REVIEW OF THE, JAN SWASTHYA RAKSHAK SCHEME OF THE GOVERNMENT OF MADHYA PRADESH JULY - DECEMBER 1997 · Community Health

REVIEW OF THE, JAN SWASTHYA RAKSHAK SCHEME OF THE GOVERNMENT OF MADHYA PRADESH JULY - DECEMBER 1997

Item

Title: REVIEW OF THE,
JAN SWASTHYA RAKSHAK SCHEME OF THE
GOVERNMENT OF MADHYA PRADESH
JULY - DECEMBER 1997
extracted text: CPHE

REACHING HEALTH TO THE
GRASSROOTS
THE JAN SWASTHYA RAKSHAK SCHEME
OF THE

I
I

GOVERNMENT OF MADHYA PRADESH

PEER REVIEW OF JSR MANUAL
(SUPPLEMENT)
A PARTICIPATORY INTERACTIVE REVIEW
JULY - DECEMBER, 1997

Community Health Cell,
Society for Community Health Awareness, Research and Action,
<

No.367, Srinivasa Nilaya, Jakkasandra I Main, I Block, Koramangala,
Bangalore - 560 034.
Phone : (091) - 080 - 553 15 18
Fax : (091) - 080 - 553 33 58 (Attn. CHC)

December 1997

>

CONTENT LIST
Contents

SI.
No.

Introduction

Page No.
2

Comments on the JSR Manual:

I.

Dr. Shirdi Prasad Tekur

3

II.

Dr. Sham Ashtekar

5

III.

Dr. Abhay Shukla

20

IV.

Dr. Prabir Chatterjee

31

V.

Dr. Abhay Bang

32

VI.

Dr. Anant Phadke

33

VII. Dr. Ashok Bhargava

34

VIII. Dr. Ulhas Jajoo

47

IX.

Dr. Dhruv Mankad

47

1

JSR REVIEW : A SUPPLEMENT
A PEER REVIEW OF THE JSR MANUAL AND THE
SCHEME
Introduction:
As part of the JSR Scheme Review, CHC decided to build up an interactive peer

review for the process, so that the experience of the scheme and the evolution of the
manual are subjected to a critical review by a host of other ‘community based health

worker’ trainers and a network of trainer peers is identified, who will share ideas,
comments and suggestions with the JSR trainers of the Madhya Pradesh Government.

This process will increase the cross-fertilization of ideas and there will be an interactive

dialogue between qualitative micro-level NGO experience and quantitative macro-level

government initiatives like the JSR Scheme.

All the peer reviewers were most

welcoming of the scheme and from the extent and nature of the comments - compiled

in this supplement, it is evident that the manual and the Scheme have been subjected to
an enthusiatic and detailed review. We believe that this network of CHW trainers will

be very willing to support the Madhya Pradesh government and the JSR scheme
organisers in particular, through interactive workshops that will provide support to the

further evolution of the manual and the scheme, and in the concurrent and continuing
monitoring and evaluation of the JSR Scheme.

a

SOME COMMENTS ON THE MANUAL
I Dr. Shirdi Prasad Tekur, Consultant
Community Health Cell, Bangalore.

Training & Communication,

1. The contents of the Manual are easily understandable to a matriculate, simple in
presentation and with no ambiguity.

2. Chapter 1 on Duties of JSR is comprehensive, yet medicalised, with
* focus on Tb, Leprosy and AIDS;
* elaborate duties in area of Malaria, Water purification, MCH.

These are overlapping and duplicating the roles of ANMs and MHWs.
Some degree of differentiation of activities is required to avoid this duplication and
obtain maximum benefits of the different cadres of field workers.

3. Chapter 2 - Health team in community focuses more on disease than on Health
(except MCH area). A shift in focus to more health promotive activity is required.
4. The Section - on Anatomy Chapter 3 is more elaborate than required and confusing
because of the Latin/English names used. Also the translation/presentation of
terms is not accurate, e g., for SKULL, MANDIBLE, AORTA, and illustration of
brain (p.37), section on female genital tract, etc.

5. The above section needs to be revamped thoroughly and presented as HUMAN
BIOLOGY including structure and function in a simpler manner.
6. Chapter 4 - presents the Agent - Host - Environment concept well but needs
elaboration with examples to make it more understandable. The three levels of
Prevention also need to be added to this Chapter and given due emphasis.
7. Chapter 5 - is adequate. Chapters 6 to 8 dealing with Malaria, Tb, Typhoid, Filaria
and Dengue
* offer only medicalized/patient oriented preventive measures
* have no socio-economic, cultural/other roots of these diseases discussed
* need elaboration on ‘Community Action’ for prevention/control.

8. Chapters 9 to 13 are too elaborate and need to focus down to essentials for the
JSRs to help them learn their roles/duties adequately and maximally.

9. Chapter 14 - (pl 15) has a highlighted foot note whose message is contradictory to
matter in text. [ “ALL CHILDREN less than 2.5 kg need to be seen by a Doctor”
- box mentions 2.0 kgs.)

3

10. Chapter 15 - the presentation/details of dehydration and rehydration are too
clinical. Common and noticeable signs of dehydration / rehydration like urination,
cry, activity etc., of child also needed to be added. Practical knowledge of home
based ORS and that rehydration is ‘thirst’ based need to be included.

11. Chapters 16 to 19 are elaborate, but good. Some simplification may make it easier
to comprehend.
12. Chapters 20 and 21 need to be revamped, helping JSRs understand and utilize
traditional and local practices safely for minor ailments and first-aid, utilizing WHO
and GOI manuals on these. The ‘symptomatic’ use of Allopathic, Homeopathic
and Ayurvedic medicines can be supplemented with safer, locally available
resources.
13. The “Appendix” - Anusuchi -3 on medicines always to be available with JSRs
include drugs like Analgin and Decadron which should not be recommended. Also,
medicines like Magnesium hydroxide, Benzyl Benzoate, Sulfacetamide drops in
text are not mentioned here. The three Homeopathic and three Ayurvedic drugs
also do not find any mention in the list. These discrepancies need to be taken care
of to avoid confusion and contradictions.

14. The lecture schedules of 145 hours show an unwarranted medicalization, offering
110 hours of Medical College subjects, of which 26 hours of Paediatric and
Obstetrics & Gynaecology seem proper.
15. Thirty hours of Community Health and 5 hours on Health Education are
inadequate to prepare the JSRs for their roles in the community. National Health
Programmes do not find the place in the lecture schedule they deserve, except
Malaria, Immunization and MCH. Relevant Sociology subjects are missing from
the manual and need to be added.

16. The Disease and Medical Orientation of all the chapters needs to be made Health
and Community Activity oriented, bringing in the principles enunciated in Chapter
4 and evolving avenues for practise - to make it a practically useful manual for the
JSRs.

IL

Dr. Sham Ashtekar, Bharat Vaidyaka Sanstha, Dindori, Nasik District, -422202,
Nasik Ad: Basement 1, Athawale Chambers, 430, J. Tilak Road, Nasik - 422 002.

I personally feel that the scheme must continue and we must try to correct the defects
in the best possible manner.
About the manual first. I appreciate the efforts and pains one has to take for preparing
manuals like these, in local languages and on a rather uncharted course. I have gone
through such pains myself and learnt by making mistakes. So in the first place I would
like to thank the person/s before analyzing. I have made similar mistakes myself and
have a learnt some more things while preparing the second edition of my book
inMarathi. It is not possible in a small space of a letter to write down your comments
on a manual of this size and I have something to say about every line of it. But I have
tried to make a summary note of my comments in the table here (see enclosures).

In general the manual and the syllabus lacks many things. I am enclosing a list of
chapters of my book for health workers. The manual is simply not enough to support
professional health workers. Perhaps you could think of manuals course 1 and course
2.
There are some other comments:
*

There seems to be no record format for CHWs’ clinic records . I am working on
such list which I can share later. Unless they keep records of their clinical work,
what will the supervision be like?

*

The book gives a sense of tentative agenda and lacks a scheme, which must be writ
large in the chapters.

*

We had listed about 100 essential skills for health workers in the Vachan CDRD
study (which need addition). Preparing a handbook for a skills list with
photographs/illustrations may be helpful (list is enclosed).

*

It is necessary to prepare good test-kit for the CHWs ; for a ready reference kindly
see the CHW study (Knowing Health Workers). We have developed MCQs (600),
attitude tests, skills list etc. This can be improvised upon.

*

What about the legal status for the CHWs using medicines?

*

The Madhya Pradesh PHCs have to serve large populations and there is a general
lack of enthusiasm for CHWs at that level. The six months training model is
expensive and poor on cost-benefit. If it has already been completed there is no
point in discussing it. But given a choice, we need to develop distance training

S

material, interactive training tools at some institutes and short term contact training
facilities for skills and attitude training. The training could be staggered with
inbuilt evaluation. However urgent the task, the backroom preparations have to be
thorough and effective. Otherwise we might waste one more opportunity.
Enclosures:

•Appendix 1 : Comments on the Manual
Appendix 2 : A manual for essential Primary Health Care (content list)
Appendix 3a : A feasibility classification of illness
Appendix 3b : A feasibility classification of illness (Hindi version)
Appendix 4 : Two pages from a book on diagnostics (Hindi version)
Appendix 5 : List of medicines from WHO-SEARO meant for Primary Health Care.
Appendix 6 : Information about medicines used in Jabalpur NGO training programme.

6

Appendix 1

(Comments II)

Comments on the manual

1.

Issue

2.

Contents

3.

Missing
sections

Comments

Inadequate. Especially clinical chapters are deficient ( see the list of topics of my
book)
The human biology needs trimming of some areas and addition in certain areas.
Pre-clinical subjects- like how illnesses are caused and how they heal. how
medicines work, science of nutrition etc. are hardly discussed.
I feel that apart from minor ailments that can be treated by a CHW there must be
something to do in various serious/moderately serious illnesses at the vil.age level.
There are atleast 25-30 important illnesses in which CHW has some role- of
detecting early .limiting damage, follow up. There could be a section on what to in
such matters. So it will be better to include relavant sections on these illnesses and
what is to be done. Detection of hypertension, diabetes, PSD, Peptic ulcers,
obesity, cancers, mental illnesses, tuberculosis etc must be prominently discussed,
not just mentioned. This will give them an important clinical role in the village
epidemiology, equipping them against upcoming illnesses.
A topic on science of exercise/sports should be included to introduce a culture of

Therets need to orient CHWs on geriatrics, herbs in health, occupational

4.

5.

Technical
errors
Objectivity

medicine, village toxicology' ( first aid) etc.---------------- --- ----- ---------------------Some things seem to be wrong or missed in its real meaning, for instance on pp.
109, Pregnancy toxemia is indicated to be an infection ( Sankraman\-------- ------There is a sense of falling between two stools while reading some of the sections..
for instance seep 93. Here the discussion of foreign body reaction is
incomprehensible. It makes little ; sense for a reader of this category. A simile
would have served the purpose. It confounds the reader with tongue twisting
In general the objectives of each chapter are ill defined and so the text id not fine
tuned to the needs. It overshoots or underserves the purpose of most topics. This

6.

Illustrations

7?

List of
medicines

8.

Diagnostics

9.

Language and
style

fault must be corrected.
------------- ------ ---------------------------------------- -—
Inadequate, needs many more pictures, especially photographs______________
' Needs to be expanded ( anusuchi 3), Information about each medicine has to be
included in easy to read format Why not refer to the WHO -SEARO list (I am
sending one I have drafted from this list.). I feel analgin/decadron must have been

deleted by now.
_
Lacking. Some simple tools of diagnostics are mandatory if they are expected to
do clinical work independently.
__
Needs to be rewritten , Wernerised. It is little stiff and sarkari
Cryptic writing is no good for readers who are going to practice as health workers.
There are many examples of this. See pp. 75 for instance. In the same paragraph
the anatomy of eye (like a camera) and the definition of a camera is togetherhence likely to be confused. Separate ideas need separate paragraph.
There should be more subheads ( stepping stones!)
In general it will need a lot of editing , to make it simple and appealmg. For
instance see, the last sentence on p 93.
..contd on next page

7

J

10.

Use of English
words

11.

Unnecessary
sanskritizcd
words_____
Disease
description

12.

13.

Role of CH Ws
about illnesses
and procedures

14.

Orientation of
the book to
training
mechanism
Giving
statistics

15.

16.

Treatment of
simple
illnesses ( 160163)

17.

Layout

18.

Tt

Textual errors
Herbal
medicines

20.

Good Aspects

Too ubiquitous and avoidable . for instance facial dhamarii should be replaced
with Chehariki Dhamani. Many words like referral, many anatomical words on pp.
35 could have been replaced by popular usages_________________
Needs to be minimized- use peoples' language. For instance use bachha instead of
shishu also jachaki insted prtisava. The penchant to use formal words makes
the language lifeless and administrative_____________________
Inadequate and sketchy. Readers must understand some intricacies rather than 'do
as directed' ( See tsphoid, dengue etc)
Another example is AIDS section- which fails to carry any details of the clinical
features and gravity of the illness. Such descriptions serve little purpose.________
There is seems to be some confusion about what the CHW is expected to do about
many things. For instance, there should be a clear direction as to which illnesses
he/she should treat and what is the responsibility' in other problems. (I am
enclosing a table to put this issue in some perspective ). If this approach is
developed properly, many unnecessary details will go away and many vital details
will demand inclusion. There seems to be no plan about this.____
The book has to be tailored to the training needs. If the training is more of a
distance learning kind, the books needs to be rewritten that way. If it is meant as
classroom companion, a different approach is needed. This book looks like lecture
notes and serves neither demand._________________________________________
Speak for the village, national statistics is difficult to comprehend, for instance
,see chapter on Andhatva Niwaran. Flow many cataract cases are expected in the
village is more important than MP figures._____________________
This is a very problematic section, many tilings are treated simplistically, ear pain
for instance.This could be an ASOM as well, which needs different treatment.
Same thing about khaiisi. management of this solely depends upon the underlying
illness. All this needs to be specified otherwise the CHWs are likely loose ‘
credibility.___________________________________________ ______ ________
Monotonous ! needs to be lively and pleasant. Columns would break the text into
readable sections. Type size is good but lacks beautification ._________________
Almost every page has some typing error, this needs to be taken care of.
Almost absent except one or two places. I understand that govt officers find it
difficult to endorse herbs in a govt sponsored scheme. But this must be overcome
with a consensus of Govt Vaidyas and other experts._________________________
The first aid section, child nutrition, domestic cleanliness etc are treated in a better
manner than other sections.

8

Appendix - 2

(Comments II)

A MANUAL FOR ESSENTIAL PRIMARY HEALTH CARE
CONTENTS

THIS BOOK IS FOR :

' Health care workers
■ Nurses and paramedical workers

• Health care trainers and teachers

I SOME BASIC INFORMATION
1 Human Biology
2 Nutrition
3 Biological Causes of Illnesses
4 Diagnosing Illnesses
Pharmacology and Therapeutics

' Health activists
■ Village doctors
■ Herbal and traditional healers

• Public libraries

All those seeking health information

FEATURES:

Extensive essential information on health
and medicine, authored/ assisted / edited

by subject experts
450 pages of28 *20 ems size
About

400 black and white figures &

photographs

Color

photographs

of

50 disease

II ALTERNATIVE HEALING SYSTEMS
6 Ayurveda and herbal remedies
7 Homeopathy and tissue remedies
8 Healing without medicines
III HEALTH AND ILLNESSES OF BODY SYSTEMS
9 Eye
10 Ear
11 Skin
12
Teeth.Gums & Mouth
13
Digestive Tract
14
Respirator}' System
15
Circulator} System
16 Blood and Lymph
17
Urinary System
18
Muscles and Bones
19
Nervous System
20
Male Reproductive System
21
Female Reproductive System
22
Hormonal System

IV SPECIAL MORBIDITY TOPICS

conditions
Diagnostic flow charts for important

symptoms like fever, headache, vomiting,
loose motions, cough, abdominalpain, chest
pain, white discharge etc. .

Diagnostic tables for comparing

differential diagnosis for select symptoms

Detailed information about 50 drugs
and vaccines used commonlv

50 select homeopathic remedies
C seful re mediesfrom Ayur\jeda and herbs
Essential medicolegal information

• Extensive subject index
Guidelines on scope offirst contact care

Dr Sham Ashtekar, MD
Bharat vid} aka Sanstha, Dindroi,
Dt. Nasik 422 202 INDIA
Phone : (02557) 21143, 21148.

23
24
25
26
27
28
29
30
31

Pregnancy and Childbirth
Illnesses in Childhood
Health of Elders
Sexually Transmitted Diseases
Cancers
Mental Illnesses
Accidents and First Aid
Occupational Health
Unclassified Illnesses

V TOPICS IN HEALTH OF THE INDIVIDUAL,
FAMILY AND COMMUNITY
32 Personal hygiene
33 Yoga, Exercise and Health
34 Health of the Community
35 Drinking Water & Sanitation
36 Health Services
37 Birth Control
38 Sharing Health Information with people
39 Food hygiene and Adulteration
40 Medical Jurisprudence & CPA
INDEX
Appendix : Roles and Responsibilities In First Contact Care.

9

A Feasibility classification of illnesses-For the Primary Health Care Worker
Category

A) Minor
illnesses*

Diagnosis- Treatment-e
Easy or
or less
less easy
easy
Very simple Usually
simple

Risk
involved

Examples

None or little Colds,cuts,simple
headaches,

Prevalence
in the
community

Very
common

B)Moderate Easy

Easy
Sfeasible

Moderate

Dysentry, diarrhoea, sore Common
throat,worms, malaria,
Ear infection

C)Acute *** Complex
serious
illnesses

May need
doctor's
help

Risk of
morbidity
and/or
death

Acute respiratory
infections©, Cholera,
acute abdominal pains
like appendicitis, renal
stones,
meningitis,falciparum
malaria, heart attack

Few
episodes

Long term
to health &
life

Cancer,filariasis,
tuberulosis.high BP,
rheumatic fever

Few
episodes

D) Chronic Complex
serious
illnesses***
E)
Accidents

Complex

Usually
needs
doctor's
help

Difficult, only Lot of risk to Snake bites,burns, road
first aid is
health & life mishaps, poisoningss,
possible

>

g.
£
l
GJ

Not many

* & ** are illnesses PHC workers can and shoulcdmanage, but ** category needs more
training & equipment, *** illnesses need referral, possibly with approriate first contact care.
Chronic illnesses need follow up from PHC workers, which is very important. PHC workers
have some role in all the categories. Some conditions like ARI -marked
PHC workers
have managed successfully on their own.-it is possible and is very significant.

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M
M

Appendix - 5

(Comments II)

Drugs for primary health Workers
i Name of Medicine
\ Remarks
List No = Category
\
Local
anaesthetic,
_
_I..[nj££fipn_Xylqcainc
___
_______
L..Q.9.-X.[9L}).£
uT^ suturing &_scoypion bjtc f
1.
i
NS
Anti
Inflammatory
j
A
sprin
tablets
.also
dispersible.
1
Pain
killer,
fever-reducing
2?
”3.
i Ibuprofen lab & svrup
; Pain killer, anti inflammatory
; relcif of fever, pain
1 Paracetamol
i Anti-allergic medicines i Chlorpheniramine ( also
\ Anti-histaminic ( for itch, allergic skin
5.
i
: Cctrizinc), tablets . CPM injection J rash etp)
i
i Adrenaline injection
i.A!19.rp*9
j
|
6.
i Anti Helminthic agents j Mcbcnda/albcndazolc .tab/syrup ; Broad spectrum medicine for worms
7.
i
j Praziquantel tab/syrup
i Tape worms
8.
\ Filariasis
9.
1 Diethyl carbamazinc tab.syrup
I
; Broad spectrum
■
!
Amoxicillin
oral
■
Anti
bactcrials
10.
j Furazolidine oral_____________ i Bacterial gut infections
11.
1
j Phenoxy-methyl-penicillin (oral) j URT bacterial infections.pyodermas
[2.
13.’
i Broad Spectrum anti bacterial. LRTI.UT.' 5
' Trimethoprim-Sulfa-Oral
i Some STDs.URTI
j Doxycy cline tab/cap
14.
t".
; A..s ....................
in Malaria Control Programme
j Chloroquine .ora 1
j Anti-protozoal
#
1
; do__________________________
j Primaquine tab__________
i do
; Metronidazole tab/pessarics
f
ft
: dO
;
Tinidazole
tab
18j Anti-anginal_______
j
Glyceril
Trinitrate-sublingual#
\
Anti
angial
________
I 19.
j
Fungal dermatoses
j~20?
j Miconazole________________
i Skin medicines-(Ext)
1
: do
; Whitfield ointment
2T
i anti-infective
i Gention violet susp
22.
t _________
j_do
! Neomycin+Bacitracin________
23.
j do_________
i Providone Iodine___________
24.
; Scabies, louse
Gamma BHC,..........
Benzvl
benzoate
25.
->•i .......................
...................
? External application
I Chlorhexidine sol
= Disinfectants
26.
! Hydrogen Peroxide_____________ j do_________
27.
j Gentamicin & antibacterial drops ; Anti-bacterial
j Eye applications
28.
j
Tetracy cline ointment
[ do
29.
i Antacid
; Digestive System drugs i Magnesium/Aluminium salts
30.
t\ •:Anti
... :....
emetic
:_____________________ j Metoclopramide oral_______
31.
\ do________
! Promethazine oral_________
32.
= dO
! Dicyclomine
33.
...............
I Magnesium Sulfate
: dO
34.
1
Anti-Hmorrohidal
ointment
i
\ Piles
35.
i Rehydration
:
! Oral rehydration salts
36.
37?
i Asthama
i Drugs used in asthama.
I
Salbutamol
oral/
inhalation
i
do, also as uterine stimulant .............. 38.
i To suppress dry cough_____________
Codeine tab/linctus________
; Anti-tussives_______
39.
[ Vit D
_______
j Ricketts/Osteomalacia_____________
; Vitamins & Minerals
40.
i Prevention/Treatment of def blindness
I Vit A
41.
■■\ VZarinn^
<snerific indications
inrlicnfinns
Various specific
:x
42.
j Scurvy
I Vit C
43.
| Calcium oral_________________________________________________ _
44.
Ferrous salt oral (with folic acid) i As curative and.preyentiye for aneniia
45.
j Urinary- Amalgesic
j Pyrimidine tab
46.

U.

• :.................................

I

I

t

1

: ’SUti c.\t£\^

Appendix - 6

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49

III. Dr. Abhay Shukla, Pune, Maharashtra.

Comments on 'Jan Swasthya Rakshak ManuaF
- Dr. Abhay Shukla

General comments on. the manual
The launching of a state-wide village health worker programme in todays context is
definitely a commendable step taken by tlie Govt. ofM.P.. That the training of these health
workers (Jan Swasthya Raks haks) would be full time for a period of six months is a further
positive feature as it would enable the JSR.S to tackle a wide range of health related
problems in their communities and continue to function effectively in the future.
The given manual needs to be evaluated in this context, as to what extent it would enable
each JSR to acquire a range of understanding and skills to carry out various health
activities in her/his community.
It must be admitted tliat seen in the context of this overall scenario, the manual falls far
short of expectations and suffers from many deficiencies at every level, quite a few of a
serious nature. Before going into detailed comments on selected chapters, let us make some
general comments:
A. Approach to the role of the JSR
Such a manual would be expected to have a decisive influence in defining the role of the
JSR and shaping the attitudes of thousands of future JSRs. What comes across is tliat the
JSR is a peripheral go\t functionary whose main job is to implement govt, health and F.P.
programmes and to keep records. Caring for the sick is a very low priority and awareness
generation on health issues or articulating the needs of one’s community related to health
issues is not even mentioned. The section on working in the community never mentions
anything almut hying to understand the priorities of people vis avis health or the problems
they face with the Govt health infrastructure.
In the tradition of our educational system, there is a lot of emphasis on acquiring (largely
abstract and often irrelevant) knowledge, very little emphasis on practical skills and not
even an attempt to deal with attitudes.
To some extent the blind spots of the manual can be traced to this totally 'tunnel vision’,
top-down approach.
B. Approach to health and disease
The entire approach to understanding health and disease is extremely piecemeal and
superficial. One repeatedly gets the impression that the JSR is just supposed to follow set
procedures or take ad hoc measures rather than creatively thinking to make diagnoses,
identifying health problems in his/her village or understanding disease hi either an
individu.d or community. Ihus even the understanding of the human body and disease laid
out in die book suffers from serious deficiencies:
*rfhere is not even amention of basic concepts like infection, immunity, inflammation
which are essential for an elementary understanding of disease.
Categories of micro-organisms are mentioned (e.g. viniscs, bacteria) without ever
describing what they are, how they are seen, etc. Such a simple and practically relevant
concept like: by and large bacterial diseases can be treated by anti-microbials whereas
common viral diseases cannot; is never mentioned.
*The concept that the bod}' is made up of cells, a foundation of human biology, is not
mentioned anywhere in the book.

20

*Th? entire concept of a distinction between a symptom and a disease is never made,
which is the basis ofmaking a diagnosis, even at an elementary level. Thus lire concept of
diagnosis hai’dly appeal’s in the book.
*The fact that much disease is caused by social conditions and factors is never dealt with
systematically; where environmental causes are mentioned it is in a largely victim-blaming
and condescending fashion (e.g. chapter 5).
C. Structure of the book - major omissions
Generally the structure of the book is somewhat disjointed and there is extremely uneven
level of detail regarding various topics. Nowhere have clear learning objectives been
defined , so often much material is given without clearly defining its relevance (esp.
anatomy etc.). Topics not falling in the pigeonholes of Govt, activities tend to get left out.
The following chaptcrs/sections should be added*A chapter on basic concepts of health and disease (concepts mentioned above)
*A chapter on basic pharmacology and some details about commonly used medications;
some description ofnon-allopathic systems and home remedies
*A chapter on the Public Health System: The staff and their functions at least at PHC and
Subcentre levels, and some overall idea about National Health Programmes.
*A more detailed chapter on basic epidemiology, linlcing it with preventive strategies and
describing in some detail environmental and social causation of disease. (The present
chapter is exactly 2 pages).
*A chapter/section on clinical methods including points in history taking relevant to
various cardinal symptoms; how to actually do simple physical examinations; the icievance
of findings; and how to reach a diagnosis when dealing with a patient presenting with any
of the major symptoms (e.g. fever, cough, pain abdomen etc.).
*A section very briefly describing serious illnesses not covered in otiier chapters enabling
the JSR to detect such conditions in time and promptly refer them (e.g. meningitis, cerebral
malaria, intestinal obstruction,appendicitis, perforation, ectopic pregnancy etc.); a
comprehensive list of danger symptoms/signs which would indicate urgent referral.
*A glossary with all the technical terms used in the book explained in clear Hindi.
D. Presentation, language and coherence
On this score, there is tremendous scope for improvement, to put it mildly. All except the
first two chapters are veiy poorly organised, and there is no clear sequence of section
numbers, headings/subheadings in almost all chapters. Ideally each chapter should start
with learning objectives and then a brief introduction (neither the book itself nor any of the
chapters have introductions presently). There should be a clear style of headings,
subheadings and section headings and consistently followed numbering. The chapter could
end with a brief summary and description of key new terms introduced.
The language fluctuates between sanskritised, overtly technical Hindi and technical English
transliterated into Devnagari (often erroneously). There are attempts to use simpler Hindi
also, but because of the uneven style the overall effect is not easily understandable in many
places.
Diagrams have either been borrowed without adaptation (or acknowledgement) from
fcnglish books or are originals. In either case, the labelling and quality can definitely be
improved. Many of the diagrams do not have explanatory captions.

Coinmciits on specific chapters:
It is not possible to go into details of all the chapters. Comments have been given on six
chapters by way of illusli’ation.
Chapter I

*No mention of (he special relevance and role of the JSR as a community health worker;
her/his appropriateness, accessibility, affordability, non-exploitative and demystificatory
role, relationship with people of the community etc. Role is described like atypical govt,
employee, a totally top-down, strai(jacketed and uninspiring role description. The JSR
appears as the lowest rung of Govt, health service rather than a front-line person involved
in promoting health in her/his community.

l.'SwasthyaDal...’:
No mention of attempting to understand local health priorities, heal th problems prevalent in
one’s community.
No mention of any kind of demand generation or getting suggestions or feedback from the
community on health issues.

2.'Sanchari Rogon...’:
The JSR is supposed to inform the HW(M) after an epidemic has taken place, but there is
no mention of vigilance regarding any increase in number of cases which may alert one to
the possibility of an epidemic at an early stage.

3'Malaria...’
All cases of fever, even those who obviously have common cold, purulent skin infections,
diarrhea etc. to be considered malaria?
What about simple community measures like eliminating stagnant water collections?
S.'Tikakaran’
No mention of follow up of vaccinated children for minor sequelae (e.g. fever) or alertness
regarding incidence of EPI diseases (which may be due to either low coverage or vaccine
failure).

6.'Carbhavati...’
Is the JSR supposed to do routine Antenatal checkups of all women in tlie village? Is this
not the role of the IIW(IT) ?

8. Foshan’
Mentions detection of malnourished children but does not say what specifically is to be
done for them esp. severely malnourished children (e.g. supplementary nutrition). Only a
general mention of'education of mothers regarding nutrition’; bypasses the crucial socio
economic factors responsible for malnutrition.

Z2-

9.' P ai‘ i vai ’ Niy oj rm ’
No mention of infertility.

] l.'Di^*phafnaoD...,
No lueation of road accidents, fid! fi om heights(e.g. trees), agricultural implement injuries,
scorpion bite etc.

J2.'Clioti moti bimariyon...’
There is no mention of questioning and examining the patient, and mailing a diagnosis.
Apparently treatment is to be made on an ad hoc, symptomatic basis. The list of problems
is ajumble of symptoms (e.g. fever) and diseases (e.g. ulcer); cough and cold are
combined as if they always occur together.
No mention of common problems like pyoderma, infected wounds, sore throat/tonsillitis,
amoebic dysentery etc. One wonders if the JSR is expected to treat 'ulcer’ - presumably
peptic ulcer.
Some general omissions regarding role of the JSR as mentioned in the chapter:
*Tnere is no mention of awareness building in the community regarding irrational medical
practices and the need to avoid them (e.g. unnecessary injections and infusions);
* absolutely no mention of local and traditional remedies;
* no mention of combating socially hannful health-related misconceptions e.g. relating to
infertility, menstrual taboos, causation of male vs. female child;
*no mention of how drug supplies will be obtained and dispensed and maintenance of
dii ig-re 1 a te d re c ords.

The language is often unnecessarily difficult and at times even erroneous due to attempts at
literal translations. For example, certain substitutions could make the text more
comprehensible and factually accurate .

Li

Examples of language modifications suggested in Chapter I.

Page Existing
1

Suggested
'<WW ^Ft ’4>l4<dl£l’

;<rfw

I
2

RtfcRF RTRR

2

A •'-tied fte-H

WR

STF^R RTRR

Afttw

rr

3

4

W ^FR t WFT Wi

R

Of

diw dF ORT cRqfW

SF^dd

^41

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MRcjk AdlOl RT OOd %,

3o?r ^4t
5
5
5

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ddie Tpr d4d4 FT 4cfHM cR

Rfd-HR

24

Ci;n r. ti: i 3

General comments:
'Jhere is not even a sentence oj'intnxkiction before launching into a disjointed, cliaotic,
jargonised collection of largely irrelevant facts regarding mostly human, anatomy. It is not
at all clear as to how this knowledge relates, if at all, to the work of the Jan Swasthya
Rakshak.
Ihere is no mention of the fact that the Ixxly is divided into systems which perf orm
specialised functions . A term used in some places is sfetH which literally means institute !
’the correct term would have t>een uwr.
There is absolutely no mention of tire microarchitecture of the body. Ihere is no mention of
the fact that the body is constituted of cells, anywhere in the book!
There is empliasis on giving excessive detail in technical english transliterated into
devnagari regarding anatomy, but for some reason physiology is not discussed in equal
detail or related to anatomy. No attempt has been made to place this information in
context of either clinical settings or simple, commonsense knowledge about the body
which tire trainee may already have.
Specific comments:
*There is description of types of muscles etc. without decribing their basic function to
begin witli. There is no mention that muscles and bones together are responsible for
locomotion.
^Towards the end of describing the skeleton, there is suddenly a description of the skull,
chest and abdomen, including a sketchy description of circulatory and digestive systems
which is anyway described in detail again, later. Not clear what is the context or utility.
’'Ihere is a rather detailed description of carbohydrate metabolism as part of functions of
liver which abounds in biochemical terms - neither necessary nor comprehensible.
*On p. 27, suddenly there is a second section on skin without any context which just fists
the components of layers e.g.
without any
explanation - utility is not at all clear.
*Thc section on the heart gives excess detail of structure but is not corroborated by the
diagram which is hardly' labelled. There arc one and half pages of details about major
arteries and veins wliich do not appear relevant and is hardly comprehensible without a
diagram.
♦Section 6 (starting p.32) is titled 'Organs of the reproductive system’ but deals only with
die male reproductive system ! Female reproductive organs are dealt with in die next
section. Even if unintentional it is factually misleading.
♦The section on 'Female reproductive organs’ does not describe the menstrual cycle, the
concept of hormonal clianges, process of fertilisation, very simple concepts about
pregnancy' - only some terms are mentioned haphazardly.
♦The section on Nervous system gives no description of simple phenomena like sensation,
nervous control of voluntary movement etc. - diere is just a listing of functions
(presumably of the nervous system) which is not very illuminating.
♦There is no section on the endocrine system.

The entire chapter abounds in confusing terms and statements wliich even become
laughable at times, e.g:
Xf-W** ... ’4

rHqF

$

(Literally means that voluntary muscles are found inside tlie skin).
'hT 3PT
Rw ’ - much simpler would have been
sflC

( Hiis statement is confusing because the words for stomach and abdomen in Hindi are the
same - ^d )
^TT
7r<nrr
7r*Fi
1.4 frl.dk.g. q£f 1.2 ml.dk.g. xJicrr It.
(Literally means that liver weighs 1.4 to 1.6 k.g in humans and 1.2 to 1.4 k.g. in women!!)
w to'd’
vM!
err ^idr 1

wrr uptt ... w
to
vte-ir
$ T’ft' TRnifinrr

tw te't

.

(Literally means that all the muscles relax and thus exert pressure on the lungs!)
- should be
T5
L<qr tY
(Literally means that the process of urination is called urination!)
Rr frTRt
iefr S.
FtpiTo’
....
^'31 rilij' WiT'tofFT’oTT
Tnf TTT C.S.F. W v-HT
The diagrams are of variable quality, and die labelling is usually a combination of Hindi
and English terms which is confusing. Many systems appear hanging in the air giving no
notion of where they are located in the body. Important omissions are: a simple overall
diagram of the body showing the location of all important organs; a diagram schematically
showing the lungs and heart together and process of O2/CO2 exchange; a diagram of tire
circulatory system showing major blood vessels; and a diagram of the nervous system in
entirety showing spinal cord and nerves (schematically).
In the middle of the description of the ovary, there is a diagram of an oval organ without
any labels. On careful inspection it is revealed to be not the ovary but the brain turned
sideways!
Chapter 4
71101-0 is no introduction to tlie subject or background regarding relevance of the subject,
d'lie epidemiological triad is introduced with the Agent being equated with disease
organisms - no possibility of toxins etc. The terms xhlPJ and vflqnj are used interchangeably
whereas tlie former means micro-organism and the latter means bacteria. Vims, bacteria,
protozoa are mentioned repeatedly without a word of explanation.
lhe term for host Tfrihr is quite incomprehensible or 3 ft would be better.
Environment is supposed to include the internal body environment - is this conceptually
correct?
lliere is no example of how modification of each of these three factors could lead to
changes in occurrence of disease.
'J’hcrc is an overgeneralised description of disease transmission and it appears as if all
types of microbes enter and exit the body via all routes and are transmitted by all vectors.

26

There is no notion of the specificity of mode of transmission of each disease. It would have
been better to give some specific examples like infective diarrhea, malaria, common cold.
In the table of diseases by mode of transmission, there is no mention of vector borne
diseases at all.
There is absolutely no mention of tlie Social context in causation of disease; the fact that
many diseases arc related to inadequate nutrition and poor living/working conditions and
that imi'-rovement in social conditions Ins been much more instrumental in communicable
disease control tlnn just medical measures.
All in all tire treatment of the subject of epidemiology is very cursory and is disposed off in
two pages. No attempt has been made to relate it to preventive measures which are the
subject of the next chapter.

Chapter 6
Wliile introducing the subject there is no mention of - tlie basic fact of malaria being a
vector borne disease, a basic outline of the life cycle of tlie parasite, its significance as a
public healtli problem etc.
While describing the fever there is no mention of the periodicity of fever and its episodic
nature (of course it should lie mentioned that these features are not always present). There
is no mention of enlargement of spleen as one of tlie clinical features of chronic malaria
3k
w-T’ ?
The presumptive treatment suggested is only 4 tablets of chloroquine for an adult which is
acknowledged to be insufficient byNMEP in endemic areas and should be changed to
total 10 tablets.

The radical treatment suggested also does not mention full dose of chloroquine and dose
schedule of Primaquine mentioned seems to be same for both P.Vivax and P. Falciparum.
Ibero is no description of tlie significance of vivax vs. falciparum (possibility of relapse in
the former, cliloroquine resistance and cerebral malaria in the latter).
The occurrence of relapses and possibility of cliloroquine resistance (both now common in
endemic areas) are not mentioned at all.
Cerebral malaria and its features are not mentioned at all.
(liapter 19

This cliapter mainly consists of an extremely detailed protocol of physical exanunation,
which one presumes is to be applied to all patients without discrimination.
There is no mention of the distinction between symptom and disease (e.g. fever vs.
malaria) nor sign versus disease (e.g. jaundice vs. hepatitis). Thus there is no clarity on
how to approach a diagnosis mid die entire description of physical examination does not
seem to lead anywhere.
I-Iistor/ taking is dispensed of in a few lines (paradoxically under tlie heading - points for
examiualion). There is no concept of j/rcsenting or major complaint nor special jxrints to be
enquired regarding particular complaints (e.g. couglt pain abdomen).
The protocol for physical examination runs into two and a half pages without any
dem-ircation into systems or prioritisation based on tlie patients presentation.

Z7

There is absolutely no description on Aow to go about conducting any of die examinations
c.g. of the throat, chest, abdomen .The JSR is just instructed to examine tonsils, thyroid,
liver, spleen, lungs etc. without a clue of how to do this. The text is unencumbered by any
expl ana l ory d iagranis.
T*iking of pulse is repeated at three diflerent places in the protocol ' On the other liand
simple points like examining the tongue for pallor, palpation of the abdomen for tender
areas, pedal edema arc not mentioned. The significance of any abnormality in the allimpoitani pulse, is never mentioned so if ap«x?ars to be just a magical ritual to be followed
for its own sake! hi fact there is no guideline on inteipreting any of the findings arrived at
after tlic detailed rigmarole of examination.
The chapter ends with a pedantic instruction to give more importance to detailed histoiy
taking than to physical examination. This is unfortunately contradicted by the authors
themselves who devote exactly two lines to points to be enquired in history and devote two
and a half pages to physical examination.

Chau ter 20
The entire subject of clinical medicine for the JSR seems to be treated as the lowest
priority even though it may be a high priority for both the community and (lie JSR. This is
reflected in devoting just 6 pages to treatment of minor ailments whereas anatomy/
physiology runs into 22 pages and record keeping into 17 pages!
As has been remarked earlier, there is no attempt to inculcate the practice of making a
diagnosis, nor has the relevant information required for this been provided. There is a
totally 'cookbook’ approach of 'for this - do this’ which is not only grossly inadequate but
also instills irration?il treatment practices from the very inception of training.
Ihere is a mixture of allopathic, ayun’cdic. homeopathic and home remedies advised but
none of these nicxles of treatment, let alone their integration, has been discussed anywhere
in the book-.Despite the previous detailed description of anatomy, there is no attempt to deal with
diseases system-wise which would make it somewhat more logical. The reason for the
particular ordering of ailments is obscure till one realises that the table is translated from
an (english) alphabetically listed table of simple ailments starting with abscess and
constipation and going upto vomiting and worms!
In fact there is no description of any of the diseases mentioned - which is the affected
organ/system, what is the derangement, natural histoiy, basis of treatment, complications
etc. For a six-month full time course tliis seems to be grossly inadequate clinical
infonnation. There is no mention of man}' common problems like sore throat/tonsillitis,
amoebic dysentery, pyoderma, infected wounds, trachoma, simple dysmenorrhea etc.
The scanty and disjoinied information given is also confusing and at times incorrect:

Z8

/

Topk

Rein arks

Abscess;
Constipation

No mention of tire need to drain an abscess
No mention of natural laxatives like mill;, high fibre cereals.
Fluid intake is necessaiy' but why advise only ho! water ?
No mention of the commonest giusc - febrile convulsion

means cramps
here probably intend
to moan convulsions
Cough and cold

Earache
Fever

•Headache
Indigestion

Joint pains
Pain in abdomen

No. 11
Scabies

Sore eyes
Ulcer

Vomiting

Worms

To combine the two as a single entity is itself erroneous - they
should have been dealt with separately. What is the utility of
applying menthol on tlic back? Giving chilis? No mention of
rapid breathing as a danger sign
Is sulfacetamide itn ajypropriate treatment for ASOM?
Should all cases of earache with lever be referred?
All cases including colds, diarrhea, abscesses, measles etc. to be
given chloroquine? Is 36 degree centigrade the cutoff*point? No
mention of the need to reduce blankets/covering and keep tire
room well ventilated
Should all pregnant women with a headache be referred?
The term is itself confusing and means different things to different
people. What is the utility of Magnesium hydroxide unless there is
acidity ? (it can itself aggravate diarrhea). What is the special
utility of boiled water?
Either aspirin or paracetamol can be given for symptomatic relief.
Why Magnesium hydroxide for all cases of pain abdomen - many
cases related to diarrhea will get aggravated by it. The dosage
schedule for homeopathic'drugs is not clearly given.
The disease itself is not mentioned (?Ringworm)
No mention of Gamma Benzene Hexachloride. No mention of
washing clothes in hot water
Covering the eye with a pad for ordinary conjunctivitis is
erroneous and could also be dangerous
The term is confusing as this word is usually used to denote
jieptic ulcer in lay language. Which antiseptic ointment is referred
to and what is its utility?
Should all cases of diarrhea with vomiting be referred? In most
cases the vomiting is self limited. Why Magnesium Hydroxide
again especially since most cases are due to gastroenteritis?
There arc safe, highly effective and inexpensive allopathic
treatments available e.g.Mebendazole, Albendazole - why not
advise these?

Comments on the List of medications to be used bjr the JSR:(Appendix 3)
1 .This list does not contain most drugs recommended in Chapter 20 (whether correctly
rcconimendcd tiiere or not) :
Magnesium Hydroxide tab.. Menthol, Hucaljptus oil,Sulfacetamide cyc/ear drops,
Lashunadi Vati, Mahayograj guggulu, Coloi 6 (?), MagPhos 6, Benzoic Salicylic oint..
Benzyl Benzoate lotion, Teiramycin eye oint.,Belhtdona 30, Mercsol 30, Antiseptic oint,
Cyana 30 etc.
2. This list docs not contain certain basic medications which can be quite useful for treating
a range of ailments e.g. Metronidazole, Aspirin/Ibuprofen, Mebendazole, Vit. A, Gentian
Violet etc.
3. This list contains certain drugs which are either hazardous or redundant and surprisingly
precisely those have been mentioned by brand name rather than scientific name (hopefully
just an accident)Analgin: A dmg widely banned, for which safe and inexpensive alternatives exist.
Avil: Does this refer to tablets or injections? What are the specific indications?
Decadron: In cither tablet or injection form what are the indications for use by the JSR?
Are we not promoting irrational therapy by putting this on the basic drug list?
Neospo.rin powder/oint.: This is quite an ex]>ensive, brand topical preparation containing
three antibiotics. Costs much moic than, and is probably as effective as Gentian Violet or
plain Neomycin.

30

IV.

Dr. Prabir Chatterjee, Community Health and Development, Christian
Medical College - Vellore - 632 002, Tamil Nadu.

There are quite a few spelling errors in the Manual. There are also places where the
treatment is that of the old government recommendations than the currently accepted
practice.
Examples : Page 58 (5) Malaria - the manual recommend 600 mg. chloroquine
(“presumptive treatment”) rather than the WHO’s radical treatment of 1500 mg.
(which takes care of FALCIPARUM).
Page 66 (1) TB - the manual refers to Rifampsiliny. (!)

Question 69 : Filaria - one wonders whether Chyluria is really an important sign of this
disease and whether it needs to be highlighted in a manual for middle level health
workers.
Page 204 - Appendix 2 (Code of conduct) expects the student to “obey all orders of all
health department officials”. After the SATHIN’s problems in Rajasthan one wonders
whether this would be the best.
Page 205 - Appendix 3 (Drug Kit) ANALGIN and DECADRON do not seem to be
warranted.

One cannot support the use of non generic names like AVIL and SAVLON especially
when cheaper alternatives are available.

It would be sensible to include:

ASPIRIN (instead of ANALGIN)
BENZYL BENZOATE
WHITEFIELD’S OINTMENT
ANTACID
METRONIDAZOLE

as the middle level health worker after 6 months in service training should be capable
of using these.

On the whole however the book is excellent and the language very readable. The
companion manual for the Village Health Committee was reasonable.

31

Some questions:
CH.5, page 7 - Why not bathe a newborn immediately (unless preterm) and in cold
weather?

CH.8, page 13 - Why not describe the proportions of sugar and salt for a housemade
ORS9

CH. 11, Page 17 - Is the language here a bit stilted.
CH. 12, Page 19 - Is this a bit impractical?

CH 14, page 21 - Does TV affect eyesight? Is it common in MP villages? Why no
mention of spectacles?

CH. 16, Page 22 - Could the samiti even test salt for 10 iodine contents

V.

Dr. Abhay Bang, SEARCH, (Society for Education, Action & Research in
Community Health) Gadchiroli, Maharashtra - 442 605.

I found the concept of such worker and the new stated focus on RCH very interesting
and encouraging.

The actual contents of the job description and manual however gave feeling that there
was not much new about the contents. Moreover, the role vis-a-vis health care system
was still that of a subordinate helper at the village level. How is this worker going to
be financed (besides TRYSEM)?
A more detailed The task analysis would be very worthwhile provided MP health
department can really implement it. On the contrary, as I said in the beginning, the
concept of such worker is very attractive proposition.

32

VI. Dr. Anant R. Phadke, medico friend circle, 50, LIC Quarters,
016.

Pune - 411

1. Discrepancy between “JSR Responsibilities” in page One and “JSR Functions” in

page 202 must be reviewed.
2. Discrepancy between the space and importance given to various topics in the

manual and the number of lectures allotted to these topics in Annexure - II. (page
223-229). For example, the text matter in the manual is too little to occupy 10
lectures on anatomy; there is no text on the 10 drugs mentioned on page 224 in
Annexure - II for 10 lectures on pharmacology. Moreover the allocation of one
lecture per medicine is ridiculous, with no lecture/text on the elementary concepts
in pharmacology.

3. Every lesson should start with learning objectives and the text should be tailored to
these learning objectives. Nothing of this kind has even been attempted. Hence it
is difficult to evaluate the text systematically. Overall, one can definitely say that
there are many unnecessary details given in anatomy, whereas the lessons on
Tuberculosis, leprosy, typhoid/filaria/dengue fall short of minimum level of
understanding of the subject.
4. Treatment of common diseases is too brief (Chapter 20), sometimes not scientific
and there is no attempt to diagnose the underlying condition. Use of nonallopathic medicines in some of the conditions listed in this chapter is questionnable
when cheap, effective, simple therapy is available in allopathy.
Treatment of
common diseases is people’s felt need. But that does not seem to be the concern
of the manual.

5. The drug list as given in ‘ Chapter - 3’ is quite defective and contains even
analgin!
6. In Chapter-19, a format for clinical examination has been given. But there is
nothing on how to assess the significance of various findings.
7. The above are general comments about the overall structure of the manual. The
contentsof the manual invite a lot of criticism, changes on almost every page, every
para. There are many many technical mistakes and many controversial statements.
Going into these details is a big separate exercise.
8. Chapters 14, 15 however stands apart from other chapters. These two chapters do
not contain mistakes and are well written giving relevant information about case of
the new-born, diarrhoea, ARI, vitamin A deficiency. Though many other issues
have not been touched, atleast whatever has been covered is OK.

33

VI.

Dr. Ashok Bhargava, IDEAL (Institute for Development Education and
Learning), B 4/1 Sahajanand Towers, Jivaraj Park, Ahmedabad-380051.

On the whole the manual is very good and precise.

Some comments:
1. While all the problems related to health and illnesses covered in the manual are

important from national perspective some of these problems would be more
important from the local perspective - for example there are endemic areas for
dengue, filaria and leprosy. The JSRs belonging to these areas will require more
specific training in these health problems.
2. Anatomy, physiology and epidemiology should be taught with the respective health

problems rather than as separate topics as in Chapter -3 and 4.
3. Similarly, what health education will have to be provided to the patients, patient’s
relatives and in the community, should be covered with every health problem. For
example, Chapter 7 on TB. The chapter does not cover important health
messages. On the isolation of TB patients. Once the patient is put on ANT (Anti
TB drugs) he/she cannnot spread TB. So there is no need for isolation within the
home.

4. There is a separate chapter on the examination of the patient. Examination is
always problem specific. Important points of clinical examination should be given
with the health problem.

5. There should be a separate chapter on common gynaecological problems like
white discharge, monoliasis etc.
6. Enclosed as an Annexure is a booklet on “How to develop a training programme

with special reference to grassroot health workers” from the mfc-Primary Health
Care Cell, which would be a useful reference for JSR trainers.

Enclosure:

A. Booklet on “How to develop a training programme.

34-

Enclosure : A

(Comments VI)

HOW TO DEVELOP A TRAINING PROGRAMME

WITH

SPECIAL REFERENCE TO

GRASSROOT HEALTH WORKERS

IDEAL
(Institute for Development Education and Learnint)
B 4/1, Sahajanand Towers,
Jivaraj Park,
Ahemdabad - 390 051

Bibliography:

1. Feldman, Robert S.; Elements of Psychology. McGraw-Hill, Inc. London 1992

2. Truelove, Steve (Ed); Handbook of Training and Development. Blackwell
Business, Oxford 1992
3. Buckley, R. and Jim Caple; The Theory and Practice of Training. Kogan Page
Ltd. London 1992

4. Mager, Robert F.; Making Instruction Work. Kogan Page, London 1990
I

5. Pont,Tony; Developing Effective Training Skills. McGraw-Hill Book Co. London
1991
6. Rae, Leslie; How To Measure Training Effectiveness. Gower, England 1991

'i

.7. Evan, Christine E.; Teaching Skills. The University of New South Wells, Australia
1988

8. Abbatt, F. R,; Teaching for Better Learning. WHO, Geneva 1992
9. Corder, Colin; Teaching Hard Teaching Soft. Gower, London 1990

i

rfSTSPI
dlCMI

1
'dHchiO

'SjcL'flPII

Training
Learning
Education
Activity
Task
Exercise
Knowledge
Skills
Attitude
Criterion
Evaluation
Objectives
Motivation
Analysis
Performance
Motivation
Guided
Compensation

06

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Prepared by - Ashok Bhargava
IDEAL

15 Tulasivan Society, Jivaraj Park, Ahmedabad-380051 Phone- 621525
December 1994

'44
12

VII. Dr. Ulhas Jajoo, MGIMS (Mahatma Gandhi Institute of Medical
Sciences),
Wardha 442 102.
Jan Swasthya Rakshaks cannot work in isolation primarily because they do not enjoy
credibility as a healer. The priority health needs of the people cannot be fulfilled by the
reflected glory of the credible health care delivery system.

A crash curriculum in the indoors, does not imbibe required skills. They learn by
doing. The inwork training adapted to the local situation by a visionary trainer (as was
done at Mangrol) is required. Abstract learning is too much for them.

To seek people’s involvement in form of a functioning Health Committee is more on
paper than in practice. Unless village based worker is empowered (by resources that
he/she can offer) and buttressed by the system, people’s involvement is too much to
expect.
A service sector (Health) programme based on ‘modern’ science, will have to be
vertical (capital intensive), thus its quality depends on accountability of the system for
the common masses. It will have to dole out services and does not tend to build upon
what they have.
VID. Dr, Dhruv Mankad, Project DirectonVACHAN (Voluntary Association for
Community Health and Nurture), Vasundhara Bungalow, Shivajinagar, opp.
Vijaya-Mamata Talkies, Nasik - Pune Road, Nasik - 422 006,

1. It is highly needed scheme and deserves to be implemented extensively. It is really
nice that it has started very enthusiastically. However, the creation of a new cadre
is either not conceptualised or if it is then very hazily. There is no clarity about the
roles and responsibility of the JSRs : are they in the lowest rung of the government
health hierarchy, or the implementors of government health schemes with a little bit
of a need based health service or independent practitioners or a hotchpotch of all?
There is no clarity of its operational process : selection, training and certification,
logistic of TRYSEM loan and drug supply, supervision/regulatory mechanism etc.
2. There are very informative chapters which are essential components of the
curriculum eg., Environmental and personal hygiene. These are considered as a
part of First Contact Care.
3. The curriculum-cum-manual has been prepared the first time by any government
machinery so soon and with a different vision from the usual vertical programme
manuals based on technical skill development. Thye need congratulations for this
sincere effort. Again, however, its hastiness is reflected in the overall nature of the
manual. It is not easily readable because it has used complicated English and/or
Hindi terms eg., on p 23 a technical term. Like ‘intermediate metabolism’ written
in Devanagari script and without any clear explanation as to what it means. Lots
of unnecessary,(unrelated to the main purpose of the training manual) information
is filled in, particularly in Anatomy, Physiology. On the other hand important and
useful information is missing eg., how absorption takes place in small intestine and
its relationship to dehydration in acute diarrhoea is missing.

47

4. There is no mention about inflammation - healing, bleeding-clotting, infection
immunity as basic defensive responses of human body. Without this it is impossible
to understand the supportive role of external interventions like drugs,
immunisation, environmental intervention, etc.
5. The diagnostic system is totally absent. Without this how is the person is expected
to ‘practice’ FCC is an enigma. This - the core curriculum - should be a must,
since they are to provide curative services.

6. There is no balance between state driven health services and the demand driven
services, the former are more than the later. If they would ‘practice’ then they
would do ‘more’ of what they were trained ‘less’.
7. The overall manual is dry. The writing style needs to be changed. Lot of tables,
‘bulleted’ information, graphical presentation, drawings, photographs are needed to
make the manual ‘live’.

8. The manual should be technically approved by a panel of experts so as to conform
to the existing knowledge.

A long training programme for this kind of trainees may not be productive. Anyway
they would need a continuing, refreshing, updating and upgrading education in order
to cope up with the ‘practice’. A self learning method supported by a supervised tutorial - system may be a more effective system than just a didactic one as this one.
This would give the advantage of building up confidence of the trainees as a result of
self testing system included. Ofcourse, a periodic examination would be necessary.
I have enclosed the syllabus of training and list of drugs used by CHWs in our
VACHAN programme (see enclosure)
Enclosure:

Appendix 1 : Syllabus of CHW training (VACHAN Programme)
Appendix 2 : The Drug Kits for CHWs in VACHAN programme.

48

Appendix 1

(Comments VIII)

ANNEXURE1
SYLLABUS OF CHW TRAINING PROGRAMME
DAY SUBJECTS AND TOPICS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29

Arrival and introduction.
a) Introducing health care through herbs, b) A bird’s eye view human body.
Orientation to health and ill health..diarrhoea etc..
Human body..cells, tissues, systems.
Human body..digestion and respiration.
Human body..other systems.
Nutrition..energy, proteins, requirements, malnutritions.
Causation of diseases., immunity, inflammation etc..
Diagnosing illnesses, general approach, which diseases to treat and which to refer etc..
Principles of treating illnesses. Drug and non drug methods.
Modern pharmacology, how drugs work, ill effects. Select allopathic remedies (20 drugs ).
Eye, its diseases.
Holiday.
Ear, its diseases.
Childhood illnesses,...Introducing to other health workers from Vachan* (afternoon).
Nutrition..some more topics*.., Select topics (our own meals) with health workers* (afternoon).
Pneumonia in childhood, respiratory system illnesses.
Examination of RS. (before noon)., Skin and wounds* (afternoon).
Other respiratory illnesses, Tuberculosis, (before noon), Health education in a village *.
Skills required in village health care.
Other respiratory illnesses..(before noon), Skills..(afternoon).
Digestive system illnesses. Dental health, (before noon).. Discussion with a herbalist health worker
from other project (afternoon).
Some herbal medicinal usage *.
Digestive system illnesses.
Elementary care in womens’ health *.
Personal, domestic and Community health.
Examination (MCQs), testing skills (group method).
An introduction to Homeopathy and tissue remedies *.
Discussion, Recapitulation, evaluation of training program.

* Lists of topics covered by guest trainers.

A separate list of ‘skills’ for health workers, demonstrated in the training program is
appended with this.

If
c ■

79

-JI

A

49

7

■ h

fi

APPENDIX 2

(Comments VIII)

T HE DRUG KITS FOR CHWS IN VACHAN'S PROGRAMME
LIST OF MED J C INES SLTTL1 ED TO C11WS

NO.

14
1?
16
17

WHITFIELD OINTMENT
VITAMIN C
VITAMIN A
TETRACYCLINE EYE OINTMENT
SALBUTAMOL
PARACETAMOL
ORS
METRONIDAZOLE
MEBENDAZOLE
FURAZOLIDIN
FERROUS SULPHATE
CODEINE
CO-TRIMOX AZOLE
CHLOROQUINE
CALCIUM I. ACT ATE
CPM
B-COMPLEX

is

atropine

19
20
21
22

ANTACID
AMPICILLIN
OENTTON VIOLET
DETTOL& BANDAGE

1
2
3
4
5
6
7
8
9
10
11
12

NO.

SENIOR CHWS(> = 2YRS.)*

1
n
3
4
5
6
7
8
9
10
11
12
13
14
15

JUNIOR CHWSK2YRS..)*

VITAMIN C
VITAMIN A
PARACETAMOL
ORS
METRONIDAZOLE
MEBENDAZOLE
FURAZOLIDINE
CODEINE
CHLOROQUINE
CPM
B-COMPLEX
ATROPINE
ANTACID
GENTION V1C)LET
DETTOL BANDAGE

12

5o

i I

Go to the people
Live among them
Learn from them
Love them
Start with what they know
Build on what they have.
*

*

*

Of the best leaders
the people only know that they exist;
The next best they love and praise;
the next they fear;

And the next they revile.
When they do not command the people's trust,
Some will lose faith in them,
And then they resort to recriminations!

But of the best, when their task is accomplished,
their work done,
The people all remark, 'We have done it
ourselves!'
- Old Chinese Poem

Media: JAN SWASTHYA RAKSHAK SCHEME JSR.pdf

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