CASE STUDIES OF COMMUNITY HEALTH
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- Title
- CASE STUDIES OF COMMUNITY HEALTH
- extracted text
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SAR£I, PLAN
Half the population in Sdrai Village is tribal while the
other naif is low caste people. The land around the village
was owned by the tribals earlier but now it belonged to the
•Malik’ in the nearby village and the Sarai villagers were
working for the Malik for the wage of Rs.3/" per day. The
nearest medical facility ’was in the town about 27 km away.
There was no motorable road for 10km to the town. Diarrhoea
deaths during monsoon and famine deaths during lean season
was a common occurance. The children and mothers were highly
anaemic.
It was at the state Fr.Amal came to this village. He
spent sometime with the villagers and came to the conclusion
that something had to be done. He contacted the Sisters of
Charity and explained the condition of the village. Sr.Karuna
in that community was occassionally visiting some villages
near their station. She talked to Sr.Sneha and both of them
decided to work in the village of Sarai and obtained necess
ary permission from their superiors.
Question; What will be your plan of action if you were in
the position of Sr.Karuna and Sr.Sneha?
Mi;19.09.1986:200
Prepare,; |,y
^omr.iur .
V0fa«3rz ■ ,
c-m,
N»» Delhi-;iooi6
CASE STUDY :
Tcanl
Wa
‘'e’SDA.
CHAKRAPUR
Chakrapur is about 20 km fran the project base. It is in a hilly area
and is quite cut off fran ether villages. The people depend cn each other
for survival. Very few of them are literate. Caste feeling is not very
strong in the. village.
45$ of the villagers are Yadavs
25$
"
" Brahmins
20$
"
" Harijans
5$
"
" Kumbhars
5$
"
" Muslims
The people requested the Community Health Project (CHP) to open a health
clinic 2 years ago and gave full cooperation. They provided a place for
the clinic and repaired the road partly through shaimdan, Panchayat's cash
donation and food for work progranme started by the CHP.
Then the project'director decided to train a.V.ill age Health Worker (VHW).
He chose Lakshmi, an intelligent though poor Kumbhar woman.
After the
training Lakshmi was very efficient and'responsible in her work. The
villagers were quite satisfied with her. She was therefore also made
responsible for distributing bulgar and milk in a feeding progranme for
the village children.
a
Sane months later/ Fanners' Club was formed for the '.benefit of all in
the village. The club committee had a representative fran all caste groups.
The project's social worker, was also a member of this committee. He was
supposed to coordinate the different activities of the progranme in the
vi 11 age, though the project director had the ultimate authority.
Recently, the Farmers' Club criticised the VHW1 s work. They felt she was
distributing cnly half the bulgar and suspected she was cheating. They
canplained to the social worker and also told him that the VHW was of
"low moral character". The social worker, who respected both the club members
and the VHW, went to investigate. He found the VHW was actually distri
buting less bulgar and told the project director about this.
After some days the Farmers' Club demanded that the 2 village volunteers
that helped the VHW be replaced by people chosen by the club. The VHW
knew the project director had faith in her. She argued with the club
members that her helpers were already trained in their work and the children
listened to than. She saw no reason to waste time and effort in training
new people.
The matter was left as it was. Two months later the VHW asked all the
parents of children in the feeding programme to pay Rs. 0.25 per month for
the food. She also ordered than, to bring seme salt to be mixed with the
bulgar. The Brahmins and Yadavs of the village were adamant that their
children should not consume Harijan's salt as that amounted to breaking the
'sacred' caste code. They threatened the VHW with dire consequences if she
went ahead with her .proposal. The VHW, secure in her position, ridiculed
them aS 'High Caste Fools'.
She threatened the Brahmins and Yadavs by
saying "I'll see to it that you get no work in the food for work progranme".
Of course she had no authority to say this. A heated discussion followed.
One of the members of the Farmers' Club slapped the VHW.
=xXx=
chttzpt:19.5.’B1
CASE STUDY . < \ ISriALNAGAR
A group of Health Workers were living in a Health Centre one
mile away from Vishalnagar. A landlord of this village req
uested the Health Workers to open a dispensary and agreed to
donate land for the building. The Health Workers opened the
dispensary and had been working there for about six months'
when one day some people from the village threw stones at
them. The Health Workers were at first shocked by this vio
lence. After some days they decided to ask an outside agency
to help them find out what had gene wrong. The group did a
survey of the village and we are giving below some of the
information they found cut s
Vishalnagar has a population of 525 and there are 90 house
holds in the village. The average number of people per house
is 5.8 and the average number of children per house is 2.7.
Economic structure :
Most of the village people depend on agriculture for- their
livelihood. The total acreage under cultivation is about 400
acres.
Land holding pattern ?
farmer
farmer
farmer
1
families
66 families
250 acres
100
"
50
”
some land (less than 2 acreas each
- .landless labourers
-
The land of the landlords is cultivated by tenants but there
is no document to prove the tenancy. These tenants are small
farmers and landless labourers. At harvest time 50% of the
produce goes tc the landlord and the remaining 50% (after
subtracting the price of seeds, fertilizers, electricity bill)
is distributed among the tenants.
Wagc-s
Women are paid Rs.2/- per day
Rs.4/- per day
Men are paid
Other sources of income
There are 36 cows, 16 bullocks and 19 buffaloes in the
Village. Except for 10 animals the- rest of the livestock
belongs to the three landlords. The animals are cared for
by the Harijans for which the Harijans received Rs.3 to
Rs.5 per month as wages.
Credit :
The- landlords arc the main money lenders. There are no co
operatives or banks in the village. The village people take
loans mostly to buy grains when they have no work, for
marraiges and for funerals. They have to repay trie loan
during the harvest season and the amount is cut off from
their wages. The interest rate is between Rs. 10 - Rs.12
per Rs.100 per month. Normally after the loan has been
cut off a labourer gets no more than Rs.15 - 20.
Housing ;
The landlords live in good houses. Most of the Harijans live
in little huts. A few years ago the Government donated some
land tc 30 Harijans to build their houses. As sosme of the
land was cutside the Panchayat’s limit the Harijans were not
2.
able to get finances to build all the houses. Only 15 houses
could be completed. At the time of the survey seven of the 15
houses were in the hands of tne landlords(mortgaged) . The houses
in the possession of the landlords were rented out to the
Harijans for Rs. 10 per month.
Political Structure :
The Panchayat office is situated in the' neighbouring village.
There ar: two panchayat members in Vishainagar. These two mem
bers are the Pvippe-ts of the landlords. After their election to
the Panchayat, they have got the Government grant to dig two
drinking water wells, electricity the village and build the 15
Harijan houses.
Hindus
- 66.2%
Christians
- 33.5%
Muslims
- 0.3%
The whole village celebrates the festivals of different religions
together.
Religious groups ;
Caste structure :
There are 3 main casts in the village:
Reddys
- 25.7%
Harijans
- 37.2%
Vaddas
- 17.4%
Others
- 19.7%
Of these the Reddy are the dominant caste. Untouchability against
the Harijans is still practices. The Harijans are not allowed
to take water from the same well.
Health Status :
The staple diet is ragi, dhal and green vegetables. The rich
landlords have two meals in a day whereas the poor people have
only one. There are no serious illnesses in the last year
except for two cases of Asthma. The motality rate in children
is low. 10% cf the Harijans families had limited their family
size by the birth control operation.
Health Services :
There is no private practitioners in the village. The Government
hospital is about 2 miles a-./ay. The dispensary run by the Health
Workers does nut get more than one or two patients per day. The
Health Workers were giving medicines, grains, mild powder and
clothes to the landlord for distribution among the poor but
these things never reached the poor.
Needs :
When asked what the people needed most, the majority expressed
their wish to have a house cf their own. Some of them are living
in rented houses belonging to the landlords. (If the labourers
fail or- refuse to work in the fields of the landlord, the land
lord w^uld simply lock the houses. The other people are staying
in huts). Another need the village- people expressed was a school.
The peer people also asked to be provided with cattle as there
was no possibility of them acquiring any land. In spite of the
poverty and misery many expressed the desire to build a place
of worship.
Needs in order of people's priority:
1. Houses
2. School
3.
Cattle
4. Temple
5. Bettor wages
CASE STUDY : GUMHL
(T.W.)
Gumri Health Centre had a staff of three trained ATMs, Sindhu, Kamala
and Balana. Balama was the most experienced of the -three having worked in
a good Community Health Programme for three years. She had also attended
a course inCommunity Health and Development. Sindhu i_d Kamala had joined
Gumri immediately after their training 5 years ago. These ANMs decided
to start a Conmunity Health Progranme in the nearby villages. As Balana
was more
experienced, she was naturally chosen as their leader. .
They selected three of the villages
Together they discussed
the objectives cf their programme and how they would go about implementing ' ' ,
it.
They decided to take as target group the under-five children and
the women of child bearing age.
Balama who was aware of the necessity to
have the people involved in the progranme, insisted that they should first
spend time visiting the villages, befriending the people and learning'about
the problems of the canmunities -before starting any specific activity.
The ANMs visited several villages.
where they had been particularly well received.
Sindhu and Kamala did not contradict her, but Sindhu felt strongly that
immunisation and Family Planning progranmes should be started immediately. ■
Sindhu thought, "After all^ don’t we all know that these programmes are a
priority? Then why waste time visiting the villages, and chatting with
the people when we could already start good progranmes?"
K anal a was a
happy, go lucky person and could not care less what she started with. She
was therefore ready to follow Balama all the way.
Still, after their discussion, the following plan of action was decided:
1.
2.
3.
4.
5.
Joint weekly visits to the three villages
Primary level curative service to be started immediately
Intensive visits of the families to be done
Leaders to be identified, 4°°d rapport with the people to be
established, before starting specific progranme
Health progranme to be planned jointly with the people.
Sindhu was amused. "Whoever would think of planning with the people?"
she thought.
So they started their woik. After six months a visitor
helped the health workers to review their activities in order to find out
how things were progressing.
The following observations were made:
1.
The three villages were regularly visited by the three woikers once
a week. During these visits the patients were first seen.'
Then
the woikers visited the families separately. Besides this, Balama
and Kamala very often went together for an extra weekly visit to all
the villages. During that time Sindhu went to the PHO and obtained
from the doctor there, DPT and DT vaccines,
2.
Balana and Kanala took time to visit the fanilies, discussed with the
people and became quite friendly with all. They met the Sarpanch and
several of the important people in the village and discussed with them
the conmunity’s needs. They learot that, in two villages, there was
no drinking water facility and this was a real problem. The drinking
water had to be taken from a pool where buffaloes tocktheir bath.
2/
t
2
3.
Sindhu visited the schools and Balwadi, gathered the children
present there and gave the first dose of DPT and DT'to 450
children.
When the time ewe for the second .dose, only 200
children received the dose (it was the marriage season and many
children did not come to the school).
4.
During another visit, Sindhu had also gathered the wanen to give health education. She expected, through this programme,
to be able to motivate the women for family planning. The first
day all the women came zs they did net know what to expect.
But soon most of the women dropped out of the class.
After two months of the work Sindhu decided that it was a waste of
time to visit the villages so often and so decided to visit cnce
a month only. Balama and. Knnala continued their weekly visit with
the sane enthusiasm.
scxx========
chtti'pt: 19«5,’81
Prepared by
Community Health Team
Voluntary Heaitii Association of India
C-14, Lommani.y Ccmre, S.D.A.
blew Delin-llJ 016.
FIGHTING BACK
It started two months back when five Harijans of Karainchedu
village of Prakasam District in Andhra Pradesh were killed
by the Kamma landlords of the area.
The government refused
to arrest the culprits.
The Harijan MLA ’ s wore reluctant to
raise the problem in the Legislative Assembly.
Upon this, more
than pOO Harijans of Madiga sect moved from Karamchedu even
though the Mala Harijans refused to join them for fear of
unemployment.
The Madiga settled down in Chirala 8 K.M. from Karamchedu.
Under the leadership of Kathi Padma Rao, a Harijan college
lecturer, Karamchedu Victims Relief Committee has been formed.
From Bs,1.20 lakhs they raised as donations from various sources,
they bought 8 acres of land and have started building new homes.
Though they left Karamchedu without money or posessions, their
unity and defiance have helped them to build four thatched huts
and an open community kitchen to servo them rice or gruel twice
a day.
They have definitely clarified that they would not
accept any official help.
They have named the village
Vi j ayanagar.
The Harijan representatives of Andhra Pradesh are using this
personal trajody of the death of five Harijans as a stepping
stone to a social movement which will fight against the opression
of downtrodden in the state.
They mot at Chirala and called for
a'rail aur rastha roko1 agitation on September Sth.
This
agitation disrupted the traffic upto Hyderabad.
The demands
wore that the real culprits who arc related to political
leaders be punished and that the migrated Harijans be permanently
rehabilitated in Vijayanagar.
The Kammas of Karamchedu accuse Padma Rao of trying to gain
political leadership and money from the trajody.
They claim
that before the incident took place, there was close intorcasto relationship between Kammas and the Harijans tc the
extend that both of them were drawing water from the same pond
and that the Killing occured when Kamma youths were assaulted
by Harijans.
....
■ .
(India Today Sept. 30th ’85)
Why did tie Madiga
<• ■
.
1
Why did the Madiga. Harijans of Karamchedu take to this course
of action?
•
■
• i
■
j
What are the features of - this people's action?
What relation do you sec between the responses of the Government
and the Kammas?
i.
Why Harijans and Tribal murders are frequent occurCncos in
India?
What all factors contributed to spreading this-micro (village)
level incident to a macro' (state/national) movement? .
Community Health Department
C.H.A.
C.B.C.I. Centre
Cole dakkhana
New Dolhi-110 001
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
SHpmKKAM^ CASE_STUDY... X.DUPLICA11,ION . 0F„. SERVICES)
A team of health workers, attached to the private health
centre of Shorpakkam, decided to start a community health programme
in an area near their health centre. They knew that they would not
be duplicating Services because the Government Primary Health Centre
was situated more than 20 km. from Shorpakkam, and people visited,
attending Shorpakkam health centre had told them that nobody ever
visited their village.
The health workers of Shorpakkam had good rapport with the
villagers through the dispensary attached to the health centre.
The workers studied their OPD records and found that their patients
were mainly coming from three fairly big villages situated between
two to three km. from Shorpakkam.
The health workers discussed with the patients of the three
villages the possibility of developing community health programmes
in their respective villages. All of them were very keen on this
and repeated that nobody ever came to visit them and help them with
their health problems.
And so the health workers started their programmes in the
three selected villages. They had a weekly dispensary, mother and
child health programme with CRS food supply and house to house
visiting.
During their house to house visit of one of the villages,
the health workers came across a Government AM who was residing
in that particular village for the past one year.
It seems that
the PHC had opened three new sub centres in the past year, and one
of these sub centre was in this particular village. The AM was a
very nice person and seemed to be well accepted by the women of th
village.
chtt/la/1-3-84
Questions :
Prepared by
Voluntary Health Association
of India, C-14 Community
Centre, S• Delhi - 16.
1.
The people of one village misled to the health workers of
Shorpakkam. Why, do you think did the people hid the fact that
there was a govt, sub centre in their village ?
2.
On the base of the peole's word the health workers started a
Community Health Programme. Are there any other steps the
health workers should have taken before choosing the villages?
What steps ?
3.
If you were in the same position than the health workers of
shorpakkam, what you do now ? Explain your answer.
QUESTIONNAIRE
a. Read the list of adjectives given below.
which six adjectives
seem to you „o be the most accurate when describing villagers.
1 .
2.
3.
4.
3•
6.
Shrewd
Analytical
Competent
Generous
Lazy
Shallow
Reliable
Insecure
Mature
Conservative
unco-operative ^motional
Irresponsible Restless
Enthusiastic Frustrated
Money-minded Confused
Unreliable
Dogmatic
Ignorant
Efficient
Stupid
Paternalistic
Kind
Dependent
Sensitive
Powerful
Over-bearing
Weak
Exploited
Backward
Risk-taking
Hard-working
Impulsive
Immature
Naive
Idealistic
Progressive
Apathetic
Uncommunicative Responsible
Helpful
Appreciative
Concerned
Incompetent
Childish
Cautious
Unkind
Independent
Skillful
Supportive
b. From the same list, which six adjectives seem to you to be the
most accurate when describing yourself?
1 .
2.
4.
5.
6.
c. From the same list, which six adjectives do you think would
describe qualities most desirable in a development worker?
1 .
2.
3.
4.
5.
6.
THIRUNELLY - CASE STUDY
Thirunelly is situated in VJynad District of Kerala
State, adjacent to Karnataka boundry, with thick reserve
forests around and it has a population of 2000 people. 90%
of the inhabitants are Adivasis who once enjoyed the
ship of the entire land.
owner
But later, with the invasion of
migrants from other places, the illiterate and simple Tribals
lost all their land and today they own only 10 to 15
cents
of land and a few people have 2-to 3 acres. About 95% of
the people are agricultural labours. The nearest public
health centre is M- km. away from this village, and the
lower primary school in the area has 86 students but only
8 are Adivasis.
There is a temple in Thirunelly, which
attracts pilgrims from all over the country.
Thirunelly comes to limelight and public attention
every year because of mass deaths in the beginning of monsoon,
when there is no work,
People are affected by Diarrhoea
vomiting and fever and quite a number of them succumb to it.
Government named this phenomenon gastro-enterits. In 1977,
13 people died and many groups like Lions Club, Jeycees and
other agencies including the Diocese brought in aid from
outside. Later in 1978 Diocesan Social Service launched
a conscientization programme in their village on a massive
scale.in 1978,
8 people and in 1979, 7 died again.
Questions.
- Why mass-deaths, in Thirunelly?
A
- If you are in this situation what programmes
would you undertake?
COMMUNITY HEALTH DEPARTMENT
CHAI.
.-1ST JOHN'S MEDICAL CCLLEGE
BANGALORE
PARTICIPATION ASSzSSI-ENT (First Step)
1.
Check off the things that you did during today's session.
I listened
I read
I copied down notes
I wrote down my own ideas
■I mentally evaluated
ideas presented by
others
I offered ideas of my
own verbally
I took part in small
group discussion
I took part in \;hole
group discussion
Any other ? Specify .
2.
t
3.
I engaged in problem
solving individually --------in a team
I related theoretical
concepts to my own field
experience
I role-played
I participated in practical
activity
I created or helped create
a (communication) message
I got bored
I fell asleep
which statement best describes the way you feel in a new group ?
I ge nerally•
prefer to sit quietly and listen to others
feel quite at ease taking part in discussion
" find myself ready for some form of leadership role
sometimes wish I could take over and structure the discussion
ease
prefer to listen for a while and then participate after I
have a feel for the group
other
Imagine that you have been approached by a social reformer who
wants you to change sone aspect of _your lifestyle in the interest
of the nation or of the world , or perhaps just '‘for your own
good". You appreciate the new point of view, but are also aware
that any change on your part would involve certain personal
risk and criticism from some of your peers. What would you do?
You may check off more than one box, but if so, rank them by
number.
Take the social reformer ‘s advice and adopt the change right
away.
_____ Wait to see what other people will do.
’
Actively look for other community members who are interested,
'
and form
a study group
__
__ an action group
’Try to lear’n more awout the subject ’wS’thout letting anyone
~~ know? of your interest
ether response (specify)
______________
2
4.
1.
2.
3.
4.
5.
6.
7.
8.
9.
; 2 :
Facing problems
List f. specific problems that you and people in your peer
group often face.
Number them in order of difficulty of solution.
Put an asterisk in front of those that can be solved only
through influential connections.
Put a circle around the ones that require a lot of money to
resolve.
Underline the ones that affect you in particular.
Re-underline the one that would make you most happy if solved.
Against each of the problems that affect you, write the date
when you last did something towards solving them.
Check off tne ones that you have been able to solve
Consider: what does this exercise tell you about your
ability to confront problems ?
prk/191281
HANDLING CONFLICT
1.
Ths ELEMENTS of conflict, as examplified from "The Prisoners'
Dilerma"s
ds ASSUMPTIONS:
They may bo accurate or inaccurate.
1. Accurateg
"The object of this game is to make as-much money
as- possible, without hurting or helping the other".
2.
Inaccurate:
"The object of this game is to beat the' others".
Ss INTENTIONS:
They may be genuine or exploitive.
1. Genuine: "ije must earn money"
2.
Exploitive: "Ije must win".
C. COMMUNICATION:
It may be evaluative (judgemental, accusatory) or merely descrip
tive (direct, non-accusatory); and it may include positive or
.negative feelings.
1.
Evaluative and judgemental: "You crooks can't be trusted!"
2. Descriptive and Direct:
" I am not sure I can trust you"
3.
With negative Feelings:
"You're cheating!" (Anger)
4.
IJith positive feelings:
"Let's both play the blue card" (Trust)
D. BEHAVIOUR:
It may be reactive (against) or proactive (for); rejecting or
accepting; defensive or open.
1. Reactive : "We'll play.the red card!"
2. Proact ive:
"Let's play the blue card."
3.
Rejecting:
"|\|o negotiations with them!"
4.
Accepting;
"Let's give them a chance to prove themselves."
5.
Defensive:
"Be careful!
6.
Open: "Whatever happens, we'll stand by our word."
They are out to trick us!"
TWO POSSI 8LE APPROACHES to resolve a conflict;
A. From the level of Assumptions and Intentions:
ASSUMPTIONS
Accurat e
P
t
Inaccurate
-2-
— To move from Conflict situation to a Problem-solving one,
correct the assumptions and intentions of both sides, (seo Page 3)
g. From the level of Communications and Behaviours
_L_
Reactive
Rejecting
Defensive
(Negative Feelings: "against")
Open
accepting
Proactive
(Positive Feelings: "For")
__ To move from Conflict situation, a move to the right in this
case would be the right one.
PARENT-ADOLESCENT CONFLICT
Sit uation:
an over-protective mother and a rebellious teenager.
not her: "all I want is that my son should be happy and secure."
Son:
"i wish she’d stop talking about my, happiness.
It's she
who makes my life miserable.
Her whining and worrying
and ragging are driving me crazy’."
Assumpt ion;
1. Inaccurat e;
Mother:
Son:
"He needs me to look a ft or him."
"She's out to embarrass me ?nd make my life miserable."'
2. accurate:
Mother:
Son;
"He doesn't like my babying him."
"She's concerned about me."
Intentions:
1.
-
Exploitive:
Mother:
Son:
"He'll do as I think best and like itl"
"I'm going to see that she keeps out of my hair!"
2. Genuine:
Mother:
Son:
"I really want my son to grow up happy."
"I want to prove to her that she need not worry about me".
ASSUMPTIONS
Accurate
I'Uthsr: "He doesn't
like my babying him,
so I have to Tina out
how I can best help
him to be happy and
mat ure" •
Son: "Sho's worried
about me, s) I have
to show her, that she
need not be; that I
can stand on my own
feet".
FRO BL EM-SO LUI NG
Inaccurate
Mother: "He's not old
enough to look after
himself, so I've got
to do what is best to
help him grow up happy".
Son: "Until I can prove
to her that I don't
need her to wipe my
nose; she's going to
drive me crazy.
So
I'd better show her
that I am old enough
to take care of myself."
HELPING APPROACH
TICK'S---------------------------------------"Tit her: "He may not
.Lika it, but he'll do
as I say as long as
he's my son."
Son; "Let her worry'.
I'11 pay her off
against my father.
L'hat she doesn't know
won't hurt her'."
MANIPULATION
Mother: "He is not old
enough to look after
himself, so I intend to
tell him how to behave,
whether he likes it or
notl After all, Mother
knows best I"
Son: "as long as she
keeps nagging me and
embarrassing me in front
of my friends, I'm going
to stay as far away from
her as possible, and do
whatever I please'."
CONFLICT
-2-
III HOUSE RENT
Find out through inquiries what is the minimum rent for a
quarter in a bustee or village per month = Rs.(ill)
IV MISCELLANEOUS
Expenditure for fuel, light, etc. is calculated as 20%
the total monthly income.
(I)
Rs.
- Cloth
(II)
Rs.
- Rent
(HI)
Rs.
- F Jod
TOTAL
= Miscellaneous
Rs. ___________
X 1/4
Rs.___________.(IV)
Therefore, the minimum amount of money needed today to support
a family of four in your area = I + 11 + III
IV = Rs^-...
1.
Extent of inequality in the world todays
a. In 1350, 3/4 of the world's population possessed 5/8 of the
world's wealth.
in 1975, 2/3 of the world's population possessed l/S of the
world's wealth
b.
Whence came this uneven distribution of the world's resources?
"The tilting of tne balance in favour of the West has come about
in the last 130 years .......thro ugh the gun, through colonial plunder,
slave trade, slave labour, child labour, racial discrimination, the
creation of a dispossessed proletariate, and the destruction of the soul
and life-style of many peoples."
(s« Rayan)
c. The growing gap between the rich nations and the poor had
already been pointed out by Barbara Ward in the 1950's but the gap
continues to widen;
"Today 85/ and tomorrow 90/ rot in misery to make possible the
economic comfort of 15% today and 10% tomorrow"
( Heder Camara)
d. The result of this inequality is the ABSOLUTE POVERTY of
millions in the "fourth" world;
- 1/3 to 1/2 of the two billion human beings in Asia, .Africa
and Latin America suffer from hunger and malnutrition.
- 1/5 to 1/4 of their children, die before their fifth birth
day, and millions of those who do survive lead impoded lives, due to
brain damage, stunted physical growth and sapped vitality due to
undernourishment.
.•
•.
- The life expectancy of the average person is twenty years
less than his counterpart in the affluent world; that is, he is
denied 30/ of tho life-span of one born in the developed nations:
he is condemned at birth to an early death.
- 800 million of those people arc illiterate and, despite
continued expansion of educational opportunities, even more.of their
children are likely to be so.
e.
Julius Nyerere, President of Tanzania,. has warned the rich
nations; "Poverty is not tho real problem of tho modern world, for
we have the knowledge and tho resources wbioh will enable us to over
come poverty.
The real problem of tho modern world, the thing which
creates misery, wars and hatred among men, is the division of mankind
into rich and poor".
f.
It is not so much tho question of some having more to eat or
better clothes to wear, while others cannot provide oven the basic
requirements; it is rather the power that this wealth gives to some
to dominate, to oppress and to exploit the others.
in 00 .doing,
the rich and powerful justify themselves: "We deserve this wealth
and oowcr: we have put our Porl-niven talents to unn rnrt hp"1’ ''n"‘ nA
-22.
Extent of inequality in India today:
a. Jhile we often and with some justification, blame all our
problems on the greediness of-the affluent, developed nations, the
same ever-widening gap between the "haves" and the "ha:Ve-hots"
appears hero' even.’'’■
'\J't;
*.B.
,'!•jp:
''.M.O:
*-,
or.
1.
nor;:iv it, /. <>I
.n .■ -»}.
-.J'1’ -> j
■ini
,b. iJithin our population of upwards 600 millions-cdfi pdb'pl^1'roughly 250 million live below the "poverty line", that dividing
line''th'at deferiSSa'ias tiarp mirtlmtfm ’dK p'urilivai'' fdrlfTbri’ jtrtiflyidba'K
This'JJis: tpc bd.ttom 4O'”tie1r'c'eh't:''.'Another .2^6''ll ve,!j'irst'
a bo ve't he™ pb Vert y' I'in d'' iff 'humarr' .stfiKB-l/air' t hk1 remaining' '15120.'J ““
per ceht,' in ah a'scehcft'hg';pvra'ini‘dr|j(dpre0ht'-''Brha'dtimlnaTit',Ll Oj
class esT w'it’fr power,''"position "hntf^daiity etiuta't'iaks’ t'hb"\ra^,matb'-'1 ''' 3
rial''Hr1' fUrther'rexpibx£otl.'iffi'--tiF' tWi3t'fiof‘s’.'u®
,3Gsror.gl one cealjiirie ,yssI el blrow arid 5o daei odd '11
.bred
r-p.
In rural India, the top'ten percept own 50^ 'b'f ttfe1 -iinSirr 3
U '31i . • 1.
iv IV '!_» ;
'! J
J, , !■> ■ ■ ", iJi ! J
: Ccr i
, «.«
z'
I• r • VV
while the bottom 50 .per ,c.ent ,p^jp A^ ^t op^ ten p.er ^.ce.ntj ^get .1/3^ of
; j
annual income of the nation, while tha'bottom 50^. get lp.ps5,.thp_n ...J ’ u
this amount for all of their numbers.' 0.1% of the’ populaiiion''owns J
,morQ4M1
thcj wealth of the. orca. /:.
_
;
; ..
d... .The.; PJor" .axe o pgahi's'ecC ' wiT:.hb'^Upplitica1i‘'.pb'wer>,yari,d' ar-e'." "r''L
taken advantage of. 4 slum ;dwb'l’lerr’Admits:., VEV.pri. to; get
sweeper's job, ws havet'o phy h'briVe of Rs. 200/-'"’’
1 .
L-. .: ", \-n-.
■■ ■ JD ,
depo a.- ..' 1 . s iqr: , - n::.:i io r
's
.. e, .. i he .v^ry ,popr (bottom 40. p.c.rc^nt) Ipave less
month to spend.
Most'cannot’ read or write.' ’ .
per
8LI i ll.
;:om arid Io
I o I'-.Idoaq
s
I I'M ges
Ins ecure
Impersonal
Dependable
Conservative
Progress!ve
Flat ure
Emotional
Uncommunicative
Uncooperat ive
Rest less
Helpful
Professional
Frust rat ed
Concerned
Irresponsible
Conf uassd
Backward
Ent husiastic
Dogmat ic
Hard-working
Money-minded
Efficient
Immat ure
Loyal
Insincere
Idealistic
Undependable
0 ver-productive
Apathetic
Encouraging
Risk-taking
Responsible
Supportive
gelf-cont rolled
Unprofessional
Over-sensitive
Impulsive
Appreciative
Sup er ficial
Naive
Exploit ed
Lazy
1.
From the list of adjectives given above, which seem to you best
to describe the urban worker?
Select as many words as you wish.
you wish to add one of yo«r own,
2.
If
feel free to do so.
From the same list, which adjectives seem best to you to des
cribe the unemployed?
3.
From the same list
which adjectives seem best to you to describe
the villager?
4.
From the same list
which adjectives seem
cribe the average student?
best to you to des
-2-
5.
I^rom the same list, which adjectives seem best to you to des
cribe your parents?
6.
From the same list, which adjectives seem best to you to des
cribe yourselves?
HOUSE VISIT SURVEY
1.
Uhat community do you belong to?
2.
How many members are there in your family?
3.
Are all the children ^oing to school?
4.
How many members of tho family earn living?
5.
uhat are the market prices? rice? wheat? dal? oil? etc.?
6.
Can you manage to buy what you need for the family?
7.
Uhat are you most worried about now? low employment?
rising prices? children's education? health? debts? etc.
8.
uhat kind of injustice 'are you facing in your daily life?
unfair practices? discriminations?
9.
do
10.
you get any help from any source in solving your problems?
Uhat kind of support would you like to get from us?
could we help you?
Haw
11-
Uhat makes you feel happy about your life?
12.
Uhat are your hopes and ambitions for the future?
13.
family make-up; ages (children, teenagers, adults, old) and
sex.
14.
Type of house: mud or cement; number of rooms electrified or
not; owned or rented.
15.
Occupation of wage-earners; self-employed or not; farmer,
factory worker, government worker, contract labourer, teacher
et c.
16.
Education; how many literate; how many with basic schooling;
high schooling, higher studies; language(s) spoken.
17.
Income; sources and how it is spent on food, clothing, fuel
and lighting, entertainment, rent and other things.
18.
Savings; in what form
19.
Religion and caste
20.
Medical facilities at family's disposal.
,flt the end of each interview, you should record your findings
to these questions once you have returned home.
D
1.
ro our findings differ according to the section of town we
come from? Why might this be so?
2.
r£w does this "minimum monthly income" compare with the incomes
of the families we met during our house survey last time?
3.
Do the families we met then exceed the number of members of
the "model" family of four we have used on this survey? What
would this mean with regard to their minimum monthly needs?
4.
What may be the consequences when minimum monthly requirements
and income do not meet? Cutting corners? family insecurity?
undernourished and underclothed children? etc.
5.
What are some of the possible consequences of family insecurity?
quarrels? drunkenness? indebtedness bn.it becomes chronic? etc.
6.
Who is to blame for so many people in our community living
under or just on "the poverty line"?
7.
Where does your family shop? What type of rice does your
family buy? What typo of cloth? i-pw much rent?
How much
entertainment goes into your miscellaneous expenses?
8.
Was this a new experience for you, or have you often done
the shopping in the past?
9.
How did you go about choosing the market and the different
shops?
10.
What did you learn from this experience?
an overview of different community health PROGRAMMES IN INDIA
(MODELS AND APPROACHES)
I. INTRODUCTION
Community health approach to health care has been widely reco
gnized as the right alternative for ensuring health to the poor
millions in developing natives. In India too, governmental as
well as voluntary efforts arc made for the promotion of
community health. In the evolution of health care system, this
approach has emerged through a process of dialogue between the
medical and the social sciences in an effort to make the
health care system relevant and responsive to the sociopoliticao- economic realities in the society. Again, in the
process ofevolution and formulation of community health in
terms of its principles, philosophies and methodologies, various
models have been proposed and practised. In this paper an
attempt is made to categorize these models into four, each with
its ’own characteristic features.
Further, each model with its characteristics could be explained
as following a certain approach in community health. These
approaches are broadly divided into three. An understanding
of these three approaches could give us a frame work to assess
as to which approach each models follows. Another interesting
correlation is that each of these three approaches reflects
a certain philosphy of development work.
In the following paragraphs an introduction is made into such
an analytical overview. In the latter part of this paper the
four models with their characteristics are listed out. Under
each model, the particular approach into which it fits into
is also given with certain indicators or assessment.
ii.
Different models in community health
A study of the ongoing projects and the 1 iterature available
on them reveals that in India thole exists different models/
types of commuhity health products. They fall under four
major categories. Each one is run by differ ent types of insti
tutional set ups as big hospitals, small hsopitals, rural
dispensaries, or run by non structured voluntary health/ action
groups. Again, each model is unique in terms of infrastructure,
services rendered, needs met,and the results achieved. It
would be clear from the forthcoming table.
III. DIFFERENT APPRQACHESIN COMMUNITY HEALTH.
Three approaches have been identifyed in community health.
They are : Medical approach, health extension approach,
Comprehensive approach.
Considers health as the absence of
diseases brought about by medical
interventions based on modern sciences and technology and sees
the role of the community(the people) as responding to the
directions given by the medical rrofessionals. It has its
roots in the medical model of health care .which b elieves flfcrt the
eradication ofiill-health depends on doctors and medicines.
.
(a)
Medical approach:
(b) Health extension ap-roach;
Based on accritique of medical
approach. It accepts WHO
defenition ofhcalth as the total physical, mental and social
well being of the individual. Mere advancement of medical
2
technology and the sophistication of services w-uld not bring
health to themajority of th ep conic - especially the poor - and
that the approach should be a.~ planned redistribution of health
care facilities to reach the’ vastness of the society. The
approach also advocates other socio- economic uplift programmes
to enable people to benefit from health care facilities.
care
*
Preventive
is also emphasized.
Views health, the concept of
total well being in the context of
the situational
realities of the individual. - This concept
is elaborated by stating that health, the state ,of tdnl well
being, is also a human condition which does not improve either
by providing more services or mobilizing the community for
providing more health services. It improves only.by having the
community take control and responsibility for decisions about
trhow tomobolize , utilize and distribute services and resour
ces. Here community is thesubj ect, decision maker, It is a
process of conscientization'f organization and capacitaticn of
the community for action, it has bearing on the social,
economic,political andcultural dimensions of human life, in the
sence that the approach strives to bring about changes in then
so that there would emerge a society whete human life would be
more healthy in the complete sense of the word.
.
(c^Comprehensive approach;
IV.
COMMUNITY HEALTH AND THE DIFFERENT APPROACHES IN
DEVELOPMENT;
Development work is based. on certain analysis of the backwardness
of the people. According to the analysis , different philosophy
of development vprk are arrived at. They are mainly three
approaches: Modernization approach,“-welfare appren ch, and social
justice approach. In the context of sneaking about different
approaches in community health work, it wj uld be worth mentioning
these approaches. It is interesting to note that reflections cf
these approaches are found in the three community health
approaches.
Themodernization approach analyses poverty as the lack of
enough production and itmakes efforts to gear up product! n
through advanced! a-..technology in the field of agriculture and
industry. It believes that the result of modernization would
trickle down to the lower strata of society.
(a)
(b) The welfare approach recognizes different classes and castes
existing in the society. It is due to the co-existence of
development and under development in the society. This state
is accepted as a normal reality. Efforts are made to alleviate
the sufferingssof the poor.through organizing relief and
charity work. People are passive receipinnts here. Recently
there has been some changes in this approach and it recognizes
the participation of the people and the mobilization of their
resource. Programmes also have improved remarkably from
relief work to development programmes aimed at the uplift of
the poor, through income generating programme, literacy
programmes, vocational training etc. THjr poor continues
to
exist and the disparity between the rich and the poor also
continues as a reality. Statusquo is not disturbed.
*Conscientization is"an awakening of consciousness, the
development of a critical awareness of a person's on identity
and situation, a reawakening of the capacity to analyse the
causes and consequences of one's own situation and to act 1
logically and reflectively to transform that reality"
(David Millwood)
..3/-
- 3 -
c.
In social jus vice approach a critical analysis of the
society is employed and poverty and baclo/ardmess are under
stood as man made historical reality. The reasons are
attributed to the various forces and the dynamic at work
. in the. society. Poverty is presipitated as a result of
injustice.
Justice could be brought in only through a
restructuring of the society. It could be achieved
through empowering the people through awareness building
and organization. Ultimate development of the poor would
mean fair distribution of the means of production, living
wages, consumption of good food, availability of public
amenities, practice of human values as love, cooperation
and unity.
It becomes clear that the analysis and approaches of
development work has correlation with that of community
health work. Characteristics of modernization approach are
reflected in medical approach and features of welfare
approach find expression in health planning approach. Social
justice ap-roch goes well with, com'Tehensive approach
in terms of its analysis and approach.
V.
T.HE FOUR MODELS AND THF>-p. APPROACHES
IN COMMUNITY HEALTH
As mentioned alreadyythe community health programme existing
in the country could bo classified into four based on the
characteristic. The following tabic would give that.
Under tach ;rogramme a note is made as to which approach of
community health it belongs to. To make it clear six
indicators are given based on which bhiso assesment
is made. These indicators are: role of health services,
role of professional, role of community worker, Community
•participation, evaluation and financial support. For each
approach these indicators show different explanations.
MODEL
A ^CHARACTERISTICS
I.
Type of institution/
infrastructure
Nature of Services
Rendered
NeecS m et
Capital intensivej highly- Treatment of minor
- Extensible service from
sophisticated and insti
hospital.
physical ailments.
tutionalized big hospitals. - Curative care.
- Running village clinics.
- Referral and free
Mobile medical team with
- Referral service, free
transportaion to the
doctor a medicines.
medicines.
hospital.
- weekly or fortnightly visi s.
Result- Qualitative changes.
- People become more conscious abo
sickness and medicines.
- more patients in the hospital
- feeling of dependence in the
people, demanding free services.
- shift from home remedies and
indigenous medicines.
B.THE APPROACH FOLLOWED.
The approach followed is medical approach.
assesment on that.
..
The following are six indicators vhich would help us to make an
Indicators.
Explanation.
a. Role of health service
b. Role of Medical Professional
- means to improve the health status of the people
- Key to the programme- manager, planner, problem solver, coach, consultant,
clinician, leader, teacher, evaluator.
c. Role of community health worker
- a means by which medical advances could be applied more rapidly and
effectively.
d. Community participation
- a means to ensuiie.mdreuaceeptibility and utilization of services.
e. Evaluation
- Based on analysis and interpretation of statistics which reflect the scope
and results of applied medical science and technology.
f. Financial support.
- needed to create, expand and maintain the service.
MODEL . II
A. CHARACTERISTICS
Type of institution/
infrastructure.
Nature of services
r end er ed.
Capital intensive, sophi
sticated and institutiona
lised small hospitals.
- Extension services,
- Treatment of minor
- people meeting in groups.
- curative and preventive
- learn some preventive methods.
ailments.
care.
- Referral and free
- More patients in the hospital
- Village clinics
transporation
- Learn that they can do something
- Referral services.
to the hospital.
about health.
- Medicines at reduced
- personal and environ
rates.
mental hygeine.
- weekly or fortnightly
• visits-.- - ■ - HBalth Education
/
- MCH programmes/ immunization.
- Village Health Workers with
medical kit,
Medical team with
without doctor.
or
Needs met
Results- Qualitative changes.
B.APPROACH FOLLOWED
The approach followed is Medical approach. But there are certain changes, in the sense that it is not strictly
Medical approach. There is an indlinaticn towards Health Extention approach.
Indicators.
Explanation.
a. Role of health services.
- Means to improve the health status of the people.
- Medical professionalcontinues to te the key personnel.
gain a role -here.
b. Role of medical professional
c. Role of Community Health 'Worker
(CHW)
d. Community participation
e. Evaluation
f. Financial support
But, para medicals
- along with being a person to ensure more community acceptability for medicine?.
CHW also imparts preventive health education.
- a means to ensure more acceptability to medicines as well as a means to
disseminate ideas of preventive health education.
- based on analysis and interpretation of health statistics that shows the scop
and result of applied medical science as well as the effectiveness of prevent'•
health education.
- needed to create, expand and maintain the service.
A. CHARACTERISTICS
MODEL .III.
Type of institution/
infra s tn uct ur eT
Nature of services
r end er ed .
Needs met.
-Preventive, promotive
Rural health centres
and curative.
manned by nurses, not
institionalized, still very - Community health workers with simple medicines.
much str uc t ur ed.
- Health education, Adult
Education
A team composed of a
nurse and social
- Smallincome generating
projects
workers.
- kitchen garden
- M C H
- Collaboration with gi>vt
and other agencies.
- village meetings and
discussions on different
village problems.
- promotion of collective
action.
Better environmental
sanitation.
M.C.H. Services.
Supplimentary income
for a section of the
population.
Resulig - Qualitative changes.
- people become aware of the important
of preventive medical care.
- Less patients to go. to the hospit-l
- Better child care.
- people try to see health in relatic
to economic backwardness.
- Develop more interaction among the
villages, formation of small infor
gr oup s, mahilamand als.
- people’oecame aware of their collect'.
str ength.
B. APPROACH FOLLOWED.
The.approach followed is Health Extension approach. The following indicators would make it clear.
Indicators.
Explanations.
a. Role of health services.
- as it vews that good health is the result of planned health servicer,
experts from other fields as economists, social workers, etc- are also
involved to make services effective.
b. Role of medical professional
- The medical professional is viewed as a component rather than key. Fort .v
experts from other disciplines are also involved - economists, soci'1
workers, etc. Attempts are also made to include community leaders.
c. Role of Community Health Worker
- CHW is considered as an agent of change - and works as a multi purpose v
worker which include medical services, prevention, public health work, h
education, nutrition education, food production and housing improvements.
d. Community participation.
- Participation of the community is considered important because it provid
a resourcebase, a means to mobilize more resource - personnel, money and
material. Mainly it involves the community leaders.
e. Evaluation.
- Concerned with assesing whether a programme with a variety of activities
(raging fromfhealth to economic development programmes) provides the moss
benefits in terms of health improvements for the least amount of resourc
f. Financial support.
- Used to build small health centres and to generate community resources man power, money and material. The programme has to be made self
supp orting.
MODEL . IV
Type of institution/
infrastructure
Rural health centres/
action groups.
Flexible and non
structured.
One team composed of a
nurse and activist.
A. CHARACTERISTICS .
Nature of service
Render ed,
- Services aimed at building
healthy communities.
Community diagnosis.
- Critical understanding of
health and its relation to
unjust social order.
- Awareness building through
non-formal education
programmes.
-Organizing the people for
collective action.
-Exposing social illness.
- Formation of Action groups,
Mahila mandals, youth clubs,
village committees, Farmer's
club, Trade unions.
Needs met
Basic needs met by the
people through their
organized efforts.
Better services from
the government.
Results - Qualitative changes.
- Participation and collective acti
of the people to build up a health
corn munit y/ s oc ie ty.
- Increased self confidence and
independency.
- faith in their own power to fight
for a healty society.
- Health is considered as a right
duty andat the same timeseen as a
pollticial issue.
- people struggling against social
injustices.
- Cooperation among the people based
on c rticial understanding of soci 1
realities.
- New forms of politics and new for;
peoples' movement.
- Alternative indigenous medics L sy:;'developed.
- Demanding services from
the Govt, from health
as well as other depart
ments.
- Identifying and training
village animators.
- Promotion of low cost and
simple home remedies.
B . APPROACHES POLL WED
In this model the comprehensive approach
is followed.
The following explanation would make it clear.
Indicators.
Explanations.
a. Role of health services.
- the concept of health is totally integrated into the socio-political febric
of the community. Hence health services are a part of a stro.tegy( or an
entry point) for development and a tool in process of community growth.
of
- Since the role/health service is to enable change in the existing social!
structures (to bring about equity of opportunities andservices), the profession
is viewed as a resource- an enabler , educator and a stimulus.
The communiis the decision maker which difines the role of the professionals and the
professional is accountable to the people.
b. Role of medical professional
c. Role of communityhealth worker.
- Community Health Worker(CHW) is anagent of change, an educator, a volunteer
selected by the community. Uses health work primarly as a means of bringin.'
about change in the attitudesand behaviours, and in the long run, social
structures through health and development activities. Thus, CHW works nowrds
social justice and social, .;■ /’ political and bbbnomic equality as well as
carr.ying out the health and traditional community development tasks.
CHV-i
could be better called, community level worker(CLW) since the wrk is total
.development work.
d. Community participation.
- Community participation in health is a step which will help people gain
control over their own lives by colJactively working towards making the
socio economic and political structures compatible with and conducive to
heaith and development of the poor. It'
starts with awareness building an ■
organization. Community is the decision maker in the community programme,
and through such involvement they go through a process of learning to
live together, think together and work together and take control of ^oliciej
which affect their lives.
e. Evaluation.
- The community!s the evaluator,- it is participatory evaluation methodscommunity decides onn the obj ectives,priorities and methodologies of the
process. The development worker, as an enabler helpes the community and
workd with them. The evaluation itself is a tool and a method for
community awareness, self determination and growth. In the entire
process, stress is laid on the qualitative aspects of the people -and
the efforts at bringingabout change^in the existing health delivery-;/
system and theestablishment of alternateve models of the people
f. Financial support
-To spark off a programme finance is needed. But the goal is to start
a programme which is able to b e sustained through community contribution an
commitment not through outside finances
.
*
'Ehe investment is in education,
rather than technology and expanded services. It also means money to
identify and develop indigenous resources in terms of man power, materials
and support. In terms of health aid, it looks for seed money. Maximum
efforts are made to make use of government funds but not at the cost of
allowing them to dictate terms. It should never hamper the community
in its precess of growth towards awareness and organization.
i.O
CONCLUSION:
Community health is a term understood and interpreted in diff
erent ’.-ays by different people. This is due to the differences
in the analysis of the ill health. Based on one's analysis
the programme that is initiated would conform to a particular
approach and philosophy.
This paper, we think, would help the implementors', on of commun-r
ity health programmes ns well as those who intend to start one
to develop a still more reflective understanding.
This
understanding blended with out commitment to the poor would
help us all. to make out involvement more meaningful.
* & # jjc
#
"b .
id/83 : IOC
ab:ka 11/8? :100
>}< 'Jfi
#
EXTRACTED IT. CM THE REPORT OF A SYMPOSIUM ORGANISED
JOINTLY I'Y INDIAN COUNCIL OF MEDICAL RESEARCH ADD
. INDlfiN COUNCIL CI SOCIAL SCIENCE RESEARCH ON BALTER
NATIVE AFFROACMNi TO HEALTH CARE" AT TEE NATIONAL
USTITUTS OF i'.UTRITION, HYDEFAPAD FROM 27TH TO 3OTH
OCTOBER-1976- -
• SERVICE RESPONSIBILITY OF A DEPARTiECT OF COM" UNITY
I-EDICrnS THROUGH A HEALTH CO-ORZRATIVE
B. MAHADEVAN
*
Background
Health facilities in rural areas in the country were provided.
through Primary Health Centres 9(PHCs) started as part of an national
rural development scheme called "Co.uunity Programmes" in 1952, with a
very modest staff in each centre to form the nucleus of integrated health
services and eater to the need of about 60,000 population in a Block.
There arc now over 5,200 PHCs, each Centre caters to a population ranging
from SO,000 to 1,20,000. Each PHC therefore has to take care of a very
large number of persons. The scheme was extended to involve Nodical
Colleges in rural health work and through deliberations of many committees
tile status of PHCs was improved both qualitatively and quantitatively.
An integrated approach of providing health services to the rural people,
with the provision of two doctors to every PNC and a Basic Health Worker
(BHW) with an Auxiliary Nurse i'idwife (ANii) to every 10,000 population,
was attempted.
A pilot Mbbile-cum-Training-cum-Serviccs Hospital Scheme was
introduced in some Medical Colleges with a view to involve medical and
nursing students in rural community medicine. The intention was to
establish ultimately one mobile hospital per medical college, boro
medical Colleges were established with t o sole purpose of providing
rural health, services. Specialist car.ps were organised for cataract
operations, vasectomy and tubectomy. Alt' ough the government’s idea is
to train doctors for rural areas, these doctors arc not attracted to
such places. Hie nri.gration of Indian doctors to the more developed
countries continues . Evon passing a Parlia: ent Act which empowers
government to oblige doctors and engineers below the age of 30,years
to work for a period of four years in rural areas, the problem remains un
solved duo to the inability of providing reasonable living conditions
for them in villages.
Some medical colleges like vcllorc Christian Nodical College
incorporated in their teaching program,..c, the rural dimension in signi
ficant way. The organisers of the community Health Centre, have found
that it costs a’out Rs. 8.50 per person per year, which includes
preventive, premotive-and curative servi ces. The administration is not
very happy about this project due to the high recurring costs.
*Maj. Gen. B. Mahadevan PVSM, A.VSM Professor and Head of the
Department of Community icdicinp, St. John's rfedical College Bangalore
(Karnataka).
....2/-
- 2 The Kerala Govern;-.ent with Government of India's initial
one time grants, have established Health Co-operatives in 11 districts.
Doctors arc encouraged to seek self-employ cent in these fco-opcratives.
Doctors and paramedical staff take shares in these co-operatives. A
certain foe is levied on services, and medicines arc also paid for.
One is loolcing forward anxiously to the success'of the scheme. The
initial reaction of the people has been good.
Voluntary agencies have established a large, number of
hospitals in urban areas. However, funds arc not available to these
hospitals for any significant rural health work, although an increasing
number of dispensaries arc being opened in the rural sections of the
gountry.
From the facts and figures just given, it is clear that
the government in spite of its herculean efforts has not been able
to seriously tackle the problem and with t’c scarce allotments made
for the health services, no tangible improvements is possible in the
near future. no voluntary agency car hope to embark on a scheme where
even the government has failed irut is in a better position to try out
new methods through pilot projects.
When -planning rural health services, one has to consider
two components, namely the delivery of package of rural health
services in villages and recruit-ent of personnel who will deliver
tlic same. At the same tire, there is an inescapable need for com
plementary services which will develop- ’■■he villages economy.and .
education of the rural people, i .any rural health seboros taken up
enthusiastically at the beginning flounder for lack of popular support
that has to be expressed by financial contributions. This is the
crux of the matter. Any health delivery scheme should be a self- .
sufficient fiscal entity. ' This may be a limiting factor but the only
sound way of attempting to solvo rural health problems, is to start
it in places where conditions are favourable for the introduction of
self-supporting scheme.
Funds for rural health schemes may be raised through many ways
1. Tagging health services to co-opcrativcs. -
To start hcalt’’ co-opgrativcs by themselves is difficult
as health holds a low priority in the felt needs of the people
and nay not get the required support in the initial- stages. The
procedure of tagging on health services to existing-.co-operatives
has many advantages - good leadership, a readymade frame work of
Community administration for introduction of effective health
services and corariunity cnvoivcmont, as channels of communication
with the people ha.vc already been established. Co-operative Dairying
and larkcting Co-operative of different commodities like grains,
cereals, cottage industrial products etc., lend, themselves admirably
to this type of health services.
2. Running health services with assistance from factory
administration where labourers are from villages nearby.
A minimal deduction at the soiree of salary and a contri
bution from the factory management will help to build-up the required
funds and fortaction of a health co-operative. Geographical location
of industries and rural la.bour in close proximity arc limiting factors
but the- scheme is worthy of trial, in special areas.
3*
Assistance from Panchayats.
Please where Fhnebayats and the people arc interested in
health services and arc willing to contribute to th.. same, may venture
on this method, but unless sufficient funds arc forthcoming regularly
and persistently the schcv’c will collapse.
■ o.'r
- 3 -
A devoted team of health workers can establish themselves
in a village and build-up the required clientele and popular opinion.
The people car. then be induced to-form a co-operative and directly
employ the doctor and essential paramedical staff. Until, such time,
a central agency or other funding agency may have to meet the expenses;
This can bo attempted even without forming a co-operative in areas of
affluence, where people arc willing to pay for the health services and
employ the doctor and other staff through collection of revenue for the
purpose.
The ’bllv-r
ilk Co-operative (iE-C)
Ifellur is a village in Kolar district of Ka.rna.taka, situated
about 60 km. from the city of bangalore. The H.llur /ilk Cooperative(IS C) was an established concern with a sound and progressive leader
ship and has been functioning for many years. In addition to production
and sole of milk, it provides other benefits like provision of fodder'
and cattle foods, tractor facilities and loons at low rates of interest.
Eesidos the people of i'allur, two other villages, iiuthur
and Kachahalli arc members of the Co-operative and the total
population covered is a- out 3,000. These villages have a sill;
farm cooperative besides cooperative dairying. The economic
position was satisfactory, and therefore all. conditions wore
favourable for the introduction of other self-supporting schemes.
The inspiration for establishment of a Comprehensive
Health Care Programme for the cooperative members and their families
of these villages, came from Sr. Anne Cumins of Coordinating Agency
for Health PLannin.- and Th?. Jones of the Catholic Bishop Conference
of India. With those pioneers, the Dean and the Department of
Community Medicine of St. John's ’-bdical College, representatives
of the Karnataka Government and Bangalore Government Dairy with
leaders of the MIC worked out a scheme for tagging on a health
services to it.
The main objectives of the Mailin’ Health Project arc:
1. To study and devise methods by which tie financial
base needed for effective health services could
emerge from the people themselves in a self-sus
taining manner;
2. To help in the establishment of rural health centres
with the staff and rendering of effective health ser
vices to a wide circle of needy -people without
distinction of ro.ee, caste or creed;
3« To study the required strategy and methodology for
the effective rendering of primary health care in
rural areas by trying to determine the priority
areas in health care and devising the structure
found suitable to village conditions;
4.
To help in those developmental activities which
are very necessary to ensure effective rendering
of health services in rural areas; and
To train intern doctors, nurses and other medical
and paramedical- staff for the purpose of rendering
assistance■in rural areas.
..V-
- 4 -
The St. Join's ibdical College arid its Depart; ent of
Com unity Ibdicine were to be mainly concerned in acting as a
catalytic-agency,, in the formation of self-sustaining rural com
munity health scheme, fulfilling the above objectives.
Sponsorship was by the following agencies organisations
1. h'C.
2
• Coordinating Agency for Health Hanning
3
• Catholic I-ishops Conference of India
4. St. John’s Medical College (Dept, of Community
lie licine ).
Source of fun’s
It was csti-£.tcd that a monthly budget of Rs. 2,500-3,000
would bo. required for Training 'the Health Co-operative and financial
support was forthcoming by a joint contribution of three paisc per
litre of milk from, the UiC and bangalore Dairy, in a phased formula
as shown in Table 1 below. Ultimately the 11-0 was to completely
finance trio scheme.
Table 1 - Contribution to the Health Co-operative.
Year
I
I
I
;
Contributeons/litrc
I
lELlk Co-operative
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