BACKGROUND PAPERS ON COMMUNITY HEALTH (NGO;S)
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- Title
- BACKGROUND PAPERS ON COMMUNITY HEALTH (NGO;S)
- extracted text
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M H [Qy.{
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RF_COM_H_57_SUDHA
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VOLUNTARY
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AGENCIES IN HEALTH CARE—NEED FOR A/PARADIGM
- ALCK MUKHOPADHYAY
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aric
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Health care in India has a long tradition of voluntarism.
For
centuries, traditional healers have taken care of the health
needs of their own community as a social resp-onsibility;.by using
the knowledge, passed on to succeeding generations, of the medi
cinal values of herbs and plants available around the village.
This tradition still continues particularly in the tribal pockets
of the country.
This indigenous knowledge went through systematic expression,
culminating in the development of more sophisticated but also
institutionalised system which led to the evolution of Ayurvedic
schools.
It also led to monetised heirarchai ..form of health care
whete the "Raj Vaidyas" were for the royalty and other Vaidyas
for the commoners.
holistic.
But this system became more scientific and
There was also the gradual blooming of a variety of
schools: Ayurvedic, Sidha, Unani,, Yoga e-tecr.
With the gradual
spread of British colonialism, this system was seriously neglected
causing incalculable damage.
Unfortunately, the institutionalised voluntarism that evolved during
this phase was completely dominated by the thoughts of colonisers,
who totally ignored the rich traditional systems of health care
in InAia.
This was partly due to the fact that much of this effort
grew out of the activities of Christian missionaries.
The Indian
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elites, who had been partially involved in the voluntary effort
during that phase, also firmly believed in the supremacy of every
thing which came from the
Wcsj''.
Consequently, there was little
possibility of evolving a health system which assimilated the best
of both schools.
Perhaps the major exception was Gandhiji's
continuous effort to popularise naturopathy, Yoga and vegetarianism
through the Ashrams set up in various parts of the country.
After Independence till the mid-sixties, voluntary effort in health
care was again limited to hospital-based health care by rich family
charities or religious institutions.
In the mid-sixties, the
£
effectiveness of Western curative model of health care in the less
developed countries came under serious attack by development
planners.
The Chinese experience of decentralised health care
through effective use of motivated health cadres at the grassroot
level also received widespread attention.
Out of this rethinking
grew various models of community health programmes which emphasised
on the decentralised curative service where trained village-level
workers play a key role.
Much more importance was given to pre
ventive aspects where the community plays a more effective part
in their own health care.
There—are—experiments—of—thi-s—new—appro
in many—pe-rtnpcTq'the—country.
Unfortunately, again this refreshing
trend also missed the important role of traditional healers and
Dais in health care.
systems of medicine.
Very little attention was paid to the Indian
----
The voluntary health effort can be hroad-ly classified as—fo-l-iows:
i)
Specialised community health programmes
..3
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Many of them go a little beyond health by running income
generation schemes for the poorer communities so that they
can meet their basic nutritional needs.
'-.c—res~> Is
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ii)
Integrated development programmes
In these programmes, health is a part of the overall develop
ment activity.
Consequently their thrust in health care may
not be as systematic or as effective as the previous group
but the long-term effect of their work on health and
development of the community is significant.
iii)
Health care for special groups of neonle
This includes education, rehabilitation, care of handicapped,,
These specialised agencies are playing an important role
keeping in view the fact that hardly any government infra
structure exists in this sector of health care.
iv)
Govt»NGOs
These groups play the role of implementing government prog
rammes like family planning, Integrated Child Development
Services etc.
These services are slightly more efficient
than the government system but their overall approach is
the same.
Rotary Club's Lions Club's, Chamber of Commerce
sponsored health work
They usually concentrate on eye camps doing mass-scale cataract
operations in the rural areas with the help of various spe
cialists.
hol<^
4
-4vi)
Health researchers arid activists
These croups' efforts ere usually Involved in writing occa
sional papers, organising meetings on conceptual aspects of
health care end critiquing government policy through their
journals which have very limited circulation.
vii)
Camoaicn groups
These groups are working on specific health issues e.g.,
Drug Policy. Amniocentesis else.
—L2t3_L<7
According to a rough estimate, more than 5000 voluntary organisation s
are working on above areas1 of health care throughout the country.
But the question is, how far are these efforts being able to
address themselves to the critical issues of the State of India's
Health?
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India is bracketed with the poorest and most underdeveloped nations
of the world like Mauritania, and Nepal as far as health status is
concerned.
Also, there is an extraordinary difference between the
health status of the people of states of Kerala and Punjab on the
one hand and the people of Uttar Pradesh and Bihar on the other.
The health status in Kerala and Punjab can be compared with some
of the developed countries and UP, Bihar, MP and Rajasthan can be
termed as among the worst anywhere in the world.
Major causes of
the current impoverished State of Health in India can be attributed
to the following factors:
1.
Inaccessibility of food
In a country which boasts of 26 million tonnes of foodgrain reserve
5
-5in a good monsoon year, 40 percent of the people
minimum nutritional requirement .
\le
go without
still go through the annual
cynical debate—whether the people in drought stricken Kalahandi
(in Oriss?)
are dying due to starvation or gastroenteritis.
Every
year the government increases the salary of its employees to
protect them from the impact of inflation, but the effect of price
rise of essential commodities cn the lowest paid citizens in the
country—the wage labourers—hardly receives any attention.
According to the available statistics, the production of coarse
grain mainly consumed by the poorest sections has stagnated as the
green revolution has shifted to rice and wheat.
Pulses are often
the only source of protein for the poor, but the percentage of
growth to the total output is half of what it was in 1950, and the
per capita availability of pulses has halved from 1960.
Milk is
more easily and cheaply available in Delhi than in the places
400-1000 km away from where it is produced.
Except for isolated efforts of helping a handful of families to
increase their income through economic development programmes, the
voluntary agencies working in health care have played only a marginal
role in the critical issues that will ensure land reform, minimum
wage, low cost rationing for the poor cr poor people's need oriented
agricultural policy.
Similarly, occupational hazards which affect
the health of millions working in the unorganised sector hardly
receives their attention.
Without major effort in these key areas, appreciable change in
the health status of the people is not possible.
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2.
Lack of safe drinking water
On the eve of the Eighth Five Yar Plan, 227 lakh villages do not
have assured
otable water supply within 14 km of the village.
Again in the critical area of safe drinking water supply;—the
effort of voluntary organisations has remained limited to a few
pockets.' Most health organisations do not take this as an important
ingredient of their work though the vital link between good health
and accessibility to safe drinking water does not need much
-—
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— — - ---- ----------------------------- •----------------------- > .
elaboration.
Sanitation is a problem which we are yet to grapple with effectiv^
even in our big cities, not to mention rural areas.
The recent
major epidemic of gastroenteritis and cholera in many parts of the
country is an indication of current environmental sanitation
situation.
3.
Inappropriate health systems and services
Currently three-fourth of the health budget is poured into expensive
specialist services benefitting less than one-fourth of the popu
lation.
The existing government primary health services in rural
areas, which is barely functional in some places, is totally
defunct in most places.
This is due to shortage of resources,
lopsided priorities, devastating pressure of family planning target
chasing, lack of motivation among the functionaries.
There is
hardly any participation of the people in health care delivery.
In this broad area, voluntary agencies have played a significant
role :n developing alternative "models", as well as providing
low-cost and effective health services in many parts of the country.
7
-7They have been able to develop village based health cadres, educa
tional material and appropriate technology.
They also fill
the critical gaps that exist in the government health services.
These "models" are far from perfect; they fail to possess the
On the other
conditions of replicability by the government sector.
hand, the vastness and regional diversities that characterise
India also make it extremely problematic to think of replication
In fact, it is being increasingly
or standardisation of "models".
acknowledged that the term "model" itself, when applied to people’s
health care systems, is suspect.
There can be no prototype as
such.
An appropriate system should evolve from the people them
selves.
Just as health conditions emerge from the community's
interaction with its surroundings, it is the people's struggle
through time that also determines the nature of the services that
they get.
It is also,recognised that the task of formulating a "model" or
an appropriate, .responsive system of health care becomes a highly
challenging managerial,
sociological, technological, epidemiological
and political task which, if simplified down to current level of
,
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health planning, will produce imperfect results.
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Afte-r-a-l-l-y—the
NoO sector has—en-l-y—a—subtle difference from the government in
regard, (afiehavfng preconceived ideas, a- lot-o-f—money-and little
--
I a V of f-rt
sure knowledge of the dynamics of community health, c@m-i-ng to
"mess around" in communities.
health care are hard to find.
Genuine "models" of community-based
f
.. .8
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Thc entire concept of "participation" currently in vogue is another
problem.
In the view of the establishment, for whom anything ulti
mately referring to empowerment of people is hard to accept, the
term has been subverted to mean compliance, contribution or colla
boration.
In its true sense and implications, participation leading
to empowerment stands directly in challege to the interests of the
establishment.
The effect of community-health experiments in shaping government
policy in health care has been limited although few of the concepts
have been incorporated in the government programmes.
Also, some
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voluntary agency representatives have been absorbed in government
policy-making bodies.
This is an critical area totally neglected
by voluntary agencies./ These- voluntary initiatives are not necessa
rily in the area of extreme needs.
One finds very limited voluntary
initiatives in the BIMARU states (bihar, Madhya Pradesh, Rajasthan,
UP and Andhra Pradesh) as compared to better off states like Kerala.
Even in Kerala,
they are not necessarily in the least developed
parts of Malabar coast or Highlands.
T^ere. ^argl_hardly~~at^ ef^f or ta-iryjopming-the^ public^ opinion~<5g~mass
bcganisationr likeptrade .unions7w:peopl e ’’S'Tnovemente- or.- poiTtfcal
bcdies.-ln. generating-a; demand-f or a more-appropriate a nd'^e f f e c tive~~
hpfvireZx In spite of these limitations, the voluntary health
organisations have contributed most in providing appropriate health
services in needy areas.
4.
Building up a rational and scientific attitude towards health
9
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Pharmaccutical industries have successfully promoted "Pills, injec
tions, tonics" as health.
In rural India today, patients do not
feel satisfied by a treatment which does not include an injection,.
in Kerala the consumer demand fcr specialists and Catscan for any
ailment is reaching unbelievable pro-ortions.
Except for Kerala Sastra Sahitya Pari shad in Kerala, there are few
good large-scale efforts at demystifying medicine among the people.
The effort of specialised campaign on drug policy, anti-smoking,
amniocentosis has had some limited impact, both at the policy level,
and in educating the consumer.
Besides their functional differences, the health groups are divided
according to ideological grounds, according to being foreign or
locally funded, whether following traditional or modern medicine
and along many other groupings and sub-groupings.
Most of these
groups are dominated by a group of elite which meet, nationally or
internationally, express concern and share information but which
do not have any mechanism for transferring this information to either
the common people or social activists who might be able to use this
in their struggle.
To this elite, even Paramedics and village health
workers are mere functionaries and not agents of change.
There are hardly any efforts in forming the public opinion or mass
organisation like trade unions, people’s movement or political
bodies in generating a demend for a more appropriate and effective
health service.
10
uiven one aoove situation, oesiers tncir cupjcm. ci_ uxv x
the.health organ! satiop-s^need to fac^€he challenge of:
*
Joining in the broader struggle of social Justice with
other progressive forces.
*
Working on critical issues of socio-economic justice in
the areas where they operate.
*
Understanding of macro level health plan and working
towards a viable alternative health strategy.
*
Building up general awareness on rational and holistic health
care among the public at large so that an atmosphere can
be created for policy shift.
*
Helping to broaden the horioon of health functionaries on
development issues so that they can fulfill their public
responsibilities effectively.
This major shift of focus will put them in e position of conflict
with the state, medical establishment and medical industries.
Given
the background, origin and mandate of most health organisations,
how many of them will be able to stand up to it?
28.12.88
W
Community Health Cell
No 47/1 St Mark's Road
Bangalore 560 001
13 NOVEMBER 1989
Dear
Greetings from CHC!
The last meetino of the Community Health ^orum held at
Vidyadeep on 5th September 1'989 ended inconclusively.
It was our impression that every member present did
perceive some advantages in being associated in such
a Forum and was reluctant to let it fade away.
However
there were differing perceptions regarding the goals
and functioning of the Forum and the individuals' role
in it.
We think active pondering is needed by all of us to
evolve the characterstics of this 'orum that will
accommodate our varying needs and experiences.
ue are circulating a set of questions that may trigger
off such thinking.
Will you send back your replies by the
last week of November 1989.
The replies could become
the basis for concrete thinking on the future of the
Forum on our next forum meeting, which is most likely
to be held on 11th December 1989
Yours sincerely,
Drs Mani Kalliath and
Vanaja Ramprasad
ft
'
’OaSi'c l4-c<^llU
Co M 11 |G- 7__
Conr^cu^-iKc-a
CATHOLIC HOSPITAL ASSOCIATION OF INDIA
CONVENTION 1988
COMMUNITY NEEDS - OUR RESPONSES
Fr. Edwin M.J.
I’m asked to speak on community needs and our responses.
I should say the primary need of community health is community
itself.
^^We read and hear quite a lot about community health these days.
But strangely, cai-L—i-t—aafus-i-ng—o-r--pl-ti-a-b-le, we find that the proponents
& eZ
often enough §ail to speak about
nity health programme,
most important component of a commu
ie. communities themselves.
j'
It would seem la-bouxin-c—the obvious to—say. we need to have
communities to have community health.
/7w'>
But unfortunately,
ittr is not.s>e.
Building communities is yet to become an integral part of the
mental concept of a good many of our community health workers.
Let us begin with the question: Do—we have eernmurrirties?
We no cd-to-
What is a
community? Or: What are the characteristics that make a mass of people
into a community?
Community is a much-abused word. While conducting a course on
reporting for foreign press, Fr?\Michael Traber^W World Association
of Christian Communicators observed:
"People abroad don't get what
you mean by ’community' in India", communities for us mean castes too.'
Evidently, this is not\what we mean!
We
need to have consensus of what we mean by community when we
speak of community health.
Lei:-us list some—of— the—guiding-principles^
<2, ctf /!-&
<=>f c1. A community is not a crowd.
.
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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".
4.
A community means its memoers 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".
. .2.
2
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, consequently 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 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 participa
tion.
Only a fellow with a big voice can make himself heard in a big
village.
Small men feel too small to
speak up in bigger
structures.
A -community, with more than thirty families is unwieldy and
too\big for the small man to handle.
It.
A community that intends to have wider macro level in pact
ensures linkage with other similar communities through repres
entative 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 affecting health.
Do we have such communities?
Such structures or infrastructures,
that would make community health action more sustained and more parti
—/?
cipatory at grass-roots?
n. .. t,
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3 :-
Until we have such communities, whatever we call community health
programme may at the most be a rural extension programme and not real
community health action.
Community health is not just a programme for the people, it is
also something of the people and by the people.
They say examples speak louder. Let me share with you an attempt
where we try to integrate the community structure aspect,
infrastructure aspect,
or the
into community health action.
We call this project Basic Holistic Health Communities. Wha_t,we
envisage is a combination of the i^asic Christian Communities' concept
of Latin America and whaXwe read about Raigarh Ambigapur Health .
Association (Raha) .
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”/ Our first step here is to start organising basic communities of
thirty houses each. We have altogether 170 such basic communities now.
These communities are geographical,ensuring that nobody is left
out. This geographical aspect ensures also a permanent identity for
the communities. As long as the houses are in a given geographical
area the communities are also there. Even if for some reason or other-
some 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
oftener as the case may be. These meetings are either for prayer, or
for celebration, or for nonformal education, or for discussions on
problems affecting them, and so on.
Five representatives from each community make the representative
general body of the village. One representative from -ach community
makes the executive body of the village.
Representatives from the villages make the zonal representative
the general bbdy having a representative each from the commu
bodies,
nities, and executive committee having village representatives at the
ratio of one representative for five communities. What is discussed
below,
that is at grass root comm, lities,
reach 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 fee to spend on his own discretion upto Rs.50/-
for emergency expenses. When the president and the treasurer decide
together they can spend upto iis.100/-. The executive committee of the
village can spend upto ,is.500/-. The representative general body of the
village,
having five representatives each from the communities.
.. .4.
3
Until we have such communities,
whatever we call community health
programme may at the most be a rural extension programme and not real
community health action.
Community health is not just a programme for the people, it is
also something of the people and by the people.
Let me share with you an attempt
They say examples speak louder.
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.
Whai^we
envisage is a combination of the Basic Christian Communities' concept
of Latin America and what, we read about Ralgarh Ambigapur Health .
Association (Raha).
1-lc c hi ;
,
-
„
,
P ■ Kcpcs)-
■
,
T Our first step here is to start organising basic communities of
thirty houses each. We have altogether 170 such basic communities now.
These communities are geographical,ensuring that nobody is left
out. This geographical aspect ensures also a permanent identity for
the communities. As long as the houses are in a given geographical
area the communities are also there. Even if for some reason or other-
some 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
oftener as the case may be.
These meetings are either for prayer,
for celebration, or for nonformal education,
or
or for discussions on
problems affecting them, and so on.
Five representatives from each community make the representative
general body of the village. One representative from ach community
makes the executive body of the village.
Representatives from the villages make the zonal representative
the general bebdy having a representative each from the commu
bodies,
nities, and executive committee having village representatives at the
ratio of one representative for five communities. What is discussed
below,
that is at grass root comm-, nities,
reach 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 fee to spend on his own discretion upto Rs. 50/-
for emergency expenses. When the president and the treasurer decide
together they can spend upto Us.100/-. The executive committee of the
village can spend upto ,is.500/-. The representative general body of the
village,
having five representatives each from the communities,
.. .4.
?4
can spend upto 1,000/-.
If it is note than Js. 1,000/- the representative
general body of the village makes the decision and sends it for refere
ndum 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 anybody in any of these 170 communities to remember
the problem and the issue will come alive again.
t
,
1
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.
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 to
remain empowered.
This we do through various processes. One such programme is our
holistic health orientation camps in basic communities. This will be a
week long programme where trained volunteers help conduct health
discussion sessions in the basic communities with the help of a few
structured community-discussion exercises. Each community will be
encouraged to do also creative assimilation programmes: 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 to a wider audience the best of the cultural programmes produced
by these communities. This health camp normally will includes also an <
exhibition and also half-a-day or one-day seminars to various catego
ries of people with or without 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 basic communities. These discussion themes are structured in
such a way that they elicit participation of the community.
contains an initial activity related to the theme,
Each theme
questions to elicit
participation, a deepening process through the points given, questions
leading to community decision, and a concluding activity by way of a
song or so.
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 insurance 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
5.
-: 5
showed that the average amount was Rs.4,086/-. We will be able to
reduce this to just Rs.500/- with proper educational preparation and
involvement by the people. For this, we would need to transcend the allo
pathic boundaries and include other therapeutic systems including drug
less 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 care through zonal bodies and the referral
centres chosen by them....
h/
We feel the situation is'^ripe because (1) the diocese is going
all out to build basic communities, (2) we have already a network of
/
primary health care system through the Community Health Development
Programme of Kottar Social Service Society and (3) our Sisters running
hospitals in the diocese are actively involved in the programme and
are ready to make their hospitals available as referral centres.
/ Unfortunately,
even the example given is not yet a realized
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 reach only half way.
But we feel even that would be worth the efforts,
a step in the right direction,\/
as it would be
Because, besides the reasons given above,
initiate
h( T /
it will (1)
an on-going health communication effectively aimed at change,
(2) will
create an alternate structure for people's participation.
Let me speak a little about its efficacy as a communication
process.
Communication researchers tell us that the media by themselves
do not bring about major changes. To quote Joseph T. Klapper who
summarises the conclusions of the various researches conducted on the
efficacy of communications in his book "Effects of Mass Communications".
"Minor attitude change appears to be a more likely effect than conver
sion and a less likely effect than reinforcement". Media help actually
more to reinforce than to change.'
Various reasons have been adduced to explain this inefficacy
of the media.
One thing, people avoid messages that are uncomfortable, and
changes are uncomfortable! This makes people go through the various
filtering processes like selective exposure,
selective decision-making,
selective perception,
selective implementation etc.. and even if
they manage to implement there's the problem of congnitive dissonance,
the tension that follows major decisions that makes one revert to the
earlier position.
. . .6.
There are also quite a lot of pressures like those of culture,
opinion leadership and primary groups that militate against change.
Culture,
to begin with,
is the way people behave. Parts of any
culture is so interlinked that when you touch any part the whole thing
seems to shake, creating insecurities among the people and thus condi
tioning them against change.
People depend on the above-mentioned opinion-leaders as they
don't have either the leisure or the energy to come to conclusions by
themselves. The problem is that such opinion leaders as inspiring
security among the people are the last to accept a change.
Primary groups too exert pressure because people value the rela
tionships so much -chat they hesitate to go against the values cherished
by the groups.
Fortunately the communication pundits are offering a way out of
the problem that would with stand the filters and pressures mentioned
above. The solution: group media.
That is,
tion,
communication aimed at groups. For us,
health communica
through groups at discussion.
The interpersonal relationship in groups supplements for the
inadequacies of the media.
Well, communities don't go the full length in every aspect with
regard to the efficacy of small groups at discussion in effecting
changes. For examples, a smaller group can go faster and deeper into a
problem while a community of the size we envisage might take a little
more time.
But there are aspects where the communities have advantages that
outweigh those of the groups.
An advantage that a basic community shares with a group-at-discussion is the strength of interpersonal relationships.
An exclusive advantage of a basic community is that a community
creates an environment of new values much more easily than a group.
Someone compared a small discussion group to a hot kettle kept in an
air conditioned room.
The environment cools the enthusiasm.
Basic
community on the other hand increases the warmth of the entire room.
Another is that, unlike a small group, it has better chances of
effecting permanent alternate structures.
Permanent structures are a requirement for sustained action.
When the leftist revolution broke out in the sixties in Paris, a
politician cooly remarked:
"Revolution? We don't bother.
But we will
be concerned if they create an alternate structure". Revolution will
fizzle away, but structures will remain.
. . .7.
7~:-
This has also political over tones as health issue is political
too. We may be able to transcend the present democratic system where
the big throats with big money manage to reach out to the length and
breadth of big constituencies and eventually represent the interests
of the big.
Religion wise,
too, these basic holistic health communities
could gradually help to bring about grass-root interreligious dialogue
and joint action on the issues of the Kingdom.
Last but not least, a good many of our dedicated personnel who
apply for funds to build hospitals to serve the poor and,
just forced
by the sheer necessity to fnaintain the hospital and the staff, end up
serving the rich, will now be able to serve the poor a little more as
people themselves will be maintaining these items.
Well,
these are some of the needs of community health.
Our response?
H |G-3
Role of Hospitals in
Community Health Care
Dr S Joseph MO
Medical Superintendent
MGDM Hospital. Kangazha
Secretary National Voluntary Health Association of India.
at:
(Presented at the convention; with the help of
visuals to substantiate the steady progress of
different stages of growth' in the quest to attain the
goal of need/value based and relevant Health Care
— From hospital care to Health Care)
Status of the Hospital
150 bedded hospital offering high tech curative
services attracting patients from surrounding towns.
Problem
The Hospital infact was an island of urban high tech
medical care in a thoroughly rural setting without
real relevance to the rural population that it really
sought to serve; many, if not most patients came
from the surrounding towns.
^Ls I am neither an expert in Community Health nor
a person dedicating full time to community health
work, insleacLof-preserting-concepts-and-logistics
relating to community health, I shall share our own
experience over the past 22 years of working in a
rural community hospital in central Kerala. During
this period we have been an integral part of the life,
growth and diversification of the programmes of the
M.G.D.M. Hospital at Kangazha.
Solution
To innovate medical programmes relevant to the
health needs of the rural people.
Phase I — High Technology Headstart
Phase II — Hospital Based Community
Extension work
The M.G.D.M. Hospital was founded by the Late
Shri P. Gee-Varghese whose vision, benevolence
and conviction, that man is only a custodian of
God's resources, led to the founding of this
institution. His goal was to bring the benefit of
modern medical care to rural India and thus he
chose the remote location of Kangazha, where no
health facility existed. The programme started as a
hwayside dispensary and then moved on to the
"location where the institution now stands. In late
1967, four postgraduate doctors, two doctor
couples, one being us, joind Shri P. Gee-Varghese
in this endeavour. The hospital was then being
manned by one doctor who continues to be on the
team, presently as Chief of Opthalmology.
For the next five years several ideas were
considered within the limits of the constraints,
aimed at reaching out to the rural marginalised
section of the community. Hence hospital based
community extension work was started in the form
of village level general clinics and mother and child
clinics, thus bringing the services of doctors/
specialists to those who could ill afford such
services. To this was added community free eye
camps with free follow up surgery in the hospital.
Status of the hospital
200 bedded speciality referral hospital.
Problem
Community extension work had limited coverage of
the sick, who are poor No programme for 'Health
Promotion' of the masses, for enabling themselves
to remain healthy. Causes of illhealth appeared
closely linked to poverty and backwardness.
Between us we had the skills to carry out major
cardiothoracic/general surgical work and offer the
infrastructural support. In the space of 3 years the
hospital grew to be a 150 bedded one, offering by
then prevailing standards, high techology services
like closed heart surgery, lung and oesophagus
surgery, endoscopy etc. At the end of three years
when one doctor couple moved on to another
mission hospital, the occasion arose for an
introspection and the following findings were arrived
Solution
To initiate a study of the true health problems of the
community and to offer comprehensive community
based health care.
29
Phase III — Community based services
different agencies, both religious and secular in
implementing a Preservation of Eye Sight
Programme, much in line with the National
Programme for prevention of blindness. The
strategy was to work through trained village level
health workers, supported by field level and
institutional backup supervisory/specialists services.
With a 6 month pilot study of the community it
became clear that poverty was the cause of much
illhealth and an integrated development approach
was necessary to promote health in the community.
In January 1978 antedating the Alma Ata
declaration, a comprehensive integrated oclnmunity
based health programme was launched in six
villages covering 500 families in each village, based
entirely on socio-economic backwardness and
cutting across all barriers of religion, caste and
creed. Several economic upliftment programmes
were launched in areas of agricultural promotion.
availability of credit, veterinary inputs, and seed
money scheme etc besides hygiene, environmental
sanitation, health education, mother and child care,
tuberculosis control programme, basic curative
service etc. This was achieved through community
participation, utilising a three tier approach. School
health programme was launched covering 34
schools. This model of school health programme
won wide acceptance as a low cost model, which
harnessed the obtaining resources of teachers/
pupils as facilitators.
Status of hospital
250 bedded referral hospital offering all speciality
services except the superspecialities.
Problems
Though the strategy was cost effective much effort
required to be expended on developmental inputs
which became increasingly available indigenously
over the years. The need to integrate the
programmes offering preventive, promotive, educa
tive. curative and rehabilitative (community based)
was felt Much wider programme coverage was
required to increase cost efficiency.
Solution
To launch a complete HFA programme including all
dimensions, as stated in the Alma Ata declaration.
This integrated health and development approach
stood fully endorsed by the Alma Ata declaration
which was published by end of 1978.
Phase V — Full ‘HFA’ coverage
A full HFA programme was launched in 1987
networking with well established lead agencies such
as the Malanadu Development Society. Peermade
Development Society besides Bethany Perunad,
Young Workers Movement at Pulinkunnu etc This
project is entitled PRACHAR (Programme for Rural
Awareness in Community Health. And Rehabilitation)
Status of the hospital
225 bedded speciality hospital with update of
technology to cover all basic specialities.
Problem
Though the validity of the community based
participatory integrated health and development
approach was established, the impact of this was
limited to a small population. The dimension of
rehabilitation in the primary health care approach of
health for all (HFA) remained largely untackled.
except for monetory assistance to a few physically
handicapped for establishing small trade.
It presently covers a population of 1,50.000 and the
community based rehabilitation is achieved through
five stages of intervention As most workers in the
health field are still none too familiar with the
concept of CBR. we shall consider this particular
input in greater detail
CBR is carried out in 5
Stages
Solution
Instead of a direct exclusively institutional
programme (going it alone), to Network with like
minded health/developmental agencies in the field,
so that benefit reached a far greater population and
would avoid duplication while reducing costs
Stage — I
Prevention of disability through Vitamin A
prophylaxis, nutrition education, antenatal care.
primary eye/ear care etc and identification of the
physical, hearing, visual and mentally handicapped.
through the services of trained village level workers.
working in their own communities. These workers
were appropriately trained by Protect PRACHAR
Phase IV — Networking
Thus emerged the concept of networking with ctner
agencies to achieve greater cost effectiveness.
cooperation between voluntary agencies and to
relate to Govt sponsored National Health Policy
Programmes.
The
Inst
networking
was established
with
Stage — II
Assessment of the nature, degree of disability
through trained CBR supervisors and specialists in
the four disciplines related to disability and planning
the rehabilitation course, at field level clinics to be
organised in neatly seventy locations
13
30
Stage — III
Those requiring institutional curative/corrective
services are given free care in MGDM hospital.
Besides surgical correction, artificial aid, hearing
aids, spectacles, low vision aids, speech therapy,
psychotherapy and physiotherapy are offered in the
institution Those requiring permanent institutional
services on account of gross multiple handicap are
facilitated to achieve this at established centres for
the handicapped
in the past year. 573 handicapped people were
v.-ntified. who are presently receiving rehabilitative
services at different stages of the process.
Over the past two decades, there was a
proportionate growth of the vertical dimension
curative care programme alongside the horizontal
community health programme thus achieving a
balanced growth without prejudice to either. While
the curative care could be construed to be one
where 'Mohammad came to the mountain’, in the
community level services 'Mountain went to
Mohammed'. It was not a question of either curative
or community based services, but was both and
other ancillary intersectoral services
largely
mobilising available resources, to achieve the larger
goal of 'Health for Al!'.
Stage — IV
Reorientation of the disabled in the community
enabling the person to achieve daily living
skills/vocational rehabilitation, mobility training,
mobilising family/community resources. The pro
cess is facilitated by village level workers and
trained CBR supervisors. For economic rehabilita
tion locally available monitoring resources are fully
mobilised.
These efforts can at best be judged as attempts by a
traditional hospital structure to take on its share of
responsibility in achieving the National Health
Policy goals, in promoting the cause of 'Health for
AH', and above all in attempting to realise in some
measure our preferential option for the marginalized
section of the community in our Christian
stewardship mandate. Undoubtedly, many other
possible modes of contributing to these goals
remain unexplored, but suffice it to say that if all of
us as hospitals do pursue the mandate seriously,
even though, HFA may not be attained by 2000 AD.
in the rest of the country, there is indeed a bright
prospect that the goal could be realised in the State
of Kerala, where voluntary hospitals abound
Stage — V
The disabled are sought to be fully integrated and
made self reliant with the active participation of the
family members and local community.
The expertise of hospital specialists is thus utilised
to bring relief to the handicapped who cannot
normally afford these services. Specially trained
supervisory staff carry out the community based
rehabilitation of the handicapped aimed at
integrating them fully with the community. The
programme also envisaged a comprehensive
monitoring and evaluation input, thus preparing the
ground for future fuller cooperation with the
Government sources, hopefully working towards an
equal partnership with the government sharing all
resources. This would be necessary to achieve self
reliance and non-dependance on outside funds as
an intermediary goal
Should we rise to the occasion, we may well hope to
witness the dawn of a new era where 'Health' with
Equity and Justice will no more remain an elusive
dream.
31
C O tv\ \ 1 I £ . (-1
^7
ORGANIZING PEOPLE for health
- Problems and Contradictions.
Anant R S
(This reflection is based on the experience of work in a
health-education-concientization oroject in a few rather
remote, backward villages near Pune, and on the debates,
discussions in the Medico-Eriend-Circle)
General Perspective on Health-work
Most of/the major determinants of the health status of a
population - food, water,
sanitation,
cultural relations
are far beyond the control of health
workers.
shelter,
work-environment,
But Medicos can, with the helo of the community,
organise preventive and therapeutic (symptomatic or curative)
services, can do health-education and advise the planners on
health-imolications of different socio-economic interventions.
These medical interventions are very valuable to orevent
certain deaths and diseases,
to relieve human su-ffering. But
they have only a marginal role in improving the overall
e
health-status of the population.
For example,
infant and
child mortality can be reduced with immunizations and ORT...etc.
but no health-programme has abolished malnourishment in
children
of a nation.
The department of health aiming to improve the health
of the people throuoh so many national disease control orograms
and now through the programme of ’Health for All by 2000 A.D1
is therefore a utopian, misleading idea.
thorough going socio-economic change,
As a oart of a
medi'al 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.,0" would be delivered by the health-ministry/
health projects by the NGOs,
though very attractive, is a
2
2
misleading one.
All
that health-people can hooe to achieve is
"Health-care for An by 2000 A.D".
This is not sterile semantics.
There is a strong reason
and a context^or making this distinction.
spread technocratic,
There is a wide
and managerial illusion that improvement
in health of a nation,
whidn is in reality, prrimarily a function
of socio-economic development,
can be achieved with technolo
gical, managerial interventions.
Lay people are made to believe
that the beneficient state through its Heal th-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,
ment,
unemploy
Other basic
inflation, drought and ecological disaster.
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 Bor 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'
work'
can,
but of doing some
in fact, make very valuable, basic work.
'basic-
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.
technical,
This is not a purely
There are many sociological,
practical issues to be resolved.
ideological,
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.
3
3
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-work alone 7
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
The problem of ooverty and of
people around health issues.
paucity of basic amenities is so overwhelming that hural 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 All'—unless the oeople them
selves actively participate in the decision making and
implementation.
Even if it is not possible to build an
organisation of rural poor exclusively on health, health
should be one of the activities of a group trying to organise
the rural poor for.
3u3tice 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
.... A
4
village Eommunity Develooment 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,
diarrhoea, conjunctivitis, scabies, wounds,
etc.,
malaria,
skin infections
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 peoole.
Rural poor 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-educotion
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:
5
5
Our VHUs have a much greater support from the community
than iahat 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 of time for this work;
These tIHUs
attend frequent meetings,
participate in other programs of ths organisation, trabel
to and camp at other villages.
All this is possible because
of/a support from the community.
The honorarium of a mere
fe.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 theraoi-
sts and that of the compoundsr-turned-doctor, has been
considerably curtailed.
'injection-culture'.
Some dent has been made in the
People have collectively approached the
health authorities to complain about some specific grievances
about delivery of health services.
about a case of injection-oilsy;
(for example,
representations
a florcha
aoout 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
e
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 meetins 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 attemots
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 extent
that oeople start influencing the health services and policies
in accordance with their own needs.
a.
There is a tremendous gan 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,
a tendency of not paying for this self-help,
a period of/time,
there is
even though over
people have realised that these tablets are
ag/effective 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 domina'nt-cul t ure .
b.
Many people as yet
to see the work done by VHU§,
as a kind of social work done by the representatives of the
people.
Many feel that these UHIJs 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 meet inn;
help and advice is sought;
a call for a meeting,
even for a Morcha is positively tesponded to.
their
Shibir or
But still the
idea of a movement has not taken real roots.
c.
The Government health structure has cooperated by
providing medicines,
sending their health personnel at request
7
7
etc.
In one remote area,
a feu of our illiterate VHWs were
incorporated as Government’s "Village Health Guides" (because
the PHC doctor was very much impressed by their knowledge),
even though the minimum educational qualification required
for this oost is 0th standard.
(This mutual coooeration
helps the health authorities to fulfill their targets for
remote areas)
But the Government authorities (all males)
dislike the questioning attitude,
women VHUs.
" rude manners" of our
When our VHWs asked a ^HC doctor,
about the budget of the PHC,
in a meeting
and the expenditure under diff
erent heads, he got infuriated.
Relations were also strained
because a florcha was organised to demand justice in case of
an injection-palsy in a boy after an injection in his arm.
Any attempt to take democracy seriously, to know and to
question some of the practices in the PHC are frowned upon.
The 'beneficient authority'
obliges by cooperating as long
as its hegemony is not threatned.
"People's oarticipation"
is a nice slogan,
but when it is taken seriously in a
critical fashion,
such attempts are despised.
This in
turn dempens the already low initiative of the oeople for
assessing their own right.
Such
of
are the problems and contradictions in the -process
'organising people for health care'.
Both from a
theoretical as well as practical^view point,
there is no
that without the collective participation,
control by
the people in fulfilling their health care needs,
the health
delivery system will not really serve the people,
But the
doubt,
process is a very complex,
slow and difficult one.
It is
easier to talk about nice things, but very difficult to achieve
them.
A lot of practical and analytical work has to be done
before we can confidently talk about a strategy of "Health
Care by the peoole" or under the control of the people
<T_. o
h
IG' S'
(A note to Health Hcticn Team in Secunderabad)
Health Action
July 1989
Theme: Community Health In India :
1.
f/new vision of Health Care
This issue will consist of a longish Lead article put
together by the CHC team in Bangalore which explores various
aspects of Community Health in India including the following:
a.
Health Development in India
b.
Taking Stock of this development
c.
Health scene in 80s
d.
Alternative Community Health Project phenomena
e.
Recognising the new paradigm
f.
Community Health and Primary Health Care
i.
o
Vs PHC ii) Role of Hospitals iii) Movement dimension
g.
Community Health - Issue Raising
h.
Community Health — Training initiatives
i.
Community Health - Research Centres
j.
Building the new Health paradigm
The article includes a series of box items or quotations from
the diverse materials that have emerged in this process.
Since
the Lead article is a longish one it could be interspersed
by shorter contributions mentioned in (2)
2.
In response to the Editor's
from .six
letter we received contributions
resource people which have been edited for issue.
a.
Alok Mukhopadhyay - VHAI
b.
Fr Edwin - Kerala
c.
Dara Amar - St John's
d.
Jacob Cherian - Ambilikkai
e.
Anant Phadke - mfc
2
2
f.
Abhay Bang - SEARCH
An article by S Joseph in the CHAI Hosoital Convention
Proceedings on the same theme (refer page 29-31 of proceedings)
can also be used, a copy of which is encloseo.
3.
The CHC is also putting together the following as a
.Community Health Resources inventory
a.
50 titles from the Community Health ferment
b.
A list of journals -and bulletins
c.
Some profiles of health projects
d.
An address list of all projects/initiatives mentioned
0
in the issue.
e.
A reference list for the lead article
(Throughout the lead article the source is shown as the
name of the author or group with a number in the bracket
which pertains to number in reference list)
4.
For visuals to animate the issue we suggest that one could
take liberally from the many publications mentioned in the
list givino due credit, e.g
i. Cartoons in mfc anthologies (11,
ii.
13 of title list)
12,
Photographs and diagrams from Anubhav series (Ford Foundation)
(46 of list)
(31 of list)
iii.
Line drawings from 'Taking Sides'
iv.
UHAI- Health Worker Training Kit and Better Care Series
(14 and 19 of list)
v.
5.
CHAI Publications (30 and 32 of list)
For Cover page
^e suggest a collage made out of the most striking of the
title list - striking in photography or title,
series intersoersed with mfc, UHAI, CHAI,
e.g Anubhav
ISI, Lok Paksh, CSA?
CSE Report Publications etc.
. . . .3
3
6.
To symbolise diversity
and the Indian experience ue suggest
maos of India with stars in locations of orojects,
centres,
research centres,
training
issue raising groups etc.
Either
one or two larg’e maps in the text or small ones throughout.
7.
fl set of additional ’fillers'
items have also been included.
They could he introduced if space is available somewhere along
the line.
8.
Ue have indicated with lines only some ideas for box items
or underlining, making bold or italics etc.
However tffe
Health Action Team ’in Secunderabad are more experienced and
better gualified to do this effectively.
Ue leave this aspect
completely to their own judgement since their skill is well
exemplified in previous issues.
CHC teaiuH
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^7
Community Health
A Resource Centre Directory
A to Z
(This inclunes 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, Neu Delhi 110 016.
3.
Action Research in Community Health (ARCH)
At i P.O Mangrol,oVia Rajpipla, Dist Bharuch,
4.
Gujarat 393 150
Arogya Vikasa
Keshava Shilpa, Kempegowda Nagar,
Behind Uma Theatre,
Bangalore 560 019.
5.
Action For Welfare & Awakening in Rural Environment (A'JA.RE)
5-9-24/78, Lake Hill Road Hyderabad 500 463.
6.
Banwasi Seva Ashram
Gov.indpur, Dist Mirzapur, Uttar Pradesh
z7. Bodokhoni
C/o Fr Chako, Diocese of Behranpur, Ganjam District,
Z,
Orissa
8. Catholic Hospital Association of India (CHA I)
Post Box 2126,
157/6, Staff Road,
Secuncjerapa(j 500 003.
9. Christian Medical Association of India (CMAI)
Smruti Theatre Compound, Mount Road Extension,
10.
Christian Fellow Community Health Centre (CFCH)
Santhipuram,
11.
Anna District,
Community Health Cell
No 47/1,
12.
Ambilikkai 624 612, Tamilnadu.
(CHC)
St Mark's Road,
Bangalore 560 001.
Centre for Social Action (CSA)
Gundapoa Block,
13.
Nagpur 440 001
64, Pemme Gowda Road,
Bancalore 560 006.
Comprehensive Labour Welfare Scheme of United Planters'
Association of Southern India (CL MS-UPASI)
Glenview, Coonoor 643 101, Nilgiris, Tamilnadu
14.
Child in Need Institute (C INI)
Vill '-’aulatpur, P.O. Amgachi, Via Doka, 24 Paragams South,
West Bengal 743 512
15.
Centre for Science 4 Environment (CSE)
B07 Vishal Bhavan, 95 Nehru Place, New Delhi
110 019.
2
2
16.
CSI Mi- istry of Healing
10 Sambandam Street, T.Nagar, Madras 600 017
17.
Deenabandu
Training and Service in Community Health A Development
R K PetT631 303, Tamilnadu.
18.
Foundation For Research in Community Health (FRCH)
84-A, R G Thandani Marg, Sea Face Corner, Worli Bombay 400018
19.
Indian Council of Medical Research (ICMR)
Ansari Nagar, Post Box 4508, Neu Delhi 110 029
o
20.
Indian Council of Social Sciences Research (IC6SR)
IlPft Hostel, Indraprastha Estate, New Delhi 110 002
21.
Indian Institute of Education
128/2 Karve Road, Kothrud, Pune 411 029
22.
Institute of Health Management (IHMP)
Pachod, Dist Aurangabad 431
23.
121, Maharashtra
International Nursing Services Association,
India (INSA)
No 2 Benson Road, Benson Town, Bangalore 560 046
24.
Indian Social Institute,
(iSl)
10 Institutional Area, Lodi Road, New Delhi 110 003
25.
Jawaharlal Nehru University (JNU)
Centre for Social Medicine & Community Health
New Delhi 110 057
26.
St John's Medical College & Hospital
(SJMC)
Sarjapur Road, Bangalore 560 034.
27.
K.E.M. Hospital
Sardar Mudliar Road, Rasta Peth, Pune 411 011
Kottar
28.
Social Service Society (KSSS)
Post Box 17,
29.
Nagercoil 629 001, Kanyakumari District.
Kerala Sashtra Sahitya Parishad(KSSP)
Parishad Bhavan, Chirakulam Road, Trivandrum 695 001
30.
.
Lokvidyan Sanghatana
759/97 D, Santibhuban, Prabhat Road Lane No 2,
# 30 a (see
Deccan Gymkhana, Pune 411 004
Page 3) 31. Mallur Health Cooperative
Siddhalaghatta Taluk, Mallur, Kolar District,
32.
Karnataka
Medicare
Kasturba Medical College, Manipal, Karnataka
33.
Medico Friend Circle (MFC)
Village Deugarh (Deolia), Via Partabhgrah, Dist Chittorgarh
Rajasthan 312 621
. . . .3
3
34.
MGDM Hospital
Devagiri PO, Kangazha, Kottayam 686 555, Kerala
35.
Ministry of Health and Family Welfare (MHFW)
Government of India, Nirman Bhavan,
36.
New Delhi
National Institute of Health and Family Welfare (NIHFW)
New Mehrauli Road, New Delhi 110 067
37.
The Niligiri Adivasi Welfare Association (NAWA)
Fair Glen Annexe, Kota Hall Road, Kotagiri, Nilgiris 643 217,
38.
The National Institute of Mental Health & Neurosciences (NIMHANS)
Hosur Road,
39.
T.N
Bangalore 560 029.
Padhar Hospital Cpmmunity Health Project
Betul Dist. Madhya Pradesh
40.
Rural Unit for Health and Social Affairs (RUHSA)
RUHSA Campus.P.O, Christian Medical College & Hcgiital,
North ^rcot District 632 209, Tamilnadu
41.
Raigarh Ambikapur Health Association (RAH4)
C/o Bishop's House, P.O Kunkuri, Raigarh Dt. Madhya Pradesh 496225
42.
Society for Education Welfare and Action_Rurai (SEWA)
Ohagadia 393 110, Disc Bharuch, Gujarat
43.
The Social Work and Research Centre (SURC)
Tilonia, Ajmer District, Rajasthan 305 812
44.
Socialist Health Collective (SHC)
Bombay
45.
Streehitakarini
Dac|ar, Bombay
46.
Vivekananda Girijana Kalyana Kendra (VGKK)
8 R Hills 571 313, ^ia Chamrajanaoar, Mysore Dt.
47.
Voluntary Health SeTuices (VHS)
V.H.S Campus, Adyar, Madras 600 020
48.
Voluntary Health Association of India (VHAI)
40,
Institutional Hrea,
South of IIT, New Delhi 110 016
# 30 a.Lok Paksh
Post Box 10517, Neu Deihi 110 067
45 a.Society for Education, Awarenes and Research in Communify
Health (SEARCH)
At P.O Gadchiroli, Maharashtra 442 605
Journals/Bulletins
1.
Health for the Millions
Voluntary Health Association of India,
40,
2.
Institutional Area, South of III,
Neu Delhi 110 016
medico friend circle bulletin
MGIMS,
Block 'B', Vivekanand Colony, Sevaqram, Warriha 442 001,
Maharashtra
3.
Socialist Health Review (Now known as Radical Journal of Health)
19,
June Blossom Society, 60 A, Pali Road,
Bandra (^est)
Bombay 400 050
4.
Contact
Christian M'edical Commission, World Council of Churches,
150,
5.
route de
1211 Geneva 20,
Switzerland
FUTURE
UNICEF,
6.
erney,
73 Lodi Estate, Neu Delhi 110 003
LINK (ACHAN Newsletter)
Asian Community Health Action Network,
Madras 600 004
61 Dr Radhakrishnan Road
\4 I b • 8
c
A
A CO^.mUMTV HEALTH RESOURCE INVENTORY
(50 titles from the Indian experience)
The 70s and 80s have seen an 'explosion' of
'Community Health'
materials on the Indian scene,
with the increasing wealth of
grass-roots field experience.
Most of these materials are
unfortunately still in English and inspite of the presence
of large networks of NGO health initiators these are still
not as widely known or as widely read as they should be,
A Community Health Cell,
tentative Bibliography has identi
fied over 150 such materials.
A shorter version with sources
is given here highlighting 50 of them.
Titles and Source
A-Indian Council of Medical Research,
Nevi Delhi
1.
Alternative Approaches to Health Care,
2.
Evaluation of Primary Health Care Programmes,
3.
Approoriate Technology for Primary Health Care,
B-Ministry of Health and Family Welfare,
1976
1980
1981
New Delhi
4.
Health Services and Medical Education (Srivastave Report)
5.
Manual for Community Health Worker,
6.
Manual for Health Worker - Female Vol
7.
Manual for Health Worker - Male
1975
197B
I&II,
1979
Vol I&II,
1979
8.
Manual for Health Assistants (Male & Female)
1980
9.
Primary Health Centre Training Guides I—IV 1960
10.
Handbook for the delivery care to mothers and
children in a community Development Block (Oxford University
,.
r~ ■
Press)
,
C -Medico i-nend Circle
11.
1980
In Search of Diagnosis - Analysis of Present system
of Health Care
1977
12.
Health Care - Which way to go?
1982
13.
Health and Medicine - Under the Lens
1985
2
2
0- Voluntary Health Association of India, Neu Delhi
14 . Teaching Village Health Workers - a guide to the
process
1978
15.
Manual for Child Nutrition in Rural India
1978
16.
Where there is not doctor (revised Indian edition)
1979
17.
The National Health Policy
18.
A Manual of Learning exercises for use in health
training programmes in India
19.
1983
Better Care Series (8 problems)
£- Indian Social Institute,
Neu Delhi
20.
Moving Closer to rural poor
1979
21.
Health i Culture in a South Indian village
1979
22.
People's Participation in Development Aporoaches to non formal education
23.
1980
Changing health beliefs and practices in rural
T amilnadu
1981
24.
Learning from the rural poor - experience of MOTT
25.
Development uith people - experiments uith
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
i
i ssue)
1986
31.
Taking sides - the choices before the health worker 1986
32.
Trainers manual for training community level
workers
1987
3
3
H- Foundation for Research in Community Health,
33.
Bombay
Community Health Projects in Maharashtra - an
evaluationreport
34.
19 S 1
Health Status of the Indian People
I- National Institute of Mental Health and Neurosciences, Bangalore
Manual of Mental Health for Medical Officers
1985
■36. Manual of Mental Health for Multipurcose workers
1985
35.
3- National Institute of Health & Family Uelf '.re,
Neu Delhi
37.
Evaluation of CHU Seheme - a collaborative study
38.
Management Training for Primary Health ^are.
K- Indian Council of Social Sciences Research,
39.
New Delhi
An Alternate system of health care services in
India - some proposals
1977
L- Centre for Social Action, Bangalore
40.
Health Care in India
19B3
41.
Rakku's Story
1984
M- Institute of Education,
42.
Pune
Health for All - an alternative strategy
(ICMR/ICSSR Study Group)
1981
N- Centre for Science and Environment,
43.
The State of India's Environment - the
second Citizens'
1964-85
report
0- Kerala Sashtra Sahitya Parishad,
44.
Neu Delhi
Tribandrum
1984
Science as Social Action
P- Community Health Cell, Bangalore
45.
Community Health: The search for an alternative
process (Draft report)
Q- Ford Foundation,
46.
1987
New Delhi
Anubhav ■3e r i e s :
Experiences in Community Health
(12 project reports available)
1987
R- Some Foreign Publications (with Indian case studies)
47.
Health by the People (UHD,
48.
Practising Health for All (Oxford University
Press)
Geneva)
1975
1983
49.
Intersectoral linkages and health development
('JHO, Geneva)1984
50.
Disabled Village Children - A guide for community
health workers, rehabilitation workers and
families (Hesperian Foundation, U.S.A)
1987
C.o <ia
H
IR. A
h
Participatory Action Research Leads to People's Movement
Drs.Abhay and Rani Bang,
•SEARCH', Gadchiroli.
A malaria supervisor was the first patient of alcohol
addiction that we encountered in Gadchiroli when we started
working in this remote and tribal district
of Maharashtra
o
in 1986.
It took 6 months of counselling,
3 hospitalisa
tions and a bofcjt of vomiting of blood to weab him away
from liquor addiction.
A teacher was our next patient.
He could be de-addicted only when he was convinced that he
had developed cirrhosis of liver and would die within months
if he continued with liquor.
In first 2 years, we could de-addict about twenty
patients each year by the typical counsel1inq-hospitelisation
approach.
And by our rough estimate there were twenty
thousand liquor addicts in the district.
The situation
was hopeless.
But unfortunately the educated people didn't seem to
share our concern about this problem.
so what?," was their response,
Men
*
always drink,
has it our Gandhian fad
which made us look at the liquor as a social problem, « p
we wonderedy
mentally shelved the problem for a while.
In the third year of our work, we had organised a
series of camps of rural women and youth.
One topic they
all wanted to discuss was the problem of liquor.
homen opened up to describe how their own lives
Rural
were
ruined by the liquor addiction of the males - husband,
brother,
realised.
son son in law '.
Every woman had sufferred,
they
The topic became so popular that when it was
not on the time table of a camp, woman complained that
they were deprived of this topic while the other woman in
the earlier camps had ^Opportunity to discuss it '.
An extra
session in the night from 1C PM to 2 AM had to be arranged.
Everybody was not for liquor, we realised.
krt.
At least half
J
the populationywas against it.
Youth from 2 villages said they wanted to do something
. . 2
2
about this./an experiment,
they organised a social ban on
liquor in their villages.
The young boys would patrol the
roads in the night.
in the village.
They wouldn't allow a bottle to enter
Those found drunk were fined,
we all
shared the pleasant surprise that this approach worked ’.
when this experience was described in a meeting of all
tribal activists and voluntary organisations of the district
a collective decision to launch a mass campaign was taken.
But did we have a concrete case ;
A small croup was entrusted with the responsibility
of collecting facts about? liquor problem in the district.
A survey of 104 villages was organised with the help of
village health workers.
information from the excise and
prohibition department was collected with the help of a
group of teachers,
what were
the findings of this crude
research ?
1)
- About 1 lakh males in the district frequently drank,
20,000 were addicted and about 1000 died each year
due to alcoholism.
2)
- The Government had issued licenses to 57 shops to sell
liquor and permits to 2000 persons to buy and possess
up to 12 bottles of liquor at a time.
In effect these
2000 permit holders were acting as subagents to sell
the liquor in the villages.
3)
- Total annual sale of liquor in the district was of
70 million rupees, exactly equalling the total annual
development plan of the Government for the development
of this most backward district in the state.
4)
- This was against the guidelines of the cential govern
ment which clearly stated^nd sale of liquor should be
allowede in the tribal areas.
3 elements had come together
1)
Collective realisation of a common problem which
caused tremendous sofferrinc to all.
2)
Concrete facts cack up this realisation.
3)
Common will and organisation to act. /'See how the
chemical s reaction was triggered.
'
Within months this became a mass movement in the
district.
Youth and women formed ‘mandals’
and passed resolutions to ban liquor.
in their villaoes
Taluka level confer
. . 3
3
ences against liquor were organised at 4 places.
Finally
a district level conference against the liquor was planned.
3000 delegates from 150 villages gathered, more than half
of them being women, who described their sufferrings from
liquor and how they tried to counter this by collective
action.
2 MlAs from the area, the district collector.
Police Chief and the
to people's mood.
excise officer attended and e listened
People even stood yp to describe how
the police offerred protection to the liquor venders and
harrassed them when they opposed illicit liquor.
Department
had to take punitive action QJ^these police.
A district level Darumukti Sangathan
*
Libaration from liquor)
(organisation for
was formed and resolutions passed
demanding closure of all the licensed liquor shops in the
district.
People took responsibility to see that the illicit
liquor wouldn't be sold
in their villages.
And people really did it|
A community ban on the sale
or consumption of liquor has been
villages.
- • effectively put in 200
Women of Chandala Tola,
the drunk men overnight and took
procession next day.
the liquor was
locked
them out in a public
People from the surrounding villages
accompangied us to a village
defying this movement,
a tribal village,
called Ranbhumi which was
and warned the village of bycot unless
A
banned in Ranbhumi too.
errant village joined the movement.
been completely weeded out.
Next day the
Illicit liquor has
But what about the sale of
licensed 1? liquor ?
i~.
delegation from the district has twice met Chief
Minister demanding closure of the licensed liquor
shops.
The people's pressure on this issue is so strong that all
3 MlAs from the district have
represented this demand.
The proposal is before the cabinet now ’.
Gadchiroli is
knocking on the door’s of the state government in Bombay,
1000 Km away from it.
The expression of people's will and power in Gadchiroli
if e
on the issue of liquor has oiven lead to many orcanisations
4
4
The programme has been taken up at state
in Maharashtra.
level by Shetkari
Sancathana (Farmers' Organisation)
*hat does the whole story bring out for us
fantastic result is not the main point.
was identified,
The
The way the problem
researched and emergence of mass action
from it - the participatory process of action and research
is the key. y/Wo amount of hospital based deaddiction or
individual counselling would have touched even the fringe
of the problem,
even though it would have provided us a
lifelong work.
Exotic medical research would have produced
findings locked in the files and journals.
hands with people,
But by joining
we could see the issue develop in to
a people's w-i-th—people; ~we'~could—see—the—issue—develop
in. to a—pcoplo! movement against liquor. Experiences
like this unfold the deeper meaning of the famous
Chinese
(TorA H
GO M MU M ITy
I 6.1 O
X
CUnnll VE CAriE Tv HEAfjTu CAlcS ~_k_JOJdtTnY
5-7
* Dr. Thomas Abraham
** Dr. S. Joseph
M.G.D.M. Hospital, Devagiri,
Kangazha, Kott ay am, Keral a.
The M.G.D.-i. Hospital was founded in 1964 by Sri. P.
Geevarwnese, whose benevolence and conviction that man is only
a custodian of God's money, made this venture possible.
He
envisaged the goal of cringing tne Benefit of modern medicine
to tne rural population as an expression of God's love and
concern specially for tne underprivileged wno areAcreated in
lis image.
In a snort space of three years, facilitated by a team
or medical specialists,the hospital made a giant strides in
to.-velo; iny itself into a 100 beded referral hospital, where
closed neart, l.n.
and other major surgical proc..cures were
undertaken witn _ood results.
At this point an occasion for
introspection arose about the future direction of the hospital
programme and tne goals and objectives it strove to serve.
Founded for bringing medical relief to the backward rural
population, it was realised that the institution on account of
its nign teen services was attracting mostly patients from
the town around where sucn services
ere illavexlable tnen.
it w.'s reckoned tnat institution had in fact become a satellite
uro tn uoe.ic-l facility located in
tu/orou_ .;Ly rur-L setting,
with little relevance to tne people it primarily sought to
serve.
Looking outwards
Critical appraisal of tne real health needs of the rural
population :’.rouxtd brought nome the message tnat to serve
health needs of tne people a significant reorientation and
2/
reprioritisation of the programme mandate was necessary.
Cons e uently a small beginning was mr.de in tne form of commu
nity extension medical work throu. n mother ana child clinics,
i:?jnunis”.ition programme and nutrition supplementation.
Constraints- of material resources was a significant limita
tion for tne programmes until tne institution was brought
under tne aegis of tx^e i-lalanxara Orthodox Syrian Church, to
whicn it now belongs.
In tne next pnase, free eye camps ana follow up work
al on
witn otner community level medical extension services
were offered, wnich benefited a large number of rural people
who
-oulo not ailora tne Benefit of medical xasi speciality
services.
owever, our grassroot exposure to tne rural scenario
..iin_ tnor-e years, made nr .
Infolly avsne t.v-t tuc- real
needs r>ecia.ly of the rural poor went much beyond medical
ce.it
nc that an/ integrated health and development programme
was the only answer.
_2®-“d5iliL_“ii3£n_xieal tn_end juevelonment
In 198p a pilot stuay was commissioned witn tne help
or social scientists to assess tne true nealtn needs of tne
people, beyona tne pale of curative health,
nased on tne
r’inuin. s of this survey in January 1978 an integrated nealtn
mu socio-iv lOmic development pro re.mrie we lumcned in six
villages around witn established satellite units in these
locations, where a nurse practitioner (ANM yts trained in
primary nealth care by us) and health worker resided and
>
oi.tered primary nealtn care at tne peoples door step with tne
net
oi volunteers from tne community who came forward to
ps.rtici ate in tni^ programme.
Tnese volunteers were trainee
t • eeco.n. nealtn ana development promoters ana they ^ave
-h-
reward) end organised a participatory forum to channelise
ana facilitate development inputs.
Variety or' agricultural
economic ana veterinary programme were instituted for tne
benerit or tne poorest section of tne population.
lieaical Services
of curative,preventive and. educative
not Xv were offered to tne op population.
2. scnool nealtn programme covering, >4 schools was also
Thi s
es tne
Of trie teacners -nd pupils to run a self-reliant,
o
roune tne ear basjic curative and eaucative nealtn programmed
was enaorsed oy tne bWSCO (reported vide
CovuiucnU
N
m-r
replicable end
71
model.
rearsaxin- to
11 v;
ltd
merged in late 1J78, tne aecluration virtually
operational
ategy of integrated. development.
to tne programme ana helped overcome
seme doubt
raised about toe validity and relevance of
nealtn cue programme wnicn appeared to be multidisciplinary.
From island of cnange to becoming a ’Movement'
Our experience with the community based health and
aevelopment services convinced us that tne strategy was right,
out y't tne impact remaineu only as ’islands
_o cn'-.;.'.
t
’t corn./-1 .
of iormin0 a ’movement' to bring about
change in a significant measure it became clear that 'networking
witn tn
*-
' i :eji minded agencises and tne government'infre
strict a
was inevitable.
.u
fresh strategy was initiates oy collaborating witn
other li’i-C!’
nd secular agencies with a tracic record of
-4-
crcdible field services, througn a Preservajiition of 2ye
i
li^nt io^isame, Launched in 1J7B. Tnis programme was
delivered tinsign village Level healtn workers.
Our
experience over tne next few years validated tne feasibi
lity of ’networkIng1 witn likeminded agencies.
Tne experience gleaned through such collaboration
is practical lessons in ecumenism and secularism,
taught
whicn transcend the usual diivisive forces in our community.
■^2i2ii£L_211G_G2m:nunity_neaLtn_sei vices
Our experience ovex tne past 2b years nas snown tnat
community .ieal tn services can develop alona witn nospital
service witnout prejudice to eitncr.
xstit
i.
inc growtn oi our
tion from a wayside dispensary to a 2bo ueddea
multispeciality referral nospital went nand in nana witn
tne community Level services covering a population of over
2 lacs population.
Given the 'political will' and un
stinted commitment to tne maildate of e^pousinl our
preferential option for tne poor and the marginalised, sucn
a xoalaneea ...rowtn xna of a multi-dimensional healtn care
programme snoula oe leasiole7mooilising tne total resources
oi a nospital.
_-i£u_£OYerage _ througn juet wording
In 1>‘S7 a complete Hl'A programme '*
is.cn:-.j-
(acronym
i r>
for tin r; ..r.x- for rur-ol c.w.nrenessA co-i i inity nesitn ana
xeaabilitation) was launcned with tne partnership of lead
agencies in tne field sucn as tne malanaau .development
.oc.ety,
•eeii-.u'; development Society besides netnany Asaam
rerun-.u, unristian ’.VorKers movement etc.
inis programme tnrougn networking reaches out to areas
1bO .Ims away, delivered tnrougn 220 field level nealtn
workers
it includes community based rehabilitation (0 n h-)
-5-
of tne handicapped as against tne prevalent institutional
cased rehabilitation with limited coverage.
W.H.O. estimates
tnat about 10- of any given population suffers from some degree
of 'handicap' and hence can be managed, effectively only
tmougn a community based strategy.
Tne programme embodies
inter agency, intersectoral ana inter-cnurcn cooperation which
are essential to achieve cost effective, i-elevant and
credible ±a asniEXE services to the rural poor.
This
piogiamme also mobilises available Government resources; the
increasing good will and openness of Government agencies to
collaborate witn the voluntary sector codes good for the
future development of our rural population.
Concept of networ-King besides enabl^’Oopti^mal utilisation
of scarce resources allows for intersectoral co-operation,
for enhancing tne credibility of the voluntary sector as
unified force, for transcending the fissiparous tendencies in
tne society, for demonstrating the feasibility of an ecumenical
approach, for demonstrating our concern for and sharing in the
National and global goals for health care/development ana
i
pavin tne way for effective programme limeade witn the Govern
ment ? 1 -o c rv i cps.
The constraints of running such a programme are significant.
■ -■en tne spiritual testament and the refrain of the Panama
Canal aiggeis "The difficult, we will do now;
Tne impossible
will tune a little longer’
this end more should be possible NOW.
- We wisn to acknowledge our gratitude to all our colleagues
partners ana well wishers who over tne years nave contributed to
tnis programme; witnout tnem tnere would ue no programme.
C~.a tv\
H
■n
----------
■ --- -------------'
'-r^ •'• l-^..'. •■ ... ?■"
Community Health : Learning from our failures
A Report from DEENABSNDHU, Tamilnadu
(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 oerhaps not
repeat them,
thus saving time and efforts)
COMMUNITY HEALTH : Community Health,
as it is known today,
International organisations
started in the early seventies.
and resource agencies from the West latched on to this -.new
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 :
6
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,
time and money,
thereby wasting a lot of
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 oasic know
ledge of social sciences was a great handicap and retarded
our progress; often a trial and error method had to be
adopted.
Apart from the attitudinal problems bo-tn out of
established values reinforced by sophisticated education,
we faced some early problems.
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
16 - • I
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
moved away.
A t 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 stateo target group
was the landless poor,
the majority of those sent to its 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 VHW.
point",
though used as an "entry
The village clinics,
tended to slow the process of acceptance of the VHW
by the community and we stopped doing them entirely after four
years.
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.
VHWs established their credibility,
Once the
we found that the commi
ttee was not really necessary.
We now operate on the basis
of trust between us and the VHW,
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 soohisticated 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
6
3
the people's economic^) deprivation.
The emphasis we now
lay on herbal remedies is a response to this.
We havS seen
the proven efficacy of several herbs commonly used at the
community level.
We started with a base hospital oroviding secondary care.
The hospital had a very busy and often lucrative practice.
o
We 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 VHWs also diminished the
number of people who needed secondary care.
We now believe
that if enough preparation of the community is done,
it
should be possible to start programmes without base clinics^
which ere often a hindrance.
We also believe strongly that
existing government facilities should be used,
are inadeguate,
and if theyj
people should be organised to demand better
services rather than duplicating services.
We started this as a total community programme,
and the poor alike,
for the rich
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,
transport of milk to the dairy.
milk co-operatives and
Not taken into consideration
e
was th^r fact that the landless barijans were not used to cows
had bo place to grow green fodder, and if they had any tbilk
4
4
sold even the last drop to the dairyy while their children
The land-rowning classes, on the other
were malnourished.
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
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:
harijan.
All programmes - health,
husbandry,
etc - were,
The VHWs too,
the landless and the
agricultural,
animal
offered exclusively to this group.
served only them,
Thus our focus became defined
and we were able to serve the taget group better.
Community Participation
Expectations of community participation started coming into
vogue in the early 70s.
assumptions:
We,
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";
by way of labouh. was participation;
that 25% contribution
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.
We had, in fact,
imposed a orogramme
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.
We 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 oriorities
and planning to evaluation.
To claim that we have been entirely
successful in this would be untenable, but serious efforts have
been made over the years.
Since we were unable to make defined
parameters, evaluation of this aspect is difficult.
It is also
hard, because the programme as we said earlier, has evolved
through-many stages and has undergone changes in its objectives.
Self-Sufficiency
self-sufficiency
As a corollary of community participation,
Several ways
has been a goal in itself as well as a process.
of seeking this goal were experimented with, particularly with
regard to the support of VHWs.
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 VHkJs to charge for their services,
small amount.
even a very
The question remained, however: why should the
already marginalised and oppressed people be made to pay for
their health services while a lot of resources all over the
country were being allocated to serve, the "haves" and the
urban elite?
Me 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,
hence,
Using a community-based approach,
self-reliance.
(appropriate personnel and
technology) ue learned that it is possible to make communi tic s
self-reliant.
Source: CONTACT, A bimonthly publication of the Christian Medical
Commission,
Switzerland)
(No 82 December,
1984)
d orv\
K
I
1 7—
\
Guast Editorial
FROM MEDICAL SERVICE TO HEALTH ACTION
TO COMMUNITY HEALTH
In 1975, a Government Expert Committee (5hrivastava
Report)
suggested that "we take a conscious and deliberate
decision to abandon the present health model and strive
to create instead a viable and economic alternative suited
to our own conditions, needs and aspirations". To most readers
of HEALTH ACTI N, this would seem a rather paradoxical
suggestion considering all the rhetoric in the media about
family planning programmes, universal immunization programmes,
technology missions for immunization and Health for All claims of
the government on the one hand and the growth of the high
technology diagnostic centres, capitation fee medical
colleges, private hos ital chains, highly advertised health/
medical insurance schemes and the increasing flood of drug
formulations in tha market.-jn, £zCc trf-Kin..
What model should we be abandoning and what are we to
build instead?
In this issue we highlight the growing interest in
the ’alternative health care approach'
seen in the last two
decades in the country and explore the issues and perspectives
generated and the lessons being learnt from the wealth of
the grass roots experience in community health in India.
From a hospital oriented, drugtS and high technology
Medical
Service that was unable to meet the health needs of
the people we have moved to a wide range of Health Actions—
preventive, promotive, curative,
rehabilitative focussed on
the community. This magazine itself reflects this metamorphoses.
However, activists and researchers,
issue raisers
and trainers, project initiators and development workers
.2
2
who are in the midst of all this health
a'
tion
a1-
the
community level are beginning to identify critical
problems and lacunae in our present thinking about health
itself.
If Health for All has to be achieved someuhere in
the future, if not by 2000 AD,
then Health action must be
centred in the developmental process and located in its
socio-political-cultural-economic context.
COPINUNITY
HE__ALTH ACTION will then mean much more than medical
service or health action.
A recent WHO publication highlights the new
values of 'Health for All' movement as Equity, Prevention,
Sharing, Cooperation,
Social Oustice,
Human Rights, Opportunity,
Responsibility, Participation,
Self-reliance, Empowerment.
It is these dimensions in their diversity that
this special issue seeks to explore and highlight.
The lead article explores the disenchantment with
the medical model and describes the
'alternative health
care project phenomena and the evolving new paradigm of
community health'.
It also .highliohts some issues and
initiatives in the community health movement.
Additional articles by participants of this
new movement explore various other dimensions building
on their own field experiences.
Com H 1 b• I
t
57
EXPLORING jargon
The World Health Organization has defined Health as a
'state
of physical, mental and social well being and not merely an
absence 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 1 a process of improving the physical, menial and social
uell 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
o
community health
1.
Pledicine: 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 Pledicine: Systematic study of human diseases with
special reference to social factors
.... 2
2
6.
Socialised Medicine (^tate medicine):
The control of medical practice by an
organisation of the government,
the practitioners
being an integral part of/lhe 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 Medicine: 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
COMPARISON OF HEALTH MANPOWER AND INFRASTRUCTURE IN 1981 WITH BHORE COMMITTEE
RECOMMENDATIONS 1971
Recommended"'
1981
685‘Millior(2)
POPULATION
Projection as
required by
Shore
Committee
PRIMARY HEALTH CENTRES
DB6T0RS
NURSES
HEALTH VISITORS
MIDWIVES
DENTISTS
1:20,000
1;2,000
1:300
1:5,000
1/100 births
1:4,000
Actuals
Shortfalls
34,250
5,T740fe)
3,42,500
(3)
2,68,712v
73,788
2,283,333
(2)
1,50,399v
2,132,934
137,000
231,530
170,500
@
19,03^
@
23,20C^
8,648
28,510
117,967
208,330
161,852
® Trained upto 1981
Source:
1.
Shore Committee Recommendation
Report
2.
Health Atlas of India,
3.
Health Information of
India,
1987
1986
Task
The material sent by Community Health Cell, for the July
issue on Community Health was estimated to be 80 pages.
Health Action can take only 48-50 pages of text apiart
from Advertisments and other matters.
In order to edit
the material to the requirement , a reduction of 2/5
of the material is called for.
Suggestions
After reviewing the content list and the details of the
cover story (CHC) the reduction could be done as "follows.
1.
The articles by Fr Edwin, Dr Dara S Amar and
Dr Jacob Cherian could be removed and featured
in the next issue.
2.
All the fillers excepting No 'I i.e, Exploring Jargon
and No 4 i.e CHAI Vision can be deleted, from this
issue ano featured as fillers in subsequent issues.
3.
Within CHC cover story item No 4 i.e Health Scene in
80’s including the box on National Health scene could
be dropped since these statistics have appeared in
many other ways in earlier issues.
4,
In item No 6 of the same st?ry box 13 Evolving
policy alternatives could be dropped ad also Mission
Hospitals Edict in item 8.
5.
In item 11 the long list of Community Health Training
opportunities in India i.e box 18 can be deleted.
A one page modification of the training centres is
being sent.
6.
The profiles of 30 projects can also be dropped.
7.
The idea of maps showing projects/training centres/
research centres/coordinating groups could be
integrated in one large map and only those mentioned
specifically in the text in one way or the other
in the articles could be shown as small stars.
This
map will have to have clarifying note that it does not
show all the projects and centresz&uT'oKly a feu
mentioned in the text.
Its basic aim is to show that
this phenomena has support from all over India .
If
in the time available it is complicated it could be
dropped.
2
J‘-vC'zVC
Altered Reference list
(The number in the brackets indicates the original number in
the first bracket and the changed number in the second bracket)
ICMR-ICS3R, Health for All - An Alternative Strategy, 1981
(1)
(1)
(2)
(2) Central Bureau of Health Intelligence, Health Atlas of
of India 1986
(3)
(3) Srivastava Report, Health Services & Medical Education,
(4)
(4) Ashish Bose,
($)
(5) Community Health Cell, Report on Community Health: The
Search for an alternative process, 1987
(7)
(6)
(8)
(7) Eric Ram,
(9)
(8) Antia N H, Medical & Non-Medical Dimensions of Health,
National Academy of Medical Sciences Oration, Apr 87
(10)
(9) VHAI, Pamphlet 1978
(11)
(10) CHAI Policy Statement 1983
(12)
(11) CMAI Policy Statement 1986
(13)
(12)
(14)
(13) 0 Banerji, Health Services in a Country: Postulates
of a theory, Ldk Paksh (1986)
(16)
(14) LINK Neuietter of ACHAN, Vol 7 No 2 Aug-Sept 1988
(17)
(15) Medical Seruice
(18)
(16) mfc pamphlet,
(19)
(17) AIDAN, Banned & Bannable Drugs, VHAI, 1986
(20)
(18) KSSP Pamphlet 1988
(21)
(19) FRCH Annual Report 1987
(22)
(20) ARCH Pamphlet 1985
1975
’For whom the target tolls’ Health for the Millions
VHAI, Low cost Health Care, Health for the Millions
Aug 1978
'Contact' 44 Apr 1978
ACHAN Pamphlet 1982
1986
2
8,
The table on Shore Committee Recommendations is being
modified since it is too complicated.
A simpler version
is being sent.
9.
In the resource inventory you may keep the 50
and delete all the rest.
The Bulletin list is
unnecessary since I find that the Journal Scan
regularly scans most of the journals mentioned.
10.
The reference list of the lead article should be
retained uith the numbers.
Some changes will have to
be made in light of the deletions.
A new reference
list is being sent.
11.
JUe would like |rou to mention CHC Taam Bangalore as the
AUTHOR OF THE COVER STORY.
Somewhere in the magazine
at a place which you think suitable you can mention
the following.
The Community Health Cell Team which
put together this special issue., is an
informal resource team based in Bangalore
which promotes Enablig; dimension in
Health Action, Socio-Epidemiological
perspective in Health Planning and
Participatory management in Health
Care.
The Team consists of
1. Ravi Narayan
2, Thelma Narayan
3. Gopinathan K
4. Shirdi Prasad Tekur
5. Nani Kalliath
6. Nagarajan N S
7. John S
ft Reference List
1.
ICMR-ICSSR, Health for All — An alternative strategy, 1981
2.
Central Bureau of Health Intelligence, Health Atlas of India 1986
3.
Srivastava Report, Health Service & Medical Education, 1975
4.
Ashish Sose,’For whom the target tolls’ Health for the Hillins
5/b. CSI, Ministry, The National Health Scan0j Voluble Indices
a handout,
1987
6. Community Health Cell, Report on Community Health: The
Search for an alternative process, 1987
9.
VHAI, Lou cost Health Care, Health for the Millions Aug 1978
8.
Eric Ram,’Contact’44 Apr 78
9.
Antia N H, Medical & Mon-Medical Dimensions of Health,
National Academy of Medical Sciences Oration, Apr 1987
10.
VHAI, Pamphlet 1978
11. CHAI, Policy Statement 1983
42. CMAI, Policy Statement, 1986
vf3. ACHAN, Pamphlet 1932
14.
D Banerji, Health Services in a Country: Postulates of a
theory, Lok Paksh )1986)
15.
VHAI, Essentials of National Health Policy, 1987
16.
LINK, Newsletter of ACHAN, Vol 7 No 2 Aug-Sept 1988
17.
Medical SBruice>
18.
mfc Pamphlet,
19.
AIDAN, Banned & Bannable Drugs, VHAI, 1986
20.
KS3P Pamphlet 1988
1986
21 FRCH, Annual Report 1987
22. ARCH, Pamphlet 1985
■23 Satyamala C et all, Taking sides, Choices before a
Health Worker, Anitra Trust 1986
I
A Reference List
1.
ICMR-ICSSR, Health For All - An alternative strategy,
2.
Central Bureau of Health Intelligence, Health Atlas of India 1986
1981
3.
Srivastava Report, Health Service & Medical Education, 1975
4.
Ashish Bose,’For whom the target tolls’ Health for the Millins
5.
CSI, Ministry, The National Health Scene. Voluble Indices
6.
Community Health Cell, Report on Community Health: The
a handout, 1987
Search for an alternative process, 1987
9. VHAI, Lou cost Health Care, Health for the Millions Aug 1978
8. Epic Ram,’Contact’44 Apr 78
9. Antia N H, Medical & Non-Medical Dimensions of Health,
National Academy of Medical Sciences Oration, Apr 1987
10.
VHAI, Pamphlet 1978
11.
12.
CHAI, Policy Statement 1983
CMAI, Policy Statement, 1986
13.
ACHAN, Pamphlet 1982
14.
D Banerji, Health Services in a Country: Postulates of a
*
theory, Lok Paksh )1986)
15.
VHAI, Essentials of National Health Policy,
1987
16.
LINK, Newsletter of ACHAN, Vol 7 No 2 Aug-Sept 1988
17.
Medical SQ3?uj_ce>
18.
mfc Pamphlet, 1986
19.
AIDAN, Banned & Bannable Drugs, VHAI, 1986
20.
KSSP Pamphlet 1988
21 FRCH, Annual Report 1987
22. ARCH, Pamphlet 1985
23 Satyamala C et all, Taking sides, Choices before a
Health Worker, Anitra Trust 1986
<2. o tv\
I 6• ’ 9
*«n exploration or' ten ci verse initiatives in comm unity health
in I noir- nave led us to recognising a neu paradigm of
Cars'
'Health
evclvin ? in the country.
Kev components cf this neu paradigm in a technological and
managerial sense are:
- Community Orc ’.ni nation and participation in Health
- Ap ropriate Technology for Health
Community support to Health Care -- financial/resources
- Involvement cf Traditional Healers, Dais and indigenous systems
- education for Hea1th
- Health uith Integrated Development
Critical value and i*
-.ues
- Social
of the npu oaradigm are:
Ano'vsis, Conflict Management
- Participatory Team decision making
- Community buildinn efforts
- Den y s t i f ’ c a t i o n and skill
transfer
- Individual/Community autonomy
- Medical 121 11 r a 1 i = m
- Accountability and socio-economic audit of Health Services,
The overall
lessor ue are learning is that if 'Health for All'
by 2D01/AD has to oe a reality for the large majority of our
people then thiTf has to be a major shift in our thinking
about Healtn and Health Care from the orthodox Medical model
of health ue have to move touards understanding,
and practicing a 'Spcial model of Health'
appreciating
that uill
tackle
health problems at its deeper roots.
This shift of emphasis must take place at all levels and at
all dimensions of existing health care planning and management.
The shift uouln include the follouing emphasis change
<2 C 1
Community/Village Health
Workers
Involvement of
Traditional Healers
Dais and indigenous
systems
Community Organization
and Participation
in Health
COMMUNITY
! Appropriate
Technology for
! Health
HEALTH
Health with
, Integrated
' Development
Conmunity support to
Health Care—
financial/resources
iTechnological/Managerial
Components of the new
paradigm
Source; Community Health Cell
Reflections
Education
i for
I Health
Social Analysis,
Conflict Management
Individual/
community
autonomy
Participatory
Team decision
.making
Community
building
efforts
Medical
Pluralism
Demystification and
skill
transfer
Accountability and
Socio-medical audit
of Health Services
i
I
;
Source: Community Health Cell
Reflections
Critical values/
Issues
of the new Paradigm
/>:'7
THE PARADIGM SHIFT
Medical Model to Social Model of Heal th
INDIVIDUAL
------ >>
COLLECTIVE/COMMUNITY
------ >
PERSON
&
SOCIETY
PATIENT
&POPULATION
ANTI DEATH
ANTI DISEASE
PRO LIFE
PRO LIVING
PHYSICAL/MENTAL
PREDOMINANTLY
PHYSICAL/MENTAL/SOCIAL/
i
CULTURAL/POLITICAL/ECONOLOGICAL
DOCTORS/NURSES
MEDICAL AUXILIARIES
TEAM OF HEALTH WORKERS
DISEASE
PROCESSES
SOCIAL
PROCESSES
HOSPITALS/DISPENSARIES
DRUGS/TECHNOLOGY
—PROVIDING SERVICES
INTRACELLULAR
RESEARCH
------ >
----
PATIENT AS BENEFICIARY,
CONSUMER
HEALTH PROMOTING AND
COMMUNITY BUILDING CENTRES
AND PROCESSES—ENABLING/EMPOWERING
THE PEOPLE
SOCIETAL RESEARCH
PEOPLE AS PARTICIPANTS
■■■
PROFESSIONALISED
COMPARTMENTALISED
MYSTIFIED KNOWLEDGE
^UEST FOR VACCINE
AGAINST DISEASE
----- >
■
DEMYSTIFYING,
PERSON CENTRED
AUTONOMY CREATING
AWARENESS BUILDING'KNOWLEDGE
QUEST FOR AWARENESS BUILDING
PROCESS TO IMMUNIZE AGAINST
UNHEALTHY SOCIAL PROCESSES
Will the Community Health action initiators work together
to out pressure on the 'established medical system'
to commit
itself to this new vision of Health Care?
Will the Community Health action initiators work together
to out pressure on 'Health Policy and decision makers'
to
move beyond oolicy statements and qet community health
oriented programmes and actions off the ground?
Will the Community Health action initiators work with the
people and their organisations to enable and empower them
to get the means,
structures, oppottunities,
skills,knowledge
and organisations that make health possible?
All these are unanswered questions.
Micro level experiments
have shown that a lot is possible, but macro level change
requires a collective understanding and a collective action
that is still to emerge.
WILL COMMUNITY HEALTH HAVE A CHANCE?
om
-
H 11>.) S'
I I
NG0/Research Centres in Community Health :
Some Profiles
* foundation For Research in Community Health, Bnmhav
(Maharashtra), Estb:
Non-government
1975
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 Maharastra;
Health service projects (NGQs 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 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
a
th : ead .
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 heal th^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,
and
non formal school and finally a just
humane rehabilitation policy for tribals disolaced by an
ambitious irrigation project in the area.
^Society for Education, ftuareness and Research in Community
Health (SEARCH) Gadchiroli (Maharashtra) Estb:
The society has adooted Gadchiroli district,
tribal district in Plaharashtra ,
1984
a oredominantlv
for its education,
building and research activities.
awareness
Presently they have 0, long
term projects on the study of Active Resoiratorv Illnesses in
children;
community.
and a study of women's health focussing on the
The society also seeks to evolve methods of inter
vention 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
liouor issue and its community context./'It has also tried to
modify the health care/medical practices at tne District/level
to make it more responsive to the needs erid the oeoole's
situation.
,
Gorv\ VA I b- lb
V
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
□iological roots of disease and much of the research efforts
sponsored by ICMR and other national and regional,government
and private research centres has been in this direction.
of it has been imitative research,
India'
Most
'we too have done it in
sort of focus and there is the continued myopic will
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 people is in Q' riraVe'f''s'b c~rgta3. problems
in the wider social reality and to study them in a sociobottlenecks and 83
epidemiological context,.
'■sefitECa creative innovations is the need of the hour.
Some
ICMR institdions like the National Institute of Nutrition
in Hyderabad, National TuterCulosis Institute in Bangalore
and the Vector Control Research Centre in Pondicherry have
treaded the path of societal research and made unigue
contributions to Primary Health Care and Community Health
but these are the exceptions to the overriding rule.
•
Have the NGO Health action initiators fared better?
Is anyone interested in health related societal research
in the country?
The development of NGO health research units keeping
. . .2
0
2
in tune u i t h and exploring in depth issues arising out of
tno
emarging Community Health movement are feu 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 Heal th,(SEARCH)
Gadchirole (Maharashtra) ,
are examoles
A feu of the larger NGO Health P-rojects like CHOP,
(Maharashtra)
SEUA-Rural (Gujarat), CINI (Calcutta),
Pachod,
Jamkhed
(Maharashtra) and RUHSA (Tamilnadu) have also begun to take up
some key research issues but this uhole interest io still
in a nascent state.
The Social Medicine and Community Health Department at
GNU is tne only other national centre uhich is undertaking
societal research relevant to Health Care and Health policy
issues.
The medico feiend circle's efforts in providing
counter research expertise in the Bhopal disaster and its
aftermath uas also a beginning of this neu trend.
Much needs to ue 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 uho
see Research as an important need.
It also needs innovative
'researchers' uho uill be uilling 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 preoc,cupation uith
such 'balonnist researchers'
9
'microscopic research'
available for the task?
are
Com V-( 16- (-)\
S'7
Traditional Medicine
(1)
Amalaki (Emblica officinalis 6aertn.)
Parts used
Fruits (fresh or dry). The seed
should be removed before use.
Uses
Anaemia, bleeding, giddiness, pain
and burning sensation in the abdomen,
greying and falling of hair, eye diseases.
This can be used in all age groups as a
general tonic.
(2)
Ardraka (Zingiber officinale Rose.)
Parts used
Underground stem (rhizome)
Uses
Loss of appetite,
either fresh or dry
indigestion,
flatulence,
nausea, cough and fever due to upper
respiratory tract infection, joint pains.
(3)
Dhanyaka (Coriandrum sativum Linn.)
Parts used
Fruit
Uses
Indigestion, colicky pain,
sunstroke,
burning during urination and scanty urine,
piles,
fever.
2
2
(4)
Haridra (Curcuma longa Linn.)
Parts used
Underground stem (rhizome)
£
Uses
Intolerance to dust inhalation,
running of nose,
respiratory diseases particularly in
cases of difficulty in breathing and
cough due to allergy,
itching senstation
all over the body, jaundice, wounds
(5)
Lashuna (Allium sativum Linn.)
Parts used
Bulb or segments (bulbils)
Uses
Loss of appetite,
flatulence,
indigestion, cough, piles, skin diseases
chronic fever, obesity, pain and
swelling of joints, poor eyesight.
(6)
Maricha (Piper nigrum Linn.)
Parts used
Fruit
Uses
Cold, cough,
sore throat, boarse voice,
influenza
contd.... page 3
Note: For further information such as description,
preparation, dose, refer Manual for Community
Health Worker of the Ministry of Health and
Family Welfare, Government of India, New Delhi
October 1978
3
(7)
Nimba (Azadirachta indica A. Juss)
Parts used
Whole plant especially leaves,
fruit, bark and tender twigs.
6
Uses
Ulcers,
itching, skin disorders
fever, biliousness, wounds,
ear discharge.
4
C-Orvv H lb. I 8
RECOMMENDATIONS
0P ICMR-IC5SR on 'Health For AH' - An
Alternative Strategy
1.
The Government of India shpuld,
in consultation with
all concerned, Formulate a comprehensive national
policy on health dealing with all its dimensions,
viz.,
ohilosoohical and cultural,
socio-economic,
nutritional, environmental, educational, preventive
and curative.
The coordinated and planned imple
mentation oF this oolicy should be the collaborative
and cooperative responsibility oF individuals,
Families,
local communities, health personnel and
State and Central Governments.
2.
The basic objectives oF this policy should be:
a.
to integrate the development oF the health
system with the overall plans oF socio-economic-
political transFormation;
b.
to ensure that each individual has access to
adequate Food and is provided with an environment
which is conducive to health and adeouate
immunization,
c.
where necessary;
to devise an educational programme unich will
ensure that every individual has the essential
knowledge,
skills and values which would enable
him to lead an eFFectively healthy liFe and to
participate meaningFully in understanding
and solving the health problems oF the Family
and the community;
d.
to replace the existing model oF health care
services by an alternative new model which will be
- combining the best elements in the tradition
and culture oF the people with modern science
and technology,
2
2
- integrating promotive, oreventive
and curative functions,
- democratic, decentralised and participatory,
- oriented to the people, i.e., providing
adequate health care to every individual and
taking special care of the vulnerable groups,
- economical,
and
- firmly rooted in the community and aiming
at involving the people in the provision
of the services they need and increasing
their capacity to solve thein own problems,
and
e.
to train the personnel,
to produce drus and
materials and to orginise research needed for
this alternative health care system.
3.
A detailed time-bound programme should be prepared,
the needed administrative machinery created and
finance provided on a priority basis so that this
new policy will be fully implemented and the goal
of "Health for All" be reached by the end of the
century.
(Recommendations of the ICflR/lCSSR on "Health for All"
An Alternative Strategy)
C.brv\ kj (jjc;
^7
BASIC PRINCIPLES IN CHAI'S COMMITMENT TO COMMUNITY HEALTH
c
1.
Community Health is am 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 gives priority or emphasis to the health
team,
3.
primary health care and community needs.
Community participation is an essential comoonent of
Community Health.
This recognises the potential rolgtif
others to help educate, organise, mobilise and supoort
community development activities where .the people have a
say in and control over their own future.
Community
participation thus becomes involved in people'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,
seconcary and tertiary care approach to
the needs of the community and the resources available.
Therefore this aporoach accepts the role and potential
of the 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 pare services.
5.
In the provision of services in Community Health there is a
bias towards those who are oppressed, exploited,
the marginalised.
Thus priority would be given to rural
areas and urban slums.
women,
the poor and
tribals, dalits,
Special groups for concern would be
small nfarginalised farmers and
landless labourers.
2
2
o
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.
There is a place for voluntary agencies in Community Health.
8.
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 care systems and relating health
services to the culture and socio-economic situation of
people.
Appropriate indigenous medical practices and
trained practitioners,
or traditional birth attendants
are encouraged in Community Health.
10.
In the final analysis Community Health is not aoolitical.
If it concerns the welfare of people and the provision of
adequate and appropriate health care then health becomes a
social justice issue.
It is concerned with structures and
systems of society that seem to benefit a few at the
expense of many.
CLo ta H I 6-2-O
<_
CHAI's Philosophy and Vision of its Community Health Programme
The Community Health Department of CHAI also felt the need for
a 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
80% of its population lives in the rural areas and
scout 90% of the country's health care system caters
to the need of the urban minority, a new orientation
and rethinking of the whole 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 a refulfil1ed,
socal well-being
is ensured and psychological as well as spiritual
needs arc- met.
Accordingly a new set of pararreters
will have to be considered for measuring the health
of a community such as the people's part in decisipn
making,
absence of social evils in the community,
organising capacity of the people, the role women
and youth play in matters 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
ft
ceal needs of vast majority of the people in the
country.
The root causes of illness lie ds^
in social evils and imbalances,
to which the real
. . .2
D
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 he re whould 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.
PRIMARY HEALTH CARE
DECLARATION OF ALMA-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 an
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 development of the community.
It is the first level of contact of individuals, the family
and community with the national health system bringing health
care as close as possible to 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
includes atleast: education concerning prevailing
3.
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,
family planning;
including
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;
involves,
4.
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.
requires 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 trfe 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
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 health team and to respond to the
expressed health needs of the community.
o
Com 1 1 Ks.T-'Z-
s
n
ALFIA ATA - - Ten Years After
A decade ago, on September 25,
1978,
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 dightly in planning for the year 2000.
In its first evaluation report, WHO claimed that some
progress has been made towards HFA 2000.
Paradoxically, it
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 cotterage in child immunization
and the final eradication of small pox, cannot conceal the
wide gulf which still exists between the urban "haves" and
WTO-'
the rural "have-nots".
Nearly 65 percent of people inAIndia
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.
example,
For
100 to 200 out of every 1000 infants born alive
still die during their first yea? of life.
In spite of the dismal statistics, some progress has
been made in the decade since Alma Ata,
in the infant mortality rate,
death rate,
including reductions
the crude birth rate and
and an increase in life expectancy.
the
The concept
of the community health worker, who is selected oy the local
community to serve the community, has had considerable
impact.
Medical education has been re-oriented toward social
goals, ahd 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
nocratic aporoach (joes not work.
Many now believe th.nt
short term staategies such as "selective Primary Health
Care" should be abandoned because they are in opposition
to the fundamental principle of HP A 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 and baSic oroblems
that generate poor health.
What is needed is an integrated
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. Vijay Hoses,
Head, Department of
Community Health, Christian Medical Association
of India in FIONA PLUS,
Issue 3 December 1988)
ft REPORT FROM KERALA
BASIC HEALTH COMMUNITIES
--Fr Edwin M3
Building communities is yet to become an integral
part of the mental concept of a good many of our community
h - alt h workers.
What 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 communitv together.
In this sense a community "works together".
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 programmesobut 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,
consequently 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
.3
3
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 with 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 intepds 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 affecting 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
community health programme may at the most be a rural
extension programme and not real community health action.
Community health is not just a programme for the
people; it is also something of the people and by the people.
4
4
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 COMMUNITIES
Our first step here is to start organising basic
communities of thirty houses each. We have altogether
170 such basic communities now.
These communities are geographical, ensuring that
nobody is left out. This geographical aspect ensures also
a permanent identity for the communities. As long as
the houses are in a given geographical area the communities
are also there. Even if for some reason or other some 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 oftener as the case may be. These meetings are
either for prayer, or for celebration,
or for nonformal
education or for discussions on problems affecting them and
so on.
Five representatives from each community make the
representative general body of the village. 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
5
5
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
6
decide together they can spend upto Rs. IOC'.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 anybody 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.
X
... 6
6
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 to remain empowered.
This we do through various processes. One such
programme is our holistic health orientation 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-discussion exercises. Each community
will be encouraged to do also creative assimilation programmes:
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 to a wider audience the best of the cultural programmes
produced by these communities. 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 basic 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 conceding activity by
way of a song or so.
7
7
Our next process will be to make these communities
accept responsibility for their own he '1th care. This
we intent to do by way of promotion a holistic health
insurance scheme run by the people themselves.
Our health insurance programme is expected to consist
of the following components:
non formal
education
through basic communities, collection of funds rhrough
basic communities,
primary health care through village
level representative body and its appointees,
secondary
and other levels of health care through zonal bodies
and the referral centres chosen by them.
Unfortunately,
even the Example niven is not yet a
realised dream. Well, this is the vision. Up are not. yet
sure how far we will reach. I*lay
be in spite of our
optimism we may reach only half way. But we feel even that
would be worth the efforts, as it would be a step in the
right direction.
H
\
lb. xu.
r
S'!
HEALTH OF PEOPLE IE WEALTH OF NAU01.
Dr.Jacob Jhcrin
Director & Chief Eurgcon
Christian Fellowship Community Health Centre
AMHimjUil.617. 611 - T.J.
The present national scheme of Primary Health Can ere is not so much a
success as it was expected to be (world Health Organisation report).
Still
thousands of people in our country die of infectious conditions, poor nutrition
Alternative and appropriate systems of delivery of Primary
and bad sanitation.
Health Care have been explored, tried and met with success at many places.
Christian Fellow ship Community Heal tn Centre at Ambilikkai ira ned Multipurpose
Community Health workers for the first time in our country as early as on 1958.
The
training was reorganised into a regular course in 1971 witn Government recognition.
In those days we used to call the® Community Health Guides.
This training was
much appreciated and it was crowned with success.
The Government of India accepted it
as Multi Pur pose Health Workers scheme later on.
Conn’.unity' Health Guides (M.P.H.W)
working in the field of Health and Medical services especially in rural p-.o’
c_ .:>•.•
under supervision of medical officers, are doing a ’wonderful job.
In our
area 43 Community Healtn Guides, covering 1.5 laths of rural population, arc doing
dedicated work,
they have achieved rem;-rkeble r suits durin
the last 25 years,
e.g., Infant mortality rate was, brought down from 130 per 1000 to 69 per 1000, birth
rate from 31 per 1000 to 19.5 per 1000 and general death rate from 13 per 1000 to
9 per 1000.
Almost all infective con.dtionc are wiped out from the area.
tisojah a network of Mini dealt’, centres.
We work
Two Multi Purpose health workers and thr.-e
village health .orkers won in each mini health centre covering 5000 population.
Similarly in Voluntary sector, ot.i r institutions like the one in Jaukhed
V"
are training and placing simple illiterat.'. tillage women ,.s Voluntary Health workers
in their project,
They too have achieved very good results.
by world eval th Organization.
This was also •ocognised
Training and organisation of M; th. =r sangams
nd
Halwadies are other examples of succe r— ventures and alternative system piloted
bv Voluntwr.y sector tiioupa it may not ;-iv> tne full covers. ...
t.’roag". :i aiui insurance by Voluntar'.
of success story in
using
ueliv r g oi .w .ta
tervice, nudra:- i. yr.
. r exn.-.pl..
he field of hw.lt:’- delivery by ndoptinr a d.tlcs’ent £■■■ s<ri::r
lay-first-aid' rs.
I
in our Community Health Field, even leprosy program is integrated with
r'.ulti ^ur.iose Health Worker's service.
The leprosy /paramedical workers are
expected to detect the new cases which have become comparatively much less in
our area.
Once detected and diagnosed, cases are held (followed up)
Purpose Heal'th workers (C.H. Guides).
by Multi
Soon we are lipping the National Leprosy
Eradication program will be integrated with Community Health net-work, which the
Government of India is contemplating to do in 19;2.
Since
Guides are well experienced and quick in the delivery of
our Community Health
Health Services and also
many of the targets to be achieved by the turn of the century (<000 A.D) alloted
to them in the limited population (2500 population fon each Health Guides) are
already achieved, they are turning their attention towards socio-economic developmen
as health is very much dependent upon socio-economic development.
Limitation of f>-nds is the greatest handicap of any Voluntary Organisation.
If dedicated service of Voluntary Organisation could be coupled with adequate
and timely supply of material and monetary resources, gr^at tilings, could be achieve
in any field especially in the important fields of Health and Development.
In the usual development
process in any country, one could
see that
Voluntary pilot modules or models, research and experiments, lead the nation in the
right track.
A good community health system, based on mother and child care,
sanitation, immunization, nutrition, control of population growth and proper care
of minor ailments, should be further ooosted by Health Education and adult
Education, and ecorjftiic development.
Early
five-year-plans in our country were
concentrating on building up big hospitals, Medical Colleges and post-rrudua.e
teaching institutes and; also rnucn thrust was given on green revolution.
was a good move in the right direction but side by side
shou£_: have b
n given its due importance.
industrial
Tnis
revolution
Thank Go ■ the trend of general policy
of our Government in the latter periods of five-year-plans is set in the right
direction, towards ''Balanced, economy’', Community Health, and ^Control of population
.
*
Adult education, Industrial Revolution (both snail and big) and Green revolution
are pushed to the fore-front.
Soon it is hoped that craziness for sick palaces
on the part
(Big Hospitals) and urban Medical Colleges
the
government will be replaced by Community Health Projects, Adult education and Family
Welfare
programs and socio-economic and a riculture-promotion activities.
It is a pity that still our country is not able to prevent becoming victims of
draught and flood by developing ecology (Social forestry) ana preservation of rain
water and connecting all yrivers
with canals after building sufficient dams
and also buildin.-- bunds on all the banks of rivers.
is an asset to work up such herculean tasks.
of economic development ?
Vast population already existing
W:.y do we think here of those areas
Because unless socio-economic condition is improved, health
of the peoole cannot be promoted beyond a certain limit or level.
Unbalanced race
for scientific achievements and material targets are also equally danger.us unless it
is balanced 'with selfless service, deep spiritual mottoes and motives and also our
hunder and thirst after high moral values.
TRAINING FOR C01DUNITY HEALTH CARE
Dara S Amar
(This jbaper highlights some of the attempts made in St J'ohn's
Medical College, Bangalore,
to orient Health Workers,
including Medical students,
towards Community Health Care.
The attempts have provided invaluable insights into this
important goal.
Being a Medical College, St John's aims
at providing the training component in the formation of
health teams)
The Salient features of our present programmes are :
1.
Health_Team_Trainin2
St John's Medical College is in a unique situation to train
various members of the health team under one roof.
We
are able to create a better understanding among the members
of the team of each other's role.
Medical students, Nursing
students, Community Health Workers, Deacons, School teachers,
Village mothers etc.
are the various health team members
who get their training at the college.
While the ideal objective is health and development, by
virtue of the training and competence of the faculty, the
emphasis has been on training in health.
It is comple
mented by traaining in development by other organisattions.
Community Participation
One of the main objective of the community health progra
mme of the college is the development of a participatory
process wherein the villagers themselves are responsible
for the financing of health care, supply of materials
and manpower.
This is particularly exemplified by the
Mallur Health Co-operative Centre, a project initiated
jointly by the college and the Mallur Milk Copperative
in 1973.
Village Health Committees have been formed at
each of the rural health centres and decisions are
2
2
participatory in nature.
A large part of the organisation of
speciality rural camps are also done by the villagers.
This
is through their village youth groups and Mahila Mandals.
Even in the training of the health workers including medical
students,
the village leaders are drawn in as resource
persons.
Coordination_with 0ther_a2enci.es
We work in coordination with governmental and non-governmental
health institutions.
Programmes such as the Rural Mobile
Clinics, Universal Immunization Programmes,
integrated Child
Development Scheme, National Social Service and Rural
Internship Training are examples of such coordinated efforts.
Our teaching faculty also act as guest faculty for various
sister institutions and organisations involved in health and
development.
Intonated Health Care
Villagers in India often resort to indigenous systems of
medicine.
The training at the college of the health workers
including our medical students,
includes training in Herbal
Medicine, Herbo Mineral Medicine, Acupressure, Homeopathy
and Yoga.
Many of our graduate doctors working in remote
rural areas, have substantiated the fact that there is need
for integration with other systems of medicines as is being
attemoted at the college.
Heal th_Education_-_A_priority_
After years of experience in training health team members
for the villagers, we-'feel' the re is a greater need to pay
attention to training in health education.
run,
In the long
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 trailing programmes conducted
3
3
at the college.
Innovative methodologies such as Child to
child health education, rural mothers motivation programmes
and rural school teachers health education training programmes
are some of the important programmes organised by the college.
The health education methodologies include the development
of local audio-visuala aids in the form of simplified demo
nstration models using locally available 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.
Nutrition
education involves teaching the village mothers to use their
own traditional recipes in a nutritionally correct manner.
The
aim here is to strengthen the existing traditional diets which
are often nutritionally far superior to the imported diet from
the urban areas,
Greater stress is laid on the use of local
cereals, pulses etc.,
along with promotion of breast feeding
as well as local weaning diets for the children.
Sensitisation to the rural milieu
In order that all the trainees at St John's,
including medical
students and nursing students, must understand the dynamics of
rural life, special training programmes are organised on a
residential basis at our rural health centres.
These rural
residential training programmes stress 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
4
4
senitize the health worker to the various aspects of rural
life and how each of these aspects is related to the total
health of the villagers.
Reachinc out
Considering the resources and facilities available for
health care at St John's it is quite natural to try and reach
out to the underserved areas using the available resources
for health care.
Rural camps in the field of eye, ear, nose
and throat,
teeth, child health and General Surgery
skin,
are conducted in the villages.
Methodoloqies have been
evolved at the village level to ensure asepsis and follow-dp
for post operative care through the use of trained school
teachers, youth volunteers and traditional healers.
Specialist care,
is thus made asailable at the village itself.
In the bargain,
the faculty have gained confidence that it
is possible to reach out with even advanced health care to
the villages.
These 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 inva
luable experience!
Understanding health and disease_holostically
In order that our health team trainees do not dichotomise
health care into various compartments,
the training programmes
focus on families rather than individuals.
Through programmes
such as the Clinico-social case study' and field family.
health care projects,
the trainees are ma-e to understand
the cause and consequence of disease in terms of multiple
factors rather than only the clinical signs and symptoms
of the disease affected person.
Emphasis is laid on
5
5
the planning ano management of health care at minimal cost.
Our graduates would, also he cost conscious and make their
programmes financially self perpetuating in the village
communities rather than make the people depeddent on
charities.
Servina the_urban_under-grivilioed
Urban slums in and around Bangalore,
Medical College.
are also served by the
Health programmes such as immunization
Coverage against the major killer dieseases for children,
maternal and child health clinics for expectant mothers
and school health programmes,
health activities.
are some of the urban based
In addition,
the Medico-Social Unit C”2h
also aids in counselling for alcoholism, drug addiction,
juvenile deliquency etc.
Continuing education_
Although basic training in health care is imparted to various
categories of health workers,
it is important a follow-up
is done on the utilisation of the knowledge gained at
St John's.
For this purpose,
several methods are followed.
At the professional level, doctors can seek elective posting
in selected specialities for further skill ehhancement.
Regional Colloquia are organised for sharing professional
experience among Community Health Workers and Rural doctors.
This provides an opportunity for learning from each other.
Continuing education is also provided by St John's for
health agencies from afar.
The United Planters Association
of Southern India (UPASI) works in collaboration with the
Department faculty to train their Medici Officers, Nurses,
Compounders and even their Estate Managers in the field
of health care and health management.
Periodical newsletters
6
6
also act as a means of networking for graduates and
Community Health Workers working in various parts of the
country.
Development as_part of health
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 youth.
Functional literacy
programmes and vocational guidance are some of the o-her
services rendered in the villages.
Our health trainees,
including our medical students, participate in these de
velopmental programmes under their National Social service
activities, which is coordinated by the depatment faculty.
Conclusion
All the programmes are updated constantly, depending on
the feed back received of their effectiveness and efficiency.
The emphasis is on training and health education rather than
mere provision of multiple services.
This ensures that
whatever have been the programme inputs,
be long,
the results will
lasting self perpetuating and effective
C- o nA V !
STAGES IN COMMUNITY HEALTH SERVICES LEADING TC MORE COMPLETE
PRIMARY HEALTH CARE DEVELOPMENT ARE:
Stage 0: Community has to come to the hospital resulting in
limited access to health care.
Stage 1: Mobile clinics which give episodic services unable to
deal with complications developing between the
intervals of care.
Stage 2: Public Health Services'which attempt to achieve disease
control without necessarily depending on active
recepient community involvement.
Stage 3: Hospital-based, community-oriented, Primary Health
Care where all resources and health funcationaries
are taken regularly and frequently from hospital
bases into communities requesting and cooperating
actively with this assistance.
Stagg 4: Community Based Primary Health Care (CBPHC)
with
facilities and health personnel firmly established
in communities requesting them and actively cont
ributing to their implementation.
Tertiary hospitals
are then used only for referrals,
training and
assistance as and when required.
Stage 5: Multi-sectoral, multi.disciplinary integration of many
different comoonenfcs in each community,
leading to
improved health and economic developmemt.
Stage 6: Education, organisation, mobilisation of resources
and active implementation of socio-economic development
of people for their own total health at the micro
project level.
Stage 7: political activity by communities at the macro
level to ensure primary health care with the quality
of wholeness in life for all.
(Source: Fiona Plus, A Bi-monthly bulletin on Primary Health
Care in Community Health,
)
COMMUNITY HEALTH :
DIFFICULT CHOICES
Each health worker interested in improving the health
status of the poor oeople will need to make a few imoortant
decisions:
* Where does she want to spend most of her time - in the
dispensary or in the village?
* Which group of people does she want to work with - the
better-off or the poor?
* Does she want to continue with her present activities the
way they are or does she want to bring about a change
in her role?
* Will her present institution support her if she wants
to change the direction of her work or does she need
to work with another group?
* Can she build up support for her work and herself from
any source?
* Is she willing to go through the personal struggle which
such work may involve?
Similar decisions taken by other health workers and their
experiences can be a source of encouragement and support
to all of us struggling to make these decisions.
I
—Sathyamala et al, Taking Sides
COMMUNITY HEALTH TRAINING IN INDIA—■■■■■
*
K.e.t-1
CV£MV'^ <1^ ov.r^i
CcnXWe
* Four weeks training programme on COMMUNITY ORGANIZATION
AND DEVELOPMENT in English, Telugu and Tamil for
X
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
o
HEALTH PROJECT. For details write to:
Head 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
V"
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
and health and management information system. The
course is open to people who are involved in primary
health care services. The medium of instruction is English.
for further information contact:
Institute of Health Management
Pachod
Dist Aurangabad
o
Maharashtra 431121
10 weeks training programme on COMMUNITY HEALTH AND
DEVELOPMENT : conducted by International Nursing
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 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 to:
The Programme Director
INSA/INDIA
2 Benson Road, Benson Town, Bangalore 560046
. .3
o
3
5
*
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 560034
6
*
Four months Certificate course in INTEGRAED RURAL
DEVELOPMENT: conducted by RUHSA. 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
hosoita], 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
9
Health Care Administration Office
St John's Medical College Hospital
Bangalore 560034.
CO
*
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.
O' *
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^Caterir
2.
PG Diploma course in Health and Development
3.
Multipurpose Health Workers (ANM) course
4.
Village Health Workers (VLW) course
5
o
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
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. This 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 accouting; basic labour
legislation etc. For details, write to:
The Coordinator
Community Health Education Training & Personal Development
Voluntary Health Association of India (VHAI)
40 Institutional Are^a, 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 e
For details write to:
The Centre of Social Medicine and Community Health
Jawaharlal Nehru University, New Delhi
110067
.. . .6
9
6
j
Successful M.Phil graduates can pursue their PhD
1
work (3 years)
in the same discipline.
The Centre also conducts Masters programme in
'J
Community Health (MCH)
for MBBS and MSc (Nursing)
holders. MCH holders are eligible to pursue their
I
PhD programme in Community Health.
6 ox
THE NATIONAL HEALTHSCENE
f' J|"'- ---L-
VOLUBLE INDICES
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 1975-81.
Pertussis
Around 300,000 cases reported annually.
Poliomyelitis
Estimated number of cases ranged from 141,000 to 234,000 a year.
Annual incidence rate is around 1.5 to 1.8 per 1000 children
i*
0-4 years.
<3
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
o
'
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 falls
Him
in
. .2
0
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
J
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 yeais 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 perce it
of out door patients and upto 35 percent of indoor patient are
children below five years. The cese fatality rate is 10-16
percent.
Malaria
A major problem of resurgence—man-made urban malaria.
I
Filariasis
Hundren million people in India living in endemic regions
facing the threat.
Malnutrition
i
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
27.5
18
9
70
60
20
% new bom weighing less than 2.5 kg
2.5 kg
% of anaemia among pregnant
women
i
■Blindness attributable to Vitamin A Deficiency
*
occurs among 20-30,000 children in India.
o
Water supoly and sanitation
Only 31% of the 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%
Source: CSI Ministry of Healing
(5) _
I
EVOLVING POLICY ALTERNATIVES
The National Health Policy statements are beginning to
echd these ideas and values.
Whether this is 'oopulist rhetoric'
only time will tell.
Pen B
or a serious 'rethink
.......................
................. -
NATIONAL HEALTH POLICY,
_________________ __ __________
1983
yV'l’
h
2
Recommendations
■
r°£_£®structuring
■•
T
1
5
Services
>
1. Organised 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 station?
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 super speciality
services
9.
Mental 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
( IS )
. .... ... .
3$. 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 movement1'.
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.
Ppiicy 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-government
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
9
iv.
Health in the education process
Health issues are increasingly becoming part of the
syllabi of formal? non-formal and adult education
programmes in the country. Schools are also
gradually becoming focus of health activity.
v.
Hea1th 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 erneroinq 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 thet 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.
9
3
All these trends call for a guarded optimism since
a series of negative trends are also becoming
increasingly stident. These are—
o
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
supported by a combination of social, economic and
political factors. Foreign funding agencies are
vying wittj, 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.0 Most of these projects are 'medical1 providing
packages of services with little or no understanding
of the values/vision of the health movement or a
social analysis.
iii.
Verticalization 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.
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,
o
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.
a
ISSUE RAISING - A CRITICAL TASK
When we think of
’Community Health'
of voluntary agencies,
or of health projects
it is customary to think of micro level
field exoeriinents 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 few individual
'charismatic'
NGO health innovators
have participated and contributed to
'expert committee refle
ctions'
But on a more long term
initiated by the government.
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 theEe such groups in the country.
In the 70s the
medico friend circle emerged as one such group out of the
ferment that marked the Indira/3P era leading to emergency
and its aftermath.
Over the 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.
The Kerala Sashtra Safyitya 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 ef late become an important and
crucial
'heath issue'
raising group in Kerala.
The people's
science Moviment in Maharashtra and more recently the Karnataka
Rajya Vignena Parishad have also begun to exolore health issue.
Another important network on the national scene is the
All
India Drug Action Network which has brought together a
, . . .2
2
wide variety of individuals, groups and associations into a
movement for a rational 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
the level of the people discussing issues and raising
consciousness about the various dimensions of the problem.
The 'Bhooal 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
,
a
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-re^onsiveness of the established
status quo system to issues of justice on the
'Drugs'
and
'Bhopal' matters.
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
THE f!ED ICO-FRIEND-C IRCL E
Works touards a pattern of medical care adequately geared to
the predominant rural character of our country.
Works touards a medical curriculum and training tailored to the
needs of the vast majority of the people in our country.
Wenfcs toioevelop methods ot medical intervention strictly
guideo oy the needs of our people and not by commercial interests.
Stands fcr popularisation and demystification of medical science.
Believes in a democratically functioning health team and
democratic decnetralisat ion 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-towards a kind of medical practice built upon human values,
concern for human needs,
equality and against negative, unhealthy
cultural values and sttitudes in sodety, e.g. glorification of
money and power, division of labour into manual and intellectual,
domination of men over women,
urban over ratal,
foreign over
Indian
Believes that non-allooathic therapies be encouraged to take their
proper place in the modern system of medicd care -— medi co-frei nd circle — perspective and activities.
1984
ALL INDIA DRUG ACTION NETWORK (AIDAN)
AIDAN consists of numerous health,
consumer,
legal aid and
human rights oroanisations and people's science movements.
It is a awoing network of academicians, professionals,
social activi±s,
individuals and organisations who are
deenly concerned about the drug issue and working towards
the adootion end implementation of a peonle-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
Co UMx.
..... ..
KERALA SASHTRA SAHITYA PARISHAD (KSSP)
believes that science
The Kerala Sashtra Sahitya Parishad (KSSP)
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, chanoe.
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 cemoleted
twenty five years of work.
voluntary non-governmental cPnganisation,
A purely
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,
tnis small group has transformed itself into a mass organi
sation of peoole 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,
dualised,
indivi
institutionalised and highly costly and catering
to the needs of a
wealthy minority.
KSSP feels that a People's
Health Movement alone can change the health delivery system
in fabour of the rural poor.
KSSf/is organisi'ng health camps,
classes and audio-visual campaigns P’:’--''-: rjzrra on extensive
scale.
KSSP has recently started fcx a big campaign to expose
the anti-people and unethical policies of the multinational
drug companies.
Have completed a very comprehensive health survey covering the
whole of Kerala. On the basis of the sutey results,
the KSSP
intends to formulate a people's health programme for Kerala,
The
KSSP is mounting a vigorous compaign against the recent drug
price hike.
KSSP publications like 'Hathi Committee - A decade
after’,
’The Drug Information Packet’,
Drugs'
have received wide acclaim, j ( ^0 )
'Banned and Bannable
Training 'enablers1 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
0,3 K'ClC # >
fuwilco
in community heal th/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 health1
social medicine1
and 'preventive and
i'e-'1'' '
in the country in many respects,
chief among which are:
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 trainingxof local health
workers„
iv.
They all promote demystifration of medicine,
eGmmtitfcthhbiraa 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
o
2
In this dimension they range from centres which
train for the delivery of an integrated package
of services to 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 have1 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 front 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),
Nurses Association (INSA, Bangalore)
and a
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 tlere been an attempt initiated by
VHAI, Nev; 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.
o
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
1 Primary Health Care1
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 co/nmunity and country
can afford 1
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 wer,^:
1. Equitable distribution
2.
•
Community participation
3. Multisectoral approach
4, Appropriate technology
Apart from a series of technological and managerial
innovations that were considered in the view of Health
action that emerged at Alma Ata,
probably the most
significant development was the recognition of a
process'
dimension in Health care including
organisation, community participation,
'Social
community
and a move towards
.... 2
9
2
equity.
Health service oroviders uoultjfce willing nou to
appreciate social stratification in society, conflicts of
interests among different strata and to explore conflict
management.
These were not explicitly delineated but were
innerent to the issues raised in the Declaration.
An
equally important fact uas,that/these perspectives emerged
from the pioneering experience of a large number of voluntary
agencies ana seme health ministftUS 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 nou become fashionable in
India to use 'Primary Health Care'
to describe all Alternative
Health Action and synonymously uith Community Health(CH). 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.
Uh at are these differences
*
1. Primary Health Care concentrates on Primary level (first
line contact) and ignores orientation of tertXXry 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
caste/class and other dimensions in society.
Conynunity Health recognises stratification and conflict
and the role this plays in accessibility and opportunity
inhealth.
3.
Primary Healch Care leaves the 'development'
and modern
isation conceot unquestioned.
Community -lealth locates itself in the centre of the
development debate and looks at health culture in a
□holistic way.
... .3
9
3
4 . Primary Health Care leaves the medicalisation of health
and the mystific 'tion and heirarchy of medicine unconfronted.
Community Health confronts both these issues and tries
to evolve an alternative plural,
demystifietC-
■,
non-heirarchical value system.
5.
Primary Health Care has now become selectivised and all
these who would prefer vertical topdown,
s
solution,
selective, health
funded by government and nori-government,
international funding agencies have begun to gain control
ommunity 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.
THE ANTWERP I’lAMFiSTO FDR PRIMARY HEALTH CARE
Academicians,
community health specialists and practitioners
f^m 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
aporoach.
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 activaj 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
^Bincentrates 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,
best,
since, at their
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,
9
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 ableto play a great oart 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
0
2
* Health services must orovide 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
o
remains to be done.
This manifesto is issued because the oroliferation of selective
health intervention programs undermines the health services
at the exact moment when they try to reorganise themselves
4
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 additioti, experience has taught us that selective
interventions tend to become permanent even though they are
presented as "interim" responses only.
they need
In fact,
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 peoole's oarticipation in decision making about
their own health.
The undersigned thus wish to reaffirm the principles of Primary
Health Care in its comorehensive form, and reject other
approaches instituted and propogated as "selective primary
health care".
/
Q
COMMUNITY HEALTH AND 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 bad 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
tne hospital and dispensary are characterstic examples.
Does this mean that the
’community health approach’
and the existing medical system of hospitals,
health centres, doctors, nurses, drugs,
dispensaries,
technology, centres
of specialisation, education and research are incompatible?
Qhile recognising the need for a ’paradigm’
attitude and aporoaches from the
to the
shift in
’provision of medical care’
’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 hihgly 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 pa-y
for them.
Gradually the forces of a market economy of which
.... 2
o
2
such a model is an integral part,
alienates the structure
from the poor and underpriviliged and all those who basically
cannot afford the luxuries of the type of health such
systems symbolise.
Houever, since community health is basically a new
vision^ a new value system and
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
no^t just as the problem of individuals.
c.
more socio~epidemioj?oqically 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 a nd
hopes of the people, the patients,
the 'beneficiaties'
the consumers,
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
o
3
irrelevance and gradually become supportive infrastructure
of a more just and healthy society.
However this change
cannot be miraculous or based 041 just good intentions
or any anount of wishful thinking.
commitment to social analysis,
It must be a serious
participatory evaluation
and critical seif-searching for greater relevance by
all those concerned with planning and decision making
in the present superstructure.
IW ;
! aJ 'fc fk i
e
.Lx
*
'
0
0
“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
s
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
o
2
1986
CHRISTIAN MEDICAL
“commitment to community
«
ASSOCIATION OF INDIA
health....a process that
(300 institutions
(protestant) plus
5000 individuals
associated witV these)
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
0
M7
lo(H|
HEALTH FOR ALL
ICMR/lCSSR
Prescription
A MASS MOVEMENT
TO
Bi REDUCE POVERTY, INEQUALITY
AND SPREAD EDUCATION
Bi ORGANISE POOR AND UNDERPRIVILEGED
TO FIGHT FOR THEIR BASIC RIGHTS
Bi MOVE AWAY FROM COUNTER-PRODUCTIVE,
CONSUMERIST WESTERN MODEL OF HEALTH
CARE AND REPLACE IT BY AN ALTERNATIVE
EASED IN THE COMMUNITY.
•>
nr—
HEALTH SERVICES IN A COUNTRY
dK
Postulates of a theory
Health Service development is
a.
a socio-cultural process
b.
a political orocess
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 rask 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 obher members of the^iteam,
which can take full advantage
of the scope offered by the base (i.e.,
the complex of
ecological, epidemiological, cultural,
social,
and economic factors at play)
political
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.
- 0 Banerji (
| L| )
(&' RECOGNISING THE NEV PARADIGfl
has been a
This alternative health care project phenomena
spontaneous upsurge in the last two decades and not an organised
From 1984, a team of us have been studying
planned movement.
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
action.
failures,
Our attempt has been to look at successes and
strengths and weaknesses, opportunities and threats
of all these community health action initiators.
taking a 'macro view'
Also by
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 tleir right, and involves the increasing
of the individual,
family;■
and community aionomy 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,
Experiment 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 manpower resources.
. . . .2
2
While facilitating these managerial/technological innovations
the Community Health action initiators have to seriously
face up to a wide variety of
issues'
i)
and 'value
that are:
Organisation of non-formal, informal, demystifying
and conscientising
ii)
’social processes'
'education for health'
Initiating a democratic, decentralised,
programs;
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 organise,
involve all those
who do not/cannot participate at present;
iv)
a
Questioning the over-medicalised value system
of healthcare and trailing 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-eipidemiologically oriented
- more democratic,
- more accountable
vii)
Recognising the cross-cultural conflicts inherent
in transplanting a Western Medical model on a
non-western culture and hence exploring integ
ration with other medical cultures and systems
in a spirit of dialogue.
. . .3
viii)
Recognising 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 oroject of measurable activities;
but has to transform itself to
a new vision of health care;
a naw value-orientation in action
and learning;
a movement,
a means,
not a project;
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 Action
Network have all icTentified with this new thrust in the
IV
policy statements of the 19 80 s ( | CJ t,2-)
The ICMR/lCSSR Health for All prescription includes
these dimensions as well (
MJ "
M2 1_
A plea for a Neu Public Health is the latest in a series
of issues and theoretical perspectives emerging from
academic centres as well.
P<.|-
I (-(,
72-
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.
| '3ox \ 3
__________
*
"
“'
*
.....
..
'
* I.
'
i i
I tiiiri M«' iiili-ui«inliUt
'The flandwa Experience'
o
Several Community Health Projects have demonstrated that most
communicable diseases can be controlled even under the existing
socio-economic conditions.
In the Nandua 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 sufifiering 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 villag: 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 of 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 tVe rest of his family.
taught
They also
other simple 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,
new case of deformity;
there was not a single
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 i^i deaths from gastro-enteritis
not onl^i because of ORT but because of the creation of an
eoidemiological conscioisiess 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 undert&en in this
project, yet the so-called targets set by the PHO were over
reached even in family planning.
This people-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 experience has shown that
they cannot undertake these functions themselves even at a
far greater cost.
The present approach has only led 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 jrole of the Community Health
Centre shoulo nevetthless be of monitoring the people's
health with priority to the promotive and preventive
services.
The ICSSR/1CMR 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 per annum leaving only
a marginal sector for tertiary hospital care.
Also, that
this can be achieved only if the people have th§ 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 be 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 oublic as
well as the private sector.
Dr N H Antia 0J)
5
o
their own people in times of crisis.
approach in the
The pedagogical
training session will determine whether these
village workers will become 'Lackeys of the existing system'
or the 'liberators of their people'
as David Werner had
warned from his flixican 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 leader^iip qualities did emerge and action
on issues wider than health was cpnerated.
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 pation_in_hea11h_decision
/
making
In addition to training oillage health workers many of these
projects have attempted to involve the community or their
representatives in the planning and decision making process
through the organisation of local village informal leaders.
Many had involved existing
youth groups
mahila mandals (women's groups)
farmers associations
cocperati ves
and
teachers and religcdu 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
6
o
i. Firstly ths involvement of all sections of the community.
In the strafied village set-up with certain caste and
class groups dominating decision making and exploiting
certain other groups,
purposeful involvement of dis
advantaged and oppressed sections of the village often
mean even exclusive involvement.
ii. Secondly the health action initiators must be willing to
learn from the people and their own experience of local
culture and social reality.
dialogue'
This means a 'democratic
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.
g.
Initiating community organisation
The qualitative differeqpe from the/above approach is only
of emphasis.
o
Many projects have themselves initiated or
catalysed the development of
a -
.'.jLs, <-
youth clubs
mahila mandals
farmers associations
and various group activities recognising the need for local
organisations to participate in planning and sustaining health
actions.
This action has also emerged 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
religious divisions that
various social, cultural,
political,
divide society at large.
Hence building groups relationships
.. .7
-?
9
and group organisations arolind issues and common actions are
themselves pre-requisites for community health actions,
h.
A quest for financial self-sufficiency and cjneration
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 oft'en result in the
exclusion of those sections of the community which need the
health services most, especially when the
purchasing,
:
capacity of people is so skewed.
Many projects have howevfe'r 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
'Health1 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
0
0
8
health.
The efforts have been demystifying and conscientizing,
heloing groups to understand the broader issues in health care
as part of a wider awareness building process.
These have
been specific comnonents of health action^br have been intro
duced as components of existing adult education and non-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,
own families and their community,
j.
that of their
share the same vision.
Conscientization and political action
There are some projects uh'ere the health teams based on thar
own exoerience have begun to show a deeper understanding of
issues for conscienti^&tion and recognise the need to support
political action especially those of
mass organisations.
'people movements'
and
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.
The Alternative Community Health_ProJect_Phenomena_~_Three_guestions
Since the late sixties and particulary in the seventies a large
number of initiatives and projects began to get established
outside the government system by individuals and groups keen to
adapt health care approaches to the needs of our people.
agencies in Health Care (now
Broadly classifed as voluntary
also referred to as non-governmental organisations (NGOs)
policy documents)
in
these initiatives were predominantly rural
to begin with but later some of the focus also shifted to the
tribal regions and urban slums.
Starting with illness care most of them moved on to whole
range of activities and programmes in Health and Development
creatively responding to local needs and realities.
Each
project or initiative evolved in the context of a local
reality and a local health situation.
social
Since these were diverse
each of them evolved their own process of action, package
of services and local health organisation.
t*
WHO were
the Community Health Project initiators ?
The originators of these projects were doctors,
nurses, health
and development activists, who had been challenged and stimulated
by the social disparities and health needs
of the large majority
of people in the communities they served.
They came from different ideological backgrounds - Gandhian,
Christian, Marxist agd other convictions.
They differed widely
in their understanding of the development process; their
perceptions of governmental efforts; their conceptions of their
own roles in developmenythe source of their funding and their
initial understanding of the health process itself.
They all
however shared a common conviction that something needed to be
done c and could be done if one tried to understand the local
situation in depth and react
Community.
<9
creatively to the needs of the
5-b._Hou did these initiatives evolve
These initiatives evolved in a variety of ways.
Health was some
times the entry point, sometimes it got into the package at a
later date.
Today they represent a wide variety of origins and
bases.
a.
A rural development programme with a health component eg R CJ H S A ,
Tamilnadu, Banuasi Seva Ashram,5 UP
b.
A community based medical/health programme, eg Mini PHC of VHS,
Tamilnadu, RAHA Project, MP
c.
An integrated development programme in a tribal area. eg. VGKK,
Karnataka.
d.
An adult education/non-fcrmal education programme with a
health component, dg AUARE, AP
e.
" science education programme with a health component
eg Kishore Bharati, MP
f.
A nutrition supplementation prog amme with a health component.
eg Project Poshak'& Project Palghar , Maharashtra
g.
A cc nsc i en t i zat io n/a wa reness building programme with a health
component, eg.
h.
Bodokhoni, Orissa
A community extension/outreach programme of a hospital
eg MGDM Hospital Project, Kangazha
i.
A field practice area of a medical/nursin^paramedical
training
institute, eg. Mallur Health Cooperative, Bangalore
j. A school based health programme eg Dee na ^eva Sangha,
k.
6.lore
A health programme as a component of a trade union movement
eg. CMSS Health Project, D a11i Rajhara, M ' p •
1.
A health programme as a component of a project focussed on
m.
Health as a component of a community action in urban slums
women's issues eg. Women's voice 8.lore,
eg.
n,
SEUA Ahmedabad
Streehitakarini, Bambay
A health programme for workers organised by an employers
association, eg CLW5, of UPASI
for tea plantations,
Kerala & TN
and so on
As the 'community health'
action initiatives grew in experience
and numbers a second generation of initiatives evolved:
a.
Issue raising groups like mfc, AIDAN, KSSP
b.
Coordinating/networking groups like VHAI, CHAI, Ch’AI and ACHAN
c,
d.
Community Health training centres like RUHSA, St John's and others
‘-ommunity Health Research Centres like ARCH, FRCH, SEARCH 4 others
These will he oescrihed later.
o
IJUAI 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 healths
The component of the new approach to health action in the
'
Community are:
a.
Integrating Health with_Development activities
Recognising ill health as the product of poor nutrition,
poor
poor housing and poor environment many health projects
CJ C-V
had gradually^involved with
income,
agricultural extension programmes
supply
*
water
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.
Ei®-entive , Promotive and_Rehabilitative orientation to
£g^lth action
Most 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
Maternal and child health care
... .2
o
2
Family Welfare activities
Environmental
sanitation: Particularly safe drinking water supplies
and sanitary disposal of excreta,
sullage and refuse
Nutritional supplementation and nutrition education, and
school health oroorammes
9
were the components
Rehabilitation as a health oriented action was seen mainly in the
context of people suffering from leprosy.
More recently the concept
of community based rehabilitation is also being experimented within
a few projects.
Basically this new approach believes in the
organisation of the disabled in the community into associations
and involving them in efforts to improve their own conditions
through programmes of education,
income generation,skill training
and self reliance.
_Search
c.
and experimentation with low cost, effective and
appropriate technolo^j/
Many projects had triedd to evolve
health care technologies,
or promote more appropriate
The emphasis was not only on it being
low cost "but also on it being more culturally acceptable,
demystif
ying and more within the operational capabilities of local people
and health workers.
These included
improved dai (ffiBA) kits
nutrition mixes prepared from locally available foods
indigenous MCH calendar °
locally manufactured lower limb prosthesis, b ngles and tapes
to measure nutritional status of children
low cost sanitation options
home based or-al rehydration solutions
herbal and home remedies from the badkyard or kitchen.
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
9
7
APPROPRIATE TECHNOLOGY
E°L_!J]£H_y2iE
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 mother and child care - Also
a personalised health teaching aid0
2.
Arm circumference insertion tape
f
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.
Chi Id 1s bangle
Typically Indian method for diagnosing undernutrition 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.
o
Amenisia recognition chart
Simple coral used to detect anaemia by comparing the colour
of tongue, loiber 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 di sin§ectant,this kit costing a few paises can
be used to prevent tetanus in the new born.
7.
Better Child Care
A Q informative booklet with colourful pictures and
... .2
o
2
basic messages to help health workers and mothers to
-
discuss child care issues
(V)
"Technology can only be considered apprppriate
if it helps lead to a change in the distribution
of wealth and power
9
"
3
use low-cost media alternatives like flash cards and
flip charts and also to adapt local folk media and
traditional cultural/a£t 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 ’nachna1
(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
—————————
o
Local health resources include local family based traditions
of health and self care 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 associiion to an
o
. . .4
8
WoCAL HEALTH RESOURCES
1 The_Miraj Experience'
1. Training of Indigenous Dais
173 Dais out of 186 identified by a survey were trained.
The
emphasis of the training was 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
well 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 ANFI 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.
o
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 of/the project would invite these
practitioners during their weekly village visit to join them
in examining and teeating patients.
This training method was
beneficial to both parties concerned.
Eric Ram (
9
$
)
4
acceptance of some 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 villa2e 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
maternal and child health care
family welfare motivation
environmental sanitation
identification - reporting - basic measures in
'communicable disease control especially
-»»
malaria
o
leprosy
tuberculosis
mental health care
and so on has been probably the most characterstic feature of
(
fag)
all these projects./ ’The selection methodology,
methodology,
the range of skills and the
the training
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 mt 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
THE CCVER STCRY
Community Health In India
Preamble
This story attemnts to bring to the Readers
of Health Action a birds eye view of an emerging
ornress in
India in which there is a growing shift
of emchssis in health work from
o
lectors and Nurses
Hospitals and Dispensaries
□rugs and laboratory investigations
surgery and medical technology
to
Village/Community based health workers
Health. educat ion/awareness building
Appropriate health technology
Community based he?.lth actions
Involvement of traditional healing
practices
Intregrated rural development
AV
and so on
The orocess reflects a growing dissatisfactionwith the
hospiral/institutional based high technology models of
bealtn 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 y——ihmb needs
and our social realities.
t~ yy
~-yh
\Je have
.. 2
9
2
attempted tc explore as much of the diversity as nnssihl^
?5 well as "j5»w<^rom the wealth of documentation,
reflections
ejZ’edura t i o n a 1 m e t e r i als that this larmmio genPT 11 i.i i.j r
2
attempted tc exolore as much of the diversity as possible
of initiatives in community oriented, community based health
action as well as ciuote from the wealth of documentation,
reflections and educational materials that this ferment is
gene rating.
9
HEALTH DEVELOPDENT IN INDIA
The Constitution of" India adopted in 1950 clearly recognises
the government’s responsibility for the health of all the
people ano tnis commitment has led . to the evolution of a
large number of health programmes over the last AO 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,
nurse midwives, basic health workers,
auxiliary
block
extension educators for these health centres.
* The National
orogrammes 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,
* Establishment of pharmacies and training of pharmacists
Proauction of medical technology needed for hospitals
and dispen-aries.
_____ ___ ^2LJ___
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 Puolic Health as among its orimary duties.
It shall ensure
that the health and strength of workers,men and women,
*
and ihe tender aoe 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
3. TAKING STGCK
In 1972, when we celebrated the Silver Jubilee of
cur indenendence, there began a critical reflection and
introspection on the preceding twenty five years of
develooment. This was an important milestone and it
* became a focus to take stock of the strengths and
weaknesses of our planning and development particularly
in the context of the continuing poor guality of life of
a large majority of Incian citizens. All aspects of
national develo ment came under scrutiny and health
policy was no exception.
3
a.
ASSESSING ACHIEVEMENTS/fA ILURES
A study group of the Indian Council of Medical Research
and the Indian Council of Social Sciences Research in 1984
listedout the achievements and failures of the whole health
care strategy as follows:
'U'KING STOCK
he Indian Council of Merii
A study group d
the Indian Council of
the achi ev
ciences Research listed out
'fits and failures of t
ole strategy a,
ous:
Achievement
s
——------ — — — — — —
Life expectancy doubled
Health care services expanded
'
Manpower training centres increased
Small pox uas eradicated
Plague, Cholera and Malaria controlled
Maternal and Child Health 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 cr.re was outdated and counter
productive benefitting the rich and/jell to do
upper and middle classes
2.
Health uas a low-priority national
investment
^civicc
| c pg t<h
1971
SHORE COMMITTEE RECOMMENDATIONS FOR
Recommended I
POPULATION
Estimated (1971)
Actuals (1971)
1981 (Actuals)
548 million
685 million(2)
370 million
PRIMARY HEALTH
CENTRES
1:20,000
18,500
27,400
5,112
34,250
5,740?
DOCTORS
1:2000
1,B5,000
2,74,000
1,61,129
3,42,500
2,68,712^
73,7?8
NURSES
1:300
12,333,333
1,326,666
80,620
2,283,333
150,399<2>
, -
HEALTH VISITORS
1:5000
74,000
109,600
* 8,347
137,000
@ 19,033/
MIDWIVES
1/100 births
100,000
225,776
* 9,253
231,530
@ 23,2002)
'
DENTISTS
1:4000
92,500
137,000
5,512
170,500
8,648
/t>lzS5X
'
Projection
as required
by Shore
Committee
As required by
Shore Committee
to actual
population
\
A
i... -
* Trained upto 1971
@ Trained upto 1981
Source:
Health Atlas of India, 1986
%r'~l1i!ndl.ijj.nk of1 HnrJ.~ttr~fnfqrjnnflnh
o<—1S8-6Health Information of India,'
T9&7~7?---—
3b
quantitative expansion
By 1972, when ue celebrated the Silver Jubilee of our
independence we had made rapid strides and a phenomenal
quantitative expansion of health care services. This
increase in manpower and infrastructure development continued
into the eighties.
Insert charts 1B, 21,
27, 28
30 and 31 from Health Atlas
of India,
1986 (Central Bureau
of Health Intelligence—C3HI).
At bottom-pf charts mention
source: Health Atlas of India,
1986,
C8HI.
By 1984, we had increased the number of hospitals
and dispensaries three fold, doctors five fold,
nurses
ten fold and dental colleges seven fold—remarkable
development indeed it seemed.
However, when we compare this infrastructural
development with the Shore Committee's long term coals
enunciated in 1946 itself,
we find the situation very
different and the so called’rapid growth'
becomes
questionable.
__________ _______ __________________________ C <7 ‘t'
Insert Table with 198{, totals
1 •
compared with Shore Committee
recommendations.
Increasing numbers with goals and base lines can be
very misleading!
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 committeeAhad to say:
1. ”A 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 peoole 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
ooverty 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!
Ue have adopted tacitly,
i
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
I
terms of consumption of specific ponds and services;
!
basic values in life which essentially determine its
|
quality get distorted; over-professionalization increases
I
costs and reduces the autonomy of the individual;
’
the
and
... .2
2
ultimately there is an adverse effect even on the health and
These weaknesses of the system are
hap-’ness of the peoole.
now being increasingly realized in the West 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
ssional i zat 1 on is obviously unsuited tr the sccio-econnmjc
conditions of a developing country like ours.
It is therefore
a tragedy that we continue to oersist with this model even
wtjen those we borrowed it from have begun to have serious
It
misgivings about its utility and ultimate viability.
<*
is, therefore, desirable that we take a conscious and
i
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
»
(for which we have severe constraints).
3.
n
In the existing system,
the entire orogramme of health
services has been built up with the 'metrooolitan and capital
c it is as centres and it tries to spread itself out ir/lhe
rural areas throuoh intermediate institutions such as
Regional,
or Rura]_ 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 SO percent of the oeople of India who should
really he thfyf'ocus of all the welfare and developmental
. . .3
3
effort of the State.
It is, therefore, uroent 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 thrin 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.
— t.
------------------------------------------------------------------------------------- -
4.Throughout the last two hundred years, conflicts have arisen
in almost every important aspect of our life,
between our
traditional patterns and the corresponding systems of.the
West to which we have been introduced.
aspects,
In many of these
the conflicts are being resolved through the
evolution of a new national pattern suited to our own
genius and conditions.
unfortunately,
In medicine and health services
these conflicts are yet largely unresolved
and the old and new continue to exist side by side, often
in functional dishormeny.
A sustained effort is,
therefore
needed to resolve these conflicts and to evolve a n itional
system of medicine and health services, in keeping with
v
our life systems, needs and aspirations.
Plany 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 fop more relevant alter
natives and approaches.
-A MULTITUDE OF
QUESTIONS
Fhat do all these statistics and critical introspection mean
to the rural people who have suffered neglect for years?
Have
the post-independenee policies made an impact on their lives?
Professor Ashish Bose while reoiewing the Family Welfare
programme has this to say:
0°/
"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
su b-centres?
* Why are medicines not available to the poor?
* Why is there no follow-tup of acceptors of
sterilisation?
* Why are women brought to the PHCs for
laparoscopic operation?
* Why are the X-ray machines not working in
so man'y PHCs and hospitals?
* Why is there no facility for oxygen and
o
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 A N Ms 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
will win and the government would lose. The sad fact is that
the infrastructure remains unutilised because it is by
and large not operational”.
T
Experts and academics, policy makers and r searchers,
health personnel and the people all of them have agreed
that the Quantitative exoansion of the health infrastructure
ano programmes has been at the cost of the quality of the
programme. There was need to evolve a system and approach
more relevant to our social reality.
°
Who would begin this task?
Contents
THE COVER STORY
Community Health in India
Preamble
2. Health Development in India
2a.
Constitutional pledges
Box 1
3. Taking stock
3a. Assessing achievements/failures
Box 2
Achievements
3b. Quantitative expansion
Insert charts 18, 21, 27, 28
30 & 31 from Health Atlas
of India, 1986
Bhore Committee recommendations
Box 3
3c. Critical introspection
Insert
Box' 4 (1-4)
A multitude of questions
Box 5
4. The health scene in
80s
The national health scene
Box 6
5. The alternative community health
project phenomena—three questions
Appropriate Technology for
MCH work
Box 7
Local health Resources—
The Miraj experience
Box 8
The Mandwa experience
Box 9
6. Recognizing the new paradigm
Recognizing the new paradigm
Box 10
Health for all ICMR/ICSSR
Prescription
Health services in a country
i_ Evolving policy alternatives
Box 11
Box 12
Box 13
7. Community Health and Primary
Health Care
Antwer-p manifesto for primary
health care
8. Community health and hospital
medicine
' Insert Mission Hospital—200OAD
L an edict (CHAI)
0
Box 14
2
9. Community Health—Is a movement emerging?
10. Issue raising - a critical task
11
medico friend circle (mfc)
Box 15
All India Drug Action Network (AIDAN)
Box 16
Kerala Sastra Sahitya Parishad (KSSP)
Box 17
Training 'enablers' not 'providers'
Community health training in India
12
Box 18
From Intra cellular to Societal Research
Non-Governmental Organization
Research Centres in Community
Health—some profiles
Box 19
CONCLUSION
The paradigm shift
Box 20
-'A :
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RF_COM_H_57_SUDHA.pdf
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