for anyLo y in any of these 170
communities to remember the problem and the issue will come
alive again.
Once we build these basic communities we use these
communities for nonformal education on health concerns.
They become grass root forums for health motivation#
participation through decision-making evaluation and follow up
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Here the care is taken not just to propose solutions
but more especially to make them see the problems themselves
so that through the process of ongoing situational
evaluation they are enabled tc remain empowered.
This we do through various processes. One such
programme is our holistic health orien'afcicn camps in
basic communities. This willbe a week long programme where
trained volunteers help conduct health discussion^
sessions in the basic communities with the help of a few
structured community-di cussion exercises. Each community
will be encouraged to do also creative assimilation pro rammes:
whatever they learn in the discussions in an evening is
translated by the community into cultural programmes
to be staged in the community next evening. The village
level celebration that will take place the last day will
bring tc a wider audience the best of the cultural programmes
produced by these com unities. This health camp normally
will include also an exhibition and also half a day or one
day seminars to various categories of people with orwithout
audio visual programmes. Wherever possible we
would include
also house visiting programmes, and a health survey of the
village.
In addition we prepare discussion themes and circulate
them among the badic communities. These discussion themes
are structured in such a -way that they elicit participation
of the community. Each theme contains an initial activity
related to the theme, questions to elicit participation,
a deepening process through the points given, questions
leading to community decision, and a conciiding activity by
way of a song or so.
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Our next process will be to make these communities
accept responsibility for their own health care. This we
intend to do by way of promoting a holistic health
insura ce scheme run by the people themselves.
Recently we had a survey to find out the average annual
medical expenses incurred by a family. This survey, conducted
in four villages, showed that the average amount was
Rs.4086.00.
We will be able to reduce this to just Rs.500.00
with proper
educational preparation and involvement
by the pec le. For thio, we would need to transcend the
allopathic boundaries and include other therapeutic
systems including drugless ones.
Our health insurance programme is expected to consist
of the following components: nonformal education through
basic communities, collection of funds through
basic communities, primary health care through village
level representative body and its appointees, secondary
and other levels of health cure through zonal bodies and the
referral centres chosen by them.
Unfortunately, even the example given is not yet a
realised dream. Well, this is the vision. We are not yet
sure how far we will reach. May be in spite of our
optimism we may r ach only half way. But we feel even
that would be worth the efforts, as it would be a se
step in the right direction.
ORGANIZING PEOPLE FOR HEALTH
— Problems and Contradictions^
Anant R S
(This reflection is based on the experience of work in a
health-education-concientization project in a feu rather
remote, backuard villages near Pune, and on the debates,
discussions in the Medico-Friend-Circle)
General Perspective on Health-uork
Most ofAhe major determinants of the health status of a
population - food, water,
sanitation, shelter, uork-environment,
cultural relations
are far beyond the control of health
workers,
But Medicos can, with the help of the community,
organise preventive and therapeutic (symptomatic or curative)
services, can do health-education and advise the planners on
health-implications of different socio-economic interventions.
These medical interventions are very valuable to prevent
certain deaths and diseases, to relieve human su-ffering. But
they have only a marginal role in improving the overall
health-status of the population.
For example, infant and
child mortality can be reduced uith immunizations and ORT...etc.
but no health-programme has abolished malnourishment in
children
of a nation.
The deoartment of health aiming to improve the health
of the people through so many national disease control programs
and now through the programme of ’Health for All by 2000 A.D'
is therefore a utopian, misleading idea.
As a part of a
thorough going socio-economic change, medical interventions
can be a very good supplementary tool to improve the overall
health-status of the people.
But the idea that "Health for
All by 2000 A.D" would be delivered by the health-ministry/
health projects by the NGOs, though very attractive, is a
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misleading one.
All that heolth-people can hope to achieve is
"Health-care for An by 2000 A.0".
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This is not sterile semantics.
There is a strong reason
and a contexi/tor making this distinction.
There is a wide-
spread technocratic, and managerial illusion that improvement'^
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in health of a nation, whidn is in reality, prrimarily a function
of socio-economic development, can be achieved with technolo-
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gical, managerial interventions.
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Lay people are made to believe
that the beneficient state through its Health-Programmes, or the
Health-Projects run by NGOs, would improve the health of the
people with the help of modern science and technology.
These
slogans are being promoted in the context of the continuing
crisis in the economy leading to increase in poverty, unemploy
ment, inflation, drought and ecological disaster.
Other basic
element required by for the success of "Health for All" —
improvement in socio-economic situation of the people—is in
practice, missing due to this economic crisis.
What remains is
the misleading idea of "Health for All" to be achieved by the
efforts of the health-workers.
Those who undertake health-work primarily with an
intention of not ’giving a few pills’ but of doing some ’basicwork* can, in fact, make very valuable, basic work.
Many
improvements and some thoroughgoing changes are needed, many
new ideas, practices have to be founded and developed, many
vested interests to be fought in the field of organising
medical care and health-education.
technocratic work.
This is not a purely
There are many■sociological, ideological,
technical, practical issues to be resolved.
Health—work, done
with the aim of taking up one of the so many challenging issues,
can be very valuable, basic work, a historical need today.
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But in the existing socio-economic frame work and its
crisis let there be no illusion of really improving the
overall health of the people through health work.
Health-uork alone ?
Anybody, who has any idea of the situation at the
grass root level, would agree, that in the rural areas,
it is not possible to build an organisation of the common
people around health issues.
The problem of poverty and of
paucity of basic amenities is so overwhelming that fcural poor
are not in a position to rally around exclusively for health.
Those, whose basic needs are met, can perhaps form an
organisation on issues like occupational health.
in Pune, a Citizens’
Recently
group has been formed to discuss and
work even on the issue of mental health.
In rural areas,
and in the unorganised sections in the cities, however,
things are quite different.
But at the same time, unless
poor people become aware of health issues and actively seek
influence medical service, these services would continue
to be cut off from the people, and would continue to serve
the interests of those who need these services.
In other
words "health-care for all" can not be realised in its true
spirit unless it is'Health by AH’—unless the people them
selves actively participate in the decision making and
implementation.
Even if it is not possible to build an
aganisation of rural poor exclusively on health, health
should be one of the activities of a group trying to organise
the rural poor fcr
Justice and for development.
It is with this perspective, that a health-education-cum
conscientization work is being done for the past seven years
in a rather remote, backward aeea near Pune.
Neither the
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3
But in ths existing socio-economic frame work and its
crisis let there be no illusion of really improving the
overall health of the people through health work.
Health-work alone ?
Anybody, who has any idea of the situation at the
grass root level, would agree, that in the rural areas,
it is not possible to build an organisation of the common
people around health issues.
The problem of poverty and of
paucity of basic amenities is so overwhelming that tural poor
are not in a position to rally around exclusively for health.
Those, whose basic needs are met, can perhaps form an
organisation on issues like occupational health.
Recently
in Pune, a Citizens’ group has been formed to discuss and
work even on the issue of mental health.
In rural areas,
and in the unorganised sections in the cities, however,
things are quits different.
But at the same time, unless
poor people become aware of health issues and actively seek
influence medical service, these services would continue
to be cut off from the peoole, and would continue to serve
the interests of those who need these services.
In other
words "health-care for all" can not be realised in its true
spirit unless it is’Health by All’--unless the people them
selves actively participate in the decision making and
implementation.
Even if it is not possible to build an
aganisation of rural poor exclusively on health, health
should be one of the activities of a group trying to organise
the rural poor for
justice and for development.
It is with this perspective, that a health-education-cum
conscientization work is being done for the past seven years
in a rather remote, backward area near Pune.
Neither the
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village Eommunity Development Association, on whose behest
this work is being done nor the local organisations are
health-organisations as sush.
Health work is considered as a
part of a broader work of education, conscientization,
organisation on a range of socio-economic issues.
Health is
considered neither the main issue nor a mere entry point.
Even with a limited aim, and with the support of the broader
social work done by the local organisation, the process of
increasing the health awareness amongst this marginalised
population and of fostering collective self-help has been
very gradual one and beset'
with many problems.
Achievements, Problems, Contradictions
Our health-work consists of training of Village Health
Workers (chosen by the marginalised people themselves) in the
diagnosis and treatment of routine viral fevers, malaria,
diarrhoea, conjunctivitis, scabies, wounds,
skin infections
etc., and distribution of iron and Vitamin-A supplements to
children and pregnant women.
These elementary curative
services are used to:
a.
establish the credibility of the Village Health Workers;
b.
as an occasion to interact with the people;
c.
an attempt to meet the felt-need of the people.
Rural peor are not much interested in general health-education;
given the arduous life they life.
But a rural poor is more
incluned to listen to why’s and how’s of diarrhoea-control,
when he/she is suffering from diarrhoea and effective treatment
is given by the same person who gives health-education about
diarrhoea.
Hence the strategy of coupling health-education
and therapeutics.
The result of this strategy is a mixed one.
Let me give
some examples of positive experiences and then of some problems
and difficulties:
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Our VHUs have a much greater support from the community
than that the Government’s VHU has.
They are trained much
better because both the trainee and the trainer are really
interested in this work and its philosophy.
spend a lot bf time for this work;
These MHWs
attend frequent meetings,
participate in other programs of the organisation, trabel
to and camp at other villages.
All this is possible because
of/a support from the community.
The honorarium of a mere
Rs.50/- per month does not explain the interest, efforts of
these VHUs.
(Many of the VHUs even do not get any monthly
honorarium).
The quack practice of some traditional therapi
sts and that of the compounder-turned-doctor , has been
considerably curtailed.
’injection-culture’.
Some dent has been made in the
People have collectively approached the
health authorities bo complain about some specific grievances
about delivery of health services.
about a case of injection-p&lsy;
(for example, a Morcha
representations
about below
par functioning of health-services at the grassroot level..etc)
Slide-shows organised by VHUs on prevalent diseases like
sables, diarrhoea are quickly being sought after.
More
than one hundred women from different villages had walked
for a few kilometers and had waited patiently for hours to
see a slide show on women's reproductive health.
This
indicates the interest of rural women in knowing about their
own body and health.
Discussions in meeting and Shibirs
about nutritional requirements of labourers, and of women,
about the relation between water supply and health has had
an impact.
In the consciousness of a section of the people
in the organisation, this new health-knowledge has given an
additional justification for the demand of higher minimum
wages, of leave from hard work during pregnancy, for improve
ment in water supply,
6
6
These developments are in a way collective attempts
towards control over health care activities; are rudementary
forms of organised efforts around health issues.
along with such achievements,
However,
there are some knotty problems
which show that it is still a long way to go before the
awareness of the health problems increases to such an extant
that people start influencing the health services and policies
in accordance with their own needs.
a.
There is a tremendous gap between the consciousness
of health-workers and that of the people.
interested in medicines;
People are primarily
rather than knowledge.
There is a
strong tendency of going to the commercial quack for an
injection, pay him five or ten rupees.
But when it comes to
paying ten paise for the tablet taken from the VHW, there is
a tendency of not paying for this self-help, even though over '
a period of/time, people have realised that these tablets are
agfeffactive as these injections.
There is less of a tendency
to see that this process of self-help becomes self-reliant
the dominant tendency is either to seek a commercial treatment.
It is not easy to go beyond the stereotype responses conditio
ned by the dominant-culture.
b.
Many people as yet
to see the work done by UHU§,
as a kind of social work done by the representatives of the
people.
Many feel that these VHWs work ’because they do not
need to work at home’ or ’because they must be getting
something from the agency’.
This is in spite of the fact
that these VHWs were chosen by the people in a meeting; their
help and advice is soughfc;’?.a call for a meeting, Shibir or
even for a florcha is positively feesponded to.
But still the
idea of a movement hast) not taken real roots.
c.
The Government health structure has cooperated by
providing medicines, sending their health personnel at request
....7
A
Heport from DEENABANDHUfTamilnadu)
Community Health : Learning from our failures
)
(Dr Prem John and Dr Hari John, graduates of CMC Vellore
recount the lessons they learnt from their failures so that
others may benefit from their mistakes and perhaps not
repeat them, thus saving time and efforts)
COMMUNITY HEALTH ? Community Health, as it is known today,
started in the early seventies.
International organisations
and resource agencies from the West latched on to this
hew
concept and touted it as being a panacea for all ills in the
community.
In the early stages there was a tendency on
the part of practitioners as well as promoters, to give less
publicity to problems and failures and to uphold "successes".
This resulted in '
1. a number of well motivated people going into community
programmes without learning from the failures of others and
thus having to reinvent the wheel, thereby wasting a lot of
time and money, and
2. community health being practised in a haphazard
and
"non-scientific" way.
In fairness we should mention here that there were very few
models to go by and learn from.
But the lack of basic know
ledge of social sciences was a great handicap and retarded
our progress; often a trial and error method had to be
adopted.
v
Apart from the attitudinal problems bo,tn out of
established values reinforced by sophisticated education,
we faced some early prlblems.
We were well received by the better-off, and it was they who
offered houses in villages free of cost for establishing
clinics.
This fulfilled our requirement of "community
participation".
Only later we realised that all our clinics
2
2
were established in upper caste villages and to large extent
the poor were excluded from the services provided by us.
It
took us two years before we realised the implications and
x
moved away.
At the beginning we spent many months explaining our objectives
to "leaders” in the community and asked them to select village
health workers.
We found that though our stated target group
was the landless poor, the majority of those sent to .ys by the
communities were from the land-holding classes.
to remedy this situation.
It took time
Mobile clinics were held on a
scheduled basis and it was several years before we learned
enough to see only those patients who were deferred to us
by the VHU.
The village clinics, though used as an "entry
point”, tended to slow the process of acceptance of the VHU
by the community and we stopped doing them entirely after four
ye ars.
Village health committees were formed with much fanfare but
after some time became inoperative when the committee members
found that apart from "prestige", there was no monetary
benefit to be had.
Some of the committees also used the
VHW to run errands, etc,, and had to be cautioned.
Once the
VHWs established their credibility, we found that the commi
ttee was not really necessary.
We now operate on the basis
of trust between us and the VHU, and between her and the
community.
Of course, two independent control mechanisms
do exist in the programme, more to see the effectiveness of
the VHW than to "supervise".
Use of sophisticated drugs and diagnostic tests were a
legacy of our expensive medical education, and we inflicted
them on the community for a long time before really understanding
3
3
the people’s economic'/ deprivation.
The emphasis we now
lay on herbal remedies is a response to this.
Me havfi seen
the proven efficacy of several herbs commonly used at the
community level.
Me started with a base hospital providing secondary care.
The hospital had a very busy and often lucrative practice.
Me found that we tended to spend more time "curing" people
and slowly started de-emphasising this aspect.
The effec
tive service carried out by the VHMs also diminished the
number of people who needed secondary care.
Me now believe
that if enough preparation of the community is done, it
should be possible to start programmes without base clinics,
which are often a hindrance.
Me also believe strongly that
existing government facilities should be used, and if theyx1
are inadequate,
people should be organised to demand better
services rather than duplicating services.
Me started this as a total community programme, for the rich
and the poor alike, for the upper and the lower caste, for we
believed that we had a duty to all.
During the initial stages,
we found that the services offered by us were being extensively
used by those who "have" land, money, education and who are
often from the upper castes.
This resulted in one of our
primary objectives being fulfilled - to double income levels .
A mid-programme assessment revealed that though we had largely
achieved this objective, it was at the cost of the poor, who
showed only marginal growth while the "haves" showed specta
cular growth.
initiated.
This was evident in a dairy programme we
This package programme involved bank loans for
cows and feeds, fodder development, milk co-operatives and
transport of milk to the dairy.
Not taken into consideration
was tha fact that the landless harijans were not used to cows
had bo place to grow green fodder, and if they had any ihilk
4
4
sold even the last drop to the dairyji while their children
were malnourished.
The land-rowning classes, on the other
hand, increased income levels significantly through the
dairy programme.
Also, we believed that the transfer of
milk from impoverished areas to the cities to be made into
o
cheese, choclate and condensed milk was not socially just.
This and other lessons made us resolve to work only with
the target group i.e., the powerless:
the landless and the
harijan. All programmes - health, agricultural,
animal
husbandry, etc - were, offered exclusively to this group.
The VHMs too, served only them,
Thus our focus became defined
and we were able to serve the taiget group better.
Com^unit^-Panticipation
Expectations of community participation started coming into
vogue in the early 70s.
assumptions:
Me, too, started with a lot of
that communities are homogenous and therefore
able to take collective decisions based on common good;
that
communities consider health as a priority and that they will
identify and act upon their "felt needs"; that 25% contribution
by way of laboujf was participation;
that food-for-work progr
ammes were community participation, etc.
Only later did we
realise that widespread acceptance of our project did not mean
community participation.
Me had, in fact, imoosed a programme
on the community and had clearly defined areas in which they
should participate, thus acting contrary to our aim of enabling
them to make decisions affecting their lives.
Me believed that the "leaders" expressed the collective need
of the people and many of our earlier schemes were based on
this assumption.
After several years of our education by the
community, we were able to see thefolly of this and involve
the entire community and not just "leaders" at all levels of
5
5*
programme implementation, right from identification of priorities
and planning to evaluation.
To claim th'-it we have been entirely
successful in this would be untenable, but serious efforts have
been made over the years.
Since ue were unable to make defined
parameters, evaluation of this aspect is difficult.
It is also
hard, because the orogramme as ue said earlier, has evolved
through many stages and has undergone changes in its objectives.
££l£z££££i£i£2£2
As a corollary cf community participation, self-sufficiency
has boen a goal in itself as well as a process.
Several ways
of seeking this goal were experimented with, particularly with
regard to the support of UHUs.
One way was to provide services
to the rich to raise resources.
There was an inherent danger
in this, for we spent far too much of our times serving the rich
and this was contrary to our ideology, too.
Another alternative
was to ask the VHUs to charge for their services, even a very
small amount.
The question remained, however; why should the
already marginalised and oppressed people ba made to pay for
their health services while a lot of resources all over the
country were being allocated to serves the "haves" and the
urban elite?
We had this problem until we realised that "self-sufficiency"
referred to the project, while what we were aiming to build at
the community level was ’'self-reliance".
Ue were working
towards building community capability in health care and,
community capability in health care -and-, hence, self-reliance.
Using a community-based approach,
(aponpriate personnel and
technology) we learned that it is possible to make communities
self-reliant.
Source:CONTACT, A bimonthly publication of the Christian Medical
Commission, Switzerland) (No 82 December, 1984)
A
CuMMU NIT Y HEAL TH R ESOUR C E INVENTORY
£50 titles from the Indian sxperience^
The 70s and 80s hava seen an ’explosion* of ’Community Health*
materials on ths Indian scene, with the increasing wealth of
grass-roots field experience.
Most of these materials are
unfortunately still in English and inspits of the presence
of large networks of NGO health initiators these are still
not as widely known or as widely read as they should bo,
A Community Health Cell, tentative Bibliography has identi
fied over 150 such materials.
A shorter version uith sources
is given here highlighting 50 of them.
Titles and^Source
A-Indian Council of Medical Research, Neu Delhi
1.
Alternative Approaches to Health Care, 1976
2.
Evaluation of Primary Health Care Programmes,
3.
Appropriate Technology for Primary Health Cara,
1980
19B1
B-Ministry of Health and Family Welfare, Neu Delhi
Health Services and Medical Education (Srivastava Report)
5.
Manual for Community Health Worker, 1978
6.
Manual for Health Worker - Female Vol I&II,
1979
7.
Manual for Health Worker - Male
Vol I&II,
1979
8.
Manual for Health Assistants (Male & Female)
19B0
9.
Primary Health Centre Training Guides I-IV 1980
10.
1975
Handbook for the delivery care to mothers and
children in a community Development Block (Oxford University
C-Madico Friend Circle
11.
Pr0SS>
1980
In Search of Diagnosis - Analysis of Present system
of Health Care
1977
12.
Health Gare - Which way to go?
1982
13.
Health and Medicine - Under the Lens
1985
2
2
0- Voluntary Health Association of India, Nau Delhi
14,
Teaching Village Health Workers - a guide to the
process
15.
1978
Manual for Child Nutrition in Rural India
1978
15. Where there is not doctor (revised Indian edition)
17.
The National Health Policy
18.
A Manual of Learning exercises for use in health
training programmes in India
19.
1979
1983
Better Care Series (8 problems)
£- Indian Social Institute, New Delhi
20.
Moving Closer to rural poor
1979
21.
Health & Culture in a South Indian village
1979
22.
People’s Participation in Development Approaches to non formal education
23.
1980
Changing health beliefs and practices in rural
1981
Tamilnadu
24.
Learning from the rural poor - experience of MOTT
25.
Development with people - experiments with
participation and non formal education
26.
27.
1985
Social activists and people’s movements
F- Lok gaksh,
1982
1985
Neu Delhi
Formulating an alternative rural health care
System for India
1982
28.
Poverty class and Health culture in India
29.
Health and Family Planning services in India -
an epidemiological,
socio-cultural and political
perspective.
G- Catholic Hospital Association of India, Secunderabad
30 Health and Power to people (medical service special
issue)
1986
31.
Taking sides - the choices before the health worker 1986
32.
Trainers manual for training community level
workers
1987
3
H- foundation for Research in Community Health, Bombay
33.
Community Health Projects in Maharashtra — an
evaluation report
34.
1981
Health Status of the Indian People
I- National Institute of Cental Health and Neurosciences, Bangalore
35.
Manual of Mental Health for Medical Officers
1985
36.
Manual of Mental Health for Multipurpose workers
1985
3- National Institute of Health & Family Welfare, New Delhi
37.
Evaluation of CHU Seheme - a collaborative study
38.
Management Training for Primary Health ^are.
K- Indian Council of Social Sciences Research, Neu Delhi
39.
An Alternate system of health care services in
India - some proposals
1977
L- Centre for Social Action, Bangalore
40.
Health Care in India
1983
41.
Rakku’s Story
1964
M- Institute of Education, Pune
42.
Health for All - an alternative strategy
(ICMR/ICSSR Study Group)
1981
N~ Centre for Science and Environment, New Delhi
43.
The State of India’s Environment - the
second Citizens’ report
1984-85
0- Kerala Sashtra Sahitya Parishad, Tribandrum
44.
Science as Social Action
1984
P- Community Health Cell, Bangalore
45.
Community Health: The search for an alternative
process (Draft report)
1987
Q- Ford Foundation, Neu Delhi
46.
Anubhav beries: Experiences in Community Health
(12 project reports available)
1987
R- Some Foreign Publications (with Indian case studies)
87. Health by the People (WHO, Geneva)
1975
48.
Practising Health for All (Oxford University
Press)
49.
Intersectoral linkages and health Development navaj-jgg4
50.
Disabled Village Children - A quids
health workers, rehabilitation uJ3lrqsflx
families (Hesperian Foundation*
1983
1987
TRADITIONAL MEDICINE
Ficus Carica
Fig. Tree (Anjir)
Use
1. Tooth ache
apply few drops of milky jiiice of the
tree by breaking a small branch. This can
be repeated if pain persists
2. Ring worm
rub the affected area with the milky juice
twice a day until ring worm disappears
3. Warts
wash the feet well and dry. Place few drops
on the warts and repeat every night until
wart disappears.
4. Diabetes
figs are considered to have antidiabetic
properties. Few drops of milky juice of
figs in water every morning reduces
the sugar in the blood.
Lilliacease - Aloe vera/lndian aloe (H-Ghikavar)
Use
1. Psoriasis
split the leaves of an aloe vera plant,
apply the juice directly to psoriasis and
let the juice dry. In a week it should be
healed.
2. Bald head
fresh juice is to be applied on the scalp.
3. Constipation
juice is a drastic purgative. Use fresh
juice 1-2 tsf for adults.
2
2
4. Dandruff
apply fresh juice on the scalp for an hour
and then wash it off. Repeat this daily until
dandruff disappears.
5. Burns
it has been proven a good remedy for
burns, treating effectively even 3rd degree
burns„
6. Halwa can be made out of freshy part of the plant which
is a remedy for indigestion and peptic ulcers.
Boat lilly, Comrnelinacea
Rhoeo spalhacea - Boat Lilly
Use
1. Whooping cough
leaves and. flowers are boiled to make a
hot decoction. An oz. of the liquid is given
3 times a day and whooping cough disappears.
2. Bacillary dysentery : boil the leaves for 10 minutes and use
the decoction 3-4 times a day.
Papiliomacea - Fabaceae, Pongam oil tree - Karanj
Use
1. Herpes & scabies
apply the oil extracted from the seed for
3-5 days
2. Rheumatism
The oil massage with Karanj oil is considered
beneficial to those suffering from rheumatism
3. Bronchitis
the powdered seed is used as an expectorant
in bronchitis
4. Leprosy
oil of the seed is used in leprosy by the
tribals.
.... 3
3
Graminae
Lemon Grass
Use
1. cold and cough
widely used in cold aii cough. Tea
is prepared from leaves
2. Fever
it is given as a diaphoretic in fever
also carminative
3. Diuretic
tea made from the leave is diuretic
Euphorbiaceae - Phylanthus Niruri
Seed underleaf - Egg woman
Use
1. Jaundice
whole plant is used as a remedy
for jaundice
2. Diabetes
the plant is considered to be useful in
4B*
3. Dysentry
diabetes
infusion of the young
4^1
shoots are
often used for dysentry
4. Skin ailments
juice is taken from the plant and
rubbed for skin ailments
References 1988 Table Calendar, Holy Family Hospital, Nev; Delhi
BASIC PRINCIPLES IN CHAI'S COMMITMENT TO COMMUNITY HEALTH
1. Community Health is a'm approach to health care services.
It takes into consideration a philosophy, attitude and
commitment of working with people to help them help
themselves.
--------- --- • --
It is not a project, department or funding
system.
2. Community Health focusses on the promotion and maintenance
of health and giv s priority or em-hasis to the health
team, primary health care and community needs.
3.
Community participation is an essential component of
Community Health.
This recognises the potential rolpifaf
others to help educate, organise, mobilise and support
community development activities where the people have a
say in and control over their own future.
Community
participation thus becomes involved in paople’s democratic
rights and their contributions to the development of their
society and nation.
4.
In Community Health there is a recognition of a three tier
system of primary, secondary and tertiary cars approach to
the needs of the community and the resources available.
Therefore this approach accepts the role afid potential
ofthe hospital as integral to the Community Health.
A
commitment to Community Health is not necessarily anti
hospital. Yet the hospital needs to be supportive of
Community Health and recognise and accept this wider concern
in health care services.
5.
-7
In the provision of services in Community Health there is a
bias towards those who are oppressed, exploited, the poor and
--
the marginalised.
Thus priority would be given to rural
areas and urban slums.
Special groups for concern would be
women, tribals, dalits, small marginalised farmers and
landless labourers.
2
2
6,
The organisation of services under Community Health would
be appropriate, acceptable, easily available and affordable.
It would be cost effective and willing to use unskilled, semi
skilled adequately trained local health personnel,
7.
Thera is a place for voluntary agencies in Community Health,
B. Community Health accepts that health cannot be improved by
health services alone; health and development need to be
interlinked and interdependent,
9. There is a place for appreciating local customs, traditions,
beliefs and health cars systems and relating health
services to the culture and socio-economic situation of
people.
Appropriate indigenous medical practices and
trainad practitioners, or traditional birth attendants
are encouraged in Community Health,
10. In the final analysis Community Health is not apolitical.
If it concerns the welfare of people and the provision of
adequate and appropriate health cars then health becomas a
social justice issue.
It is concerned with structures and
systems of society that seem to benefit a few at the
expense of many.
ASIAN COMMUNITY HEALTH ACTION NETWORK (ACHAN)
was formed in 1980 by a group of twenty people with substantial
experience in working in health care among the poor in Asia
and operates through its network of concerned individuals and
non-gobernmental organisations in fifteen Asian countries, most
of whom have been engaged in innonative primary care at the
community level
ACHAN
seeks to spread a philosophy of community based health care
that envisages a process of self reliant human development for
the oppressed poor in Asian communities which will result in
genuine social change.
ACHAN
views health as the physical, mental, social, spiritual,
economic and political ohcneness of the individual and the
community
ACHAN
believes that health problems and priorities should be viewed
in terms in which the community sees them and that the community
should be actively involved in planning, implementation,
monitoring and evaluation of health care programmes
KERALA SASHTRA SAHITYA PARISHAD (KSSP)
The Kerala Sashtra Sahitya Parishad (KSSP) believes that science
which could become a powerful instrument of social change is in
the hands of vested interests and has therefore become an
instrument against the majority.
however, change.
This state of affairs should,
Scientific temperament should become an
■ integral part of the life process of the people.
A powerful
process of conscientization and scienticisation should take
place to achieve this goal.
KSSP has completed
twenty five years of work.
A purely
voluntary non-governmental organisation, it was initiated
by a small group of scientists who took to the task of po
pularising science through books and periddicals in simple
Malayalam, the mother tongue of Keralites,
Through the years,
this small group has transformed itself into a mass organi
sation of people from all walks of life.
HEALTH BRIGADE
KSSP is very strongly questioning the relevance of the present
day health delivery system which is curative oriented, indivi
dualised, institutionalised and highly costly and catering
to the needs of a
KSSP feels that a People’s
wealthy minority.
Health Movement alone can change the health delivery system
in fabour of the rural poor.
KSSlYis organising health camps,
classes and audio-visual campaigns £fflH0^HK-on extensive
scale.
KSSP has recently started W a big campaign to expose
the anti-people and unethical policies.of the multinational
drug companies.
Me have completed a very comprehensive health survey covering the
whole of Kerala. On the basis of the suney results, the KSSP
intends to formulate a people’s health programme for Kerala.
The
KSSP is mounting a vigorous campaign against the recent drug
price hike.
after’,
KSSP publications like ’Hathi Committee - A decade
’The Drug Information Packet’,
Drugs’ have received wide acclaim.
(
’Banned and Bannable
)
4^ s-i-^
STREEHITAKAR INI :
Bombay’s Slums
An organisation of women living in slums, which started
with Maternity, Child Health and Family Planning Services by
volunteer doctors,
and extended into areas of non-formal educ-
ation,: female literacy, income generation programmes for women
and running of creches for uncar—fives.
Their small savings
scheme won the Government campaign award for 1985.
Ths health component is tackled through Community Health
workers and utilises the nearest government hospitals for
referral.
The stress is on creating awareness about health
and promoting utilization of the facilities available.
K.E.f-1 HOSPITAL, RURAL HEALTH PROJECT, Pune District, Maharashtra
A Co-operative effort of a voluntary organisation with
the Government in providing Rural Health Services.
Socio
economic development programmes are with the involvement of a
separate organisation - UNDARP, with close links to the
health project.
Health activities are through Community Health Guides
of KEM with Multipuroose workers of the Government cadre at
the grass roots.
The Ssc ndary and Tertiary links are the
upgraded P.H.C at Vadu and KEM Hospital at Pune.
All activities
are facilitated by awareness programmes at Mahila mandals and
youth clubs.
SOCIETY FOR EDUCATION, WELFARE AND ACTION - RURAL
SEL'A - Rural - Dhagadia, Gujarat
An experiment in health management, towards creating a
participative self-reliant organisational culture in Integrated
Health and Rural Development.
The government had handed
SE/WA - Rural principal responsibility for total health care.
The delivery of health services is through a four tier
infrastructure, with the CHVs, AUUs, TBAs at Community level,
ZIP Us at tertiary level, Mobile Dispensary with M.D and MP Us
at middle level and a fully equipped referral hospital with
consultants and paramedical staff at the Central level.
SEUA-Rural has won the WHO's SASAKAUA HEALTH PRIZE for
1965.
Activities in non-health areas include Gramin Tekniki
Kendra, Tutorial classes for Tribal boys and girls and Economic
programmes for/jomen
COMPREHENSIVE LASCUR WELFARE SCHEME OF U.P.fi.S.I
- Plantations of ^amilnadu and Kerala
A Labour Welfare Scheme based on the belief that health
is indispensable to the productive performance of workers. It
has sensitized the management to the validity of the prenise that
the employee's health and welfare are convergent with the
employer’s interest.
Voluntary ’LINK WORKERS’ form the key element in Health
education and linking the Community to the health services
consisting of Maternity and Child Health, Family planning.
Environmental Sanitation, Safe drinking water supply and Health
education programmes.
MINI HEALTH CENTRES PROGRAMME OF VOLUNTARY HEALTH SERVICES
Chenglsput District, Tamilnadu
Aim at enlarging the
scope of functions of the Primary
Health Centre, emphasising preventive care, treating the
family as a unit and ensuring community co-operation.
The
Mini-Health Centre is ths model point of delivery of health
care, the components being Maternity services, child welfare
and nutrition, family welfare, minor ailment treatment, commu
nicable disease control, referral and most important of all dat
collection and health record maintenance.
The LAY-FIRST-AIDER
(L.F.A) is the grass roots contact, with Multipurpose workers
and a part-time Doctor at the M.H.C.
Ayurvedic and indigenous
medicine are utilized, and a form of medical insurance by
prepayment helps in community participation.
This is now adopted statewide as a model
ACTION FOR WELFARE AND AWAKENING IN RURAL ENVIRONMENT
s(A.W.A.R.E)
Andhra Pradesh (Telangana)
Seeks to create self-sustaining rural and tribal communi
ties through a process of socio-economic and psychological
invigoration.
Thair activities include Agricultural development,
Social action for education, Community programmes, Women’s
development, F&iabilitatioo of bonded labourers and landless
poor, cottage industry and marketing.
The health philosophy ’JEEVANA SRAVANTHI’ which means
life’s flow started unexpectedly following natural disasters
and led to a sustained activity.
The services are through
village health workers, Paramedical Community Health Workers
and Dais,
An innovation is a floating health centre on boat
catering to 300 villages along the banks of Godavari.
They work along with Governmental and NGOs as a
re-inforcing element.
COMPREHENSIVE HEALTH AND DEVELOPMENT PROJECT - Pachod, Aurangabad Dt
Maharashtra
A Project to make rural health more effective within the
overall policies and framework of the government programme by
wider application of innovative modalities and rational and
efficient use of limited resources.
The services provide complete maternity care, Health and
nutrition education, growth monitoring and nutritional
surveillance of children and Environmental programmes, through
Community Health;
Workars.
The problem os illiteracy among the
CHWs has been overcome using simplified systems and symbolic
reporting, while the Health Education messages developed
locally are unsophisticated, appropriate and beief.
RURAL UNIT FDR HEALTH ANC SOCIAL ACTION
- K V Kuppam ^lock, Tamilnadu
Reflects a holistic approach to health, in asscci&ion
with
ths local community, the government and other voluntary agencies
They provide integrated health and development services
to the
poople, including Adult education, Vocational training,
Income
generation, Agricultural development and agro-support services.
The health component is formed by the Family Care
Volunteers (FCVs), Health aides (Afts) and Rural Community
Organisers (RCOs) with close health and non-health activity
linkages.
Collective leadership models are saen in Village AaVj_30ry
Committees, Block Development Committees, Women’s groups,
Young farmers clubs and socio—aconoiric groupsuith similar
occupations.
They believe that HEALTH 15 BOTH A MEANS AND WEABURE OT
DEVELOPMENT
CHILD-IN-NEED INSTITUTE - 24 Paraganas, Us st Bengal
Caters Primarily to the health needs of the disadvantaged
semi-urban population around the southern outskirts of Calcutta.
CINI associates with national and international agencies in
research, consultancy and training for Primary Health Care^
while it operates mainly in the field of Maternal and Child
Health along with Community organisation
and community deve
lopment.
The Health services are village based clinics run by
Mahila Mandals which is the Eocal point of all activities.
The Emergency Ward and Nutrition Rohabilitation Centre of the
ill and severly malnourished child is a facility used much
further than the project area itself.
CINI has had a multiplier affect through persons trained
here having weaned off after starting similar new projects.
8ANUASI
SEVA ASHRAF-I, Mirzapur District, Uttar Pradesh
An integrated rural development programme based on the
Gandhian philosophy of self-sufficiency.
community development centre (Agrindus)
The Agro-industrial
was the nucleas of
diverse activities which included agriculture, land recla
mation, irrigation, afforrestation, dairy, village industries
functional literacy, village fund (gramkosh) people’s organi
sations (gram swarajya sabhas) and legal aid (Lok adalat)
The Health component was a three tier structure of local
health volunteers (Swasthya mithras) village health posts
(gramin doctors) and Agrindus clinic.
The programme included
minor ailment cars, indigenous medicines, health education
nutrition education
BCDDKHOk'I, Ganjam District, Orissa
An adult education/informal education programme that took
up health issues for action.
group (dahlia Sangha)
Two village organisations, women's
and men's organisation (Gramya Sangha)
were formed and some health animators were trained to manage
common ailments and ptoblems.
The organisations initiated
a grain bank, a savings scheme, functional literacy programme,
community goat rearing programme subsidesed by IRDP and non-
formal school for children.
The health animators believed that
these programmes were as important as disease treatment since
they worked at the root causes of ill health
MALLUR HEALTH CO-OPERATIVE, Siddlaghata Taluk, Karnataka
A field practice area for St John’s Medical College, Bangalore
the Mallur Health Co-operative was initiated by a Dairy Co-operative
taking on the responsibility of health for its village.
Starting
with a health cess per litre of milk produced the cooperative
organised a health service which included curative,
preventive
and promotive services with cooperation with the government health
centre as well. Years later the health cooperative was changed
to a Health endowment fund by the cooperative.
RAHA, Raiqarh Ambikapur Health Association, Madhya Pradesh
An informal network of 3 base hospitals and 47 small rurihl
health centres which initiated village health promoters training
programme with the help of a mobile team.
In addition,
school
health programmes with volunteer school health guides (from
among teachers).
TB control programme and an innovative
Medical insurance scheme was also organised.
DA3HAR HOSPITAL COMMUNITY HEALTH PROJECT, Babul district,
Madhya Pradesh
A comprehensive health care programme as an outreach
of a mission hospital with credibility in local area.
The
components included training of village health workers,
training of dais, health education, provision of immunization,
minor medical care and family planning care.
Non-forral
education in literacy, agriculture and hygiene and health
were also included.
The haalth workers are supervised by
a mobile community health training team.
RPH”AR-T-SEHAT programme, Kdtbhalwal block, Jammu j Kashmir
A project organised by the Government of Jammu &
Kashmir to train teachers of village schools as primary
health care guides.
Their function included minor
ailment treatment,health check up, health talks to child
ren and villagers on nutrition, immunization,
family welfare
environmental sanitation, MCH and personal hygiene, nutrition
supplementation programmes for school children and super
vision of village functionaries responsible for collecting
vital statistics
COMMUNITY HEALTH PROGRAMMES—PROFILES
The Nilgiri Adivasi Welfare Association (NAUA),
Tamilnadu
The NAUA was founded in 1958. Community health
programme include,
health education;
ing;
apart from medical care,
adult education;
nutrition;
encouragement of school
income generating projects in cooperation with
bank and voluntary bodies.
government^
The tribals are
being enabled to develop and adapt to the changing
environment.
The increasing literacy amongst young
people has helped them improve in this direction.
The Association is concentrating on the
rehabilitation
of these people keeping in view their varied stages of
development ano
survival problems.
The tribals now
value education and seeit as a way to a better future.
Vivekananda Girijana Kalyafia Kendra,
A voluntary organisation working
tribals in these areas with the
BR Hills,
'ith the
Mysore
Soliga
ideal of'service of
God in man1.
By building
people's organisations,
Soliga Abhivrudhi Sanghas,
the
external distortive
influence on tribal culture is minimized and
developmental activities include community organization;
education;
adult education;
vocational training;
cottage industries;
agriculture;
cooperatives in liaison with the
agencies.
housing and
government and other
MEDICARE,
Kasturba Medical College,
Manipal
Rural Maternity and Child Welfare Home:
seven
centres with 6 beds each with supporting facilities
for delivery,
at a distance of 3 to 20 miles from
the hospital are run.
A team from the hospital
visits each centre once a week.
health education,
Intensive
safe water supply and sewage disposal
with the help of Panchayat,
pest control measures and
immunization programmes;
family welfare programmes
are undertaken apart from a comprehensive
medicaland dental health care scheme.
Total Health Care Project, Tamulpur Block,
Kamrup Dist.
Assam
Started in 1976 covers a population consisting of
tribal and other backward castes in 204 villages of
the Block. Activities of the project include
provision of various basic health services like family
planning,
immunization, attending to minor ailments,
control of tuberculosis,
St Xavier's Social
leprosy and- malaria etc.
Service Organization,
Ahmedabad
A voluntary agency wor ing in the slums of Ahmedabad
in areas of community organisation through
Seva Samiti'
and
'Pragathi
'Jagruthi Mahila Mandal'. Their economy
generating activity is by promoting skills in garment
and quilt making,
electronics, masonry,
while strengthening areas like poultry,
^making and
plumbing etc.
agarbathi making,iCCbc-
screen printing industry already existing there.
The health component is deliver d by community health
workers in areas of nutrition,
antental care,
infectious
disea es and family planning methods by a locally evolved
training programme.
prime importance
Health education has been accorded
STREEHITAKARINI ; Bombay's Slums
An organisation of women living in slums, which started
with Maternity, Child Health and Family Planning Ssrvices by
volunteer doctors, and extended into areas of non-formal educ
ation,
female literacy, income generation programmes for women
and running of creches for under-fives.
Their small savings
scheme won the Government campaign award for 1985.
The health component is tackled through Community Health
workers and utilizes the nearest government hospitals for
referral.
The stress is on creating awareness about health
and promoting utilization of the facilities available.
K.E,M HOSPITAL;, RURAL HEALTH PROJECT, Pune District, Maharashtra
A Co-operative effort of a voluntary organisation with
the Government in oroviding Rural Health Services.
Socio
economic development programmes are with the involvement of a
separate organisation - UNDARP, with close links to the
health project.
Health activities are through Community Health Guides
□f KEM with Multipuroose workers of the Government cadre at
the grass roots.
The Secondary and Tertiary links are the
upgraded P.H.C at Vadu and KEM Hospital at Pune.
All activities
are facilitated by awareness programmes at Mahila mandals and
youth clubs.
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SOCIETY FOR EDUCATION, WELFARE AND ACTION - RURAL
SE'JA - Rural - Dhagadia, Gujarat
An experiment in health management, towards creating a
participative self-reliant organisational culture in Intagrated
Health and Rural Development.
The government had handed
SE'JA - Rural principal responsibility for total health care.
The delivery of health services is through a four tier
infrastructure, with the CHVs, AUUs, TBAs at Community level,
fflPUs at tertiary level, Mobile Dispensary with Fi.O and I'lPIJs
at middle level and a fully equipped referral hospital with
consultants and paramedical staff at the Central level.
SE'JA-Rural has won the WHO’s SA5AKAUA HEALTH PRIZE for
1985.
Activities in non-health areas include Gramin Takniki
Kendra, Tutorial classes for Tribal boys and girls and Economic
programmes ^or/jomen
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RURAL UNIT FOR HEALTH AND SOCIAL ACTION
“ K V Kuppam Slock, Tamilnadu
Reflects a holistic approach to health, in associiion
with
the local community, the government and other voluntary agencies.
They provide integrated health and development services
to the
people, including Adult education, Vocational training,
Income
generation, Agricultural development and agro-support services.
The health component is formed by the Family Care
Volunteers (FCVs), Health aides (ftft.s) and Rural Community
Organisers (RCOs) with close health and non-health activity
linkages.
Collective leadership models are seen in Village Advj_sory
Committees, Bieck Dgvelopmont Committees, Women’s groups,
Young Farmers clubs and socio-economic groupsuith similar
occupations.
They believe that HEALTH IS BOTH ft MEftNS AND MEASURE OT
DEVELOPMENT.
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COMPREHENSIVE LASCUR WELFARE SCHEME OF U.P.fi.S.I
- Plantations of ^"amilnadu and Kerala
A Labour Welfare Scheme based on the belief that health
is indispensable to the productive performance of workers. It
has sensitized the management to the validiy of the prenise that
the employee’s health and welfare are convergent with the
employer’s interest.
Voluntary ’LINK WORKERS* form the key element in Health
education and linking the Community to the health services
consisting of Maternity and Child Healthy Family planning,
Environmental Sanitation, Safe drinking water supply and Health
education programmes.
MINI HEALTH CENTRES PROGRAMME OF VOLUNTARY HEALTH SERVICES
Chengleput District, Tamilnadu
Aim at enlarging tho
scope of functions of the Primary
Health Centre, emphasising preventive care, treating the
family as a unit and ensuring community co-operation.
The
Mini-Health Centre is the model point of delivery of health
care, the components being Maternity services, child welfare
and nutrition, family welfare, minor ailment treatment, commu
nicable disease control, referral and most important of all data
collection and health record maintenance.
The LAY-FIRST-AIDER
(L.F.A) is the grass roots contact, with Multipurpose workers
and a part-time Doctor at the M.H.C,
Ayurvedic and indigenous
medicine are utilized, and a form of medical insurance by
prepayment helps in community participation.
This is now adopted statewide as a model.
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ACTION FOR WELFARE AND AWAKENING IN RURAL ENVIRONMENT
s(A.W.A.R.E)
Andhra Pradesh (Telangana)
Seeks to create self-sustaining rural and tribal communl
ties through a process of socio-economic and psychological
invigoration.
Their activities include Agricultural development,
Social action for education, Community programmes, Women’s
development, Fthahilitatinn of bonded labourers ano landless
poor, cottage industry and marketing
The health philosophy ’JEEVANA SRAVANTHI’ which means
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s’s flow started unexpectedly following natural disasters
Ths services ars through
and led to a sustained activity.
village health workers, Paramedical Community Health Workers
An innovation is a floating health centre on boat
and Dais,
catsring to 300 villages along the banks of Godavari
They work along with Governmental and NGOs as. a
re-inforcing element
COMPREHENSIVE HEALTH ANO DEVELOPMENT PROJECT - Pachod, Aurangabad Dt
Maharashtra
A Project to make rural health more effective within the
overall policies and framework of tha government programme by
wider application of innovative modalities and rational and
efficient use of limited resources
The services provide complete maternity care, Health and
nutrition education, growth monitoring and nutritional
surveillance of children and Environmental programmes, through
Community Health
Workers,
The problem op illiteracy among the
CHWs has been overcome using simplified systems and symbolic
reporting, while the Health Education messages developed
lly are unsophisticated, appropriate and beiaf
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CHILD-IN-NEED INSTITUTE - 24 Paraganas, West Bengal
Caters Primarily to tha health needs of the disadvantaged
semi-urban population around the southern outskirts of Calcutta.
CINI associates with national and international agencies in
research9 consultancy and training for Primary Health CareB
while it operates mainly in the field cf Maternal and Child
Health along with Community organisation
and community deve
lopment.
The Health services are village based clinics run by
f'lahila Mandals unich is the £ocal point of all activities.
The emergency Uard and Nutrition Rehabilitation Centre of the
ill and sevsrly malnourished child is a facility used much
further than the project arsa itself.
CINI has had a multiplier effect through persons trained
here having weaned off after starting similar new projects.
BANUftSI ■
SEVA ASHRAM, Hirzapur District,, Uttar Pradesh
An integrated rural development programme based on the
Gandhian philosophy of self-sufficiency.
community development centre (Agrindus)
The Agro-industrial
was the nucleas of
diverse activities which included agriculture,, land recla
mation, irrigation, afferrestatien, dairy, village industries
functional literacy, village fund (gramkosh)
people’s organi
sations (gram swarajya sabhas) and legal aid (Lok adaiat)
The Health comoonent was a three tier structure of local
health volunteers (Swasthya mithras) village health posts
(□ramin doctors) and Agrindus clinic.
The programme included
minor ailment care, indigenous medicines, health education
nutrition education.
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BCDOK’riDNIt Ganjam District, Orissa
An adult education/informal education programme that took
up health issues for action.
Two village organisations, women’s
group (Mahila Sangha) and men’s organisation (Gramya Sangha)
were formed and some health animators were trained to manage
common ailments and ptoblems.
The organisations initiated
a grain bank, a savings scheme, functional literacy programme,
community goat rearing programme subsidesed by IRDP and nonformal school for children.
The health animators believed that
these programmes were as important as disease treatment since
they worked at the root causes of ill health
MALLUR HEALTH CO-OPERATIVE, Siddlaghata Taluk, Karnataka
A field practice area for St John's Medical College, Bangalore
the Mallur Health Co-operative was initiated by a Dairy Co-operative
taking on the rasponsibility of health for its village.
Starting
with a health cess per litre of milk produced the cooperative
organised a health service which included curative, preventive
and promotive services with cooperation with the government health
centre as wall. Years later the health cooperative was changed
to a Health endowment fund by the cooperative.
RAHA, Raiqarh Ambikapur Health Association, Madhya Pradesh
An informal network of 3 base hospitals and 47 small rur&l
health centres which initiated village health promoters training
programme with the help of a mobile team.
In addition, school
health programmes with volunteer school health guides (from
among teachers).
TB control programme and an innovative
Medical insurance scheme was also organised.
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PAJHAR H05-ITAL COMMUNITY HEALTH PROJECT, Betul district,
Madhya Pradesh
A comprehensive health care programme as an outreach
of a mission hospital with credibility in local area.
The
components included training of village health workers,
training of dais, health edu ation, provision of immunization,
minor medical care and family planning care.
Non-fornsl
education in literacy, agriculture and hygiene and health
were also included.
The health workers are supervised by
a mobile community health training team.
RFHRAR-I—SEHAT programme, Kdtbhalual block, Jammu
Kashmir
A orojsct organised by the Government of Jammu &
Kashmir to train teachers cf village schools as primary
health care guides.
Their function included minor
ailment treatment,health check up, health talks to child-
ren and villagers on nutrition, immunization, family uelfare
environmental sanitation, PICH and personal hygiene, nutrition
supplementation programmes for school, children and super
vision of village functionaries responsible for collecting
vital statistics.
SOCIETY FOR EDUCATION, WELFARE AND ACTION - RURAL
SEUA - Rural - Ohagadia, Gujarat
An experiment in health management, towards creating a
participative self-reliant organisational culture in Integrated
Health and Rural Development.
The government had handed
SEJ’JA - Rural principal responsibility for total health care.
The delivery of health services is through a four tier
infrastructure,: with the CHVs, AWWs, TBAs at Community level,
MPWs at tertiary level, Mobile Dispensary with M.O and MPWs
at middle level and a fully equipped referral hospital with
consultants and paramedical staff at the Central level.
SEWA-Rural has won the WHO's SASAKAWA HEALTH PRIZE for
1985.
Activities in non-health areas include Gramin Tekniki
Kendra, Tutorial classes for Tribal boys and girls and Economic
programmes for/jomen
STREEHITAKARINI :
Bombay’s Slums
An organisation of women living in slums, which started
with Maternity, Child Health and Family Planning Services by
volunteer doctors, and extended into areas of non-formal educ
ation, female literacy, income generation programmes for women
and running of creches for uncer-fives.
Their small savings
scheme won the Government campaign award for 1985.
The health component is tackled through Community Health
workers and utilizes the nearest government hospitals for
referral.
The stress is on creating awareness about health
and promoting utilization of the facilities available.
K.E.M HOSPITAL, RURAL HEALTH PROJECT, Pune District, Maharashtra
A Co-operative effort of a voluntary organisation with
the Government in providing Rural Health Services.
Socio
economic development programmes are with the involvement of a
separate organisation - LINDARP, with close links to the
health project.
Health activities are through Community Health Guides
of KEM with Multipuroose workers of the Government cadre at
the grass roots.
The Secondary and Tertiary links are the
upgraded P.H.C at Vadu and KEM Hospital at Pune.
All activities
are facilitated by awareness programmes at Mahila mandals and
youth clubs.
COMPREHENSIVE LA5CUR WELFARE SCHEME OF U.P.B.S.I
- Plantations of ^amilnadu and Kerala
A Labour Welfare Scheme based on the belief that health
is indispensable to the productive performance of workers. It
has sensitized the management to the validty of’ the pienise that
the employee’s health and welfare are convergent with the
employer’s interest.
Voluntary ’LINK WORKERS* form the key element in Health
education and linking the Community to the health services
consisting of Maternity and Child Health, Family planning,
Environmental Sanitation, Safe drinking water supply and Health
education programmes.
MINI HEALTH CENTRES PROGRAMME OF VOLUNTARY HEALTH SERVICES
Chengleput District, Tamilnadu
Aim at enlarging the
scops of functions of the Primary
Health Centre, emphasising preventive care, treating the
family as a unit and ensuring community co-operation.
The
Mini-Health Centre is the model point of delivery of health
care, the components being Maternity services, child welfare
and nutrition, family welfare, minor ailment treatment, commu
nicable disease .control, referral and most important of all data
collection and health record maintenance.
The LAY-FIRST-AIDER
(L.F.A) is the grass roots contact, with Multipurpose workers
and a part-time Doctor at the M.H.C.
Ayurvedic and indigenous
medicine are utilized, and a form of medical insurance by
prepayment helps in community participation.
This is now adopted statewide as a model.
e
ACTION FOR WELFARE AND AWAKENING IN RURAL ENVIRONMENT
:(A,W.A.R.E)
Andhra Pradssh (Telangana)
Seeks to create self-sustaining rural and tribal communi
ties through a process of socio-economic and psychological
invigoration.
Their activities include Agricultural development,
Social action for education, Community programmes, Women’s
development, F&iabilitatioa of bonded labourers and landless
poor, cottage industry and marketing.
The health philosophy '3EEVANA SRAVANTHI' which means
life’s flow started unexpectedly following natural disasters
and led to a sustained activity.
The services are through
village health workers, Paramedical Community Health Workers
and Dais,
An innovation is a floating health centre on boat
catering to 300 villages along the banks of Godavari.
They work along with Governmental and NGOs as a
re-inforcing element.
COMPREHENSIVE 1 HEALTH AND DEVELOPMENT PR03ECT - Pachod, Aurangabad Dt
Maharashtra
A Project to make rural health more effective within the
overall policies and framework of the government programme by
wider application of innovative modalities and rational and
efficient use of limited resources.
The services provide complete maternity care, Health and
nutrition education, growth monitoring and nutritional
surveillance of children and Environmental programmes, through
Community Healths Workers.
The problem os illiteracy among the
CHWs has been overcome using simplified systems and symbolic
reporting, while the Health Education messages developed
locally are unsophisticated, appropriate and beief.
RU.^AL UNIT FOR HEALTH AND SOCIAL ACTION
- K V Kuppam Block, Tamilnadu
Reflects a holistic approach to health, in association
with
the local community, the government and other voluntary agencies
They provide integrated health and development services
to the
people, including Adult education, Vocational training,
Income
generation, Agricultural development and agro-support services.
The health component is formed by the Family Care
Volunteers (FCVs), Health aides (AAs) and Rural Community
Organisers (RCOs) with close health and non-health activity
linkages.
Collective leadership models are seen in Village Advisory
Committees, Block Development Committees, Women’s groups,
Young Farmers clubs and socio-economic groupswith similar
occupations.
They believe that HEALTH 13 BOTH A MEANS AND MEASURE OT
DEVELOPMENT
CHILD-IN-NEED INSTITUTE - 24 Paraganas, Mast Bengal
Caters Primarily to the health needs of the disadvantaged
semi-urban population around the southern outskirts of Calcutta,
CINI associates with national and international agencies in
research, consultancy and training for Primary Health Carey
while it operates mainly in the field of maternal and Child
Health along with Community organisation’ and community deve
lopment.
The Health services are village based clinics run by
mahila Sandals which is the focal point of all activities.
The Emergency Ward and Nutrition Rehabilitation Centre of the
ill and severly malnourished child is a facility used much
further than the project area itself.
CINI has had a multiplier effect through persons trained
here having weaned off after starting similar new projects.
BAN'JASI
SEVA ASHRAfl, Flirzapur District, Uttar Pradesh
An integrated rural development programme based on the
Gandhian philosophy of self-sufficiency.
The Agro-industrial
community development centre (Agrindus) was the nucleas of
diverse activities which included agriculture, land recla
mation, irrigation, afforrestation, dairy, village industries
functional literacy, village fund (gramkosh)
people’s organi
sations (gram swarajya sabhas) and legal aid (Lok adalat)
The Health component was a three tier structure of local
health volunteers (Swasthya mithras) village health posts
(gramin doctors) and Agyiodus clinic.
The programme included
minor ailment care, indigenous medicines, health education
nutrition education
8CD0XH0NI. Ganjam District, Orissa
An adult education/informal education programme that took
up health issues for action.
Two village organisations, women’s
group (Mahila Sangha) and men’s organisation (Gramya Sangha)
were formed and some health animators were trained to manage
common ailments and ptoblems.
The organisations initiated
a grain bank, a savings scheme, functional literacy programme,
community goat rearing programme subsidesed by IRDP and non-
formal school for children.
The health animators believed that
these programmes were as important as disease treatment since
they worked at ths root causes of ill health
MALLUR HEALTH CO-OPERATIVE, Siddlaghata Taluk, Karnataka
A field practice area for St Oohn’s Medical College, Bangalore
the Mallur Health Co-operative was initiated by a Dairy Co-operative
taking on the responsibility of health for its village.
Starting
with a health cess per litre of milk produced the cooperative
organised a haalth service which included curative, nreventive
and promotive services with cooperation with ths government health
centre as well. Years later the health cooperative was changed
to a Health endowment fund by the cooperative.
RAHA, Raiqarh Ambikapur Health Association, Madhya Pradesh
An informal network of 3 base hospitals and 47 small rur&l
health centres which initiated village health promoters training
programme with the help of a mobile team.
In addition, school
health orogrammes with volunteer school health guides (from
among teachers).
TB control programme and an innovative
Medical insurance scheme was also organised.
PAl'HAR HHS-ITAL COMMUNITY HEALTH PROJECT, Betul districts
Madhya Pradesh
A comorehensive health care programme as an outreach
of a mission hospital with credibility in local area.
The
comnonents included training of village health workers,
training of dais, health odu ation, provision of immunization,
minor medical care and family planning care.
Non-forral
education in literacy, agriculture and hygiene and health
wars also included.
Ths health workers are supervised by
a mobile community health training team.
RFHRAR-I-SEHAT programme, Kdtbhalwal block, Jammu & Kashmir
A project organised by the Government of Jammu &
Kashmir to train teachers of village schools as primary
health care guides.
Their function included minor
ailment treatment,health check up, health talks to child"
ren and villagers on nutrition, immunization, family welfare
environmental sanitation, MCH and personal hygiene, nutrition
supplementation programmes for school children and super
vision of village functionaries responsible for collecting
vital statistics
THE ANTWERP MANIFESTO FDR PRIMARY HEALTH CARE
Academicians, community health specialists and practitioners
from several industrialised and Third World countries gathered
in Antwerp, in November 1985, for a 2 day seminar where they
took stock of the achievements of the Primary Health Care
approach.
Since the 1978 Alma Ata Conference, the member states of the
World Health Organization agreed that this Primary Health Care
strategy, which sees people as active partners, is the most
suited to answer their needs and can provide the basis for
Health for All.
However, in Third World countries, in spite of the lessons of
history and of past experiences, major national and international
donor agencies are diverting scarce resources into a short term
approach known as "selective primary health care".
This aporoach
concentrates exclusively on certain interventions claimed to be
the most efficient and aimed only at sections of the population.
This self-contradictory term should be banned, since, at their
best, such programs can only be considered as "selective health
status interventions".
This approach is in total contradiction
with the fundamental principle underlying Primary Health Care.
These principles are;
* The main roots of poor health lie in living conditions and
the environment in general, and more specifically in poverty,
inequity and the unfair redistribution of resources in
relation to needs, both inside individual countries and
internationally.
* Since health is only one of the concerns of people, it is
self-defeating not to consider them as partners who are able
to play a great part in the protection and the improvement
of their own health.
They thus have to be fully and really
involved in the making of decisions which affect their
health, including of course, the provision of health services.
2
2
* Health services must provide both curative and preventive
care, as well as promotive and rehabilitative measures .
This has to be done in a coordinated and integrated way
which responds to the people’s needs.
The Primary Health Care approach is being used with success
in many parts of the world.
Being a continous process, much
remains to be done.
This manifesto is issued because the proliferation of selective
health intervention programs undermines the health services
at the exact moment when they try to reorganise themselves
towards Primary Health Care.
It is issued also because these interventions purport to offer
"quick solutions" and "instant success" for which they divert
scarce resources from the solution of the real underlying and
continuing problems, thus helping to maintain ill health.
In addition, experience has taught as that selective
interventions tend to become permanent even though they are
presented as "interim" responses only.
In fact, they need
specific structures which a country could not easily get rid
of at the moment it decided to reorient its health policy
towards comprehensive Primary Health Care.
And, above all, the selective approach rules out the possi
bility of people’s participation in decision making about
their own health.
The undersigned thus wish to reaffirm the principles of Primary
Health Care in its comprehensive form, and reject other
approaches instituted and propogated as "selective primary
health care".
ALF1R ATA----- Ten Years After
A decade ago, on September 25, 197B, the Alma Ata
conference formulated at Primary Health Care .(PHC) strategy
to achieve "Health for All" (HFA) by the year 2000.
Some
argue that there has been virtually no success and that we
should abandon the strategy.
Others maintain that consi
derable progress has been made and that we only need to
redefine the objectives lightly in planning for the year 2000
In its first evaluation report, WHO claimed that some
Paradoxically, it
progress has been made towards HFA 2000.
is the developed countries that have benefitted most,
Deve
loping countries still have not achieved much success in
PHC coverage.
The obvious success stories, such as the
achievement of 50 percent coverage in child immunization
and the final eradication of small pox, cannot conceal the
wide gulf which still exists between the urban "haves" and
Yu » <»■'
the rural "have-nots".
Nearly 65 percent of people inilndia
are trapped in the vicious cycle of poverty, malnutrition
and infectious disease, which reduces their capacity to
work and limits their ability to plan for the future.
For
example, 100 to 200 out of every 1000 infants born alive
still die during their first year of life.
In spite of the dismal statistics,
some progress has
been made in the decade since Aima Ata, including reductions
in the infant mortality rate, the crude birth rate and the
death rate, and an increase in life expectancy.
The concept
of the community health worker, who is selected by the local
community to serve the community, has had considerable
impact.
Medical education has been re-oriented toward social
goals, &hd the teaching of preventive and social
medicine has been upgraded.
There has been a signifciant
progress in re-orienting the PHC to maximize the use of
limited resources through better management.
....2
2
One lesson learned in this decade is that the tech■ nccratic approach does not work,
Many now believe that
short term strategies such as "selective Primary Health
Care" should be abandoned because they are in opposition
to the fundamental principle of HFA through PHC. Such stra
tegies, which offer quick and relatively cheap remedies
for common health problems, will only divert scarce resou
rces from the solution of the underlying arid baflic problems
that generate poor health.
What ie needed is an intogratod
socio-economic-health development approach that works from
the grass roots up and which gives people control over their
own health
(Source; Article Br Dr, Uijay Moses, Head, Department of
Community Health, Christian Medical Association
of India in FIONA PLUS, Issue 3 December 1988)
PRIMARY fe.-lth care
DECLARATION CP .'LfA-ATA — 12.9.1978
RELEVANT EXTRACTS
Primary health care is essential health care based
on practical, scientifically sound and socially acceptable
methods and technology made universally accessible to
individuals and families in the community through their full
participation and at a cost that the community and country
can afford to maintain at every stage of their development
in the spirit of self-reliance and self-determination. It
forms am
integral part both of the country’s health system
of which it is the central function and main focus, and of
the overall social and economic develo went of the community.
It is the first level of contact of Individuals, the family
and community with the national health system bringing health
care as close as possible to where people live and work, and
constitutes the first element of a continuing health care
process.
Primary health care:
1. reflects and evolves from the economic ^conditions
and socio-cultural and political characteristics
of the country and its communities and is based on
the application of the relevant results of social,
biomedical and health services research and public
health experience;
2. addresses the main health problemsin the community,
providing promotive, preventive, curative and
rehabilitative services accordinglly;
2
2
3. includes atleasts education concerning prevailing
%
health problems and the methods of preventing
and controlling them; promotion of food supply and proper
nutrition; an adequate supply of safe water and basic
sanitation; maternal and child health care, including
family planning; immunization against the major infectious
diseases; appropriate treatment of common diseases and
injuries; prevention and
control of locally endemic diseases; and provision of
essential drugs;
4. involves, in addition to the health sector, all related
sectors and aspects of national and community development,
in particular agriculture, animal husbandry, food,
industry, education, housing, public works, communications
and other sectors; and demands the coordinated efforts
of all those sectors.
5. r' quires and promotes maximum community and
individual self-reliance and participation in the
planning, organization, operation and control of primary
health care, making fullest use of local,national and other
available resources; and to this end develops through
appropriate
education the ability of communities to
participate;
6. should be sustained by integrated,functional and mutually
supportive referral systems, leading to the progressive
improvement of comprehensive health care for all, and
giving priority to those most in need;
3
7. relies at local and referral levels, on health workers
including physicians, nurses, midwives, auxiliaries
and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and
technically to work as a h<alth team and to respond to the
expressed health needs of the community.
CHAI's Philosophy and Vision of its Community Health
The Community Health Department of CHAI also felt the need for
g
correct understanding of its role in the field of health.
All
the points mentioned above were the basis for its conclusions.
Accordingly we believe that:
1.
In a country like India, so vast and varied, where
30% of its population lives in the rural areas and
h
about 90% of the country’s health care system caters
to the need of the urban minority, a new orientation
and rethinking of the whola health care system is the
need of the hour.
2.
Health is the total well-being of individuals, fami
lies and communities as a whole and not merely the
absence of sickness.
The demands an environment in
which the basic needs are f ulf illed, socal well-being
is ensured and psychological as well as spiritual
needs ar? met.
Accordingly a new set of pararreters
will have to be con idered for measuring the health
of a community such as the people's part in decision
making, absence of social evils in the community,
organising capacity of the people, the role women
and youth play in mattars of health and development
etc., other than the traditional ones like infant
mortality rate, life expectancy etc.
3.
The present medical system with undue emphasis on
the curative aspect tends mainly to be a profit
oriented business, and it concentrates on 'selling
health' to the people, and is hardly based on the
ceal needs of vast majority of the people in the
country.
The root causes of illness lie deqo ub
in social evils and imbalances, to which the real
2
2
answer is a political end, understood as a process
through which people are made aware of the real
needs, rights and responsibilities, available
resources in and around them and get themselves
organised for appropriate actions.
Only through
this process can health become a reality to the
vast majority of the Indian Masses.
4.
The concept of Community Health here uhould be
understood as a process of enabling people to
exercise collectively their responsibilities to
maintain their health and to demand health as
their right.
Thus it is beyond mere distribution
of medicines, prevention of sickness and income
generating programmes
EXPLORING jargon
The World Health Organization has defined Health as a * state
of physical, mental and social well being and not merely an
aasence of diseases of infirmity
While this definition focusses on the health of individuals
it could as well be a description of the ideal state for
families and communities. Community Health would therefore
mean ’a process of improving the physical, mental and social
well being of the community and all its component members.
This interest in health action focussed on the community and
not only on the individual is not new.
From times immemorial
efforts have been made by doctors and communities to evolve
health actions that are focussed on the environment - physical,
chemical, biological, social, mechanical, psychological, culture,
ecological rather than on individual patients.
This increasing
knowledge has over times evolved into various disciplines
and today though we use these names synonymously they do have
their own distinctive meanings and focus.
In a way they also
represent the historical development of skills focussed on
community health
1.
Medicine: The art of preventing and curing disease
2.
Hygiene: The Science of Health
3.
Public Health: The branch of medicine that deals with
statistics, hygiene and the prevention and
overcoming of epidemics.
4.
Preventive Medicine: The branch of medical science that
deals with prevention of diseases
5.
Social Medicine: Systematic study of human diseases with
special reference to social factors
2
2
6.
Socialised fledicine (^tate medicine)!
The control of medical practice by an
organisation of the government, the practitioners
being an integral. part of/the organisation from
which they draw their fees and to whibh the
public contribute in some form or other
(same as National Health Service)
7.
Community Pledicines A unified and balanced integration
of curative, preventive and promotional
health services focussed on the
communi ty
As Parks textbook (standard reference in India)
says
"Once looked upon as a healing art, medicine is looked
upon today as the sum total of all activities of a
given society that tend to promote, restore and
maintain the health of the people.
Where such a
concept prevails, medicine includes more than a
physician’s action; it becomes community health"
Community Health as we understand it today includes all
the ideas and disciplines mentioned above and more.
As new
approaches evolve the definition becomes more comprehensive
THE PARADIGM SHIFT
Medical Model to Social Model of Health
----- >
COLLECTIVE/COKNUNITY
——————
POPULATION
PERSON
&
SOCIETY
ANTI DEATH
ANTI DISEASE
PRO LIFE
PRO LIVING
physical/Mental
PREDOMINANTLY
PI iY SI CAL/MEN TAL/SOCI AL/
CULTU RAL/POL ITI cal/econ OLOGICAL
DOCTORS/NURSES
MEDICAL AUXILIARIES
TEAM OF HEALTH WORKERS
DISEASE
PROCESSES
SOCIAL
PROCESSES
INDIVIDUAL
PATIENT
&
HOSPITALS/DISPENSARIES
DRUC-S/TECHNOLOGY
—PROVIDING SERVICES
INTRACELLULAR
--- —>
HEALlI-i PROMOTING AND
COMMUNITY BUILDING CENTRES
AND PROCESSES—EHABLING/EMPOWERING
THE PEOPLE
RESEARCH
--- >
SOCIETAL RESEARCH
PATIENT AS BENFFICIARY,
CONSUMER
——y
PEOPLE AS PARTICIPANTS
SINGLE FACTOR
MULTI FACTOR
RISK IDENTIFYING
PROCESS IDENTIFYING
EPIDEMIOLOGY
EPIDEMIOLOGY
PROFESSIONALISED
COMPARTMENTALISED
MYSTIFIED KNOWLEDGE
QUEST FOR VACCINE
AGAINST DISEASE
■>
DEMYSTIFYING,
PERSON CENTRED
AUTONOMY CREATING
AWARENESS BUILDING
QUEST FOR AWARENESS BUILDING
PROCESS TO IMMUNIZE AGAINST
UNHEALTHY SOCIAL PROCESSES
9
L
o
Source: Community Health Cell
Reflections
Source: Community Health Cell
Reflections
NGO Research Centres in Community Health : Some Profiles
* foundation For Research in Community Health, Bombay,
(Maharashtra), Estb;
1975
Non-government research centre which undertakes conceptual
as well as field level research to study, analyse and
wherever possible influence the cultural, economic and
political factors that affect the health of the people.
Initiatives and studies include evolution and study of low
cost community based health systems in Uran and Mandwa.
Socio-economic study of rural transformation; Women’s work
fertility and access to haalth; PHCs in Maharashtra;
Health Service projects (NGOs in Maharashtra) Health
financing in India
Stigma against leprosy
Alternative school health project
Facilitation of ICMR-ICSSR Joint study
group on Health for All an alternative strategy.
* Action Kesearch in Community Health - (ARCH) Manqrol,
(Gujarat), Estb:
1978
A group of individuals of diverse background got together to
establish this centre in the eastern tribal belt of Gujarat
to study the developmental process using the health of children
and women of the poorer sections of society as the guiding
thread.
The approach was to get involved in the complex process of
development (ACTION) and to study critically the health of the
community and the processes which results in ill health (RESEARCH)
Field based strategies evolved were programmes to attack pre
valent diseases, methods and skills of community diagnosis and
2
2
intervention, training of health assistants and part time
community health workers, ndn formal school and finally a just
and humane rehabilitation policy for tribals displaced by an
ambitious irrigation project in the area.
\
* Community Health Cell, Bangalore, (Karnataka)
.
■
Estb.
1984
A Study-reflection-action experiment started by a small core
team who moved beyond the Department of Community Medicine
of a medical college in Bangalore to explore issues and
build perspectives from community health action projects of
voluntary agencies in India.
The team promotes socio—
epidemiological analysis, participatory management and the
shift of health action from provision of services to enabling/
empowerment of the community.
(This issue of Health Action is based mainly on this
study-reflection experiment)
* Society for Education, Awareness and Research in Community
Health (SEARCH) Gadchiroli (Maharashtra) Estb:
1984
This Society has adopted Gadchiroli district, a predominantly
tribal district in Maharashtra, for its education, awareness
building and research activities.
Presently they have long term
projects on the study of Active Respiratory Illnesses in
children; and a study of women’s health focussing on the community
The Society also seeks to evolve methods of intervention which
will be at the level of the multipurpose workers of the
government PHC.
Due to its increasing community involvement the Society has also
begun to explore the dynamics of women’s health and other related
issues, the forest issues affecting tribal and the illicit
3
3
liquor issue and its community context.
It has also tried
to modify the health care/medical practices at the District
level to make it more responsive to the needs
and the people’s
situation.
\
*Health Projects like RUHSA (^amilnadu), CINI (West Bengal),
CHDP Pachod (Maharashtra) \and Deenabandhu (Tamilnadu)
,
SEWA-Rural (Gujarat) and others (see profiles of projects page)
have also begun to take up research projects on key issues
in Community Health apart from putting their own activities
on a more sound data base.
COMMUNITY H’ALTH TRAINING IN INXIfc—PROFILES
1
* Four weeks training programme on COMMUNITY ORGANIZATION
AND DEVELOPMENT in English, Telugu and Tamil for
Rural Health and Community Development Workers: conducted
by Rural Unit for Health and Social Affairs (RUHSA).
They also conduct Workshops on HOW TO START Za COMMUNITY
H ALTH PROJECT. For details write to:
Hear of RUHSA Department
RUHSA Campus Post, North Arcot Dist. 632209
2
* Six Weeks Leadership Course in Community Health and Development:
conducted by Deenabandu Training Centre. It is designed to
upgrade the skills of middle level community health workers
without specific academic qualifications. The participants
should, however, be able to read and write English. The
training programme covers topics such as concepts and
approaches to Community Health; Human Relations; communications
programme management; maternal and child health; communicable
diseases; development activities including income generation;
survey methods etc.. For details write to:
The Course Coordinator
Deenabandu Training Centre
R.K. Pet 631303, Tamilnadu
3
* Six weeks residential training programme on MANAGEMENT OF
PRIMARY HEALTH CARE: conducted by Institute of Health
Management, Pachod. The course is designed to provide a
working knowledge of the process of management in the
field of health including management"concepts; community
organization and development; principles of public health
2
2
and health and management information system. The
course is open to people who are involved in primary
health care
ervices. The medium of instruction is English.
for further information contact:
Institute of Health Management
Pachod
Dist Aurangabad
Maharashtra 431121
4
*
V
h
X
Eight
weeks Certificate
CourseXin
INTEGRATED RURAL
~
--------------\
\
DEVE:OPMENT: conducted by I^UHSA. For details write
to Head, of RUHSA Department (address as in 1) .
4-
*
10 weeks training proc-ramme on COMMUNITY HEALTH AND
DEVELOPMENT s conducted by International Nurs '.ng
Services Association (India). The course is for health
professionals and others involved in community health
programmes. It is divided into 6 weeks class room teaching
and 4 weeks field exposur-. The topics covered include
health and development, drug issues, nutrition, teaching
methodologies, communicable diseases, cost analysis etc.
The course is followed by a Workshop after one year. The
medium of instruction is English. For details write to:
The Programme Director
INSA/INDIA
2 Benson Road, Benson Town, Bangalore 560046
.3
3
5
V
*
Twelve weeks training programme for Community
Health Workers: conducted by St John’s Medical
College and Hospital. The training is both
institutional and field based. The course is directed
at attaining self-sufficiency in knowledge and skill
for independent managment of a health centre. The
trainees are also given basic skills in herbal medicine,
homoeopathy, accupressure and herbo-mineral medicine.
The course is open
to candidates with a basic educational
qualification of SSLC or equivalent engaged in health
and development work. For details contact:
The Principal
St John’s Medical College
Bangalore 56003-4
6
*
Four months Certificate course in INTEGRAED RURAL
DEVELOPMENT: conducted by RUHS.A. For details write
to Head of RUHSA Department (address as in 1).
7
*
Post-graduate
Eleven months/Diploma course in HEALTH CARE ADMINISTRATION:
conducted by St John's Medical College Hospital. The course
is not a traditional class room lecture oriented one.
Emphasis is on job training, case studies, exercises,
seminar etc. It is open to medical doctors, qualified
pharmacists, graduates in Commerce, Science and Arts with
hospital experience. Some of the topics covered in the
course are Principles of Management; organizational
behaviour; materials management; personnel management;
4
4
finance management and legal aspects of health care.
Successful candidates will be awarded a "Post-graduate
Diploma in Health Care Administration". The medium of
instruction is English and organizational sponsorship
is essential.
Fur further details contact:
The Coordinator
Health Care Administration Office
St John's Medical College Hospital
* 00
Bangalore 580034.
Fifteen months Diploma Course in Community Health
Management: conducted by RUHSA in conjunction with
VHAI. The course is residential and is conducted in
RUHSA campus. The course is open to people engaged in
health and development field preferably with a Bachelor*s
degree/Nursing Certificate. On completion of the course
a Diploma will be awarded by the VHAI. For details write
to the Director
DCHM Course
RUHSA Post, North Arcot Dist
*
Tamilnadu 632209.
Two years
Diploma course in COMMUNITY HEALTH (CH Guide):
conducted by Christian Fellowship Community Health Centre
and Christian Education, Health and Development Society.
They also conduct various training course such as:
1. PG Diploma course in Applied Nutrition and Dietics and Catering
2. PG Diploma course in Health and Development
3. Multipurpose Health Workers (ANM) course
4. Village Health Workers (VLW) course
5
5
These courses are either under Madurai Kamaraj University
or are recognised by the government. They also conduct
soecial courses on Rural Health Orientation and short term
courses for voluntary institutions. For further information
write to:
Christian Fellowship Community Health Centre
and Christian Education, Health and Development Society
Santhipuram, Ambilikkai 624612
Anna Dist., Tamilnadu
10
*
Two year Certificate Course in COMMUNITY HEALTH PLANNING,
ORGANIZATION AND MANAGEMENT. Tt-is is a correspondence
course designed for managers, supervisors and others
involved in health and development work. Thecourse
covers principles of management; personnel managment;
materials management; elementary eccouting; basic labour
legislation etc. For details, write to:
The Coordinator
Community Health Education Training & Personal Development
Voluntary Health Association of India (VHAI)
40 Institutional Area, South of IIT, New Delhi 110016
They also conduct Diploma course in COMMUNITY HEALTH
MANAGEMENT (15 months) in conjunction with RUHSA. For
details write to the addressee in 8 above.
11
*
Two years
M.Phil programme in Social Sciences in Health
for postgraduates in Sociology, Psychology, Public
Administration, Political Science, Economics, Anthropology et
For details write to:
The Centre of Social Medicine and Community Health
Jawaharlal Nehru University, New Delhi
110067
6
6
Successful M.Phil graduates can pursue their PhD
work (3 years) in the same discipline.
The Centre also conducts Masters programme in
Community Health (MCH) for MDBS and MSc (Nursing)
holders. MCH holders are eligible to pursue their
PhD programme in Community Health.
9. Training ’enablers' not providers1
The Community Health Action initiators in the country
described earlier have also developed many training centres evol
ving middle level health manpower training programmes
in community health for doctors and nurses trained in
the orthodox medical system. Many of these training centres
have evolved in NGO projects after many years of primary
field level experience.
This new crop of training programmes differ from
conventional ’public health* and 'preventive and
social medicine’ in the country in many respects,
chief among which ares
1.
Most of the training programmes are open to
anyone interested in community health not
necessarily with a basic medical or nursing degree.
ii.
Nearly’ all of them have additional components in
the syllabus like social analysis, community dynamics
other systems of medicine, development issues,
appropriate technology, training of village based
health workers and so on which are not yet components
of public health courses in the country.
iii.
Nearly all of them are focussed on organisation
and practical management of community based
health programmes and training of local health
workers.
iv.
They all promote demystifration of medicine,
community participation, community
organisation and development. There difference
lies mainly’ in their overall socio-political
perspective and the role they expect of their trainee.
2
2
In this dimension they range from centres which
train for the delivery of an integrated package
of services tc centres which train for enabling and
empowerment of communities.
v.
The duration of the course varies from 6 to 12 weeks
to 1 year.
vi«
Nearly all of them have experimented with more
participatory forms of training and generated
a number of case studies,, role plays# simulation
games and learning exercises. This is in fact
a major contribution of these programmes though the
evolution of a participatory pedagogy is still
to be adequately recognised by orthodox medical
and health manpower educators in the country.
vii.
Apart from health projects which have grown into
training centres like RUHSA, CINI, Pachod, Jamkhed,
Deenabandhu, Ambilikkai, these training groups include
a medical college (st John's, Bangalore), and a
Nurses Association (INSA, Bangalore) and two
Coordinating Agencies—CHAI & VHAI.
viii. Only one academic department (Centre of Social
Medicine and Community Health, Jawaharlal Nehru
University, New Delhi) offers MCH, MPhil and PhD
programmes in Community Health.
Only in 1988, has there been an attempt, initiated by
VHAI, New Delhi, to organise a network of Community Health
Trainers in the country. It is hoped that this step will lead
to intensive dialogue and
mutual consultation among the
trainers so that some sort of common health manpower education
policy and new approaches to training can evolve which could
have wider relevance for manpower training in the country.
COMMUNITY H'Al TH TRAINING IN INjUK:—BR0F1ISS
; r,
i
1
1* Four weeks training programme on COMMUNITY ORGANIZATION
AND DEVELOPMENT in English, Telugu and Tamil for
Rural Health and Community Development Workers: conducted
by Rural Unit for Health and Social Affairs (RUHSA).
They also conduct Workshops on HOW TO START A COMMUNITY
H ALTH PROJECT. For details write tos
Hea
of RUHSA Department
RUHSA Campus Post, North Arcot Dist. 632209
2
*
Weeks Leadership Course in Community Health and Developments
conducted by Deenabandu Training Centre. It is designed to
upgrade the skills of middle level community health workers
without specific academia qualifications. The participants
should, however, be able to read and write English. The
training prog amine covers topics such as concepts and
approaches to Community Health; Human Relations; communications;
programme management; maternal and child health; communicable
diseases; development activities including income generation;
survey methods etc.. For details write to;
The Course Coordinator
Deenabandu Training Centre
R.K. Pet 631303, Tamilnadu
3
* Six weeks residential training programme on MANAGEMENT OF
PRIMARY HEALTH CAREs conducted by Institute of Health
Management, Pachod. The course is designed to provide a
working knowledge of the process of management in the
field of health including management concepts; community
organization and development; principles of public health
2
2
and health and management information system. The
course is open to people who are involved in primary
health care
ervices. The medium of instruction is English.
for further information contact;
Institute of Health Management
Pachod
Dist Aurangabad
Maharashtra 431121
4
*
X,
\
\
Eight weeks Certificate Course in^INTECRATED RURAL
DEVELOPMENT; conducted by RUHSA. For details write
\
\
to Head of RUHSA Department (address
in i),
B
*
10 weeks training programme on COMMUNITY HEALTH AND
DEVELOPMENT 2 conducted by International Nurs;ng
Services Association (India). The course is for health
professionals and others involved in community health
programmes. It is divided into G weeks class room teaching
and 4 -weeks field exposure. The topics covered include
health and development, drug issues, nutrition, teaching
methodologies, communicable diseases, cost analysis etc.
The course is followed by a Workshop after one year. The
medium of instruction is English. For details write tos
The Programme Director
INSA/INDIA
2 Benson Road, Benson Town, Bangalore 560046
.3
3
Twelve weeks training programme for Community
*
Health Workers: ■conducted by St John’s Medical
College and Hospital. The training is both
institutional and field based. The course is directed
at attaining self-sufficiency in knowledge and skill
for independent manaement of a health centre. The
trainees ar;- also given basic skills in herbal medicine,
homoeopathy, accupressure and herbo-mineral medicine.
The course is open
to candidates with, a basic educational
qualification of SSLC or equivalent engaged in health
and development work. For details contact;
The Principal
St John’s Medical College
>
Bangalore 560034
6
Four months Certificate course in INTEGRAED RU. AL
*
PEVELOPMEI’T;.-'conducted .by RUHSA. For details write
to Headzof RUHSA Department (address as in 1).
7
*
Post-graduate
Eleven months/Diploma course in HEALTH CARE ADMINISTRATION:
conducted by St John’s Medical College Hospital. The course
is not a traditional class room lecture oriented one.
Emphasis is on job training, case studies, exercises,
seminar etc. It is open to medical doctors, qualified
pharmacists, graduates in Commerce, Science and Arts with
hospital experience. Some of the topics covered in the
course are Principles of Management; organizational
behaviour; materials management; personnel management;
4
3
4
finance management and legal aspects of health care.
Successful candidates will be awarded a "Post-graduate
Diploma in Health Care Administration". The medium of
instruction is English and organizational sponsorship
is essential.
Fur further details contacts
The Coordinator
Health Care Administration Office
St John’s Medical College Hospital
r co
Bangalore 560034.
Fifteen months Diploma Course in Community Health
Managements conducted by RUHSA in conjunction with
VHAI. The course is residential and is conducted in
RUHSA campus. The course is open to people engaged in
h'.alth and development field preferably with a Bachelor’s
degree/Nursing Certificate. On completion of the course
i
a Diploma will be awarded by the VHAI. For details write
to the Director
DCHM Course
RUHSA Post» North Arcot Dist
Tamilnadu 632209.
(
9
*
Two years
Diploma course in COMMUNITY HEALTH (CH Guide):
conducted by Christian Fellowship Community Health Centre
and Christian Educatio-, Health and Development Society.
They also conduct various training course such as:
1. PG Diploma course in Applied Nutrition and Dietics and Catering
2. PG Diploma course in Health and Develo ment
3. Multipurpose Health Workers (ANM) course
4. Village Health Workers (VLW) course
5
5
These courses are either under Madurai. Kamaraj University
or are recognised by the government. They also conduct
special courses on Rural Health Orientation and short term
0
conr.es for voluntary institutions, for further information
write to;
Christian Fellowship Community Health Centre
and Christian Education, Health and Development Society
Santhlpurarn, Ambllikkal 624612
Anna Gist., Tamilnadu
10
*
Two year Certificate Course in COMMUNITY HEALTH PLANNING,
ORGANISATION AND MANAGEMENT, This is a correspondence
course designed for managers, supervisors and others
involved in health and develo rnent work. Thecovrse
covers principles of management; personnel manngment;
materials management; elementary accenting; basic labour
legislation etc, for details, write to:
The Coordinator
Community Health Education Training & Personal Development
Voluntary Health Association or India (VHAI)
40 Institutional Ar a, South of IIT, New Delhi 110016
They also conduct Diploma course in COMMUNITY H2ALTH
MANAGEMENT (15 months) in conjunction with RUHSA. For
details write to the addressee in 3 above.
11
*
Two years
M.Phil programme in Social Sciences in Health
for postgraduates in Sociology, Psychology, Public
Administration, Political Science, Economics, Anthropology et
For details write to»
The Centre of Social Medicine and Community Health
Jawaharlal Nehru University, New Delhi
110067
6
6
Successful M.Phil graduates can pursue the.tr PhD
work (3 years) in the same discipline.
The Centre also conducts Masters procrangae in
Community Health (MCH) for MBBS and MSc (Nursing)
holders. MCH holders are eligible to pursue their
PhD programme in Community Health.
ISSUE RAISING - fl CRITICAL TASK
When we think of ’Community Health’ or of health projects
of voluntary agencies,
it is customary to think of micro level
field experiments and initiatives that have been described
previously.
However individually they can have little impact
on health policy or on the overall trends of health care
development in the country except at a local level perhaps.
No doubt a feu individual
’charismatic’ NGO health innovators
have participated and contributed to ’expert committee refle
ctions’ initiated by the government.
But on a more long term
basis and to counter ’entrenched’ medical vested interests and
attitudes there is a growing need for lobbying and
issue raising groups at national and regional levels.
This
calls for networking and dialogue around values and approaches
necessary for the emerging Community Health vision.
Are these such groups in the country.
In the 70s the
medico friend circle emerged as one such group out of the
ferment that marked the Tndira/3P era leading to emergency
and its aftermath.
Over ths years this group has brought
together people from diverse ideological backgrounds to discuss
issues relevant to health care and medical education in the
country and through its annual meetings and bulletin voiced
these concerns and explored alternatives. .5 r' ‘
f
*
The Kerala Sashtra Sahitya Parishad is a different type
of issue raising group promoting a scientific attitude but
also questioning the role of science in society.
Though
regional in its focus KSSP has af late become an important and
Fefe.
crucial ’health issue’ raising group in Kerala.
The people’s
science Movement in Maharashtra and more recently the Karnataka
Rajya Vignana Parishad have also begun to explore health issue.
Another important network on the national scene is the
All India Drug Action Network which has brought together a
,...2
THE FIEDICO-FRIEND-CIRCLE
Works towards a pattern of medical cars adequately geared to
the predominant rural character of our country.
Works towards a medical curriculum and training tailored to the
needs of the vast majority of the people in our country.
Wanfcs to'-dsvelop methods ot medical intervention strictly
guided by the needs of our people and not by commercial interests
Stands for popularisation and demystification of medical science.
Believes in a democratically functioning health team and
democratic decnetralisation of responsibilities.
Stresses the primary role of preventive and social measures to
solve health problems on a social level and the importance of
planning these with active participation of the community.
Works ~td.-rds a kind of medical practice built upon human values,
concern for human needs, equality and against negative, unhealthy
cultural values and attitudes in society, e.g. glorification of
money and power, division of labour into manual and intellectual,
domination of men over women,
urban over rusal, foreign over
Indian
Believes that non-allopathic therapies be encouraged to take the&
proper place in the modern system of medicd care —
—medico-fteind circle -- perspective and activities.
1984
('iS.)
■ffe
ALL INDIA DRUG ACTION NETWORK (AIDAN)
AIDAN consists of numerous health, consumer, legal aid and
human rights organisations and people’s science movements.
It is a gruoing network of academicians,
social activists,
professionals,
individuals and organisations who are
deeply concerned about the drug issue and working towards
the adoption and implementation of a people-oriented
Rational Drug Policy in India as a part of a people’s
Health Policy.
AIDAN’S Main Demands
* Availability of essential and life saving drugs
* Withdrawal of hazardous and irrational drugs
* Availability of unbiased drug information
* Adequate quality control and drug control
* Drug legislation reform
* Use of generic names
* Technological Self Reliance
2
wide variety of individuals, grouos and associations into a
movement for a tational drug policy and rational therapy.
AIDAN has not only worked on an alternative drug policy but
has also worked at various levels from parliamentarians to
ths level of the people discussing issues and raising
consciousness about the various dimensions of the problem.
The ’Bhopal disaster’ was another major event leading
to a great deal of involvement and networking of groups in
the country supporting the 'plea for relevant research,
rehabilitation and legal compensation policies’ for the
affected victims.
In the eighties an increasing number of smaller groups
are emerging at the national, regional and local levels around
drug, health and other issues.
The ’mfc’
now becoming a generic phenomena.
type of network is
However, all these groups
put together are still making little impact on the health
situation and are still relatively marginalised.
Lobbying and issue raising is neither a popular task nor
an easy one.
The ’Drug activists’ and the ’Bhopal activists*
have experienced the non-reqaonsiveness of the established
status quo system to issues of justice on the ’Drugs'
’Bhopal’ matters.
and
'
A national Health action network is yet to emerge in
the country.
Even when it does it will take some time before
it can make an impact.
any longer.
This task can however not be ignored
7c. Community Health; Is a movement emerging?
A study of the dynamics of community based health
action and the evolving approaches from micro level experience
show that 'community health' could become a movements
linked to a wider development and social change process
in the country. There are many positive trends which
support this possibility. However, there are many negative
trends as well which could become major obstacles
for a genuine health movement in the country.
The positive trends are—
i.
Policy reflections of the Government
Policy documents and expert committee reports have
been echoing new approaches. Many decision makers,
administrators and technocrats within the entrenched
medical system are aware of these new approaches.
ii.
"Village Health Worker Army"
A growing army of villagers and lay people have been
trained as village health.workers by both non-governrnent
and government agencies. Whatever the quality of training
this process itself is a phenomenal process of
demystification of medicine.
iii.
Non-medical Health Activists
A growing number of lay people, social workers,
developmental activists, journalists, teachers,
college students, non-medical scientists, lawyers,
consumer groups and so on are recognising the varied
dimensions of health and are getting involved in health
care issues.
2
iv.
Health in the education process
Health issues are increasingly becoming part of the
syllabi of formal, non-fomial and adult education
programmes in the country. Schools are also
gradually becoming focus of health activity.
v.
Hee. 1th on the agenda of science movements
Movements for the popularisation of scientific
attitudes like KSSP (Kerala)„ Lok Vidnyan Sanghatana
(LVS, Maharashtra) and Karnataka Rajya Vigyan Parishad
(KRVP, Karnataka) are gradually taking up more
health issues.
vi.
Health issues emer.-ing in other movements
The environmental movement has grown in recent
years with a number of processes around forest
issues, environmental issues and social problems.
In all of them, the health and nutrition of the affected
people is a growing concern. The women’s movement
is beginning to recognise health issues important
to women, eg., family planning, contraceptives,
amniocentesis and so on.
The Trade Union movement has got interested
in the’drugs issue* but thojr involvement in health
issues is still quite marginal with the exception of
independent trade unions like CMSS Dalli Rajhara
(Chatisgarh Project).
vii.
Health orientation of Coordinating groups and issue
raising networks
________________________
Groups like VHAI, CHAI, CMAI, mfc, SHC, AIDAN are
slowly increasing their commitment to lobbying on
various health issues.
3
All these trends call for a guarded optimism since
a series of negative trends are also becoming
increasingly stident. These are—
i.
Commercialization of medicine
Medicalisation, over professionalization and a
consumerist orientation of medical and health care
is increasing in the country. Medicine is becoming
big business. The mushrooming of capitation fee
medical colleges and high technology investigative
centres catering to those who can pay are components
of this trend.
ii.
Mushrooming of medicalised health projects
Health projects are mushrooming all over the country
sup orted by a combination of social, economic and
political factors. Foreign funding agencies are
vying with each other to fund the alternative.
Industrial houses are investing in it for income tax
purposes, religious and social organisations are getting
involved for prestige, power and increasing their
membership; professionals getting involved for status
reasons. Most of these projects are ‘medical* providing
packages of services with little or no understanding
of the values/vision of the health movement or a
social analysis.
iii.
Verticalizatlon of health efforts
Selectivization and vertical top-down health
programmes sponsored by government and encouraged
by International Funding Agencies like WHO, USAID,
UNICEF divert scarce resources and confuse community
health action initiators as well as waste time and
effort.
ape
4-
'4
iv. Inadequate Networking
Health action initiators themselves are not adequately
networking or lobbying with decision makers or opinion
leaders. While there has been a rich experience
of micro level experimentation there is inadequate
pooling of ideas, training, policy evolving efforts
and research;so the
.entrenched medical establishment
goes unconfronted.
v.
Status-quo forces
The ability of the existing status quo forces dominated
by the haves to internalise and coopt many of the
ideas and approaches into the'health policy rhetoric'
butdefeating the spirit of the new vision must not be
under-estimated. The increasing number of paradoxical
policies and programmes on the national scene are an
increasing evidence of this cooption.
vi. Cooption of Health
The misuse and coption of the word--health—itself
a new and disturbing trends. The Drug Industry, the
medical technology industry, the five star hospitals,
the medical professionals are all using the word heath
to describe their initiatives most of which is the
same old curative high technology, drug oriented package
deals under the new label. Alternatively through high
pressure advertising insurance programmes, screening
programmes and medical check ups to promote 'over investigatio
in the name of health is another trend.
Will the negative trends prevail and grow and prevent the
evolution of a health movement only time will tell. There
is every indication that this may be so.
COMMUNITY HE A L T H ANO HOSPITAL MEDICINE
The community health approach has evolved from the
attempts of a large number of people concerned about the
present medicalised approach to health care and its
inadequacies in responding to the needs of the large majo
rity - the poor and marginalised groups in society.
Most
of the people involved in developing components of this
new approach have themselves had much of their training
and experience initially in the hospital-dispensary
oriented system.
Some of the approaches have emerged from
a confrontation of the existing value system and culture
of the western-technological model of health care of which
the hospital and dispensary are characterstic examples.
Does this mean that the ’community health approach’
and the existing medical system of hospitals, dispensaries,
health centres, doctors, nurses, drugs, technology, centres
of specialisation, education and research are incompatible?
While recognising the need for a ’paradigm’ shift in
attitude and approaches from the ’provision of medical care’
to the ’enabling of community health* we feel that these
are neither mutually exclusive nor incompatible.
It is necessary to recognise that many aspects of the
value systems of existing hiKgly technological western
models of care which we have inherited and continue to
transplant in our country are somewhat counter-productive
to the goals of community health.
It is necessary to recognise that by their very nature,
such highly capital intensive technology systems skew
health services in favour of those who can afford to pay
for tham.
Gradually the forces of a market economy of which
2
2
such a model is an integral part, alienates the structure
from the poor and underpriviliged and all these who basically
cannot afford the luxuries of the type of health such
systems symbolise.
However,
since community health is basically a new
vision, a new value system and a new attitude it can
confront and pervade the entire existing superstructure
of health care.
Arising from community based experience as a new
vision, community health has to challenge the super
structure to become:
a.
more ’people’ oriented
i.e sensitive to the realities of life of the large
majority of people - the poor and underpriviliged,
b.
more ’community’ oriented
i.e understanding health in its community sense and
not just as the problem of individuals.
c.
more socic-epidemioloqically oriented
understanding health in its wholistic sense - which
involves the biological,
social, economic, cultural,
political and ecological dimensions.
d.
more democratic oriented
i.e more participatory and democratic in its growth,
planning and decision making process,
e,
more accountable
i.e increasing subservience of medicine, technology,
structures and professional actions to the needs and
hopes of the people, the patients, the consumers,
the 'beneficiafcies’ and the communities which they
seek to serve.
This confrontation of value systems and re-orientation
will help the superstructure and its different elements to
emerge from their present ivory-towered isolation and
3
3
irrelevanca and gradually become supportive infrastructure
cf a more just and healthy society-
However this change
cannot be miraculous or based on just good intentions
or any anount of wishful thinking.
It must be a serious
commitment to social analysis, participatory evaluation
and critical self-searching for greater relevance by
all those concerned with planning and decision making
in the present superstructure.
az ■
l)cuy
CHOI (j 7)
R £ C 0 G NISING TH£ NEU PARADIGM
This alternative health cars project phenomena
has been a
spontaneous upsurge in the last two decades and not an organised
planned movement.
From 1984, a team of us have been studying
this process through a series of reflections with individuals
and groups and network to build a new understanding of
Community Health from field level experience and grass roots
actior//
Dur attempt has been to look at successes and
failures, strengths and weaknesses, opportunities and threats
of all these community health action initiators.
Also by
taking a ’macro view’ and differences, we have been trying to
build the components of a new paradigm.
The broad definition that is emerging is:
"Community Health is a process of enabling people to exercise
collectively their responsibility to their own health and
to demand health as their right, and involves the increasing
of the individual, family;
and community atonomy over health
and over organisations, means, opportunities, knowledge,
skills and supportive structures that make health possible"
The components
of Community Health action includes:
Integrate Health with development programs,
Integrate curative with preventive, promotive and
rehabilitative activities,
Fxperiment with low-cost, effective, appropriate:
technology,
Involve local, indigenous health knowledge, resources
and personnel,
Train village-based health workers,
Initiate, support community organisations like youth
clubs, farmers clubs and mothers clubs,
Increase community participation in all aspects of
health planning and management.
Generate community support by mobilising financial,
labour skills and manpouer"resources.
Z
Z
....2
2
While facilitating these managerial/technological innovations
the Community Health action initiators have to seriously
face up to a wide variety of ’social processes’
and ’value
issues' that are:
i)
Organisation of non-formal9 informal, demystifying
and ccnsciantising ’education for health’ programs;
ii)
Initiating a democratic, dacentalised9 participatory
and hon-heirarchical value-system in the interactions
within the health team and in the health team
community interactions;
iii)
Recognising conflicts of interests and social
tensions in the existing inequitous society and
initiating action to organises, involve all those
who do not/cannot participate at present;
iv)
Questioning the over-medicalised value system
of health care and training institutios and cha
llenging these within the health team; learning
new health oriented values;
v)
Recognising that community health needs community
building efforts through group work, promoting
co-operative efforts and celebrating collectively;
vi)
Confronting the super-structure of medicalised
health delivery system to become
- more poor people oriented
- more community oriented
- more socio-epidemiologically oriented
- more democratic,
- more accountable
vii)
Recognising the cross-cultural conflicts inherent
in transplanting a Western Medical model on a
non-uestern culture and hence exploring integ
ration with other medical cultures and systems
in a spirit of dialogue.
3
vinj
Kecognising that community
health efforts
with the above principles and philosophy
cannot be just
a speciality;
a professional discipline;
a technology fix;
a package of actions;
a project of measurable activities;
but has to transform itself to
a new vision of health care;
a new value-orientation in action
and learning;
a movement, net a project;
a means, not an end
Are these the axioms of an alternative?
These new'issues’,
being
'values’, approaches to health is now
recognised by a growing number of coordinating
groups, academics and policy research groups as well.
Four coordinating groups among the NGOs including the
Voluntary Health Association of India, The Catholic
Hospital Association of India, The Christian Medical
Association of India and the Asian Community Health Actio
Network have all identified with this new thrust in the
policy statements of the 1980s(
’ j
)
The ICMR/lCSSR Health for All prescription includes
these dimensions as well (
I
)
A plea for a New Public Health is the latest in a series
of issues and theeretical perspectives emerging from
academic centres as well.
However recognising the paradigm is after all only the
first step.
Taking action to build a new structure is a
challenging and daunting task.
Converting the old system
to a new way of life is not going to be easy.
"RECOGNISING THE NEW PARADIGM1
1978
VOLUNTARY HEALTH
ASSOCIATION OF INDIA
(3000 Health Institutions
and Community Health
Programmes)
'making community health
a reality for all people,
with priority for the less
privileged millions, with
their involvement and
participation through the
voluntary health sector...."
1982
ASIAN COMMUNITY HEALTH
ACTION NETWORK
(Network of concerned
individuals and NGOs
in fifteen Asian countries)
"to spread a philosophy of
community based health care
that envisages a process of
self-reliant human development
for the oppressed poor in
Asian communities...."
1983
CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
"committed to community health
(2000 member hospitals
and Dispensaries)
....as a process of enabling
people to exercise collectively
their responsibilities to
maintain their health and
to demand health as their
right...
....2
2
1986
CHRISTIAN MEDICAL
ASSOCIATION OF INDIA
(300 institutions
(protestant) plus
5000 individuals
associated with these)
"commitment to community
heal th....a process that
empowers people to work
together to promote their
own health and to demand
appropriate health services..
relevant, low cost, effective
and acceptable...."
Source: Policy Statements of organizations
HEALTH FOR ALL
icmr/xcssf.
Prescription
%
h MASS MOVEMENT
TO
ip RE’UCE POVERTY, INEQUALITY
i’jii
spread education
Hi ORGANISE POOR AHD UNDERFRIVILEGED
TO '-IGHT FOR THEIR BA.-IC RIGHTS
Ip MOVE ANAY ^RGI' COUliTNR-PROOUCTIVE,
CONfeUK-.RIST ■.:EoiERi! MOiiEL OF HE.aLTH
car::.
replace it hy ah alternative
RAS3O I.-: ■')■:’? COK.UKITY,
J A f - ? S') I ■' OO
HEALTH SERVICES IN fl COUNTRY
Postulates of a theory
Health Service development is
a.
a socio-cultural process
b.
a political process
c.
a technological and managerial process with an
epidemiological and sociological perspective.
There is often a lag between socio-cultural aspirations
of the people and
their articulation by the political
leadership;
The lag is much more between the aspirations of the
political leadership and the achievements of community
health physicians who have the responsibility for building
the needed edifice of the health services.
The task is to narrow, if not totally eliminate, lags that
may exist within the three tiers.
Formation af a critical mass of community health physicians
and obber members of the team, which can take full advantage
of the scope offered by the base (i.e., the complex of
ecological, epidemiological, cultural,
social, political
and economic factors at play) requires a new approach to
education of community health physicians and other members
of the team.
Readymade solutions are not available from affluent countries
a superstructure of health services is to be built which is
firmly rooted in the base.
D Banerji (
)
EVOLVING POLICY ALTERNATIVES
Ths National Health Policy statements are beginning to
echo these ideas and values.
Whether this is ’populist rhetoric’ or a serious ’rethink’
only time will tell.
NfiTIufvAL HEALTH POLICY,
1983
Recommendations
For restructuring Health Services
1. Otganissd support of volunteers, auxiliaries, paramedical
and multipurpose workers
2.
Selection and training of community health volunteers
3.
Building of self reliance and effective community participation
4.
Establishment of a well worked out referral system
5.
Establishment of a nation wide chain of sanitary-cum-
epidemiological stations
6.
Concept of domiciliary and field camp approach
7.
Devising planned programmes to reduce governmental
expenditure and fully utilising untapped resources
8.
Setting up centres to provide speciality and superspeciality
services
9.
f’lental Health care and care of physically handicapped
10.
Priority to unpriviliged and vulnerable section of
society
11.
Ensuring adequate mobility of personnel of all levels
of functioning.
VHAI ( '0
)
The Community Health phenomena - Three questions
WHO were the community health project initiators?
Since the late sixties and particularly in the seventies a
large number of initiatives and projects began to get established
outside ths government system by individuals and groups keen to
adept health care approaches to the needs of our people,.
Broadly classified as voluntary agencies in Health Care (now
also referred to as non-governmental organisations (NGOs) in
policy documents) these initiatives were predominantly rural
to begin with but later some of the focus also shifted to the
tribal regions and urban slums.
Starting uith illness care most of them moved on to whole
range of activities and programmes in Health and Davelopment
creatively reacting to local needs and realities.
The originators of thesa projects were doctors, nurses, health
and development activists, uho had bean challenged and stimulated
by the social disparities and health needs of thalarga majority
of people in the communities they served.
Each project or initiative evolved in the context of a local
social reality and a local health situation.
Since these were
diverse each of them evolved their own process of action,
package of services and local health organisation.
HOW did these initiatives evolve
These initiatives evolved in a variety of ways.
sometimes the entry point,
Health was
sometimes it got into the package
at a later date.
a.
A rural development programme with a health component.
b.
A community based medical/health programme.
c.
An integrated development programme in a tribal area.
d.
An adult education/non-formal education programme with
a health component.
e,
A science education programme with a health component.
f.
A nutrition supplementation programme with a health
component.
g.
A conscientiration/auareness building programme with a
health component.
of a hospital
h.
A community extension/outreach programme
i.
A field practice area of a medical/nursing/paramedical
training institution.
j.
A school based health programme.
k.
A health programme as a component of a trade union movement
1.
A health programme as a component of a project focussed on
women's issues
m.
Health as a component of a community action in urban slums.
n.
A health programme for workers organised by an employers
association.
and so on.
As the 'community health action initiiives grew in experience
and numbers a second generation of initiatives evolved:
a.
Issue raising group
b.
Coordinating/networking groups
c.
Community Health education/document/resource centres
d.
Community Health training centres
e.
Community Health Research centees
But more about it later
^j|T were the components of Health Action in these initiatives?
There has been a tendency in many circles to see each project
as an alternative approach to health care.
Our experiences of
studying many of them convince us that many ideas, experiences,
components of service and the dynamics of action from these
projects taken together would help build an Alternative
Approach and none are independently the complete alternative.
Hence learning from the commonness of approaches and
identifying the rich variations that exist would be a more
meaningful way of deriving the new approach of community health
The component of the new approach to health action in the
Community are:
ating
uith 2svelQPmer’t_activities
Recognising ill health as the product of poor nutrition,
poor
income, poor housing and poor environment many health projects
QOV
had gradually,'involved with
agricultural extension programmes
water supply and irrigation programmes
housing and sanitation schemes
income generation schemes
basic education including literacy, non-formal education
and adult education programmes
many projects which had started with a development focus were
in turn adding a health’ care dimension to their activities.
b.
2£Bj{entive£_Promotive_and_Rehabilitative orientation to
.action
Host of these health projects had moved beyond the medicalised
concepts of health symb Used by
drug distribution to
activities - focussed on individuals and groups that present
ill health and promote well being.
Immunization programmes
Haternal and child health care
,...2
2
Family welfare activities
Environmental sanitation Particularly safe drinking water
supplies and sanitary disposal of excreta, sullage and
ref use
Nutritional supplementation anc^utrition education
and
School health programmes
were the commonest components.
I
Rehabilitation as a health-oriented action was seen mainly
■in the context of people suffering from leprosy,,
c.
Search and experimentation with low cost, effective and
.£BC^n0^°SX
flany projects had tried
health care technologies,.
to evolve or promote more appropriate
The emphasis was not only on it
being low cost but also on it being more culturally acceptable,
demystifying and more within the operational capabilities
of local people and health workers.
These included
improved dai (T9fi) kits
nutrition mixes prepared from locally available foods
indigenous I'ICH calendar
locally manufactured lower limb prosthesis, bangles and
tapes to measure nutritional status of children
low cost sanitation options
home based oral rehydration solutions
herbal and home remedies from the backyard or kitchen
and so on.
Two additional areas of technological appropriatness which
had been experimented within many of these projects were:
i. Health communications ~ Attempts had been made to
3
APPROPRIATE TECHNOLOGY
E2£«.!3£tl_k!3£k
1. Patient Retained Health Records
Coloured cards in a strong plastic cover retained with patients
who bring them during clinic visits.
Alloted spaces and
information for all aspects of mobher and child care - Also
a personalised health teaching aid.
2.
Arm circumference insertion tape
To measure mid-upper aym circumference a useful indicator of
nutritional status of individuals and communities useful for
helping workers detect severe undernutrition and for raising
level of consciousness among community concerning the
problem.
3.
Child1s bangle
Typically Indian method.for diagnosing undarnutrition by
mothers and health workers.
The bangle positive child includes
those with marasmic or third,degree protein calorie malnutrition.
4.
indigenous Calendar
With festibals, full moons and conversion to English months
to help mothers place the birth of the child on the exact
date.
5.
Amenisia recognition chart
Simple coral used to detect anaemia by comparing the colour
of tongue, loiier lip and nails with picture on card the colour
of tongue.
6.
A Sterile delivery pack
Consisting of sterile cotton tie, a new blade and a small
bottle of disinfectant,this kit costing a few paises can
be used to prevent tetanus in the new born.
7.
Better Child Care
A * informative booklet with colourful pictures and
2
2
basic messages to help health workers and mothers to
discuss child care issues
(For further details contact VHAI, Net Delhi)
’’Technology can only be considered apprppriate
if it helps lead to a change in the distribution
of wealth and power
"
3
use low-cost media alternatives like flash cards and
flip charts and also to adapt local folk media and
traditional cultural/art forms like
puppetry
/
kathas (story telling)
street theatre
music and dance forms particularly those which
were common features of the festival culture in
India.
In tribal regions effective adoptions to ’nachna’
(song and dance improvisations) was a common feature
Recording and evaluation techniques - Many projects have
ii.
evolved simple methods of recording quantifying and keeping
track of health activities or material resources utilised
by the health workers.
These were geared to the
capacities of local people (if they were people retained)
or to the capacities of the local health workers.
Many
were geared to get over the constraints of illiteracy.
d.
Recognition, promotion and utilization of local health
resources
Local health resources include local family based traditions
of health and self cars as well as traditional systems of
medicine and their practitioners.
Many health projects had
created positive relationships with
local dais (traditional birth attendants)
traditional healers
folk medicine practitioners
and
the practitioners of various non-allopathic systems of
medicine practised locally.
This relationship had gone beyond a mere association to an
4
LOCAL HEALTH RESOURCES
^Ths Eliraj Experience’
1. Training of Indioenous Dais
173 Dais cut of 186 identified by a survey were trained.
The
emphasis of the training uas on scientific techniques in home
delivery, elements of good antenatal, intranatal and post
natal care, basic cleanliness and hygiene.
They are also
taught to recognise danger signals in pregnancy/labour as
wall as motivate for family planning methods.
Dais were
provided with autoclaved delivery kits.
2.
Village health aides
40 local part time women attendants provided to help the
government ANR were retrained as village health guides who
could do early reporting of pregnant women and postnatal cases,
births and deaths, communicalbe diseases, fevers, neonates and
infants unprotected against preventable diseases, collect
mothers and children for immunization,
distribute iror/and
folic acid tablets, follow up TB, Leprosy patients and so on.
3.
Indigenous medical practitioners
6 local Ayurvedic doctors were put in charge of Ayurvedic clines
run by the project.
Also serving the project area on a private
basis were 62 untrained practitioners of Ayurvedic medicine,
33 registered medical practitioners without formal training,
3 bone setters.
The doctors offthe project would invite these
practitioners during their weekly village visit to join them
in examining and tseating patients.
This training method was
beneficial to both parties concerned.
Eric Ram (
)
4
acceptance of same of the medical and health practices of
these systems, by the projects themselves.
Promotion of
locally available herbal medicines and home remedies was
in important component in many.
e.
Training of village based health cadres
Training of locally selected individuals in the village
in basic health care activities
minor ailment treatment
first aid
recognition of illnesses needing higher levels of
referral and care
nutrition
matsrnal and child health care
family welfare motivation
environmental sanitation
identification - reporting - basic measures in
communicable disease control especially
malaria
lepro sy
tuberculosis
mental health care
and so on has been probably the most characterstic feature of
all these projects.
methodology,
The selection methodology, the training
the range of skills and the scope of training,
the plan of activities and the remuneration and community
support of these health workers reflects a wide diversity - but
the most import nt result of this trend has been the conscious
demystification of health issues and the creation of better
informed village-based individuals who are available to help
5
1a
The Handwa Experience’
Several Community Health Projects have demonstrated that most
communicable diseases can be controlled even under the existing
socio-economic conditions.
In the Mandwa Project thirty
village women given simple knowledge through weekly discuss
ions under the village tree, and with a simple supportive
service were able to achieve this.
few examples.
Let me illustrate with a
They took finger prick blood smears of any
patient suffering from fever with rigors and gave them four
tablets of chloroquine.
If the smear were positive they
gave Primoquine treatment.
More than that they drew attention
of the village to control the mosquito vector.
They were
remarkably efficient in suspecting tuberculosis in individuals
with the classical symptoms especially if they were contacts
of known cases.
If the diagnosis was established on examination
of the sputum Df X-ray they gave the 90 streptomycin injections
and supervised the regularity of the other antituberculosis
treatment by convincing the patient of its importance not only
for himself but also for the rest of his family.
taught
They also
other pimple measures like disposal of sputum to prevent
the spread of the disease.
These women diagnosed twice as many leprosy patients as the
full-time leprosy technicians, ensured that regular treatment
with Dapsone was taken after confirmation of diagnosis and
since these were in the early st ges, there was not a single
new case of deformity; the old deformed patients were helped to
return home and take regular treatment, for on having seen the
germs under a microscope they were able to convince the village
of chemical sterilization by regular treatment and induced
confidence by visiting the patients in their homes and par
taking of their meals.
2
2
There was a marked reduction in deaths from gastro-enteritis
not onltji because of ORT but because of the creation of an
epidemiological consciousness in the villages for being prepared
for the monsoons.
The immunization rate for triple antigen rose from 15% to 92%
when the village health workers started giving them injections
on their daily rounds.
Since all pregnant owmen were identified
and immunized there was not a single death from tetanus in
five years.
No mass compaigns were even undertaken in this
project, yet the so-called targets set by the PHO were over
reached even in family planning.
^his peopls-based approach even succeeded in the detection
of cancer, mental illness and in rehabilitation of the dis
abled, all without campaigns and camps and at a fraction of
the normal cost of our health services.
Let us not minimize the role of the profession and services
in such a participatory approach.
Their main function should
be of teaching and encouraging the people to look after
themselves to the extent possible and overcome the fears in
culcated through professional mystification.
Another important
role is to provide the necessary supportive service for those
few problems which require skills and facilities of a higher
level.
Their’s is not to appropriate the functions which
rightly belong to the people, for ahperience has shown that
they cannot undertake these functions themselves even at a
far greater cost.
The present approach has only lad to
exploitation of the people’s health by the private sector and
lack of accountability of the public sector without much
impact on the health status as revealed by our statistics.
The supportive professionalised services have also to be of a
graded nature starting with the paramedical worker at the
3
3
subcentre to the surgeon and physician at the Community
Health Centre.
The primary role of the Community Health
Centre should nevefcthless be of monitoring the people's
health with priority to the promotive and preventive
services.
The ICSSR/lCMR report has estimated that about
98% of all health and illness care can be undertaken
within a
1,00,000 population covered by the Community Health Centre
at a cost of about Rs. 30 per capita oer annum leaving only
a marginal sector for tertiary hospital care.
Also that
this can be achieved only if the people have thfi finaicial
and administrative control over their health services with
guidance and support by the professionals.
I know that this is a radical departure from the existing
situation and may not ba readily acceptable to those who
believe that all decisions on health must be left only to
the medical profession.
But four decades experience in an
independent India has clearly demonstrated that we have
not been able to achieve the desired result despite the
vast expansion of medical services in both the public as
well as the private sector.
Dr N H Antia
Sources Medical & Non-Medical Dimensions of Healths, National
Academy of Medical Sciences Oration, April 4,
New Delhi
1987
5
their cun people in times of crisis.
The pedagogical
approach in the training session will determine whether these
village workers will become ’Lackeys of the existing system’
or the ’liberators of their people’ as David Uerner had
warned from his Hixican experience.
In many projects, however
we discovered that once health workers had been helped to
understand the situation and plan and decide on local health
actions, certain lead rdnip qualities did emerge and action
on issues wider than health was cpoerated.
In a fishing
community women health workers had effectively organised
people to orotest against the local bus system which refused to
allow women to carry their baskets of fish on thebus to the
local market,
In many plantations health workers called
link workers had emerged as local union leaders.
Such
situation ajere not at all unusual.
f.
Increasing community partici pa tion_in_healt h„decision
making
In addition to training pillage health workers many of these
prgects hava attempted to involve the community or their
representatives in the planning and decision making process
through the organisation of local village informal leaders.
Hany had involved existing
youth groups
mahila mandals (women’s groups)
farmers associations
coperatives
and
teachers and religoij s leaders
This is a very important trend and a rather challenging approach
For community participation to be a genuine process of enabling
people to take responsibilities foiytheir own health services
two pre-requisite conditions are essential;
6
i. Firstly ths involvement of all sections of the community.
In the strafied village set-up with certain casts and
class groups dominating decision making and exploiting
certain other groups, purposeful involvement of dis
advantaged and opprossod sections of the village often
' »
mean even exclusive involvement.
ii. Secondly the health action initi tors must be willing to
learn from the people and their own experience of local
ft
culture and social reality.
This means a ’democratic
dialogue’ on equal terms and involvement in all aspects
of decision making not just participation in programmes
organised by the health team.
These two pre-requisite conditions have evolved to varying
degrees in the different projects and hence the nature of
participation is variable.
tj^organi s a tio n
9•
The qualitative difference from the/above approach is only
of emphasis.
fflany projects have themselves initiated or
catalysed the development of
h
.
youth clubs
mahila mandals
farmers associations
and various group activities recognising the need for local
organisations to participate in planning and sustaining health
actions.
^his action has also emergad from the observation that even
the poor and marginalised are not themselves a cohesive group
of a ’community’ in the real sense.
They have internalised
various social, cultural, political, religious divisions that
divide society at large.
Hence building groups relationships
...7
7
and group organisations around issuas and common actions are
themselves pre-requisites for community health actions.
h. A_quest for f inanci al self-sufficienc2_and_gneration
,
of local_resources
Many projects have concentrated on the dimension of financial
participation of the community as a dimension of community
participation.
These projects have therefore concentrated
on generating local finances through
insurance schemes
adding health functions to dairy and other cooperative
graded payment of services according to family income
festival collections
and so on.
Experience has, however, cautioned that an
exclusive pursuit of this objective can often result in the
exclusion of those sections of the community which need the
health services most, especially when the pporchasing
capacity of people is so skewed.
Many projects have however widened this approach of generating
local resources to means
local resources - material,
structural and human - that can be harnessed to support health
actions.
These have included
grains for nutritional programmes
accommodation for clinics and programmes
basic supportive services by volunteers,
grain banks, voluntary labour, building materials
ans so on.
i) Education for Health
•Health’ education has been an important approach in most
projects moving beyond the ’conservative’ health education
approaches which usually includes information transfer on
available health services and do’s and dont's for individual
....8
8
health.
The efforts have been demystifying and conscientizing,
helcing groups to understand the broader issues in health care
as part of a wider awareness building process.
These have
been specific components of health action^br have been intro
duced as components of existing adult education and nan-formal
As people discover the cause of illn
education programmes.
esses that they commonly experience, and identify their roots
within their own social situation, they are prepared
something.
to do
This has meant that this approach has often served
as a starting point for individual or group education.
School
health programmes where teachers and high school students are
oriented to do something about their own health, that of their
own families and their community,
share the same vision.
j• Epnscientization and political action
There are some projects where the health teams based on thar
own experience have begun to show a deeper understanding of
issues for conscientization and recognise the need to support
political action especially those of ’people movements* and
mass organisations.
This support may be through the
organisation of health activities particularly for members of
such movements or the addition of health demands on the agenda
of people’s struggles.
In the South, especially the demand
for provisions of water supply has often become such a
rallying point.
O'
.C~
C
'.-cXc'-'P
J
tcs~c’.
J
THE NATIONAL HEALTHSCENE
a. c:--7.n,EN '^
I
rci'-cc::;? nity- h alth
V\ kvljlc . t . i U tf •->
Tetanus
In 1981, nearly a quarter million infants died in the
first month of life. The estimated mortality rate from tetanus
is 13.3 per 1000 live births in the rural areas and 3.2 in the
urban areas.
Diphtheria
The reported incidence, which is an under estimate admittedly
is around an verage 25000 cases a year, over 1975-31.
Pertussis
Around 300,000 cases reported annually.
Poliomyeli tis
Estimated number of cases ranged from 141,000 to 234,000 a year.
Annual incidence rate is around 1.5 to 1.3 per 1000 children
0-4 years.
Measles?
Estimated number of cases was 0.96 million in 1977.
The case fatality rate is 1—3 per cent.
Tuberculosis
There are about ten million patients in India, a quarter
of them infectious. Some 500,000 deaths occur annually from
tuberculosis, most of them in children below 15 years. The
of
incidence rate/infection is
0.8 percent in the 0-4 year
age group; 1.1 percent in the 5-9 age group; and two percent
in the 10-14 year age group.
Leprosy
It is estimated in 1981 that there are 3.919 million cases with a
prevalence rate of 5.72 for 1000 population. 20 to 25 percent of all c
V
cases occur in children nearly one fourth are infectious and another
15 to 20 pe/cent suffer from disabilities. The load of leprosy falls
in the eastern belt of India comprising Andhra Pradesh,
Tamil Nadu, Orissa and West Bengal with 53 percent of
the case load.
Typhoid
Some 300000 cases are reported annually, the majority
among school children. The number of unreported cases would
be large.
Diarrhoeal diseases
About 10 percent of total infant deaths are due to diarrhoea.
40% of deaths among children under- 5 year are diarrhoea-related.
An estimated 1.5 million children under five years die of it.
Acute respiratory infections
Over 17 percent of infant d<aths are on this account,
the proportion being next only to premature births. Upto 40 percent
of out door patients and upto 35 percent of indoor patient are
children below five years. The case fatality rate is 10-16
percent.
Malaria
A major problem of resurgence—man-made urban malaria.
Filariasis
Hundren million people in India living in ende ic regions
facing the threat.
Malnutrition
It is estimated that state of malnutrition ranges from 50%
to 65% among the under fives in various places. This is not
protein-calorie malnutrition but total calorie malnutrition
ie., starvation. Results in loweiing of resistance to infection.
(poverty line - those who do not have the purchasing power to
provide themselves with 2220 K. cals per day).
3
3
India
LDCs
World
% new born weighing less than 2.5 kg
2.5 kg
27.5
18
9
% of anaemia among pregnant
women
60
20
70
Blindness attributable to Vitamin zA Deficiency
occurs among 20-30,000 children in India.
Water supnly and sanitation
Only 31% of t- e rural population has access to porta
potable water end 0.5% enjoys basic sanitation.
Rural
•
Urban
Protected water supply
10%
82.5%
Sound excreta disposal
2%
34%
Sc51>. r CC. '
C SI _ r'Lun (Z? I’-y <sf
c- 1
'
THE NATIONAL H'ALTH SCENE
A CHALLENGE FOR COMMUNITY H'ALTH
Tetanus
In 1981, nearly a
uarter million infants died in the
first month of life. The estimated mortality rate from tetanus
is 13.3 per 1000 live births in the rural areas and 3.2 in the
urban areas.
Diphtheria
The reported incidence, which is an under estimate admittedly
is around an vcrage 25000 cases a year, over 1975—81.
Pertussis
Around 300,000 cases reported annually.
Poliomyelitis
Estimated number of cases ran .ed from 141,000 to 234,000 a year.
Annual incidence rate is around 1.5 to 1.8 per 1000 children
0-4 years.
Messiest
Estimated number of cases was 0.96 million in 1977.
The case fatality rate is 1—3 per cent.
Tuberculosis
There are about ten million patients in India, a quarter
of them infectious. Some 500,000 deaths occur annually from
tuberculosis, most of them in children below 15 years. The
of
incidence rate/infection is
0.8 percent in the 0-4 year
age group; 1.1 percent in the 5-9 age group; and two percent
in the 10-14 year age group.
Leprosy
It is estimated in 1981 that there are 3.919 million cases with a
prevalence rate of 5.72 for 1000 population. 20 to 25 percent of all
cases occur in children nearly one fourth are infectious and another
15 to 20 percent suffer from disabilities. The load of leprosy falli
2
in the eastern belt of India comprising Andhra Pradesh,
Tamil Nadu, Orissa and West Bengal with 53 percent of
the case load.
Typhoid
Some 300000 cases are reported annually, the majority
among school children. The number of unreported cases would
be large.
Diarrhoeal diseases
About 10 percent of total infant deaths are due to diarrhoea.
40% of deaths among children under 5 year are diarrhoea-related.
An estimated 1.5 million children under five years die of it.
Acute respiratory infections
Over 17 percent of infant deaths are on this account,
the proportion being next only to premature births. Upto 40 percent
of out door patients and upto 35 percent of indoor patient are
children below five years. The case fatality rate is 10-16
percent.
Malaria
A major problem of resurgence—man-made urban malaria.
Filariasis
Hundren million people in India living in ende: ic regions
facing the threat.
Malnutrition
It is estimated that state of malnutrition ranges from 50%
to 65% among the under fives in various places. This is not
protein-calorie malnutrition but total calorie malnutrition
ie., starvation. Results in lowering of resistance to infection.
(poverty line - those who do not have the purchasing power to
provide themselves with 2220 K, cals per day).
3
3
India
LDCs
World
% new bom weighing less than 2.5 kg
2.5 kg
27.5
18
9
60
20
%
of anaemia among pregnant
women
70
Blindness attributable to Vitamin A Deficiency
occurs among 20-30,000 children in India.
Water sur iy ana sanitation
Only 31% of t'.e rural population has access to porta
potable water and 0.5% enjoys basic sanitation.
Rural
Urban
Protected water supply
10%
82.5%
Sound excreta disposal
2%
34%
BHORE COMMITTEE RECOMMENDATIONS DOR 1971
Recommended
370 million
POPULATION
PRIMARY
Actuals (1971)
Estimated (1971)
1981 (Actuals)
548 million
685 million
HlALTH
1:20,000
10,500
27,400
5,112
34,230
5,740
DOCTORS
1:2000
1,85,000
2,74,000
1,61,129
3,42,500
2,68,712
NURSES
1:300
12,333,333
1,826,666
80,620
2,283,333
150,399
HEALTH VISITORS
1:5000
74,000
109,600
* 8,347
137,000
@ 19,033
niDUIVES
1/100 births
100,000
225,776
* 9,253
231,530
® 23,200
DENTISTS
1;4000
92,590
137,000
5,512
170,500
8,648
CENTRES
1__________
As required by
Shore Committee
to actual
populat ion
Projection
as required
by Shore
Committee
1
* Trained upto 1971
@ Trained upto 1981
Sources
1. Health Atlas of India, 1986
2. Handbook of Health Information
of India, 1986
3. Health Information of India,
1987
HEALTH FUR ALL
ZCMR/ICSSP.
Prescription
7^
A MASS MOVEMENT
TO
:i; REDUCE POVERTY, IMEEUALITY
AND 3PM“-AD EDUCATION
iii ORGANISE POOR AND UNDERPRIVILEGED
TO FIGHT FOR THEIR 3<Y'IC RIGHTS
iO MOVE AWAY FROM COUNTER-PRODUCTIVE,
CONSUMERIST WESTERN ?4Oi.)EL OF HEALTH
CARE AND REPLACE IT RY AH ALTERNATIVE
BASED IN THE COMMUNITY.
9
c
• Source: Community Health Cell
Reflections
t
Source: Common?ty Health Cell
Reflections
HEALTH DEVELOPMENT IN INDIA
The Constitution of India adopted in 1950 clearly recognises
the government’s responsibility for the health of all the
people and this commitment has ledd to the evolution of a
large number of health, programmes over the last 40 years
These included the
* Development of the Primary Health Centre concept
for every lakh population
* The training of health teams including doctors,
health inspectors, lady health visitors, auxiliary
nurse midwives, basic health workers, block
extension educators for these health centres.
* The National programmes for communicable diseases
like Tuberculosis, Leprosy, Malaria, Filaria,
Plague, Cholera and so on.
* The Maternal and Child health, Nutrition and
Family welfare programmes.
* Efforts at re-orienting medical and nursing
education
* Establishment of research and specialist institutions
* The integration of programmes at PHC level,
evolving the multi purpose health workers and
health supervisor cadres.
2
Sox items/source
ix. Education for health
Stages in Community Health
(FIONA plus)
x. Conscientization
and political action
6. Recognising the new
paradicm
6a. Building a collective
understanding
(CHC reflections)
CH definitions
VHAI/CMAI/ACHAN/CHAI goals in 80*s
CH Components
CH Critical issues
A plea for a new public health
(D. Banerjee)
6b. Evolving policy
alternatives
7. Community Health issues
7a. Community health &
Primary Health Care
7b. Community Health &
Hospitals
Remembering Alma Ata (CSI)
10 year after (FIONA PLUS)
Mission Hospital—2000 AD
an edict (CHAI)
7c. Community Health is
a movement possible
8.
CH Issue Raising groups
- an overview
9.
CH training initiatives
— an overview
10. CH Research Centres
- an overview
Profiles—mf c/AIDZ\N/SHC/CSSP
Profiles of 8 institutions
Profiles of 4 centres
highlighting research issues
11. In conclusions
From a medical model to
a social model
The new health paradigm
12. A Basic Resource Inventory
(Readings & Resource
Centres)
Table of shifts
An Indian map with stars
HEALTH ACTION
THE LEAD COVER STORY
No.l in content list
COMMUNITY HEALTH: EXPLORING THE INDIAN EXPERIENCE
Box items/source
1. Preamble
2. Health Development in India
Constitutional Pledges
3. Taking Stock
3a. Assessing achievements/
failures
ICMR/ICSSR list of achievements/
failures
3b. Quantitative expansion
6 charts from Health Atlas
of India, 1986
3c. Critical introspection
4 paragraphs from Srivastava
Report, 1975
3d. A multitude of questions
A list of questions by masses/
personnel (Ashish Bose)
4. The Health Scene in the 80's
:Voluble Indices
Handout of CSI Ministry of
Healing
5. The Alternative Health
Project Phenomena
5a. WHO were the initiators
5b. HOW did these evolve
5c. Indian map and short
profiles of projects from
States
5d. WHAT were the components
of Health action
i. Health with development
ii. Preventive/promotive
health action
iii. Appropriate Technology
Some profiles
iv. Promoting local health
resources
Some profiles
v. Village based health
cadres
Some profiles
vi. Community participation
vii. Community organization
viii. Financial resource
generation
Some profiles
2
Box items/source
---------- — $
Kducstion^_forf health
ages in 'Community Health
IGHTv plus)
-
x. Conscicntization
and political action
6. Recocnisinr the
paradigm
6a. Building a collective
understanding
(CMC reflections)
VHAI/CMAI/ACHAN/CHAI goals in 80's
A plea for a new public health
(D,. Banerjee)
6b. Evolving policy
alternatives
7• Ccmmunity Hea.lth._i,ssues
7&. Community health &
Primary Health Care
<?,
Community Health &
Hospitals
C\
Community Health is
a movement possible
CH Issue Raising groups
- an overview
CH training initiatives
— an overviei\r
10. CH Research Centres
/
~ an overview
RefelerfjBerinfr- Alma- Ata— (CS?)
(ig^ea^"af^er. (FI£!NA_gJJiS)
Mission Hospital-—2000 AD
an edict (CHAI)
Prof il es—mf c/AIDAls/^S/KSSP
■
Profiles of I’j! i^gti^btionS
Profiles of
centres
highlightingresearch issues
11. In conclusions
From a medical model to
a social model
Table of shifts
^2. A Basic Resource Inventory
(Readings & Resource
Centres)
An Indian map with stars
HEALTH ACTION
July 1989
Theme:
1.
2.
3.
,
•
Community Health in India
Community Health
:
Exploring the Indian
Experience
Voluntary Agencies in Community Health
The need for a new paradigm
&HC,
Bangalore
:
Community Health : Learning tTVTodgtr
our failures
Alok Hukhopadhyay
Prem and Hari
John
7C
4.
Building-Holistic Health Communities
Edwin S.J
5.
Ean a Hospital be Community Hffilth oriented?
Samuel Joseph
6.
SEL^RCHd- An- experience in Community Health
Research^
’> w
Abhay Bang/
Training for Community Health Care
: A medical college experience
Dara Amar
Health of People is Wealth of Nation
Jacob Cherian
7.
8.
(icA-td Cd-C
,9. Community Health : Keeping Trach
/^^7 (° basic Resources inventory)
CHC,
' \10< Organizing People for Health
- Peoblems and Contradictions
Anant R S
Bangalore
r-'lG. OjM
FROM INTRACELLULAR TO SOCIETAL RESEARCH
The new approaches to Community Health evolving in the
country have shown that a very important but neglected area
is research into socio-reconomic-political-cultural factors
that affect health and disease and determine the nature of
health care development as well as the response of the
people.
Medical research in India has been preoccupied as in
other parts of the world with intracellulay or molecular
biological roots of disease and much of the research efforts
sponsored by ICFIR and other national and regional, government
and private research centres has been in this direction.
of it has been imitative research,
Most
’we too have done it in
India' sort of focus and there is the continued myopic wiii
view that the future of health in the country will be
determined by the discovery of a few more vaccines and
maybe the odd drug or contraceptive.
This technological
focus has blinded us to the fact that the world-over health
care action initiators are proving again and again that the
clue to health of the peoole is ii: greater''societal problems
in the wider social reality and to study them in a socio-
epidemiological context- tc determine bottlenecks and to
evolve creative innovations.is the -need of the hour.
Some
ICFIR institdions like the National Institute of Nutrition
in Hyderabad, National tuberculosis Institute in Bangalore
and the Vgctor Control Research Centre in Pondicharry have
treaded the path of societal research and made unique
contributions to Primary Health Care and Community Health
but these are the exceptions to the overriding rula.
Have the NGO Health action initiators farod better?
Is anyone interested in health related societal research
in tho country?
The development of NGO health research units keeping
2
2
<
in tune with and exploring in depth issues arising out of
emerging Community Health movement are few but these are
atleast positive signs.
The Foundation for Research in Community Health (Bombay)
the Action Research in Community Health, Mangrol (Gujarat),
Society for Education Research and Training in Health,(SEARCH)
Gadchirole (Maharashtra), Community Health Cell (Bangalore)
are examples.
A few of the larger NGO Health Projects like CHOP, Pachod
(Maharashtra) SEUA-Rural (Gujarat), CINI (Calcutta), Damkhed
(Maharashtra) and RUHSA (Tamilnadu) have also begun to take up
some key research issues but this whole interest ie still
in a nascent state.
“
The Social Medicine and Community Health Department at
□ND is ths only other national centre which is undertaking
societal research relevant to Health Care and Health policy
issues.
The medico fridnd circle’s efforts in providing
counter research expertise in the Bhopal disaster and its
aftermath was also a beginning of this new trend.
Much needs to be done by both governmental and
non-governmental groups, if the emerging 'Community Health’
approach and movement has to be put on a sound researched
,
social and epidemiological basis.
But this needs people who
see Research as an important need.
It also needs innovative
‘researchers ’ who will be willing to learn existing health
care research methodologies and then creatively adapt it
through interactive, participatory approaches to study the
dynamics of Community Health care and the evolving movement.
With the preoccupation with ’microscopic research’ are
such ’baloonist researchers’ available for the task?
NGD Research Centres in Community Health : Some Profiles
* Foundation For Research in Community Health, Bombay,
(Maharashtra), Estb:
1975
Non-government research centre which undertakes conceptual
as well as field level research to study, analyse and
wherever possible influence the cultural, economic and
political factors that affect the health of the people.
Initiatives and studies include evolution and study of low
cost community based health systems in Uran and Mandwa.
Socio-economic study of rural transformation; Women's work
fertility and access to health; PHCs in Maharashtra;
Health Service projects (NGOs in Maharashtra^ Health
Financing in India
Stigma against leprosy
Alternative school health project
Facilitation of ICMR-ICSSR Joint study
group on Health for An an alternative strategy.
* Action Research in Community Health - (ARCH) Manqrol,
(Gujarat), Estb?
1978
A group of individuals of diverse background got together to
establish this centre in the eastern tribal belt of Gujarat
to study the developmental process using the health of children
and women of the poorer sections of society as the guiding
thread.
The approach was to get involved in the complex process of
development (ACTION)
and to study critically the health of the
community and the processes which results in ill health (RESEARCH)
Field based strategies evolved were programmes to attack pre
valent diseases, methods and skills of community diagnosis and
2
2
intervention, training of health assistants and part time
community health workers, non formal school and finally a just
and humane rehabilitation policy for tribals displaced by an
ambitious irrigation project in the area.
c c. *
'll A_
* Community Health Call, Bangalore, (Karnataka)
Estb:
1984
A Study-reflection-action experiment started by a small core
team who moved beyond the department of Community Medicine
of a medical college in bangalore to exolore issues and
build perspectives from community health action projects of
voluntary agencies in India.
The team promotes socio-
epidemiological analysis, participatory management and the
shift of health action from provision of services to enabling/
empowerment of the community.
(This issue of Health Action is based mainly on this
study-reflection experiment)
* Society for Education. Awareness and Research in Community
Health (SEARCH) Gadchiroli (Maharashtra) Estb:
1984
This Society has adopted Gadchiroli district, a predominantly
tribal district in Maharashtra, for its education, awareness
building and research activities.
Presently they have long term
projects on the study of Active Respiratory Illnesses in
children; and a study of women’s health focussing on the community
The Society also seeks to evolve methods of intervention which
will be at the level of the multipurpose workers of the
government PHC,
Due to its increasing community involvement the Society has also
begun to explore the dynamics of women's health and other related
issues, the forest issues affecting tribal and the illicit
....3
liquor issue and its community context.
It has also tried
to modify the health care/medical practices at the District
level to make it more responsive to the needs
and the people’s
situation.
♦Health Projects like R'JHSA Qamilnadu), CINI ('Jest Bengal),
CHDP Pachod (Maharashtra) and Osenabandhu (Tamilnadu) ,
SEUA-Rural (Gujarat)
and others (see profiles of projects page)
have also begun to take up research projects on key issues
in Community Health apart from putting their own activities
on a more sound data base.
COMMUNITY HEALTH AND PRIMARY HEALTH CARE
In 1978, Representatives of all the countries of the World
met in Alma Ata in USSR and committed themselves to the
concepts of ’Primary Health Care’
The Alma Ata declaration which is now a famous Health
document defined Primary Health Care
’as an essential health care made universally
accessible to individuals and acceptable
to them, through their full participation
and at a cost the community and country
can afford1
Primary Health Care (PHC) emerged in Alma Ata Declaration
as an alternative view of health and health care, which
included locating health;in the wider context of socio
economic development and exploring actions beyond orthodox
medical care, that would be pre-requisites and/or supportive
of the health of communities.
The four principles stressed
in the Declaration were:
1.
Equitable distribution
2.
Community participation
3.
Multisectoral approach
4,
Appropriate technology
Apart from a series cf technological and managerial
innovations that were cpnsidered^in the view of Health
action,that emerged at Alma Ata, probably the most
significant development was the recognition of a ’Social
process* dimension in Health care including
community
organisation, community participation, and a move towards
2
2
equity.
Health service providers woult^Ge willing now to
appreciate social stratification in society, conflicts of
interests among different strata and to explore conflict
management.
These were not exolicitly delineated but ware
inherent to the issues raised in the Declaration.
An
equally important fact was that these perspectives emerged
from the pioneering experience of a large number of voluntary
■ (■'i e s
agencies and some health ministtir-s committed to the deve
lopment of a more just anc/equitable health care
system.
Since India was a signatory and evidently an enthusiastic
proponent of this idea it has now become fashionable in
India to use ’Primary Health Care’
to describe all ^Iternativo
Health Action and synonymously with Community Health(CH)'i ’ While
PHC and CH have a lot in common it is important to remember
that they are not synonymous, PHC is included in CH but CH
is a much more comprehensive term and idea.
What are these differences
1.
Primary Health Care concdntrates on Primary level (first
line contact)
and ignores orieriation of tertairy and
secondary care,
Community Health means a new approach at all three levels
2.
Primary Health Care talks about a community in apolitical
terms as if they were some homogenous group.
It ignores
C
caste/class and other dimensions in society.
Community Health recognises stratification and conflict
and the role this plays in accessibility and opportunity
in health.
3.
Primary Health Care leaves the ’development’ and modern—
isation concept unquestioned.
Community Health locates itself in the centre of the
development debate and looks at health culture in a
wholistic way.
3
3
4.
Primary Health Care leavos the medicalisation of health
and the mystification and heirarchy of medicine unconfronted
Community Health confronts both these issues and tries
ezt.
to avolve an alternative ..plural, demystification,
non-heirarchical value system.
5.
Primary Health Care has now become selectivised and all
these who would prefer vertical topdown, selective, health
s
solution, funded by government and non-government,
International funding agencies have begun to gain control
over it.
Community Health by its very terminology does not allow
selectivisation^ by concentrating on communities as
base, community as focus of action and participation,
the community health action remains comprehensive.
Jay-’bc dSvo z s 2 3pd if 2ta
community which makes thio
rnhtva. t +■ 5s t;ho
THE ANTWERP MANIFESTO FOR PRIMARY HEALTH CARE
Academicians, community health specialists and practitioners
from several industrialised and Third World countries gathered
in Antwerp, in November 1985, for a 2 day seminar where they
took stock of the achievements of the Primary Health Care
approach.
Since the 1978 Alma Ata Conference, the member states of the
World Health Organization agreed that this Primary Health Care
strategy, which sees people as active partners, is the most
suited to answer their needs and can provide the basis for
Health for All.
However, in Third World countries, in spite of the lessons of
history and of past experiences, major national and international
donor agencies are diverting scarce resources into a short term
approach known as "selective primary health care".
This approach
concentrates exclusively on certain interventions claimed to be
the most efficient and aimed only at sections of the population.
This self-contradictory term should be banned, since, at their
best, such programs can only be considered as "selective health
status interventions".
This approach is in total contradiction
with the fundamental principle underlying Primary Health Care.
These principles are:
* The main roots of poor health lie in living conditions and
the environment in general, and more soecifically in poverty,
inequity and the unfair redistribution of resources in
relation to needs, both inside individual countries and
internationally.
* Since health is only one of the concerns of people, it is
self-defeating not to consider them as partners who are able
to play a great part in the protection and the improvement
of their own health.
They thus have to be fully and really
involved in the making of decisions which affect their
health, including of course, the provision of health services
2
2
* Health services must provide both curative and preventive
care, as well as promotive and rehabilitative measures .
This has to be done in a coordinated and integrated way
which responds to the people’s needs.
The Primary Health Care approach is being used with success
in many parts of ths world.
Being a continous process, much
remains to be done.
This manifesto is issued because the proliferation of selective
health intervention programs undermines the health services
at the exact moment when they try to reorganise themselves
towards Primary Health Care.
It is issued also because these interventions purport to offer
"quick solutions" and "instant success" for which they divert
scarce resources from the solution of the real underlying and
continuing problems, thus helping to maintain ill health.
In addition, experience has taught as that selective
interventions tend to become permanent even though they are
presented as "interim" responses only.
In fact, they need
specific structures which a country could not easily get rid
of at the moment it decided to reorient its health policy
towards comprehensive Primary Health Care.
And, above all, the selective approach rules out the possi
bility of people’s participation in decision making about
their own health.
The undersigned thus wish to reaffirm the principles of Primary
Health Care in its comprehensive form, and reject other
approaches instituted and propogated as "selective primary
health care"
L M K
CONSTITUTIONAL PLEDGES
Ths Stats shall regard the raising of the level of
nutrition and the standard of living of its People and the
improvement of Public Health as among its primary duties.
It shall ensure
that the health and strength of workers,men and women,
and the tender age of children are not abused......
that children are given opportunities and facilities
to develop in a healthy manner.....
It shall make
provisions for securing just and human conditions of
work and for maternity relief
and
for public assistance in cases of unemployment, old age,
sickness and disablement and in other cases of underserved
want.
-Constitution of India
QUANTITATIVE EXPANSION
By 1972 when ue celebrated the Silver Dubilee of our
Independence ue had made rapid strides and a phenomenal
quantitative expansion of health care services
(Insert charts 18, 21, 27, 28, 30 and 31 from
HEALTH ATLAS OF INDIA,
1986
Central Bureau of Health Inteligqnce
Directorate General of Health Services
Ministry of Health & Family Welfare
Government of India
Nirman Bhavan, Neu Oelhi )
HEALTH ACTION
July 1989
Theme: Community Health in India
1. Community Health z Exploring the Indian
Experience
CHC, Bangalore
2. Voluntary Agencies in Community Health :
The need for a new paradigm
Alok Mukhopadhyay
3. Community Health : Learning through
our failures
Prem and Hari
Bohn
4. Building Holistic Health Communities
Edwin S.3
5. Can a Hospital be Community Health oriented?
Samuel Boseph
6. SEARCH:
An experience in Community Health
Research
Abhay Bang
7. Training for Community Health Care
: A medical college experience
Dara Amar
8. Health of People is Wealth of Nation
Bacob Cherian
9. Community Health : Keeping Trach
(B basic Resources inventory)
CHC, Bangalore
10. Organizing People for Health
— Problems and Contradictions
Anant R S
REHBAR—I-SEHAT programme, Kotbhalwal Block, Jammu & Kashmir
C/o Prof of Preventive & Social Medicine, Govt Medical College
A project organized by the Government of Jammu & Kashmir
to train teachers of village school's as primary health care
guides.
Activities
\
- minor ailment treatment;
- health check up;
\
- health education
- nutrition supplementation programme
for school children
COMMUNITY HEALTH
A Resource Centre Directory
A to Z
(This includes addresses of all Centres, Projects and initiatives
mentioned in this special issue)
1.
Asian Community Health Action Network (ACHAN)
No 61, Dr Radhakrishnan Road, Madras 600 004.
2.
All India Drug Action Network(AIDAN)
C/o Voluntary Health Association of India, 40 Institutional Area,
South of I I T,
3.
Naw Delhi 110 016.
Action Research in Community Health (ARCH)
At & P.O Mangrol, Via Raj^ipla, Dist Bharuch, Gujarat 393 150
4.
Arogya Uikasa
Keshava S&ilpa, Kempegowda Nagar, Bangalore 560 019.
5.
Action for Welfare & Awakening in Rural Environment (AWARE)
5-9-24/78, Lake Hill Road, Hyderabad 500 463.
6.
Banwasi Seva Ashram,
Govindpur, Dist Mirzapur, Uttar Pradesh
7.
8.
Bodokhoni
Catholic Hospital Association of India (CHAI)
Post Box No 2126, 157/6 Staff Road, Secunderabad 500 003.
9.
Christian Medical Association of India (CMAI)
Smruti Theatre Compound, Mount Road Extension, Nagpur 440 001
10.
Christian Fellowship Community Health Centre (CECH)
Santhipuram, Anna District, Ambilikkai 624 612, Tamilnadu.
11.
Community Health Cell,
(CHC)
47/1 St Mark’s Road, Bangalore 560 001, Karnataka
12.
13.
Centre for Science & Environment (CSE)
807 Vishal Bhavan, 95 Nehru Place, New Delhi 110 019.
14.
CSI Ministry of Healing
10, Sambamdam Street, T.Nagar, Madras 600 017
15.
Deenabandhu
Training and Service in Community Health 4 Development
R K Pet, 631303, Tamilnadu.
....2
2
16.
Foundation for Research in Community Health (FRCH)
84-A. R G Thandani Marg, Sea Face Corner, Uorli
Bombay 400 018.
17.
Indian Council of Medical Research (ICMR)
Ansari Nagar, Post Bos 4508
New Delhi 110 029
18.
Indian Council of Social Sciences Research (ICSSR)
IIPA Hostel, Indraprastha Estate, Neu Delhi 110 002
19.
Institute of Education
128/2 Karve Road, Kothrud, Pune 411 029
20.
Institute of Health Management (IHMP)
Pachod, Dist Aurangabad 431 121, Maharashtra
21.
International Nursing Services Association,
India (INSA)
No2 Benson Road
Benson Town, Bangalore 560 046
22.
Indian Social Institute; (ISI)
Lodi Road, Neu Delhi 110 003
23.
Oauarharlal Nehru University (3NU)
Centre for Social Medicine & Community Health
Neu Delhi 110 057
24.
St Oohn’s Medical College & Hospital (S3MC)
Sarjapur Road, Bangalore 560 034
25.
K.E.M. Hospital
Sardar Mudaliar Road, Rasta Path, Pune 411 011
26.
Kottar Social Service Society (KSSS)
Thirumalai Ashram Social Centre, Chunkankadai P.O 629 807
Tamilnadu
27.
OR KSSS, Post Box 17, Nagercoil 629 001
Kerala Sashtra Sahitya Parishad (KSSP)
Parishad Bhavan, Chirakulam Road, Trivandrum 695 001
28.
LokVidyan Sanghatana
759/97 0, Shantibhuvan, Prabhat Road Lane No 2
Deccan Gymkhana, Pune 411 004
29.
Mallur Health Co-operative
Siddhalaghata Taluk,
30.
Mallur 562 116, Kolar District
Medicare
Kasturba Medical College, Manipal
3
HEALTH DEVELOPMENT IN INDIA
The Constitution of India adopted in 1950 clearly recognises
the government’s responsibility for the health of all the
people and this commitment has ledd to the evolution of a
large number of health programmes over the last 40 years
These included the
* Development of the Primary Health Centre concept .
for-every lakh pop'll?tion
* The training of health teams including doctors,,
health inspectors, lady health visitors, auxiliary
nurse midwives, basic health workers, block
extension educators for these health centres.
* The National programmes for communicable diseases
like Tuberculosis, Leprosy, Malaria, Filaria,
Plague, Cholera and so on.
* The Maternal and ^hild health, Nutrition and
Family welfare programmes.
* Efforts at re-orienting medical and nursing
education
* Establishment of research and specialist institutions
* The integration of programmes at PHC level,
evolving the multi purpose health workers and
health supervisor cadres.
CONSTITUTIONAL PLEDGES
Ths Stats shall regard the raising of the level of
nutrition and the standard of living of its People and the
improvement of Public Health as among its primary duties.
It shall ensure
that the health and strength of uorkers9men and women,
and the tender age of children are not abused......
that children are given opportunities and facilities
to develop in a healthy manner.....
it shall make
provisions for securing just and human conditions of
work and for maternity relief.....
and
for oublic assistance in cases of unemployment, old age,
sickness and disablement and in other cases of underserved
U3nt e
-Constitution of India
THE COVER STORY
Community Health In India
Preamble
This story attempts to bring to the Readers
of Health Action a birds eye view of an emerging
process in India in which there is a growing shift
of emphssis in health work from
Doctors and Nurses
Hosoitals and Dispensaries
Drugs and laboratory investigations
surgery and medical technology
to
Village/Community based health workers
Health education/awareness building
Appropriate health technology
Community based health actions
Involvement of traditional healing traditions
Integrated rural development
and so on
The process reflects a growing disenchantment with the
hospital/institutional based high technology models of
health care which we transplanted and adopted in India
to meat the health needs of our people especially since
independence.
The process also reflects a commitment and a growing
diversity of efforts and initiatives all over the country
to adapt, innovate, create, alternative approcahes to
health care that are more relevant to our people's needs
and our social realities.
While it is not possible to
introduce readers to all the participating groups and
initiatives in the Community Health Movement we have
..2
2
attempted to explore as much of the diversity as possible
as well as quote from the wealth of documentation, reflections
and educational materials that this ferment is generating,
THE COVER STORY
Community Health In India
Preamble
This story attempts to bring to the Readers
□f Health Action a birds eye view of an emerging
process in India in which there is a growing shift
of emphssis in health work from
Doctors and Nurses
Hospitals and Dispensaries
Drugs and laboratory investigations
surgery and medical technology
to
Village/Community basad health workers
Health education/awareness building
Appropriate health technology
Community based health actions
Involvement of traditional healing traditions
Integrated rural development
and so on
The process reflects a growing disenchantment with the
hospital/institutional based high technology models of
health care which we transplanted and adopted in India
to meet the health needs of our people especially since
independence.
The process also reflects a commitment and a growing
diversity of efforts and initiatives all over the country
to adapt, innovate, create, alternative approcahes to
health care that are more relevant to our people*s needs
and our social realities.
While it is not possible to
introduce readers to all the participating groups and
initiatives in the Community Health Movement we have
2
2
attempted tc explore as much of the diversity as possible r/
;
as well as quote from the wealth of documentation, reflections
and educational materials that this ferment is generating,
HEALTH ACTION
July 1989
Theme: Community Health in India
1. Community Health : Exploring the Indian
Experience
CHC, Bangalore
2. Voluntary Agencies in Community Health :
The need for a new paradigm
Alok Mukhopadhyay
3. Community Health : Learning through
our failures
Prem and Hari
John
4. Building Holistic Health Communities
Edwin S.J
5. Can a Hospital be Community Hffilth oriented?
Samuel Joseph
6.
SEARCH:
An experience in Community Health
Research
Abhay Bang
7. Training for Community Health Care
: A medical college experience
Dara Amar
8. Health of People is Wealth of Nation
Jacob Cherian
9. Community Health : Keeping Trach
(B basic Resources inventory)
CHC, Bangalore
10. Organizing People for Health
- Peoblems and Contradictions
Anant R S
ASIAN COC.FIUNITY HEALTH ACTION NETMORK (ACHAN)
was formed in 1980 by a group of twenty people with substantial
experience in working in health care among the poor in Asia
and operotss through its network of concerned individuals and
non-governmental organisations in fifteen Asian countries, most
of whom have bean engaged in innovative primary care at the
community level
ACHAN
seeks to spread a philosophy of community based health care
that envisages a process of self reliant human development for
the oppressed poor in Asian communities which will result in
ganuine social change,
ACHAN
views health as the physical, mental, social, spiritual,
economic and political shoneness of the individual and the
■
community
ACHAN
believes that health problems and priorities should be viewed
in terms in which the community sees them and that the community
should be actively involved in planning, implementation,
monitoring and evaluation of health care programmes.
’’RECOGNISING THE NEW PARADIGM"
1978
VOLUNTARY HEALTH
ASSOCIATION OF INDIA
(3000 Health Institutions
and Community Health
Programmes)
•making community health
a reality for all people,
with priority for the less
privileged millions, with
their involvement and
participation through the
voluntary health sector...."
1982
ASIAN COMMUNITY HEALTH
ACTION NETWORK
(Network of concerned
individuals and NGOs
in fifteen Asian countries)
"to spread a philosophy of
community based health care
that envisages a process of
self-reliant human development
for the oppressed poor in
Asian communi ties.. .. "
1983
CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
"committed to community health
(2000 member hospitals
and Dispensaries)
....as a process of enabling
people to exercise collectively
their responsibilities to
maintain their health and
to demand health as their
right...."
-W
0°
....2
2
1986
CHRISTIAN MEDICAL
ASSOCIATION OF INDIA
(300 institutions
(protestant) plus
5000 individuals
associated with these)
"commitment to community
health....a process that
empowers people to work
together to promote their
own health and to demand
appropriate health services..
relevant, low cost, effective
and acceptable...."
Source: Policy Statements of organizations
the paradigm shift
Model to Social Model of Health
INDIVIDUAL
COLLECTIVE/COMMUNITY
PATIENT
&
POPULATION
PERSON
&
SOCIETY
ANTI DEATH
ANTI DISEASE
PRO LIFE
PRO LIVING
PHYSICAL/MENTAL
PREDOMINANTLY
.
PHYSICAI ,/MENTAL/SOCIAL/.
CULTURAL/POLITICAL/ECO^OLOGICAL
DOCTORS/NUP.SES
MEDICAL AUXILIARIES
TEAM OF HEALTH WORKERS
DISEASE
PROCESSES
SOCIAL
PROCESSES
HOSPITALS/DISPENSARIES
DRUGS/TECHNOLOGY
—PROVIDING SERVICES
HEALTH PROMOTING AND
COMMUNITY BUILDING CENTRES
/AND PROCESSES—ENABLING/EMPOWERING
THE PEOPLE
INTRACELLULAR
RESEARCH
-- SOCIETAL RESEARCH
PATIENT AS BENEFICIARY,
CONSUMER
--- >
PEOPLE AS PARTICIPANTS
SINGLE FACTOR.,
->
MULTI. FACTOR
RISK IDENTIFYING,
PROCESS IDENTIFYING,
EPIDEMIOLOGY
(EPIDEMIOLOGY
PROFESSIONALISED
COMPARTMENTALISED
MYSTIFIED KNOWLEDGE
DEMYSTIFYING,
PERSON CENTRED
AUTONOMY CREATING
AWARENESS BUILDING
QUEST FOP. VACCINE
AGAINST DISEASE
QUEST FOR AWARENESS BUILDING
PROCESS TO IMMUNIZE AGAINST
UNHEALTHY SOCIAL PROCESSES
takinc_stock
A study croup of> tha Indian Council of Medical Research and
jr^an Council of Social Sciences Research listed out
the achievements and failures of this whole strategy as
f ollcws:
Achievements
Life expectancy doubled
Health care services expanded
Manpower training centres increased
Small pox was eradicated
Plague, Cholera and Malaria controlled
Maternal and Child Haalth and Immunization programmes
increased
Largest Family Planning programme in the world
Failures
Health not integrated with Development
Little dent on Malnutrition and Environmental Sanitation
Morbidity Patterns not materially changed
Health Education neglected
TB, Leprosy, Filaria yet to be controlled
Infant Maternal mortality rates still very high
Population stabilization - a long way to go
Overall
1. The model of health care was outdated and counter
productive benefitting the rich anc^ell to do
upper and middle classes
2. Health was a low-priority national investment
QUANTITATIVE EXPANSION
By 1972 when we celebrated the Silver Oubilee of our
Independence we had made rapid strides and a phenomenal
quantitative expansion of health care services
28, 30 and 31 from
(Insert charts 18, 21, 27,
HEALTH ATLAS OF INDIA,
1986
Central Bureau of Health Inteliggnce
Directorate G3nsr£i of Health Services
Ministry of Health & Family Welfare
Government of India
Nirman Bhavan, Neu
)
HEALTH DEVEL0PJ3ENT IN INDIA
Ths Constitution of India adoptad in 1950 clearly recognises
the government’s responsibility for the health of all the
people and this commitment has ledd to the evolution of a
large number of health programmes over the last 40 years
These included the
* Development of the Primary Health Centre concept
for every lakh population
* The training of health teams including doctors,
health inspectors, lady health visitors, auxiliary
nurse midwives, basic health workers, block
extension educators for these health centres.
* The National programmes for communicable diseases
like Tuberculosis, Leprosy, Malaria, Filaria,
P'.ague, Cholera and so on.
* The Maternal and Child health, Nutrition and
Family welfare programmes.
* Efforts at re-orienting medical and nursing
education
* Establishment of research and specialist institutions
* The integration of programmes at PHC level,
evolving the multi purpose health workers and
health supervisor cadres.
CONSTITUTIONAL PLEDGES
The State shall regard the raising of the level of
nutrition and the standard of living of its People and the
improvement of Public Health as among its primary duties.
It shall ensure
that the health and strength of workers,men and women,
and the tender age of children are not abused
that children are given opportunities and facilities
to develop in a healthy manner
It shall make
provisions for securing just and human conditions of
work and for maternity relief.....
and
for public assistance in cases of unemployment, old age,
sickness and disablement and in other cases of underserved
want.
-Constitution of India
EVOLVING POLICY ALTERNATIVES
The National Health Policy statements are beginning to
echo these ideas and values.
Whether this is ’populist rhetoric' or a serious ’rethink’
only time will tell.
(pe i e Ye
2
will win and the Government would lose.
The sad fact
is that the infrastructure remains unutilised because
it is by and large not operational,"
"Let us turn to the personnel now.
The Block Medical Officers ask:
* Why is there no set policy for transfers
and promotions?
* Why only doctors who can wield political
influence manage good postings, while the
others ’rot* in villages for years together?
The ANMs ask:
* Why is there no concern for their physical
security when they are asked to work and live
in remote villages?
* Why did the Government insist on getting free
land from the Panchayat which in effect meant
the worst possible location for their quarters,
mostly on the outskirts of villages?
The Village Health Guides (VHGs) ask:
* Why have they not been paid their paltry
honorarium of Rs. 50 per month even after the
Government issued orders not to discontinue the
scheme under which mostly male VHGs have been
recruited?
(It was decided that in future only female VHGs will be
recruited)
Again, if there is a fair debats between the health staff
and the high level administrators, the Health Staff will
win"
CRITICAL INTROSPECTION
In the seventies, the Government of India set up an expert
group on Medical Education and Support Manpower to take
stock of the situation and suggest proposals for reforms.
This is what the expert committee had to say:
"A
1.
universal and egalitarian programme of efficient and
effective health services cannot be developed against
the background of a socio-economic structure in which the
largest masses of people still live below the poverty
line.
So long as such stark poverty persists, the
creative energies of the people will not be fully released;
the State will never have adequate resources to finance
even minimum national programmes of education or health;
and benefits of even the meagre investments made in these
services will fail to reach the masses of the people.
There is, therefore, no alternative to making a direct,
sustained and vigorous attack on the problem of mass
poverty and for creation of a more egalitarian society.
A nationwide programme of health services should be developed
side by side as it will support this major national eudeavour
and be supported by it in turn.
2.
Me have adopted tacitly, and rather uncritically the model
of health services from the industrially advanced and
consumption-oriented societies of the west.
This has its
own inherent fallacies; health gets wrongly defined in
terms of consumption of specific goods and services; the
basic values in life which essentially determine its
quality get distorted; over-professionalization increases
costs and reduces the autonomy of the individual;
and
....2
,y.c
V
2
ultimately there is an adverse effect even on the health and
happiness of ths people.
Those weaknesses of the systsm are
now being increasingly realized in theUest and attempts are
afoot to remedy them.
Even if the system were faultless,
the huge cost of the model and its emphasis on over-profe
ssionalization is obviously unsuited to the socio-economic
conditions of a developing country like ours.
It is therelftre
a tragddy that we continue to persist with this model even
when -those we borrowed it from have begun to have serious
misgivings about its utility and ultimate viability.
It
is, therefore, desirable that we take a conscious and
deliberate decision to abandon this model and strive to
create instead a viable and economic alternative suited to
our own conditions, needs and aspirations.
The new model will
have to place a greater emphasis on human effort (for which
we have a large potential) rather than on monetary inputs
(f>r which we have severe constraints).
a
3.
In the existing system, the entire programme of health
services has been built up with the metropolitan and capital
citie as centres and it tries to spread itself out irythe
rural areas through intermediate institutions such as
Regional, District or Rural Hospitals and Primary Health
Centres and its sub-centres.
Very naturally, the quantum
of quality of the services in this model are at their best
in the Centre, gradually diminish in intensity as one moves
away from it, and admittedly fail at what is commonly des
cribed as the periphery.
Unfortunately,
the ’periphery’
comprises about 80 percent of the people of India who should
really be thg't'ocus of all the welfare and developmental
3
3
effort of the Stats.
It is, therefore, urgent that this
process is reversed and the programme of national health
services is built with the community itself as the central
focus.
This implies the creation of the
needed health
services within the community by utilising all local
resources available, and then to supplement them through a
referral service which will gradually rise to the metropolitan
or capital cities for dealing with more and more complicated
v
cases.
4.Throughout the last two hundred years, conflicts have arisen
in almost every important aspect of our life, between our
traditional patterns and the corresponding systems of the
West tc which we have bean introduced.
In many of these
aspects, the conflicts are being resolved through the
evolution of a new national pattern suited to our own
»
genius and conditions.
In medicine and health services
unfortunately, these conflicts are yet largely unresolved
and the old and new continue to exist side by side, often
in functional dishormony.
A sustained effort is, therefore
needed to resolve these conflicts and to evolve a n?-tional
system of medicine and health services, in keeping with
our life systems, needs and aspirations.
Many other expert committee reports and policy statments
of the seventies began to make critical observations about
the inadequacies of the present health care model and
exhorted all concerned to search for more relevant alter
natives and approaches.
A MULTITUDE CF 'QUESTIONS
What do all these statistics and critical introspection mean
to the rural people who have suffered neglect for years?
Have
the post-independence policies made an impact on their lives?
Professor Ashish Bose while reciewing the Family Welfare
programme has this to say:
"There are questions the masses would like to ask.
* Why are doctors not available at the Primary
Health Centres and ANMs not available at the
sub-centres?
* Why are medicines not available to the poor?
* Why is there no follow-wp of acceptors of
sterilisation?
* Why are women brought to the PHCs for
laparoscopic operation?
* Why are the X-ray machines not working in
so many PHCs and hospitals?
* Why is there no facility for oxygen and
blood transfusion even in upgraded PHCs?
* Why are Government doctors so indifferent
to rural patients?
* Why don’t the PHC building have proper water
and electricity facilities?
* Why are the new sub-centres and residential
houses built for ANMs so sub-standard and
located in such forlorn places?
* Why do
contractors get away with sub-standard
construction under the so called Foreign-Aided
Area Projects?
"In this controversy, if there is a fair debate, the masses
..,.2
2
will win and the Government would lose.
The sad fact
is that ths infrastructure remains unutilised because
it is by and large not operational,”
"Let us turn to the personnel now.
The Block Medical Officers ask:
* Why is there no set plicy for transfers
and promotions?
* Why only doctors who can wield political
influence manage good postings, while the
others ’rot1 in villages for years together?
The ANMs ask:
* Why is there no concern for their physical
security whan they are asked to work and live
in remote villages?
* Why did the Government insist on getting free
land from the Panchayat which in effect meant
the worst possible location for their quarters,
mostly on the outskirts of villages?
The Village Health Guides (VHGs) ask:
* Why have they not been paid their paltry
honorarium of Rs. 50 per month even after the
Government issued orders not to discontinue the
scheme under which mostly malo VHGs have been
recruited?
(It was decided that in future only female VHGs will be
recruited)
Again, if there is a fair debate between the health staff
and the high level administrators, the. Health Staff will
win”
Will the NGOs work together to pur pressure on the
’established medical system’ to commit itself to a new
vision of Health Care?
Will the NGOs work together to put pressure on ’Health
Policy and decision makers'
to move beyond policy statements
and get health oriented programmes and actions of the ground?
Will the NGOs work with the people and their organisations
to enable and empower them to get the means, structures,
opportunities,
skills, knowledge and organisations that
make health possible?
All these are unanswered questions.
Micro level experi
ments have shown that a lot is possible, but macro level
change requires a collective understanding and a colle
ctive action that is still to eirege on our individualistic,
divided,politically sterile national scene.
WILL COMMUNITY HEALTH HAVE A CHANCE?
HEALTH SERVICES IN ft COUNTRY
Postulates_of_a_thsor^
Health Service development is
a.
a socio-cultural process
b.
a political process
c.
a technological and managerial process with an
epidemiological and sociological perspective.
There is often a lag between socio-cultural aspirations
of the people and
their articulation by the political
leadership;
The lag is much more between the aspirations of the
political leadership and the achievements of community
health physicians who have the responsibility for building
the needed edifice of the health services.
The task is to narrow, if not totally eliminate, lags that
may exist within the three tiers.
Formation ef a critical mass of community health physicians
and olblber members of the team, which can take full advantage
of the scope offered by the base (i.e., the complex of
ecological, epidemiological, cultural, social, political
and economic factors at play) requires a new approach to
education of community health physicians and other members
of the team.
Readymade solutions are not available from affluent countries
a superstructure of health services is to be built which is
firmly rooted in the base.
- D Banerji (
)
"RECOGNISING THE NEW PARADIGM"
1978
VOLUNTARY HEALTH
ASSOCIATION OF INDIA
(3000 Health Institutions
and Community Health
Programmes)
“making community health
a reality for all people0
with priority for the less
privileged millions, with
their involvement and
participation through the
voluntary health sector..,,"
1982
ASIAN COMMUNITY HEALTH
ACTION NETWORK
"to spread a philosophy of
(Network of concerned
individuals and NGOs
in fifteen Asian countries)
community based health care
that envisages a process of
self-reliant human development
for the oppressed poor in
Asian communities...."
1983
CATHOLIC HOSPITAL
ASSOCIATION OF INDIA
"committed to community health
(2000 member hospitals
and Dispensaries)
....as a process cf enabling
people to exercise collectively
their responsibilities to
maintain their health and
to demand health as their
right...."
2
2
1986
CHRISTIAN MEDICAL
ASSOCIATION OF INDIA
(300 institutions
(protestant) plus
5000 individuals
ase>ciated with these)
"commitment to community
health....a process that
empowers people to work
together to promote their
own health and to demand
appropriate health services..
relevant, low cost, effective
and acceptable...."
Source: Policy Statements of organizations
Position: 123 (35 views)