A Research Encounter: The Research Experience, Agenda and Paradigm of SOCHARA
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A Research Encounter: The Research
Experience, Agenda and Paradigm of SOCHARA - extracted text
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building community health
SOCHARA - SOPHEA
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ANNUAL TEAM RETREAT -2013
Theme: A Research Encounter: The Research
Experience, Agenda and Paradigm of SOCHARA
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9™ AND 12™ SEPTEMBER 2013
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BACKGROUND PAPERS
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SOCHARA-SOPHEA
Annual Team Retreat -2013
Theme: A Research Encounter: The Research Experience, Agenda and Paradigm of SOCHARA
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9th and 12th September 2013
Background Papers
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A checklist of the background materials
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A tentative programme
VOLUME-I
Page No.
Titles
S.No.
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INTRODUCTION
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Why Research in Health and Disease,Health Action, 2004,17(7)p4-6 - C.M.
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____________ __ _________________ _________
Francis, President/Consultant, SOCHARA
_______________ _______________
Seeking New Paradigm in Health and Health Research : An overview of the CHC
Journey (1984-2008) Thelma Narayan- Director, SOCHARA
PERSPECTIVES AND PARADIGMS IN HEALTH AND HEALTH RESEARCH_________
Informal choices for attaining the Millennium Development Goals : towards
an international cooperative agenda for health systems research ( WHO Task
Force on Health System Research) Lancet-2004 ~ 364:997-1003,( Ravi
Narayan, CHC/PHM Bangalore was a member)
__________ ■
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Research for People's Health - A researcher encounter at the Second People's
Health Assembly at University of Cuenca , Ecuador, 2005 ( A PHM/GFHR
Publications) _______________ - ________ ___________ ____________________
Research Priorities for Schools of Public Health with a focus on the Global South
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SOME RESEARCH PROJECTS OF SOCHARA ( OBJECTIVES, MATERIALS,
METHODS AND PROTOCOLS
___________ _ _____________
The Bhopal Disaster aftermath - An epidemiological and social medical survey
- summary of the report, 1985 ( mfc)
,
_________________________
Strategies for Social Relevance and Community Orientation-Building on the
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Indian.experience, July 1990 - ( Basic Premises, objectives and methodology)
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Background paper for special session in GFHR-Forum-10, Cairo,2006
( Compiled by CHCiSOCHARA, Bangalore India)
. 1
Evaluative feedback from CHAI. Members - at the fiftieth iTiilestohe - (CHAI
Golden Jubilee Evaluation Study, 1993 ( Aims and objectives, materials and
methods)_________________ _________ •
___________________
2000AD and beyond: Contextual and policy level issues important for the future
health related work of CHAI, India- A policy Delphi research study,1992 (
background, policy Delphi method study process)
______ ________________
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Reaching Health to the Grassroots-A participatory interactive review of the
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JSR Scheme of the Government of Madhya Pradesh, July-Dec 1997 ( Terms of
reference, methodology of review process)
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A study of policy process and implementation of National Tuberculosis Control
Program in India - LSHTM - PhD Thesis, (Study design and methods)._________
Jana Swathya Rakshak Yogana of Madhya Pradesh, the second Review and
Consultation report, July - November, 2Q01.( Materials and methods)_________
Disparities in Health and Health Care Services in Karnatakb, 2001, A research
study commissioned by Task Force on Health and Family-Welfare, Government
of Karnataka (objectives and methodology)__________ \__________
Review of Externally Aided projects in the context of their integration into the
Health Service delivery in Karnataka. A research study commissioned by Task
Force on Health and Family Welfare, Government of Karnataka (2001)(Project Proposal from CMH working papers series W66:8 Commission on
Macroeconomics and Health, WHO)
_______________ ________________
Understanding Global Public Private initiatives-case study of Global Alliance
to Eliminate lymphatic Filariasis - A CHC/WEMOS collaborative study -2004 (
Executive Summary, introduction , objectives, -and methodology)____________
Synthesis of Grey literature from select Asian countries about Comprehensive
Primary Health Care.(CPHC) experience-Teasdale Corti study-CHC/PHM
collaboration. (Introduction, methodology, search strategy, inclusion/exclusion
criteria and steps of review)
ADDITIONAL PAPERS
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Just listen: research and activism can walk hand in hand ( A Real Health News,
interview with Dr. Ravi Narayan) Real Health News, No.5, May 2006______ .
Pushing the international health research agenda towards equity and
effectiveness - David McCoy, David Sanders, Fran Baum, Thelma Narayan,
David Legge, Lancet - 2004-364:1630-31
■ ■■■
'■ ■■■ - _____ .
Hamari Sehat Hamari Ladai, extracts from the Bhopal Gas Disaster comic
evolved from the mfc study
_____
Towards an Appropriate Malaria Control Strategy - Issues of Concerns and
Alternatives for Achan, 1997 , VHAI/SOCHARA ( Chapter 24, Malaria Research
Challenges).
________________________ _________ _______ _______
Medical Health Research to suit the Market ( N.H. Antia/M.W. Uplekar);
Resugence of Malaria ( Ravi Narayan) - editorials, National Medical Journal of
India, Vol-10/No.4, 1997 P-155-158____________________
Guidelines for implementation of Roll Back Malaria at District level - WHO
SEARO -2003 ( Research and Development)
Health Research for the Millennium Development Goals, Report of Forum 8,
Mexico city-2006, Chapter 2 Knowledge and power (Includes - grassroots
perspective by Ravi Narayan - CHC/PHM)______________ ________________
Combating Disease and Promoting Health - Report of Forum 10, Cairo, Egypt,
( Chapter - Determinants of Health, which includes the discussion on Social
Vaccine) ____________________________________________
Equitable access - Research challenges for health in developing countriesReport on Forum 11, Beijing, China 2007.( Primary Health Cares Rejuvenation;
and chapter 3 on Zeroing in on health systems_____ _____ . ._____________
The Bamako Call to Action on Research for Health : Strengthening research for
health development and equity. Global Ministerial Forum on Research for
Health, Bamako, Mali, 2008___________ ____________
A call for Civil Society Engagement in Research for Health - towards post
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Bamako action plan, input to Global Ministerial forum on Research for Health,
Bamako, Mali 2008
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Application of Epidemiology Principles for Public Health Action- Report of a
Regional Meeting, SEARO, WHO 2009 ( conclusions and recommendations)
Montreux Statement from the Steering Committee of the First Global
Symposium on Health System Research, Montreux, Switzerland, 2010
Beijing Statement from the Second Global Symposium on Health System
Research , Beijing, China, Nov 2012
DISCUSSION DOCUMENTS:
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The 'Social Vaccine' - towards the concept of a social vaccine ( Background
paper for pienary session, Forum 10, Cairo, Egypt 2006)_________________
Civil Society Engagement in Health Research, Thelma Narayan, CPHE, SOCHARA
and PHM, for Bamako, October2008
Revitalizing primary health care: how can epidemiology help?-Plenary paper,
Ravi Narayan, South East Asia Regional Conference on Epidemiology, WHO
SEARO, 2010.
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Society for Community Health, Awareness, Research and Action - SOPHEA
Annual Team Retreat
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9th and 12th September 2013
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THEME: A RESEARCH ENCOUNTER
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The Research ExperiencerAgenda and Paradigm of SOCHARA
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Date /Time/Venue
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9thSeptember 2013
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The SOCHARA family get-together ( SOCHARA
SOCHARA Annexe
Team, ARC and Fellows) Songs & a Play
ACADEMIC & RESEARCH COUNCIL MEETING
10.15- 5
pm
(SOCHARA Annexe)
10.15- 11.15
11.15 -11.30
11.30-1.00
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3
1.00-2.00
2.00-3.30
3
Cultural Team
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Staff Annual Retreat: Research Workshop
An overview of the Research Agenda of
Facilitator
SOCHARA ( 1984- 2009): Broadening the
Ravi Narayan, Community
evidence and evolving a new paradigm
Health Advisor.
_ _____________
BREAK__________________
The Yin and Yang of SOCHARA Research -1
Participatory Research and Health Policy Action
(Overview of 5 projects of SOCHARA )
Moderators:
Ravi Narayan & As Mohamrpad
Presenters:
Karthik & Sabu
LUNCH
The Yin and Yang of SOCHARA Research - II
Participatory Research and Health Policy Action
( Overview of 5 more projects of SOCHARA)
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9.00- 10.15am
10.15- 3.00pm
( SOPHEA Trg Room)
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Resource Person/
Facilitator/Moderator
Monday_____
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Theme
3.30-3.45
________________ BREAK_________________
3.45-5.30
A Panel Discussion on Sharing of SOCHARA
Research Experiences : Strengths,
Opportunities, Aspirations, Results (SOAR)
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Moderators:
Ravi Narayan & As Mohammad
Presenters:
Karthlk & Sabu
Moderator:
As Mohammad
Panelist
Thelma Narayan
Prasanna Saligram
Rakhal Gaitonde
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10thand 11th September
2013
National Workshop : " Social Justice in Health and
Universal Health Coverage : Challenges, Pathways
(Tuesday & Wednesday)
St John's. Annexe-Ill
_____ Meeting Hall
and Possibilities"
12th September 2013
Annual Team Retreat (continued)
See Separate Program
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(Thursday)
(SOCHARA Annexe)
O.OcT■10.00 am
Understanding the CAH Process in Tamilnadu
Moderator:
As Mohammad
Presenter
CAH team, Tamilnadu
(Ameer, Suresh, Naresh
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Santosh)_____________
Reflections on Evidence gathering and its
utilization ( Research Opportunities in CAH)
10.00-11.00am
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Moderator:
As Mohammad
Presenter
CAH team , Tamilnadu
(Ameer, Suresh, Naresh, Santosh j
11.00-12.30pm
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Team Sharing and Dialogue with SOCHARA- EC
SOPHEA Trg Hall
12.30-2.00pm
2.00 -3.15pm
____ ____________
LUNCH_____________ _
Environmental Health / other Public Health
Moderator: Ravi Narayan
issues.
Presenters
-Adithya Pradyumna
-Prahlad
-MP Team (Juned, Razi,
Dhirendra, Bhagwan)
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Environmental Health
Environmental. Sanitation
Malaria/Nutrition / Maternal Health
_______________
3.30-5.00pm
RESEARCH IN SOCHARA: THE NEXT STEPS
i)
ii)
Academic and Research Council ( ARC)
Institutional Scientific and Ethics
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BREAK______________ ___
3.15 - 3.30pm
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Moderators:
Thelma Narayan
As Mohammad
Committee (ISEC)
iii) Research areas for individual team
members
iv) Research training and mentoring of
community health fellows
v)
Funding, documentation and publication
vi) Any other matters.
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28th August 2013
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WHY RESEARCH IN HEALTH AND DISEASE?
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Research is a systematic process of generating new knowledge. Research in Health and Disease is
the generation of new knowledge using scientific methods to improve and maintain the health of the
people and to identify the health problems leading to disease and to deal with them effectively and
efficiently. Research in Health and Disease is essential to help people to adopt measures conducive
to better health and to improve the design of health policy, service delivery and interventions. The
focus of the research efforts should be on
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the total health of all the people, and
annulling or reducing the burden on the people of diseases. Health Research is a vital
investment in the future. The seeds of research sown today will yield.a wealth of
results effective tomorrow.
Purpose of Research
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.Health Research is essential in every country to
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determine the country's particular health problems and set priorities among those
problems;
analyze different Measures to deal with those problems;
help in the choice of appropriate strategies and actions to achieve maximum possible
improvement in the health of the people; action without appropriate knowledge can
be wasteful; .
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develop new tools to attain better health (e.g improved lifestyles); prevent diseases
(e.g. vaccines) and treat diseases ( e.g. drugs);
make interventions cost-effective by proper planning and wise use of scarce
resources (e.g., low cost ambulatory treatment of tuberculosis; oral rehydration for
diarrhoea);
evaluate the impact of measures undertaken; and
advance basic understanding and frontiers of knowledge in health and disease.
Health and Development
There is a strong link between people’s health and the development of the country. Poor health
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reduces healthy life expectancy;
reduces educational achievement;
decreases productivity;
increases poverty and inequity.
Poverty leads’to the vicious cycle of malnutrition, low level of education, disease, poor housing and
lack of access to health care services
The 10/90 gap
Only about 10% of health research~fuTrciing is allocated to 90% of the world’s health problems. This
serious disparity is caused by the very large disparities in income between the developing countries
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and affluent countries. The-disease affecting the rich gets the attention of research workers because
of market forces. The results of the research-done in and for the people of the affluent counties
cannot be transferred readily into the low and middle-income countries.
• Communicable diseases represent a large share of the disease burden in the low-and middle income countries, whereas they have been largely wiped out in the affluent countries.
• Vaccines developed in the affluent countries may not be suitable for developing counties, due to
variety of conditions.
• The determinants of health, risk factors, levels of health care systems and services vary.
• • The availability, accessibility and utilization of health care facilities vary and especially the factor of
affordability.
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Poor Health
• reduces healthy life expectancy;
• hinders educational achievements;
• decreases productivity;
• increases poverty and inequity.
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Disease Burden (DALYs per 1.00,000 population), 1998,
Group of Diseases
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Low and middle
income counties
High income
countries
Ratio
11,206
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10.200
9,664
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4,198
1,403
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1.. Communicable diseases,
and nutritional conditions
2. Non-communicable
diseases____________
3. Injuries
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(Source: The 10/90 Report on Health Research, 2001-2002, Global Forum for Health Research)
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Priority Setting in Health Research
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We have to set our priorities correctly, because
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resources (personnel, materials and funds) are limited; and
there are problems of graded significance with respect to death, disease and disability.
Research priorities should be set, considering also the ethical principles of equity and justice.
We must focus on the determinants of health and on diseases causing the greatest burden of mortality
morbidity. We have to consider the determinants of health at the individual, family, community,,
district, state and national levels.
Who sets priorities? Priorities should be set involving all. the people concerned - individuals, families,
communities and the governments - local, state and national.
Very often, diseases of significance to the poor are neglected.
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Partners in Research
All people and organizations having a stake in health and development should be involved at different
stages of research. These include:
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Research oriented institutions
Universities and teaching institutions
Government - national, state and local
Professional organizations
Civil society,
Health care institutions
Health workers
People
Considerable amount of work is being done all over the country., from which useful, new knowledge
can be gathered. Unfortunately, most of it is not documented or inferences drawn.
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Research in Developing Counties
A powerful tool to overcome the obstacles to better health in developing counties is research. But
there are many obstacles.
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Personal; Intellectual isolation; low salaries; fewer career choices; insufficient training;
attraction to affluent counties (emigration of researchers).
Institutional: Insufficient access to information; inadequate support/technical staff;
inadequate facilities.
Environment: Lack of scientific_culture; lack of demand for research; weak public support:
bureaucratic rigidity; inadequate funds,
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But it is necessary to develop essential national health research to
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understand the. country’s pressing health problems;
prioritize them;
enhance the impact of the limited resources;
improve health policy and management
foster innovation and experimentation.
Research is often carried out in developing countries for the health problems of the rich counties
Various conditions prompt such researches; research costs are high In affluent establishments and
clinical institutions are overloaded with research projects; there is strict application of ethical
guidelines. Sponsors seeking fast and cheaper ways of carrying out the research turn to developing
counties where the costs are lower, patients willing to participate in the research are plentiful and
ethical principles are sometimes ignored.
Ethics and Research involving Human subjects
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Research jnvolving human subjects cajls for the observance of ethical principles. Often these are
violated. This is a matter of concern. These principles were initiated in 1964 by the World Medical
Association in the Declaration of Helsinki which has undergone many modifications.
The major problems have been
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Classification of Diseases
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Commission oh Macroeconomics and Health, 2001
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Disease type
Global research
effort
Example
Notes
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1. Diseasesnot
neglected
High
Cardiovascular diseases
Diabetes
High incentives for
R&D
2. Neglected
diseases
Low
Malaria, Tuberculosis
Low accessibility for
poor countries ~
3. Very neglected
diseases
Very low
Kala-azar, Lymphatic
filariasis
Extremely low R & D
funding
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The neglected and very neglected diseases are common in the poor countries. There is very little
' ■ funding for Research & Development. The very neglected are the ‘orphan’ diseases in which the
affluent counties are not interested.
Of the 1233 new drugs that reached the global market between 1975 and 1997, only 13 were for the
tropical infectious diseases that affect primarily the poor-in low and middle income counties. .
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Problems in Research in Health and Disease
Health research is beset by many problems. The more important among them are:
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lack of priority setting;
insufficient resources (persons, materials, money); .
misallocation of resources;
ineffective and inefficient use of funds;
failure to ensure wide dissemination of results;
failure to ensure that the results of research have an impact on the health of the people.
How to make health research more effective?
Set the priorities to address the major health problems
Help, correct the 10/90 gap
Increase the resources for research
Remove the isolation of research
Increase the impact of the results on peoples health - improved use of results, better
health policy; better services.
Unfortunately, research is often seen as an ‘ivory tower’ by the policy and decision makers and the
people themselves. This must change.
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obtaining free, informed consent;
withholding known effective treatment;
use of children, mentally defectives and juvenile delinquents;
drug induced toxicity - experiment continued;
adverse effects and
use of hazardous procedures.
nrinrinnT8^ ’h “f7 ou‘ res®a/oh on lar9e populations e.g. in the study of vaccines. Ethical
PnnC'Ples mus be observed. Informed consent is often difficult because of illiteracy and other
fnriivdTLi'o.
't®, mVSt Whensver Possible, informed consent must be obtained from the
ndividual subject and also from the-community, involving community leaders
Certain important requirements stand out:
1. Free, voluntary informed consent. A mere statement (including the signature of the participant)
has no meaning unless the subject or his/her guardian is capable of understanding what is being
undertaken and unless all hazards are made clear.
2. An intelligent, informed, conscientious, compassionate, responsible researcher
3. risks^XnolvedCiPated
experiments invo,ving human subjects must be far greater than the
Conclusion
Health research is a must, it is one of the most important driving forces for
• improving the health of the people and development;
• better performance of the health system;
reducing the health gap between the rich and the poor and bringing about equity.
All people must be involved in health research. This would-include the ■ specialists (biomedical
researchers, clinicians, epidemiologists, social and behavioral scientists, health economists) and all
lhvLr hSeArCh'ii j^y^4-Produced bY health research is a public good. The benefits must be
extended to all the people for the fullest attainment of health and development.
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Seeking New Paradigms in Health and Health Research:
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An Overview of Contributions by CHC, SOCHARA 1984-2008
Thelma Narayan 1
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1. Introduction - Evolving Ideas and Action
The Community Health Cell (CHC) initiated in 1984 by a group of us in Bangalore stalled with
the premise of building and strengthening a community health movement in India. This was an
idea in formation that grew over the years. We chose not to establish a community health
■program in a limited geographical area, but to be catalysts for community health among
different sectors. We defined our community as • community health and development
practitioners, social activists, health workers, academics and researchers and those working in
the health system. Thus it had as much diversity and complexity as most communities. The
team also worked directly with both rural and urban communities.
Study, reflection and action marked the first seven years of work by the CHC team and friends.
Networking and experimentation, with alternative methods of teaching-learning and researci
were used to promote community health action with a wide range of partners. This included
building links with NGOs, institutions, and national organizations in the voluntary sector such
as the Medico Friends Circle (MFC), CHAI (then called the Catholic Hospital Association of
India), the Christian Medical Association of India (CMAI) and the Voluntary Health
Association of India (VHAI). Through collective work we hoped to strengthen the critical mass
of organizations and individuals keenly interested' to improve the health status of people in
India, with a focus on the social.majority, the poor.
This required a shift from an individual oriented curative and preventive health approach to a
broader approach and resulted in the articulation of a Social Paradigm in Health. The individual
person was always important but there was a need for a larger societal shift in power structures
and in mechanisms of functioning for the dignity of the last person to be respected and for their
health to be protected and promoted.
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The Pardigm Shift
Approach
Biomedical deterministic research
Focus
Dimension
Indivdual
Physical /Pathological
Technology
Type of Service
Dhigs/Vaccines
Providing/Dependence
creating/Social marketing
Patient as passive beneficiary
Molecular biology
Pharmaco- therapeutics
Clinical Epidemiology
Link with people
Research
Participatory social/community
research________ ;________________
Community______________________
Psycho-social, cultural, economic,
political, ecological
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Education and social processes
Enabling/Empowe.ring
Autonomy Building ____________
Community as active participant
Socio-epidemiology
Social Determinants
Health Systems
Social Policy.
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1 Centre for Public Health and Equity. ( SOCHARA ), Bangalore
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An internal cum external evaluation after the seven year experimental phase recommended the
continuation of this work through a process of institutionalization. The Society for'Community
Health Awareness, Research and Action (SOCHARA) was thus registered in 1990. Another
reflection evaluation in 1998 committed CHC-SOCHARA to building a broader alliance for
health with a social justice perspective across sectors, and to developing teaching programs with
innovative methods so that a larger number of young professionals and activists from multi
disciplinary backgrounds could be oriented and supported to Work in community health and
public health.
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Over the years our understanding of underlying health determinants deepened. Our research
studies (listed later) and other involvements helped in our analysis of the health situation,
leading to varied forms of public health engagement. The need for collective global action to
address macro-policies that adversely affected health became clear. We therefore became
actively involved in the International Poverty and Health Network established by WPIO and in
WHO meetings on health and equity. More significantly CHC-SOCHARA became very
involved in preparations for the first global People’s Health Assembly (PHA) held in December
2000 in Gonoshasthya Kendra, Savar, Bangladesh. This included participation in the
conceptualization, planning and mobilization for the PHA in India, along with many other
networks with whom links had been established over several years. Around 1400 people from
75 countries at the first PHA adopted the People’s Charter for Health which became a manifesto
and-.a rallying document for constructive and critical’health action at community and policy
levels. CHC-SOCHARA continued proactive involvement in the evolving and expanding
Peoples’ Health Movement (PHM) in India and globally. The global PHM secretariat was
hosted by CHC from 2003-2006. (see www.phmovement.org) During this phase the PHM
secretariat also organized several advocacy events at the annual World Health Assemblies: the
International Health Forum, at the World Social Forum at Mumbai in January. 2004; the second
people’s Health Assembly at Cuenca Ecuador in July 2005 and the first of many events of a
new International People’s Health University, linked to the Global People’s Health Movement
(see http://www.phmovement.org/iphu/)
Enlightened and spurred by our studies on health policy processes organizational engagement
with the state also increased in the decade 1998-2008. This focused on health policy and the
strengthening of health systems using a comprehensive primary health care approach. Work has
been done with the governments of Karnataka and Orissa, with the National Rural Health
Mission, with WHO and with UNESCAP.
A community health internship and fellowship scheme for young professionals was launched in
2003 which continues as the community health learning program.. Links with public health
educational institutions were strengthened. Since 2006 we are also trying to foster a Public
Health- Movement in’public' health education and among public health professionals. Different movements flow into the larger transformative process of social change’. In April 2008 on the
occasion of the silver jubilee of CHC, the Centre for Public Health and Equity.(CPHE) has been
established by SOCHARA to take forward the health policy and research work, along with
continued support to the work of other organizations in an advisory capacity. Ground worjc is •
also being done for a community health fellowship program in Madhya Pradesh.
2. Engagement in Health Research from a Civil Society Perspective and Base
The founding group of CHC held faculty and allied positions in the Department of Community
Health in a leading medical college in South. India before setting up CHC. With this academic
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background, we continued teaching, research and practice of Communit}' Health through CHC
but based on the social paradigm, with, alternative methods and with a clear focus on
contributing consciously to. social change processes. Some of the major studies that we were
involved with include:
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As conveners of the Medico Friend Circle we supported community based studies after
the Bhopal industrial disaster, taking the findings back to people.
A two year study of the 'Social Relevance and Community Orientation of
Undergraduate Medical Education' using multiple methods (including a literature
review; feedback from young professionals; questionnaires and -visits to colleges; and
learning from community health projects) was conducted and followed up subsequently
with the State Health University, government and some educational institutions over the
years,
CHC undertook the golden jubilee evaluation of the Catholic Hospital Association of
Indict with 2500 health institutions spread across India then. This was a participatory
study with several components. As part of the Policy Delphi study of future trends was
done in 1991-92. A questionnaire to all members, and held visits to‘a 20% sample of
ai'ound 400 institutions was done by forty trained investigators. Follow up discussion
meeting were held with 13 sub-groups among the membership and with regional
groupings. The Association changed its name from hospital to health association and the
Constitution was also reviewed and renewed. The bio-medical to health paradigm shift
was accelerated. Community health work which had already been initiated was further
strengthened by CHAI.
A health policy analysis ofpolicy process and implemQnt&ticyft. factors was undertaken as
a doctoral study using the National TB program as a case study. This fed into our
subsequent work with state governments in Karnataka, Orissa, -Madhya Pradesh, and
Chhattisgarh .and with the federal government through the National Rural Health
Mission which was launched in 2005. This also led to a twin pronged approach of
strengthening the PHM and engaging with the WHO.
CHC .supported environmental health studies through a loose network that emerged
around 2001. Team members continue to work in this area.
A pilot study for the health inter-networkpro'}QcX (HIN) initiated by WHO.
Evaluation studies were done of the Jan Swasthya Rakshak (Community Health
Worker) programs in Madhya Pradesh and of the Milanin program and State Health
Resource Centre in Chhattisgarh.
I
CHC has also been a key contributor to the planning and evolution of the GLOBAL
HEALTH WATCH-1 (2005) and GLOBAL HEALTH WATCH- II (2008) These are ■
alternative world health reports put together by the Global People’s Health Movement
along with fraternal organizations who collect evidence and perspective on the current
situation and the international health challenges. Each watch has contributors from
over a hundred academics, researchers, and health activists in an unusual spirit of
collaborative action ( http://www.ghwatch.org)
International studies that we collaborated with included a study coordinated by
WEMOS in the Netherlands on Global Public Private Initiatives in health. Currently-we- are the Asian hub for a study on “Revitalizing Health for All - Learning from
Comprehensive Primary Health Care11. This study is supported by the Teasdale Corti
project, with the cq-'principal applicants/investigators being in the Universities of Ottawa,
Canada and Western Cape, South Africa. It has a strong PHM presence of persons from
the PHM Research Circle of which CHC is also apart,
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CHC and CPHE place great value on the role of research in the promotion, of Health for All.
Without measurements using quantitative and qualitative methods and systematic
observations, health workers, professionals, policy makers and communities would not be
able to analyze and understand the progress being made in health outcomes, health impacts
and health equity. Critical research from varied civil society, community, subaltern and
implementers perspectives all help to promote Health for All. Health policy and health
systems research is essential to strengthening public health systems.
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2. Enablers and Barriers to Civil Society Engagement in Health Research.
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Visionary, progressive, leadership in the civil service and the political establishment and
in organizations provided valuable policy space for health research and its follow up.
With mutual trust and respect and contributions of time and effort from all sides a
positive synergy develops. This, enabling environment can be consciously built by
groups who have an equity oriented,'inclusive approach.
However the sustainability of these arrangements can be fragile and short term. Lobbies,
and competing interests are always present. In environmental health research this has led
to court cases, setting up of counter expertise and .other attempts to influence the policy
process. However all of this is positive as it leads to a larger public debate.
If researchers see themselves only in their professional capacities as knowledge
producers, then the studies get limited to publications and bookshelves and do not
influence policy and . political processes. Skills within the research teams or
organizations for participatory, inter-disciplinary work, communication and engagement
are required,
An evolving system of engaged researcher’s interacting and working with policy
makers, practitioners, communities and civil society, transforms the knowledge
production and utilization process.
Information and communication technology when coupled with word of mouth
communication at community level has been very much more productive. ■
Status quo factors, a strong biomedical approach and unnecessary bureaucratic
procedures are often barriers to the process of enquiry and action.
_
Funding institutions and mechanisms can play a significant role in broadening the focus
of health research to research for health, development and equity:
Development of institutional capacity and human resources in research for health need
to be prioritized as part of work on health and equity, by all sectors including civil
society. The development of civil society- public sector partnerships through public-
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All the studies mentioned above were done based in the non-state civil society sector which
ottered a lol of freedom. Links were maintained as appropriate with government, academic
institutions, NGOs and a number of individuals. What we consciously did-not get into was
publishing in mainstream journals by and large (though there have been some publications). We
published reports for circulation locally where decisions and action were required. We have also
introduced local language publications.
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CHC members are part of the Global Forum for Health Research; the Measurement and
Evidence Knowledge Network of the WHO Commission on Social Determinants of
Health; the program committee of the Bamako 2008 Global Ministerial Forum on
Research for Health Development and Equity.
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public partnerships in field research would help to strengthen the public health system
which is essential to realize health rights.
• The provision of funds, mechanisms for professional support and legitimacy as well as
institutional mechanisms to strengthen capacity and ability for sustained work by civil
society based researchers will bring in fresh perspectives from community based work.
• While qualitative research, inter-disciplinary and trans-disciplinary research,
participatory action research and ethical issues in research are gaining ground - they are
still relatively marginal. This needs to be reversed and balanced by pro-active policy
measures. Civil society organizations can help to play a role in this.
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4.The Dialogue between mainstream and the alternative : The challenge ahead.
Since 1998 in particular CHC has begun a new journey of interacting with mainstream public
health, community health and preventive and social medicine or community medicine
departments to share the perspective gathered from a wealth of interaction with public health
and community health challenges in the government and non government (civil society) sectors.
The WHO SEARO has recently made an interesting observation in its Report on Public health
Capacity building in the region recognizing the need for such interaction.
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Partnerships with Alternative Sector
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“Many alternative institutions, both organized and informal, have been actively involved in
public health work as well as public health, capacity., building. Sometimes, they have been
tenried as alternative sectors. For example, in India, the following organizations, among others
have been active in public health education and training some since the 1980s and others more
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• Network of community health trainers: with inputs from many voluntary organizations,
. they have conducted short courses in community health development and management;
• People’ Health Movement;
« Society for Community Health Awareness, Research and Action (CHC);
• Centre for Enquiry in to Health and Alternatives (CHEAT)
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The list can be enriched by examples from other countries, as well as with more examples from
India. These organizations have become active in public health development due to
dissatisfaction with existing government owned PH institutions, usually run by conventional
Preventive and Social Medicine Departments, and also having low status for public health and
increasing inequity and social exclusion. A wave of community health NGO movements have
taken place to try alternative experiments and action, and to build capacity from communities
and grass root workers. Unless the National apex institutions or schools of public healt i
recognize these alternative sectors as strong resources and involve them in training and
research, a large portion of creative energy in public health will remain untapped”
Source: South-East Asia Public Health Initiative 2004-2008, WHO-SEARO
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This challenge for CHC'^nd CPHE which is the new evolving jubilee unit is to make this
dialogue between the mainstream and the alternative a creative engagement towards a new
paradigm of public health and primary health.care that makes health for all a reality some day.
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Informed choices for attaining the Millennium Development
Goals: towards an international cooperative agenda for
health-systems research
loncet 2004; 364:997-1003
Correspondence to:
Prof Andy Haines, London
School Of Hygiene and Tropical
Medicine, Keppel street, London
.Andy.Haines645htm.aLuk
Comments on the research
agenda should be sent to
Ulysses Panisset
(panissetu@>who.int; see panel 2)
..
Health systems constraints are impeding the implementation of major global initiatives for health and the
attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these
barriers. An independent task force has been convened by WHO to suggest areas where international
collaborative research could help to generate the knowledge necessary to improve health systems. Suggested
topics encompass financial and human resources, organisation and delivery of health services, governance,
stewardship, knowledge management, and global influences. These topics should be viewed as tentative
suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and
comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in
November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to
generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the
MDGs
.
The UN Millennium Development Goals (MDGs; oration is needed. Hence, WHO convened a task force to ,
panel 1) represent a compact between rich and poor suggest topics where international collaborative research
nations to improve human development. The. MDGs could help to generate the knowledge necessary to
related to child health, maternal mortality, and diseases . improve health systems and, thus, the prospects for
such as HIV/AIDS are far from being achieved by. the ' attaining the MDGs. Although the focus is on the MDGs, ,
deadline of 2015, particularly in sub-Saharan Africa.1 A . ’ many of the topics have wider relevance,
previous article2 in The Lancet has indicated how healthA wide range of decisions must be made globally,
systems constraints are impeding the implementation of nationally, and locally regarding how to address the
major global initiatives for health and the attainment of problems that need to be overcome in order to achieve
the MDGs and how research could contribute to the MDGs. Needs, values, priorities, and availability of
overcoming these barriers to progress. Improving health resources vary from country to country. Bach country
systems has the potential to assist progress, towards tlie must make its own choic.es in relation to its specific
MDGs in the near term by promoting more equitable circumstances. At, the same time, most countries are
faced with similar questions, such as:
access to effective interventions.
Researchers need to address the key challenges
faced 9 How best to address shortages of human resources
by decision makers—for example, in undertaking healthfor health and poor health-worker performance ?
system reforms and taking effective interventions to • How best to increase the use of effective forms of
health care and decrease the use of ineffective forms,
scale—recognising that there is not always one optimal
ofcare?
decision, but that research evidence should play a greater
role in influencing policy. In view of the limited attention • How to control the use of pharmaceuticals to ensure
that limited resources are well spent?
and funding devoted to this area, substantial method
ological challenges and low perceived generalisability of • How best to integrate programmes targeted at
priority problems such as HIV/AIDS into existing
findings from single sites, greater international collabhealth-care systems?
All these choices require information about the specific
Panell:TheMillennium Development Goals in summary
rnnditinns in a particular country and judgments tliat
take into account the values of the country. Information
Goal 1:' Eradicate extreme poverty and hunger
from relevant and reliable evaluations and experience
Goal 2: Achieve universal primary education
from other countries is also needed to inform judgments
Goal 3: Promote gender equality and empower women
about the probable effects of alternative policies. This
Goal 4: Reduce child mortality
information contributes to global knowledge.
Goal 5: lmprove maternal health
The Ad Hoc Committee on Health Research developed
Goal 6: Combat HIV/AIDS, malaria, and other diseases
a
five-step process for research.priority setting’ and there
Goal 7t Ensure environmental sustainability
have been a number of subsequent approaches focusing
Goal 8: Develop a global partnership for development
particularly on specific diseases or risk factors involving,
For a full list of MDGs, their targets and indicators, see http://unstats.un.org/unsd/mi/
for example, epidemiological data on burden of disease.4
mi_goal$.asp
However, health systems underpin the effective pre
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Task Force on Health Systems Research*
’Members listed at end of report.
thefoncet.com Vo! 364 September 11,2004
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vention arid care of a range of health problems, and Research topics
therefore the development of a research agenda poses There is a need for health-systems research to inform
particular challenges. It has -been suggested that in these decisions at local, national, and international levels. We
circumstances, interpretive approaches based on the have highlighted topics relevant to decisions at each of
consensus views of infonned participants may be these levels (table 1). We have also indicated which .
attractive because of "their ability to juggle multiple MDGs might be affected by research on each of the
assumptions and objectives".5 There are, of course, topics. Attainment of the MDGs will be influenced by a
different ways in which topics for health-systems research wide range of factors within and outside health
can be identified, and a number of stakeholders that have systems, so the table should be seen as illustrative
legitimate perspectives on what is important, including rather than comprehensive. For each proposed topic we
policymakers, health personnel, and civil society. The suggest that the following questions should be
topics outlined here represent to a. large extent the addressed:
thinking of the Task Force on Health’Systems Research, o What is the problem and why is it important?
which strove for parsimony in its approach. Analysis of ■* What.is known and what is not known?
the health systems constraints to achieving the MDGs,2-6 9 What research is needed and how would it help?
We are preparing brief templates that address these
previous work aimed at identifying needs for health
systems research and setting priorities,,•74, inputs from. questions for each proposed topic (see panel 2). In the
______ ‘ of~ this article
’ i we provide an overview, of a
WHO staff in Geneva, and other expert contributors (see remainder
Acknowledgments), together with preliminary regional proposed international agenda for health systems
consultations- -by WHO, have all contributed to our research focusing on topics that are likely to be of
thinking. We acknowledge, however, that further work is common interest across many countries.
needed to develop more formal priority-setting processes
Financial and human resources
for health-systems research.
The topics we present should be viewed as tentative .Community-based financing and national health
suggestions that form a basis for further discussion, insurance
Researchers, policymakers, health personnel, research • Low and middle income countries in general provide
very patchy financial risk protection to their populations,
funding organisations, non-governmental organisations, <
and the wider public are all invited to comment on these ’with resulting
.
.problems including households driven
topics as part of a wide-ranging consultation, of which this into poverty by catastrophic health expenses, and low
access- to care.’100,u
-11 Research is needed
article is part It.is hoped that by the time of the levels of ------dori to assess
Ministerial Summit on Health Research in Mexico in the financial implications of universal coverage in
November, 2004,’ it will be possible to agree on the different settings, to assess the extent to which people
agenda and subsequently achieve a commitment of will contribute to its costs from their own income, and
resources to generate the evidence needed to build the which costs will need to be covered from general tax
equitable, effective, and efficient health systems required revenues or employer contributions. The appropriate
benefit package, its costs, and feasibility of implemen-.
to achieve the MDGs.
MDG*
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Financial and human resources
Cornmunity-based financing and national health insurance
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Human resources forhealth at the district level and below .
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Human resource requirements at higher management levels
Org anlsation and delivery of health services
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Community involwmer.t
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Equ itablc, effective and efficient health care
Approaches to the organisation of health services
Drug and diagnostic policies
Governance, stewardship, knowledge management
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Governance and accountability
Health information systems
Priority setting and evidence-informed policy making
Effective approachesforintersectoral engagement in health
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Effects of global in tiatives and policies (including trade, donors, international agencies) on health systems
z
■arch could contribute to attainment of one or more of the targets for the MDG. The relationships »r<( complex and the Hit is not exhaustive,
’See panel 1 for summary of MDGs- Z-Improved knovdedgq from Health-systems rese.
becao je attainment cf MDGs will be affected by.a range of factors Interacting both directly and indirectly with health. For example, improved health could contribute to reduction of poverty (MDG 1) through several
mechanisms, including reducing loss of income from ill-health and catastrophic expenditures due to Illness and improvements in the health of women and girts could reduce gender dispantiesin educatjqn^(MDG3).
Table 1: Suggested topics for health-systems research and their potential to affect attainment of the targets for the MDGs
www.thebncet.coin V0I364 September 11, 2004
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Panel 2: Comments on the topics outlined in this article
should be sent to Ulysses Panisset (panissetu@who.ittt)
Readers.are jnvitfcd to ihdicate gaps in.the research agenda
and to suggest important research questions within the topic
areas.' We also welcome information about other relevant
research agenda setting activities.
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Human resource requirements at higher management
levels
Multiple donor-driven initiatives are placing severe
strains on Ministries of Health in some countries,”
and high level coordination and analytical skills are
needed to deal with demands. The increasing volume
of research evidence and efforts to improve health
information mean that policy makers are functioning in
a complex environment that requires integration of
changing knowledge, data, and political priorities.
Frequent rotation of staff may reduce their ability to .
perform in such an environment. These factors suggest „
that those in leadership and strategic management
positions need support, resources, and training to enable
them to function effectively. Research is needed on how
best to provide such support and how the existing higher
education institutions, such as medical and public
health schools, can help to provide the relevant training.
Organisation and delivery of health services
Community involvement
Although there is general support for the concept of
community involvement, there is a need for more
rigorous research in this area. Greater clarity is needed
Human resources at the district level and below
about potential ways in which communities can conHealth systems cannot function without adequate and tribute to improving their health status, including: 1
appropriate human resources, yet human-resource strengthening accountability of service providers; partici
development receives insufficient attention and support pation in the governance of community-based health
within health research and planning.'4 Migration of insurance; involvement.in planning and implementation
health personnel causes severe difficulties for some that incorporates communities'perceived health priorities
countries, but effective policies to reduce the adverse and preferred strategies for dealing with them.1’
effects are lacking.” Moreover, migrant remittances
are an important financial source in some developing Equitable, effective, and efficient health care
countries. The overall availability and balance of Inequities in access to health care have been
different types of personnel and skills at district and documented within, many low and middle income
sub-district level- are often inadequate and inappro- ' Countries;,2l> but little is known about how best to reduce
priate. Mid-level health workers such as clinical them with much of the evidence in the form of case
assistants have played an important role in health-care studies. Effective interventions are available for diseases
delivery in countries and in situations when other that account for most of the burden of disease in lowcadres were not available, but these workers are poorly . income countries, including common causes of child
rewarded. Lack of availability of health professionals and maternal mortality, and communicable diseases
. .
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has resulted in renewed interest in community health—including—WdV/AIDS, malaria, and tuberculosis.21
workers who can potentially play an important role in These interventions are being implemented at
achieving the MDGs, but there is a paucity of evidence disappointingly low rates and inequitably, at the cost of
about their effectiveness in low and middle income preventable suffering and millions of lives. At the same
countries.” Evaluation is needed of approaches such as time, scarce resources are frequently being wasted on.(
regular visiting of households, targeting high-risk ineffective interventions. Narrowing this quality gap
groups,
prescribing of potentially life-saving requires identification of strategies that scale up the use
’ i use of ineffective
medications (such as antibiotics) by community health’ of effective practices, decrease the
workers
and
community
1health-education ■ practices, .and help ensure equitable access to health.
... to
.. achieve the care. Situations such as urban slums may pose
programmes. We also need to know how
right balance and strength of clinical and public-health particular challenges for the delivery of care because of
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tation in different settings require study to identify the
most efficient and equitable design features of a
universal scheme.
Shortage of resources for health services, including
severe limits on government funding and the known
disadvantages of user fees, has encouraged many
countries to look to community financing, especially
. voluntary, community-based health insurance,” as a
source of additional funding. It is difficult to draw firm
general conclusions from existing evidence because
studies lack common definitions of community-based
health insurance, evaluate different objectives, and
have been criticised for methodological weaknesses.”
Research is needed to examine the potential role of
such insurance schemes in overall health-care
financing arrangements, the affordability of premiums
• to different groups and the types of support external to
the schemes that may be needed for successful
functioning.
competencies-at district and sub-district levels and what
balance of financial and non-financial incentives would
improve motivation, performance, and distribution of
health workers.”
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population mobility, violence, and crime, and research is
Learning from rigorous evaluation of organisational
needed to tailor solutions to these challenges.
innovations is mandatory for improving the per
In many countries the majority of deaths occur at formance of health systems. A strengthened evidence
home—eg, around 70% of child deaths in Tanzania.24 In base on organisational patterns and reforms would
some cases, there is failure to recognise serious illness; enable better advice to be given to policy makers.
in others, despite recognition, available interventions are
either not used or not used effectively. Delays in women Drug and diagnostic policies
seeking and accessing skilled care for childbirth lead to People in low income countries often pay for drugs out
high maternal mortality.2S-“ Thus, evaluation is needed of tlieir own pocket and costs may amount to 60-90% of
of approaches to improving the. recognition of serious total household expenditure on health.11 Ability to pay is
illness (particularly in women and children), appropriate also a concern for governments: increasing expenditures
care-seeking behaviour, and the implementation of on drugs puts pressure on policy makers to control drug
effective interventions.
costs and ensure that funds are well spent. At the same
Many strategies for improving quality.—such as audit time, low and middle income countries face additional
and feedback, decision support, and educational challenges, including counterfeit drugs, major problems
outreach—have been tested in high-income settings, but with the supply, distribution, and financing of essential
few have been adequately assessed in low and middle medicines, and regulation of prescribing.’2-13 Lack of
income countries.27 The rise of non-communicable access to effective drugs leads to preventable deaths, and
diseases and HIV/AIDS in many parts of the wc'orld has providing access to affordable essential drugs is one of
le.d to greater emphasis on the need for better systems to the targets for Goal 8 (panel 1). Inappropriate use of
manage chronic. disease, which will require under antibiotics and antimalarial drugs can lead to drug
standing how health systems in low and middle income resistance, adverse reactions, and wasted resources. In
countries can facilitate continuity of care, support self the .case of diagnostic technologies, advances in
management where possible, and provide decision molecular diagnostics and imaging have the potential to
support for health workers that is consistent with . bring improved diagnosis to poor communities/
communities/*4 but
. scientific evidence and patient preferences."
also for misuse. Improved use of drugs and diagnostic
technologies can improve health outcomes and, in some
Approaches to the organisation of health services
circumstances, can result in substantial savings without
Reforms in the organisation of health services have been adverse health consequences. On the other hand, cost
presented as a key solution to inefficient and inequitable containment strategies can have unintended effects on
delivery of health care in developing countries. Proposed health and costs.
reforms included separating the functions of purchasers
and providers; creating internal or quasi • markets Governance, stewardship, and knowledge
within the public sector; creating executive agencies to management
manage the health sector; decentralisation of health Governance and accountability
service management to local health administration Good governance has been shown to be key to the
levels or to local government; giving increased autonomy effectiveness of general development assistance.”
to hospitals and contracting out services to tire private Ensuring strong systems of governance and appropriate
sector.” Mixed-experiences with reforms, encompassing accountability mechanisms within the health sector
both failed and slow implementation, and relatively few underpins health-sector performance. For example,
success stories, have lead to questioning of their value, health providers who are not held accountable for their
especially when applied with little adaptation to local performance are likely to be unresponsive to community
circumstances.10 However, published work is scattered and patient preferences; this may in turn reduce the
and incomplete in coverage and often methodologically demand for care. Corruption not only wastes money but
weak, making it veiy difficult to draw any general also distorts incentives and is likely to reduce efficiency
conclusions.
within tire sector. For example, if contracts for services
It is important to find an appropriate balance between are awarded on the basis of personal contacts and bribes,
vertical and horizontal approaches and, in particular, to then this is likely to affect adversely the quality of the *
identify how -best to coordinate and integrate disease service provided by the contractor.
specific programmes into health systems. In many low
Multiple aspects of corruption could be investigated,
and middle income countries, non-governmental organi but in view of growing development assistance
sations are key providers of care to marginal groups. expenditures on drugs, particularly antiretrovirals, there
However, the relation between these organisations and is an urgent
w
imperative to study the nature and quantity
the p-ublic sector is often one of mistrust; affecting the of leakages of prescription pharmaceuticals from the
delivery of care, and research is needed to understand public sector, and the interests that allow this to continue.
appropriate forms of collaboration between different
A focused and targeted effort is neei
eded to investigate ~
types of provider.
governance structures for a variety of key health-sector
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Effective approaches to intersectoral-engagement in
health
There are a range of policies and interventions in a
number of sectors that could have far reaching effects
on health. These include agriculture, education,
transport,
housing,
social
welfare
and
telecommunications policies; National transport
Health information systems
policies may, for example, affect health through traffic
The development of health-management information injuries, air pollution, and transportation to health-care
systems in poor countries has usiually been heavily and facilities.41 Socioeconomic development activities for the
often adversely influenced by the information needs of xpoor such
?j as micro-credit42 or conditional cash
donor agencies and international vertical (single health- transfers41 may help prevent ill health and provide
problem) programmes?6 The result is that health financial access to treatment. However, empirical work
management information systems in low. and middle in low and middle income countries testing the impact
Income countries are fseverely underdeveloped, often of these and other development activities is limited.
with a haphazard collection
of patchy
..
__x_ information
.. . that
.1 . Access to adequate amounts of clean water and
is scattered throughout various programmes with sanitation has major health benefits,44 but evaluations of
limited, if any; -feedback to those who collect the policies and actions for achieving this goal at low cost
information. These, information systems are riddled are lacking. It is uncertain how best to engage policy
with inaccurate and inconsistent data, expensive 1to makers from other sectors in considering health
operate, and time consuming and demotivating for outcomes. A better understanding of the incentives and
large numbers of health staff. Health-management
«
t disincentives that motivate their attitudes and decisions
information systems often fail to record data on is needed.
inequalities in a rigorous manner, so that monitoring
trends in inequalities is impossible. Research on the Global influences
development and implementation of sustainable low- Global factoi>rs are increasingly impinging on national
cost national health-management information systems %health
* ‘ policies and systems, for example through the
and district-level minimum essential indicator sets, General Agreement on Trade in Services (GATS)
which are appropriate to the needs of poor countries,” agreement that regulates trade in services, potentially
are high priorities.
including health services.4536 The policies of global
institutions such as the World Bank, the International
Priority setting and evidence-informed policy making
# Fund, World Trade Organization, WHO, and
Monetary
In cross-country, comparisons, the impact of public the Global Fund for AIDS, TB and Malaria, affect the
spending on health has been found to be quite small, development and performance of health systems in
with a coefficient that is typically numerically small many countries. Conditionalities laid down by large
and statistically insignificant?" The poor often spend donors, such as the US Government's Millennium
substantial sums of money on private services because Challenge Account and UK Chancellor of the
public-sector resources - are concentrated on services Exchequer’s proposed International Finance Facility,
for richer population groups?’ Without explicit could also affect health. This influence is exerted both
consideration of priority setting, this situation is likely as a result of the flows of financial resources and also
to remain unchanged: resource allocation is too often because, in some cases, global institutions have a
dictated by historical patterns, and maintains vested pivotal role in determining both disease priorities and
interests. Development and multicountry evaluation of policies for health systems. Additionally, certain
a process to incorporate, explicitly and transparently, policies, for example concerning trade, affect the
important equity concerns, non-health effects* of health determinants of health, which in turn affect the
interventions, and other ethical issues into priority, burdens on health systems. As such, the impact of
setting is needed. This assessment can highlight global influences needs
* to be studied to provide the,
existing inequities, and at the same time show what evidence to shape macroeconomic policies and trade
tradeoffs exist between efficiency and equity and other relations. Donor priorities may compete and in some
societal concerns.
cases conflict with each other; therefore, evaluation is
Decision-makers must have access to reliable and needed for mechanisms such as basket funds, sector
relevant research evidence to make well-informed wide approaches, and other approaches to coordinating
decisions about health care. Generating, synthesising, donor activities. The absorptive capacity of countries to
making available, and improving the use of reliable and use donor resources effectively and to coordinate the,
relevant health systems research for low-income inputs
inputs of
of multiple
multiple donor
donor. .agencies
agencies may
may be
be a key
key
countries presents major challenges and requires the limiting factor in developing functioning health
development and use of appropriate methods?0
systems.
actors (providers, insurers, regulators) and different
types of accountability (financial, performance, and
democratic). In the near term, such studies may be
focused particularly on decentralisation and public
private partnerships that are increasingly being used to
extend service coverage.
o
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vww riiel3!'.cer.com Vol 364 September 1.1, 2004
i 1
■
i
Public Health
Valid and transferable research
A revised document taking into account responses
Rigoroixs health-systems research requires contributions to tire consultation and including the templates outlining
from many disciplines including epidemiology, research questions in each topic area will
biostatistics, health economics, sociology, anthropology, be submitted to WHO following the Mexico Summit
and policy analysis. Both qualitative and quantitative on Health Research. It is hoped that tire report
research methods have important parts to play. In some will stimulate subsequent commitments of resources
circumstances, interventions can be assessed with and international collaboration to address agreed
randomised trials—particularly cluster trials, in which priorities.
Only a decade exists before the target date for the
the unit ofrandomisation may be communities or health
facilities—but such opportunities are often missed. MDGs in 2015. It is now a matter of urgency to ensure
However, many research questions cannot be addressed that health systems become the focus of national and
by randomised designs—for example, because they may international efforts to improve capacity to deliver
be systern-wide-in their scope. Other approaches, such effective interventions in an equitable fashion to those
as interrupted time-series analyses, need to be who can benefit. Health-systems research is essential to
. considered, as well as process evaluations to understand reduce our collective uncertainty about how to achieve
better how and why interventions work or do not work as the MDGs and to provide a basis for well-informed
intended. Participatory action research has potential to decisions and actions through which the findings of such
elucidate both constraints to success of interventions, as research can be implemented.
wellas improve performance of health staff.47 Contextual Task Force members
factors are generally thought to be important effect Francisco Becerra-Posada, Coordination General of die National
of Health, Ministry of Health. Mexico, Mexico City, Mexico;
modifiers, but are often poorly described by researchers,1
Donald Berwick. Institute for Healthcare Improvement, Boston, USA:
making it difficult lo determine why a particular Zulfiqar Bhutta, Department of Paediatrics, Aga Khan University,
intervention or policy has been effective or ineffective. Karachi, Pakistan; Mushtaque Chowdhury, BRAC, Dhaka, Bangladesh;
BaseL Switzerland;
Better description of relevant contextual factors and Don de Savigny, Swiss Tropical Institute, Basel,
greater reliance on multicentre or multicountry Andy Haines, Dean's Office, London School of Hygiene and Tropical
Medicine, London, UK; Adnan Hyder, Department of International
research, where a given research question can .be Health, Johns Hopkins Bloomliberg School of Public Health, Baltimore,
. addressed across a range of settings, is needed.48 USA; John Lavis, Health Sciences Centre, McMaster University,
Recommendations for improved design of non Hamilton, ON, Canada; Pisake Lumbiganon, Department of Obstetrics
randomised studies have recently been published.49 and Gynecology, Faculty of Medicine, Khon Kaen University,
Khon Kaen, Thailand; Anne Mills, Department of Public Health and
Collaborative research networks could, in addition to Policy, School of Hygiene and Tropical Medicine, London, UK;
.
. .. I.........................
. Ifakara
' -•
.Health
. ‘
undertaking. large-scale multisite health-systems
Hassan
Mahinda,
Research and Development Centre,
research, play an important part in building research Ifakara, Tanzania; Ravi Narayan, People's Health Movement Secretariat
(global), CHC-Bangalore, Bangalore, India: Andrew Oxman, Informed ■
capacity and promoting use of research findings.
Choice Research Department, Norwegian Health Services Research
The role of systematic reviews in summarising the Centre, Oslo, Norway; David Sanders, School of Public Health,
strength and relevance of the evidence and helping to University of the Western Cape, Bellville, Cape, South Africa;
set a research agenda is well established for evaluating Nelson Sewankambo, Makerere University, Faculty of Medicine,
Kampala, Uganda; Goran Tomson. IHCAR. Division of International
clinical interventions but less so in health-systems Health, Department of Public Health Sciences, Karolinska Institutet,
research, in part because of the methodological Stockholm, Sweden; Cesar Victora. Universidade Federal de Pelotas,
challenges of synthesising evidence from different Pelotas, RS, Brazil.
contexts using a range of methodological approaches. Conflict of interest statement
Although many of the systematic reviews undertaken by A Hyder is a consultant for WHO. A Mills is Chair of the Board of the
the Cochrane Effective Practice and Organisation of Alliance for Health Policy and Systems Research, and is paid part time.
for this. The other authors declare no conflict of interest.
Ca re group address relevant questions about the effects
of organisational and financial interventions and include Acknowledgments
We are grateful to Tikki Pang and Ulysses Panisset of WHO for their
studies using a variety of relevant designs, few are from guidance and support as well as their coordination of the processes of
low income countries.27 Systematic reviews across all the consultation, which was ably assisted by Patrick Unteriechner. Thanks
areas outlined in table 1 are needed to inform decisions are also due to Tim Evans, Assistant Director General of WHO, who set
up the Task Force and contributed to its outputs. We thank allThose who
about actions and future research.
provided information about potential priority areas and commented on
The research community and policymakers must drafts of the paper, and will list these contributors in full at a later stage
interact more effectively if the findings of health-systems in the consultation. The views expressed in this article are those of the
research are -to have an effect. The’ challenge of Task Force and are not the official policy of WHO.
improving the use of research will be covered in a References
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1
Conclusions
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www.th<?lancet.CQfii Vol 364 September 11, 2004
I ’
This is the report of :
"Research for People's Health"
A Researcher’s Encounter at the Second People's Health Assembly
Organized by:
The Second People's Health rXi scmbiy of the People's Health Movement
University of Ceunca, Faculty of Medical Sciences
International People's Health University
National Association of Facultic. of Medicine (.Al 'EME), Ecuador
Global Forum for Health Research, Geneva
This report is also available at the website
\w-w.phmoycmenr. org/ pha2
-9
Acknowledgments
III
■
• 1
•
Dr.Jaime Morales SM, Conference Coordinator
•
Global Forum for Health Research Sccrctariacteam
•
People's Health Movement Secretariat (Global) team
•
Cartoons developed to illustrate the following Paper: Baum, Fran (2005) Research and the
Struggle for Health (presented at “Research for People's Health”) by Simon Knccbonc
(email- sknknee@senct.com.au).
•
Other cartoons from Communin' Health ('ell, Bangalore (www.sochara.org)
Financial Support for the encounter and publication was obtained from die University of Cuenca
and the Global Forum for Health Research (uww4dobalforumhcalth.org)
Printed at
Bangalore, India
'T«i
Printed by
People's Health Movement (Global Secretariat)
C/a CHC, 359, Srinivasa Nilaya,
Jakkasandra 1st Main,
1st Block, Koratnangala,
Bangalore, India
Ph.: +91-^1-51280(109
1
E-mail: sccretariat@phmovemcnt.org
Second People's Health Assembly of
the People’s Health Movement
14,h and lb01 July, 2005
Cuenca, Ecuador
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fundamentals i.e. to improve the health of the citizens of the world. It has been
oriented to reap economic profits that benefit a small minority and this was
referred to as theli 10/90 Gap”.
RESEARCH FOR
PEOPLE'S HEALTH
The Conference included a forum for the presentation of experiences and
proposals, as well as for reflection, debate and search for alternative research
SYNTHESIS
methodologies. This is important because the world's dominant paradigms have
not resolved, its major health problems but have contributed to the situation
wherebyafewarebenefitingatthecostof the majority.
ROUND
Second Health Assembly of the People’s Health
PARTICIPANTS IN THE CONFERE^^^^
Movement and the International People's Health University
> -"6. *'
Researchers from the five continents representing
more than 20 regional and global organizations,
made presentations.
at the Faculty of Medical Sciences of the University
* was
of Cuenca from 17 to 22 July 2005. A research encounter
bringing together researchers from all over the world
committed to people’s health problems.was organized as a
pre-A.ssembly
. e v p. n t
‘ o n
14 and 15 July 2005. The purpose was to reflect on and
debate the problems related to research on
!■
People's Health conducted globally.
The Conference takes place in a situation in which
i
globalization, with its lack of regulation,
has
produced more
inequities
than
' -‘
solutions;
i
health has become increasingly commodified;
i
the majority of the population do not have
access to health or health care or access has
They were invited to discuss and reflect on actual
situations and to propose new methodologies and
forms of learning for the future^
On the final day, a panel discussion cpmprising'of
the Steering Committee of the Latin American
and Caribbean Health Research Forum
(LACHRF) was held. Their presence was supported by the
Global Forum for Health Research. As part of the panel, Dr
Francisco Becerra explained .the process behind the
establishment of the LACHRF and' announced that the
Committee would also circulate a position paper soon.
been limited substantially.
This situation has been exacerbated by the presence of
problems stemming from technological and scientific
wo
dependence;
inadequate research
relevant to
MH
THEMATIC |
1
Research
as a
tool for the
liberation and
transformation of People's Health;
1
New research paradigms for People's Health;
1
To review supportive, democratic, and social
i '
People's Health, and the increasing; obstacles to the
enhancement of opportunities and conditions to lead a
meaningful life. Research, has not been focused on
/ •t
■
1
■
participation for the development of knowledge
enabling the ■transformation o£__People's Health and
lives.
2
2.0
and social movements in order to discuss how they can
W EMERGING FROM THE CONFERENCE
work together to address tllC piObltHlS being
researched; the foeps and the methodologies; tire goals
and priorities; the resources;, and the means of
dissemination and action following the research
process.
. !J
After the presentations by the panelists and ensuing
discussions of the researchers, the following central
ideas emerged:
It is important to understand that research is a
tool for social transformation. Advantage
should be taken of its potential for exposing and
fighting for equity in health, for the
To achieve this, we treed to design alternative and creative
strategies to increase tire commitment of researchers and to
breakdown the "10/90 Gap" in health research. For this, It is
empowerment of the community using
political, psychological, cultural, and social
means.
.-•?
necessary:
>
This is. indispensable in order to destroy the .
myths of the role of research and the dominant
biomedical paradigms. that attempt co impose
the belief that research is a privileged activity, of
the scientific and economic elite and therefore
inaccessible to the People. •
•
❖ The
the training of health
professionals. This must be done at the same
time so as to effect changes in research
paradigms;
> To build multidisciplinarj'
teams
of
researchers and social organizatbions to
investigate common problems in the world
with the aim of improving the Peoples'
Health;
>
To build real and virtual networks of
researchers, regional
networks; to
encourage the development
and
participation in programmes and multi
centre projects; and to use the internet wide
for the dissemination of studies
that
scientific needs and social
needs must be addressed:
separation
change the dominant biomedical
paradigm in
distinction, between,
the
To incorporate research into social
mobilization and to use the findings
to effect changes in Public Health policies;
To
♦♦♦ There is a need to rethink, the relationship
between researchers and the community it is
important to look at the community as tfie
subject of investigations and not the object.
New paradigms must therefore be advanced,
including the genuine integration of researchers
into the community: The key is for the latter
to have critical and inclusive participation.
is
I
between,
scientific communities and
local social communities
indicates the incompatibility of
interests. Meetings to plan studies
should not only involve researchers,
contribute to the development of new
research paradigms.
but also people's organizations
3
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To monitor rhe worsening of health indicator
when various health and education systems are
privatized.
The challenge of researchers would
be to present evidence of
these effects of
discussions of the objectives, methodologies and the
resources to be used. This contributes to the collective
>.health development process.
V
privatization on education and health in order to
forums and encounters that deal with
common health problems.
Researchers, in collaboration with
organizations and social movements, should take on
Latin America is to learn by inventing
locally or to perish imitating the global”.
the challenge of presenting social and scientific
evidence to prevent the wave of privatization,
especially in health and education, from continuing to
extend throughout the world causing more pain and
marginalization.
v
51
We should take advantage of the potential of
research
for
social transformation
and
•.
To define collectively themes of research that call for
researchers and social organizations to unite their
efforts to better understand and address health
problems.
improvements in health.
<•
V
words of Jose de Souza: "the challenge for
^"^'■^^LENCES FOR THE FUTURE
♦>
____
.‘1Ir£X!
global, regional, and local networks,
> To promote the interconnection of Regional
;•
■
It is necessary for researchers in
and support organizations and social
movements through the formation of
To understand • that research is a necessary
resource for more effective interventions;
.1 ;:
■
People's Health to collaborate with
prevent it from occurring in more countries.
research through networks, remembering the
■
It is critical that, we move beyond the dominant
biomedical research- paradigm. This is also
related to the .dominant biomedical paradigm
in the training of the health professionals.
i
'Before changing things; we must change the
•
-
people that change things'. - Jose de Souza.
'Bi
?.' ■ "I
5 S
❖ Health research is not a private activity of economic
and scientific elites. We should incorporate the
community as subjects and not as objects of research. .
There should not only be dialogue among researchers
but also between researchers and the organizations and
Cuenca, Ecuador
July 2005
Dr. Jaime Morales S.M.
Conference Coordinator
IF
IfF
social movements that participate in the research. This
would
include
r'
5
Of
6
i
The Forum of Researchers suggested the following:
RESEARCH FOR
PEOPLE’S HEALTH
TO COUNTIU^;
V
Discussions in Health Research should include health
sector officials who should be involved in the change
processes.
•V
An.important "Researcher's Encounter" was held
between the 14th and iSth of July 2005 in the Faculty of
Medical Sciences of the University of Cuenca, Ecuador, as
‘ an associated event of the Second Health Assembly of the
People’s Health Movement.
At this conference the
researchers in People's Health made a number of
observations and recommended methodologies to improve
.Research should aid in the revision and update of agreed
V
Research should help to influence state policies and
thereby, help prioritize allocations of economic
resources torhealch, education and nutrition in addition
to controlling apd preventing diseases.
rhe health and life of the people of the world.
V
National and local expenditure relating co the use of
sectoral funds for health research should be monitored
in terms of priorities as well as to assure the conducting
of health systems research.
V
It is important to value research principally from the
These recommendations are oriented towards training
TO RESEARCH
’nst*tut‘ons’ governments, investigators, NGOs and civil
society representatives
Research should bring
about social action by the
V
mobilization of people A .
. and communities as
participants and
Reference must be made to the
accounts of the progressive
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collaborators. Biomedical
thinkers of the world and
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consideration given to their
..
health research proposals
be •
research
should
integrated
with social
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research.
relevant to the current social, economic, political and
cultural contexts.
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There should also be a sincere effort to in regrate
quantitative and qualitative health research.
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point of view of health and life.
.. Participants in the research
forum in Cuenca should carry’
these messages to forums in
different countries.
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health standards to ensure that they remain within legal
frameworks and contexts.
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Research findings should be shared with members of
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The new paradigm should not be taught, but rather be
learned together with the community taking part in the
research.
the community with whose assistance research findings,
and conclusions came about.
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Research should involve dialogue between investigators
V
It is imperative that the social research component of
health research be strengthened:
V
Postgraduate education/
and representatives of communities as well as the
people directly.
V
There should be the creation of virtual information
spaces for the learning of new research paradigms
action.
without denying or restricting access to any information
v
The universities should be charged with developing
that conforms to ethical norms.
V
community research programs in a participatory way.
An international committee should be convened,
V
It is necessary to reach the community titrough
education using schools and other means in order to
enhance the community's health with a more holistic
and lasting influence.
V
Through university outreach, proposals for
including biomedical as well as social and cultural
components and primary health care.
V
Research should be multidisciplinary and bring about
dialogue between professionals in the health sector with
participatory research can be developed.
professionals of other sectors such as social science,
economics, etc
V
There must be efforts to establish strategic alliances for
research in heal th'and social sciences.
V
There is a need to improve the capacity to develop
research proposals.
The research process should aim to improve
collaboration among investigators and with local mass
•I
V
It is important to network with national, regional and
international forums of health research.
V
specialization should
conform more to community-based and participatory
,'"T
There must be adequate allocation of economic
V
media, local governments and other political sectors.
resources for the application of strategies with
emphasis on health promotion at all levels.
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AINING INSTITUTIONS
allftl.e researchers; who atfende'd^
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There should be serious revision in education of
human resources in health, within the-framework
of the new paradigm of research.
New resources should be identified in universities
that would help engagement in new paradigms of
research,—<
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the Forum, will be pleased to wcri. towards the
, achievement ol these recor.u.Hndations.>.
1
ResegrchcisFtom^^ftescarch for I’eopb•' • Health: A R<-searcher’s Ericoujiter.”
at the Second People’s Health Ass< :n!>ly c f the I’cop.c's Health.Movement
Cuenca, 15
• ?-
10
IB
sa
Institution_____________
Superior Institute of Medical
Sciences
Theme
___________
Pertinent methodological
Eduardo Espinoza
University of San Salvador
Francoise Barten
University of Nijmegan
Narendra Gupta
People's Health Movement
How to make equipment the
results of research
Rescue of innovating experiences
in health ____________________
Constructing a new thinking on
research in people's health to
bring about social liberation and a
health life____________________
Alternatives to strengthen the
social
Name of Panel
Leticia Artiles
Panelists of
alternatives w
___________
th-'. Health
“Research for People’s Health”:
a Researcher’s Encounter at
The University of Cuenca, Ecuador,
14-15 July 2005
Name of Panel
PANEL 1
PANEL 4
President: Dr. Marco
Alvarez
Theme
Institution
University of Cuenca
'<
President: Dr. Hernan
Hermida
University of Cuenca
Secretary: Leda. Carmen
Pazan________________
David Sanders
University Western Cape
Sylvie Olifson-Hour et
David Legge
Claudio Schuftan
I -
Making health research matter: a
suggested new paradigm
People's Health Movement
Global Forum for Health
Research_______________
International People's
Health University
Case for more research in poverty
and health.___________________
Research for health and life
People's Health Movement
Public Health Consultant,
Vietnam
Ten thoughts about research
University of Cuenca
Antonio Alves da Cunha
Latin American and Caribbean
Health Research Forum______
Latin American and Caribbean
Health Research Forum
Francisco Becerra Posada
PANEL 5
President: Dra. Elvira
Palacios
University of Cuenca
President: Dr. Jos6
Cabrera
Secretary. Leda. Maria
Merch^n_____________
Donald Simeon
Cesar Hermida
The transforming action of research
PANEL 2
Secretary: Leda. Maria
Iturralde_____________
Delia Sanchez
University of Cuenca
Secretary: Dra. Lorena
Mosquera
Thelma Narayan
Thando Ngomane
Deien de la Paz
Prem John
Global Equity Gauge.
Alliance (GEGA)
Global Equity Gauge Alliance
University of Philippines,
Manila
The Transforming Action of
investigation as Basis for Social
Mobilization
People's Health Movement
People’s Health Movement
Secretary: Or. Jose Luis
Garcia________________
Fran Baum
Ravi Narayan
Constructing a new thinking on
research in people
PANELS
’ ... T
PANEL 6
President: Dr. Jose Ortiz
The community and research.
President: Dr. Fernando
SempMegu
University of Cuenca
Secretary: Dr. Sergio
Guevara_________
Ren6 Pdrez M
University of Cuenca
International Public School
National Association of
Faculties of Medicine ( 'XFEME),
Ecuador
Miguel San Sebastian
Latin American and Caribbean
Health Research Forum
Latin American and Caribbean
Health Research Forum .
University of Cuenca
University of Cuenca
Council on Health Research for
Dcvdopment (COHRED)_____
SOCHARA,
People's Health Movement
University of Cuenca
Making Health Research
work., .for everyone___________
Methods of integration of the
scientific and local communities.
Methods of integrating of the
investigators
University of Cuenca
Flinders University
People's Health Movement
People's Health Movement
International School of Public
Health. Umea, Sweder.'
Research and the Struggle for
Health________________________
Research for People's Health:
Towards an Alternative Research
Paradigm_____________________
Ways of integrating researchers
in the struggle for people's health.
Rescue of innovating experiences in
health
12
11
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Alternatives to strengthen the
participation in the creation of
knowledge and understanding of
People's Health_______________
National health system & health
research in Brazil_____________
Health Research: Fora, Policies
and Systems for Maternal
Mortality in Ecuador___________
Report of the Task Force on
Health Systems Research
Latin-American and Caribbean
Health Research Forum________
Form of integration of the
scientific and social local
community
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RESEARCH PRIORITIES FOR
SCHOOLS OF PUBLIC HEALTH
WITH A FOCUS ON THE
GLOBAL SOUTH
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31st October 2006
18.00 - 19.30
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Background paper
Extracts from key documents and declarations
since 2000
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Compiled by
Community-Health Cell
Society for Community Health Awareness, Research
and Action,
Bangalore, India.
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Research priorities for Schools of Public Health
- with a focus on the Global South
Special Session : Forum 10, Cairo
31st October 23006
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Background Notes
To provide some background stimulus for the special session, we include below extracts from
papers, charters and declarations, mentioned in the earlier background note circulated with the
invitation to the Session. This compilation encourages participants of the session to look at
new perspectives and new priorities to be discussed at the session and also add their own
perspective and suggestions as well.
1.
People’s Charter for Health 2000
(From first People’s Health Assembly, Savar, Bangladesh,'December 2000)
• “Health is a social, economic and political issue and above all a fundamental
human right. Inequality, poverty, exploitation, violence and injustice are at the root
of ill-health and the deaths of poor and marginalized people. Health for all means
that powerful interests have to be challenged, that globalisation has to be
opposed, and that political and economic priorities have to be drastically changed"
• ‘ Demand that research in health, including genetic research and the development
of medicines and reproductive technologies, is carried out in a participatory,
needs-based manner by accountable institutions. It should be people and public
health oriented, respecting universal ethical principles”
• “Strong' people’s organizations and movements are fundamental to more
democratic, transparent and accountable decision-making processes.
It is
essential that people's civil, political, economic, social and cultural rights are
ensured. While governments have the primary responsibility for promoting a more
equitable approach to health and human rights, a wide range of civil society
groups and movements, and the media have an important role to play in ensuring
people’s power and control in policy development and in the monitoring of its
implementation"
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2. Making research matter: a civil society perspective on health research
David Sanders, Ronald Labonte, Fran Baum, & Mickey Chopra
Bulletin of the World Health Organization, October 2004, 82 (10) p757-763
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“It is important that research into underlying health determinants identifies risks
not only in local and national contexts, but also in a global one; that is, research
should link local phenomena to globalization processes that condition and
constrain local possibilities. The national level is also important. National
governments negotiate or agree to the rules of globalisation (eg., trade
agreements and conditions for debt relief or development assistance). National
governments, acting within the opportunities or constraints created by
globalization processes, also make decision regarding resource allocation that can
dramatically affect enquiry in access to services and to underlying health
determinants at local levels".
"Detailed case-studies, combining quantitative and qualitative methods, generally
provide the information necessary to understand why health systems do or do not
work well in providing care that is not only efficient, but also effective and
equitable. Health systems research needs to shed more light on the importance
of, and barriers to, primary • health-care approaches that link health-care
. interventions to underlying health determinants, and hospital-based care to
community contexts, .engaging citizens and CSOs in the research process. In
particular, research on the mechanisms of community governance is needed to
determine which models allow for effective community management. Participatory
research conducted through partnerships between academics and civil society
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groups has much promise as a means of harnessing local knowledge and laying
the foundation for the application of the knowledge generated by research".
)
•
"A second aspect of social change research examines the conditions under which
research evidence influences policy change. Policy making is fundamentally
about power and interests, and anecdotal experience .suggests that research
findings are used more successfully when they are pad of campaigns involving
mobilized groups of citizens".
•
“Promoting participation and partnership of civil society in health research
There are three ways in which the participation of CSOs in research - as users or
as generators - can be increased. These include • influencing commissioning and
priority-setting; becoming involved in the review process and in research
production by changing funding rules; and through formal partnerships between
communities and universities that link CSOs with academic researchers. These
are not alternatives; each offers important ways in which research outputs can be
influenced to reflect more closely the interests of civil society ".
“Currently CSO voices have very little influence over the research priorities that
are set. This may in part account for the near absence of research on the social
and economic determinants of health or the political economy of health, and the
emphasis on diseases prevalent among the affluent populations of industrialized
countries".
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3.
Pushing the International Health Research agenda towards equity and effectiveness
(A PHM viewpoint)
David McCoy, David Sanders, Fran Baum, Thelma Narayan, David Legge
The Lancet, 2004; 364:1630-31
•
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“With respect to research on the social, political and economic determinants of
health, we draw attention to three points. The first is the need for more research
into the effects of globalisation on poor health and growing health inequities, and
on the development of proposals to reform the current global, political and
economic institutional order.
In addition to research • on more effective
mechanisms for global resource, redistribution, research should focus on how
health equity can be protected from the market failures of economic globalisation
and the operation of transnational commercial interests. Second, we want more
research applied to the question of .why the cancellation of the odious debt of
many poor countries has not been forthcoming, why many rich countries’
development assistance still falls short of the UN’s 0.7% gross domestic product
target, and why bilateral and multilateral trade agreements continue to be
unfavourable and even punitive towards the poorest and sickest people. Third,
more research is needed into the design and financing of systems and basic
services and into how these factors determine access to good quality care and
other health inputs (eg., water and adequate nutrition). As health ■ systems
become increasingly inequitable and fragmented, research on the drivers and
effects of the liberalization, segmentation and commercialization of health-care
systems is essential.
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“Despite substantial sums of money being devoted to health research, most of it
does not benefit the health of poor people living in developing countries - a matter
of concern to civil society networks, such as the People’s Health Movement
Health research should play a more influential part in improving the health of poor
people, not only through the distribution of knowledge, but also by answering
questions, such as. why health and health care inequities continue to grow despite
greatly increased global wealth, enhanced knowledge and more effective
technologies.
•
“These three points complement the call for more research on why available ancT
affordable technology and knowledge are not used, for example, to prevent
millions of children from dying of diarrhoeal disease and acute respiratory
T7
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asinfections. Appropriate research would indicate how the mainly social and political
barriers to application of existing technologies might be overcome.
This
achievement could be aided by country case studies that combine an analysis of
the political economy of poverty and ill health together with the health systems
factors that help or obstruct access to effective health care. Such research would
bring together political and social scientists, health economists, public health
professionals, ethicists, and civil society organizations".
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“To promote the transfer of knowledge from research into policy and practice,
several issues should be examined. Presently, there is a research culture and
incentive system that encourages researchers to be more concerned with
publishing their results in academic journals than with ensuring that their research
leads to improved policy and practice.
Furthermore, policy makers and
programme impiementers in developing countries are either skeptical about the
value of research, or do not have the skHls to appraise and use new information.
The scarcity of capacity in the public sector has been further aggravated by the
steady brain drain of capable health professionals to richer countries or from the
public sector to the domestic private or non-government sectors (including the
health research sector)".
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“Research geared towards practical, health systems development is also often
qualitatively different from research, that is geared towards the imperatives of
academia and the medical industry.. For example, research on the efficacy of
interventions in a controlled environment is different from that on the practicability
of applying effective interventions in the real world. More action research that
involves service providers can help to bridge the gap between research and
implementation, and ensure that research is embedded within a day-to-day
realities and constraints of under-resourced health care systems. The use of
participatory research methods can also help poor communities shape health
systems to meet their needs".
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“Research findings are also more successfully implemented when researchers
include mobilized citizen constituencies. Successful implementation is aided first
by ensuring a vigorous community of civil society organizations with a mandate to
keep a watch on health policy development and implementation; second, by use
of research funds to actively foster the capacity of these organizations to change
the commissioning and priority setting for research; and third, by including civil
society organizations in research production and encouraging partnerships that
link them with academic researchers".
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“Finally, the imbalance in power between researchers in rich and poor countries
must be bridged. Many academic and non-government institutions in more
developed countries benefit disproportionately from the meager research funds
that are focused on poor health in developing countries. This imbalance is in a
context where academic and research institutions in developing countries are
struggling to gain their own funding and find it difficult to retain good staff.
Practical ways of addressing the inequities within the health research community
might include mapping out the distribution of research funds for health problems
between research institutions in rich and poor countries, documenting the
obstacles to the development of research capacity in developing countries and
conducting in-depth case studies of the health-research funding policies and
patterns of selected donor and international agencies.
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Informed Choices for attaining the Millennium Development Goals: towards an
international cooperative agenda for health systems research
WHO Task Force on Health Systems Research, 2004
■ (www.thelancet.com Vol 364, Sept,11 2004. p997-1003.
Suggested topics for health systems research and their potential to affect attainment of the
targets for the MDGs [there is need for health systems research to inform decisions at
local, national and international levels. We have highlighted topics relevant to decisions at
each of these levels]
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5.
Financial and human resources
community based financing and national health insurance
human resou.-ces for health at the district level and below
human resource requirements at higher management levels
Organization and.delivery of health services
community involvement
equitable, effective and efficient health care
approaches to the organization of health services
drug and diagnostic policies
Governance stewardship, knowledge management
governance and accountability
health’ information systems
priority setting and evidence informed policy making
effective approaches for intersectoral engagement in health
Global influences
Effects of global initiatives and policies (including trade, donors, international
agencies) on health systems.
Health Research for the Millennium Development Goals A Report on Forum 8, Mexico City, 16-20 November 2004.
Chapter 2 : Knowledge and Power
[From a grassroots perspective (Ravi Narayan, PHM), p29-30]
"A major challenge for researchers is to decide what evidence for health problems
is crucial and significant, Narayan said adding that social, economic, cultural and
political factors are not given the importance that they are due. Researchers are
trained to consider biomedical factors: clinical, epidemiological and techno
managerial. He suggested that “people-oriented" perceptions be substituted for
these “professional" perceptions in a paradigm shift that he believes is the single
most conceptual challenge to address the Millennium Development Goals and the
“10/90 gap".
•
“In a "plea on behalf of the people for a sense of balance", Narayan said social
determinants like poverty, gender bias, conflict, stigma and social exclusion must
be considered in assessing evidence on disease".
•
“Whose evidence are you taking?" he asked. “The governments’, the academics’,
the industries’, the NGOs? - or also, the community, peoples’ organizations, the
socially excluded?"
•
"Who decides on the implications of funding? The government? The industry and
market forces? International funding agencies? The World Bank and WTO and
- their-alliances?
Or also, the people, peoples’ organizations and people's
movements?"
•
“The shift in health research that Narayan envisions would move the focus from
the individual to the community, towards more consideration of the social,
economic and political factors and with emphasis on the educational and social
processes.
"A social vaccine is closer than the AIDS. vaccine," Narayan
concluded’’.
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6.
Research for People’s Health : A Research Encounter at the Second People’s Health
Assembly, Cuenca, Ecuador
PHM I University of Cuenca - Faculty of Medical Sciences I Global Forum forHealth
Research / and.International People’s Health University, July 2005
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Research for People’s Health - A Declaration
"To Researchers:
• It is important to value research principally from the point of view of health and life.
• Research should bring about social action by the mobilization of people and
communities as participants and collaborators. Biomedical research should be
integrated with social research.
• There should also be a sincere effort to integrate quantitative and qualitative health
research.
• Research findings should be shared with members of the community with whose
assistance research findings and conclusions came about.
• Research should involve dialogue between investigators and representatives of
communities as well as the people directly.
• There should be the creation of virtual information spaces for the learning of new
research paradigms without denying or restricting access to any information that
conforms to ethical norms.
• An international committee should be convened including biomedical as well as social
and cultural components and primary health care.
• Research should be multidisciplinary and bring about dialogue between professionals
in the health sector with professionals of other sectors such as social science,
economics, etc.
• It is important to network with national, regional and international forums of health
research. .
. . .
:.
• The research process should aim to improve collaboration among investigators and
with local mass media, local governments and other political sectors".
‘To Training Institutions
There should be serious revision in education of human resources in health, within the
framework of the new paradigm of research.
•
New resources should be identified in universities that would help engagement in new
paradigms of research
The new paradigm should not be taught, but rather be learned together with the
community taking part in the research.
It is imperative that the social research component of health research be
strengthened.
Postgraduate education / specialization should conform more to community based and
participatory action./
.
The universities should be charged with developing community research programs in
a participatory way.
It is necessary to reach the community through education using schools and other
means in order to enhance the community’s health with a more holistic and lasting
influence. Through university outreach, proposals for participatory research can be
developed.
There must be efforts to establish strategic alliances for research in health and social
sciences.
•
There is need to improve the capacity to develop research proposals.
There must be adequate allocation of economic resources for the application of
strategies with emphasis on health promotion at all levels".
7, The Cuenca Declaration
• The Second Peopfe’s Health Assembly, July 2005, Cuenca, Ecuador
(People’s Health Movement)
• “To launch a comprehensive campaign to achieve the “Global Right to Health and
Health Care"/at the local, national and international levels, to defend health and
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social security (including health care) systems, and to document and oppose
health inequities and denial of the right to health".
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“To continue to monitor and provide inputs for the WHO Commission on the Social
Determinants of Health to ensure that it effectively addresses the political and
socio-economic causes of poverty, ill health and health inequity and engages in
meaningful dialogue with civil society as much as possible;.
•
“To address the crisis of human resources for health (HRM) by: improving working
conditions, training, support and supervision for health workers; implementing an
International code of practice on ethical recruitment, financial compensation to
exporting countries, return and reorientation of health workers in the diaspora
through incentives, and establishing a global fund for HRM".
"To engage with formal training institutions and challenge the dominance of the
biomedical paradigm of health cafe. It will incorporate diverse strategies for
reorienting health worker education to comprehensive PHC, keeping people in
communities at the center".
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“To document, analyze and disseminate research findings on key issues
pertaining to the principles In its Charter, including gathering analyzing and
disseminating key evidence for its constituency of the efficacy and sustainability of
initiatives in comprehensive primary health care".
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Future Actions to strengthen Schools of Public Health
These include:
> Developing of evidence based public health policies;
•••• > Development of institutional capabilities for closing the gap between
knowledge and practice;
> Development of appropriate human resources at all levels;
> Health promotion, health lifestyles with involvement of civil society;
> Strengthening of public health regulation and health financing;
> Community based public health research; and
> Ability to solve complex societal problems through multi-disciplinary
interventions.
♦ Research competencies (to be developed) by Schools of Public Health
> Expertise in epidemiology and bio-statistics
>. Critically evaluating data
> Identifying gaps in knowledge
> Enunciating Research questions
> Designing and implementing studies
> Carrying out health systems research and sensitivity analysis
> Understanding efficiency and carrying out cost effectiveness studies
> Preparing research papers
> Organizing dissemination of research results
> Carrying out meta-analysis
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South-East Asia Public Health Initiative 2004-2008 : Strategic Framework for
Strengthening Public Health Education WHO-SEARO Document SEA-HSD-282,
June 2005.
•
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"To become a forum within which intellectuals can support local activities in their
action and struggle".
Developing as a reputed research and advocacy group
Notes from a PHFI Inaugural Workshop (2005)
• It should work to foster networking, creating policies and working on areas of
research that are not adequately addressed as of now. It should not compete with
existing research institutions and public health departments which are already
7
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doing research in a number of public health problems - eg., communicable
diseases, cancer, diabetes, cardio-vascular diseases, etc.
It should promote an interaction between research and the health care system so that locally generated research that is responsive to an adverse economic
situation is used by the health care system.
It should promote the nation wide acceptance of research methodologies and
modules that have been set up by councils of medical research and other
institutions.
It should promote interactive dialogue between researchers - biomedical and
social and behavioural scientists and also with advocacy groups, planners arid
civil society and community.
It should promote the spread of research information to the community by more
active partnership with grass root workers.
It should also promote evidence based decision making in health care planning by
making available research evidence to help planners.
It must strengthen the commitment of public health community to public health
research (if something is not respected it does not get done).
It must foster research i.e., country centric and innovative because especially in
public health we have to deal with less resources, large numbers and large
distances. Focus of research should be on poor population not well to do.
It must assess new technology critically especially looking at how it can improve
the health of our country and also promote technological innovations.
Research priorities could include
a. studying implementation gap and implementation science
b. socio-economic determinants of health including gender disparity, equity and
access
c. focus on unorganized sector and its impact on health
d. women’s health
e. starvation and food / nutrition security as a public health issue.
f. decentralization of public health system
g. health as a human right issue
h. health.system research which should be fed back to the system to increase
efficiency of the system.
i. Public - private partnerships and their efficacy
j- Health and social policy research including measurements of existing policy.
It should promote evidence based introduction of public health measures for
communicable and non-communicable disease control.
The research promoter should be with a strong social medicine and community
health approach and not just the orthodox bio-medical approach.
Research partnership should promote links with community based organizations,
people’s movement, groups of rational practitioners and PSM departments in
medical colleges.
Research’ should reflect on entire health spectrum of disease and problems and
systems and not just be bio-medical in its approach. It should be fostered by
encouraging a deeper understanding of the social, economic, cultural, political and
ecological dimensions of health and disease at the graduate education level and
in the orientation and training of young researchers.
The research policies.supported, must ensure that the benefits of research must
reach the community / population otherwise the policy should be seen as
incomplete.
It should balance-focus on drugs, vaccines and new technologies with strong
commitments to health system research, health promotion, and approaches that
foster education and social processes.
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Some initiatives towards Research priorities in Public Health (Global South)
a)
In 2001 AD the People’s Health Movement (PHM) evolved with a mandate in its
People's Charter for Health demanding that ‘research in health... is carried out in a
participatory, need -based manner by accountable institutions. It should be people and public health-oriented, respecting universal ethical principles’.
b)
Since 2002, the Global Forum for Health Research began to/evolve regional forums
in Latin America. South East Asia and other regions to enhance the dialogue among
local researchers at regional level.
C)
In 2004. the International Peoples Health University (IPHU) was formed and held its
first session for public health and people health activists from all over the world
before the second Peoples Health Assembly in Cuenca in July 2005. The IPHU
-session led to a process of small groups of public health enthusiasts collecting
evidence on social determinants, primary health care and trade and health.
d)
In March 2005, the WHO launched a Commission on Social Determinants in Health
(WHO-CSDH) to look at the available evidence on social determinants from different
parts of the world especially the Global South and to explore how to use this
evidence to evolve international and regional health policy.
e)
In June 2005, in the WHO-SEARO region a South East Asia Public Health Initiative
2004-2008 evolved to strengthen public health as a discipline, and strengthen
schools of public health including strengthening community based public health
research for generating evidence for better public health policy and capacity
f)
In July 2005, just before the second assembly a Research Encounter for People's
Health was organized by the University of Cuenca, Faculty of Medical Sciences,
International Peoples Health University, National Association of Faculty of Medicines,
Ecuador, the Global Forum for Health Research, Geneva and the Latin American and
Caribbean Health Research Forum. A booklet from this meeting (in English and
Spanish) was released at the Forum 9 in Mumbai. The Conference looked at new
research paradigms to help research become a major partner of social
transformation and opportunity for people and communities to be partners in the
research effort.
g)
In March 2006, in India, a Public Health Foundation of India (PHFI) was launched
with Indian and global public health leadership supporting the development of public
health capacity building in India with a South Asia focus and commitment to public
health research on social determinants, health systems, health impact assessment
and other relevant areas.
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THE BHOPAL
DISASTER
AFTERMATH:
An epidemiological
and socio-medical
survey
A summary of the
report
medico friend circle
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PREFACE
Dedicated to the thousands
who died or were disabled
by the Bhopal Gas Disasterone of the worst industrial
accidents in recorded history.
The Bhopal disaster has been an unprecedented occupational
and environmental accident. Equally unprecedented have been the
imperatives for relief, rehabilitation and research in the aftermath-of
the disaster,
With a resolve
The. local situation has been extremely complicated and
dynamic. While health service providers and researchers have had
to face many medical challenges; government and voluntary
agencies involved in relief and rehabilitation have had to face many
logistical and organizational challenges.
to prevent medical research from
becoming an instrument of
exploitation of human suffering
With a determination .
For the medico friend circle too, in its intervention in research
and continuing education strategies in support primarily of voluntary
agencies, it has been both a challenge and a thought provoking
learning experience. The experience of planning, organising,
analysing and communicating our research findings based on a
modest study has brought us further in touch with the apathy,
vested interests and status quo factors which obstruct action in
favour of the disadvantaged in society.
to make medical research
an expression of
human concern
I
-
A summary of the epidemiological and socio-medical
investigation conducted by a team from the medico friend
circle, in Bhopal, 18-25 March 1985
Price. Rs. 2. 00
Having seen the intensity of health problems of the disaster
victims and the inadequacies in the stiategies employed to
ameliorate them we cannot but help raise critical comments on all
components of the social medical system who are there to handle
such problems.
Our objective, however, is more than critical analysis. Through
this epidemiological study we have tried to make our oivn-small
contribution to a better understanding of the health problems that
prevail. in the aftermath of the disaster. We have also made
suggestions for a more comprehensive relief and rehabilitation
strategy.
. A word of caution here-rnost of our observations are of the
situation as it existed at the end of March 1985. Six months have
passed in the process of analysis, consensus
'JJ
TME BHOPAL DISASTER:
seeking and understanding our findings. During these six months
XTS
many further developments -- both positive and negative— have
place
taken
Bhopal
in
at the
governmental and
the
introduction
non
The disaster that took place on the dark, wintry night of 2/3
December 1984 in Bhopal is the worst man made environmental
accident in recorded history. The shocking, official estimates of
1754 human deaths, an equal number of dead cattle and the
governmental initiative.
We hope that this report .will atleast help to highlight to our
physical and mental disablement of over two lakhs people, by a
mixture of toxic gases including Methyl Isocyanate (MIC), do not
adequately express the tragedy that has occurred.
readers among other matters that-
(i) what people say and feet is as important evidence as what we
can discover through our over-mystified medical technological
The relief efforts, initiated immediately, were handicapped and
hampered by the lack of authentic information on the nature of the
gases rele2sed, by the unwillingness of the Union Carbide to
release information and by lack of relevant information among the
approach;
(ii) in the absence of a community oriented epidemiological
perspective, decision making about relief efforts following a
State and Central authorities.
disaster can be adhoc and often irrelevant; and
The doctors at the Hamidia Hospital, Bhopal, where hundreds
of the victims rushed, were faced with an acute emergency which
. they never anticipated, of whose exact nature they had no inkling,
and for the treatment of which they had no ready sources of
information.
(iii) for research to be relevant to the lives of the people, the
findings and inferences drawn must be communicated to the
health service providers and the patients themselves through
an effective communication strategy.
Since the nature of the toxic gases released into the
atmosphere had not been made public either by the Union Carbide
Finally we hope that through this report, we shall stimulate
or by the Centre (which sent high level technical experts to Bhopal),
debate, dialogue and a commitment to a deeper understanding of
. this had to be a conjecture based on reason and visible evidence.
the problem leading to more relevant and meaningful interventions.
Bangalore
Ravi Narayan
2 Oct. 1985
Convenor
,i
Soon, two theories emerged to account for the varied
symptomatology and stunning mortality of the victims. The
development and testing of these theories, had they been done
properly, would undoubtedly have added immensely to scientific
knowledge. What is more important is that it would have relieved
the sufferings of thousands of people. The local realities have,
however, revealed the power stru-
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ggles in the medical community and how it ignores in the process,
but believes that both have important roles to play in explaining the
the victims; the lack of human concern leading to withholding of
varied symptomatology.
probable proper treatment; the indifference of our medical and
J
This theory stemmed from the observation that the tissues and
scientific community to communicate with our largely illiterate but
not unintelligent masses.
blood of the dead victims were bright red in colour. This occurs
both in cyanide and carbon monoxide poisoning. Haematological
(blood) studies by ICMR ruled out the possibilities of carbon -
The Two Theories
monoxide poisoning.
The protagonists of the first theory,, the 'Pulmonary theory'
believe that isocyanates of which MIC is one, damages only those
Cyanide on the other hand might have been inhaled directly as
tissues with which they come into direct contact and cannot be
hydrogen cyanide or might have been released in the body after
carried by the blood to internal tissues and organs. Thus MIC can
the breakdown of the MIC molecule.
damage only the lungs, eyes and skin and this according to them
Normally, there is a small cyanogen pool in the body formed
explains the predominant involvement of the eyes and lungs in the
by the generation of small amounts of cyanide or cyanogenic
Bhopal victims. They also believe that symptoms, if any, related to
substance during normal metabolic processes. These cyanide or
other systems must be due to hypoxia caused as a result of lung
cyanogenic
' damage. This theory is strongly supported by a dominant section in
radicals
are
converted
into
relatively
harmless
thiocyanates by a liver enzyme called rhodanase and excreted in
the Gandhi Medical College and the medical community in Bhopal.
the urine. Certain foods like cabbage etc., and smoking are known
They believe that early deaths were due to carbon monoxide
to increase the cyanogen pool as evidenced by an increased
poisoning - one of the constituents of the released gases. They
excretion of thiocyanates in the urine. Cyanide/cyanogen interferes
refuse to accept any alternative theory.
with oxygen utilization in the body.
—7-+—4-------------------------- ---------------------
This theory cannot fully explain the varied symptoms of the
The protagonists of the enlarged cyanogen pool theory have
established that MIC in the body gets attached to the haemoglobin
victims: nor the fact of multi-systemic involvement without lung
involvement seen in many patients. While another isocyanate,
toulene diisocyanate (TOI) has been shown to cause brain damage,
the protagonists of the present theory are silent as to Why MIC
t
by a process of carbamylation. They believe that by a mechanism
as yet unknown the cyanogen pool within the body is increased. In
these circumstances, its conversion to thiocyanate by rhodanase,
cannot do so, too. Public Health specialists in the U. S. say that this
can be accelerated by administration of sodium thiosulphate (NTS).
exposure can lead to permanent lung involvement and blindness.
This is the rationale in using NTS as an antidote for cyanide
This is in contrast to the Union Carbide which maintains that MIC
poisoning. The resultant thiocyanates are excreted in urine, and
can have no lasting damaging effects.
this can be used .to test the proposed theory itself.
The main protagonist of the second theory, the 'Enlarged
Cyanogen Pool theory', is the Indian Council of Medical Research
(ICMR). In fairness to this body, it must be stated at the very outset
that it does not reject the first theory
The ICMR conducted a double blind clinical trial using sodium
thiosulphate and glucose as a placebo on gas affected patients in
January. Majority of patients who received NTS showed significant
improvement and 10 out of the 19.
w
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patients showed an eightfold increase in urinary thiocyanate levels.
Those who received gluqose did not show significant Changes.
Unfortunately, and due to reasons best known to itself, the ICMR
has not made the details of the findings of this crucial trial, public.
The opponents of the theory too have conducted a trial-not double
/ •
The ICMR summaries of research undertaken and press
releases available to us were inadequate and sketchy. We decided
blind, which they say does not confirm the hypothesis. They too
have withheld their findings from public scrutiny.
that we would go primarily by the broad range of symptomatology
with which the patients in the, community were presenting. We
supplemented this by a thorough physical examination and undertook
haemoglobin estimations and lung function tests. A criticism against
this approach’of reliance mainly on symptoms could be that it lacks
objectivity. However, we believe that a thorough study of symptoms
is a perfectly valid method of study as has been accepted in a whole
tl
The Study by mfc
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The mfc had decided at its annual, meet held at the end of
January 1985, to respond to a series of appeals from various non.governmental organizations(NGOs)and citizen's forums to undertake
an epidemiological investigation, so as to support the victims and
. the NGOs in their struggle for proper relief and a more meaningful
rehabilitation process:
Some members of mfc visited Bhopal in mid-February to assess the
situation and the actual epidemiological survey was conducted
between 18-25 March 1985. by 11 members of mfc and 3 friends
from the Baroda Medical College.
range of.medical conditions like chronic bronchitis, ischaemic heart
■
disease, arthritis etc.
The study poputation
The study was a community based, case/control study.
Two slums were selected for the study: (i) J P Nagar situated in the
close vicinity of the Union Carbide factory and the worst affected by
the gas leak, (ii) Amia Nagar 1 0 km away with the least exposure,
which served as the control. There was no area which was similar to
It must be admitted that the mfc had neither the human power
nor the material resources to launch a full scale investigation. Our
JP Nagar in socio-economic and environmental characteristics and
yet escaped exposure and, therefore, Anna Nagar with the least
exposure was the best control that could be chosen.
initial, fact finding survey revealed:
(i)
official secrecy regarding all information on the
disaster;
(ii)
absence of open scientific debates;
(iv) to make recommendations for a more meaningful relief and
rehabilitation policy.
Rapport was established with the people by explaining to them
our objectives and making it very explicit that we were not there to
offer any financial compensation, medical treatment etc. The slum
(ihy lack of encouragement to NGOs. The
mfc therefore decided to:
dwellers were given a hand out in Hindi explaining the role of mfc
(i) make an epidemiological assessment of the current health status
and a commitment was made that the salient findings of our study
and our recommendations would be made available to them.
and health problems of the people;
(ii) to examine the findings in the light of the two controversial .,
theories;
Sample Selection
(iii) to evolve a critique of the medical reasearch and relief
The families for study were selected by random sampling, an
accepted statistical method used in community-
programme;
03
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based studies. Only subjects above 10 years of age were selected.
Those less than ten years were excluded in view of their probable
inability to report symptoms correctly. All details were entered in a
pre-designed proforma. In addition, lung function tests were done by
standard procedures using a portable spirometer by a doctor fully
The.commonest symptom was breathlessness on accustomed
exertion. The. following symptoms were highly significantly different
(higher) in JP Nagar as compared to Anna Nagar: cough with
familiar with measuring these under field conditions.
muscle ache, abdominal pain, nausea, and anxiety/depression (see
table). The following six symptoms were also significantly different:
dry cough, breathlessness at rest, watering of eyes, skin problems,
bleeding tendency, and impotence. On grouping the symptoms
according to the systems, most of them are related to the pulmonary
system (respiratory), the gastrointestinal system (digestive), the eye
and the central nervous system. It is important to note that this
survey was conducted more than three months after the disaster,
and the victims still continued to suffer so many multisystemic sym
expectoration, chest pain, blurred vision, -photophobia, headache,
fatigue, loss of memory for recent events, weakness in extremities,
Observations
The two slum populations* were similar in age and sex
composition, in the number of smokers and of people with long
standing respiratory problems like asthma, tuberculosis etc. The JP
Nagar residents who were the more affected, were slightly better off
economically but this is of no significance in so far as morbidity rates
in JP'Nagar are concerned. (For details of actual figures, see our
ptoms. Moreover every individual in the JP Nagar sample reported
at least one serious symptom but many in the Anna Nagar sample
did not report any such. Probably the most crucial finding of
significance was that 35% of the patients had gastro-intestinal,
central nervous system and eye symptoms in the absence of any
lung findings. This cannot be explained by the theory that the
multisystemic symptoms are due to hypoxia (decrease of oxygen in
blood stream) secondary to lung damage. It points to the possibility
Report.)
An unexpected finding was that people as far away as Anna
Nagar. (obr control population) were minimally exposed and we
observed a larger number of serious symptoms in this group than
one would expect. This fact narrows down the differences in rates of
symptoms observed between the two populations. The health impact
of the toxic gases on the exposed population is therefore much
greater than what our study reveals.
The subjects described a broad range of symptoms arising
from most of the different systems in the body. Each symptom was
described in such graphic detail that it was obviously based on the
patient's own experience and could not be malingering or wild
imaginations as some are apt to allege. Since these symptoms could
arise due to different causes and since the residents of Anna Nagar;
the controls, were also exposed to the gas, albeit to a small extent,
the latter also reported those symptoms. However; JP Nagar
residents had a much higher (statistically highly significant)
incidence of these symptoms compared to Anna Nagar.
r-ig
of a circulating toxin in the blood, affecting all the systems.
Our findings also refute the speculation that much of the
present morbidity is due to a high prevalence of chronic diseases
like tuberculosis, asthma, bronchitis etc., and high rates of smoking
among the affected basti population.
Women in the reproductive age group reported menstrual
irregularities such as shortened menstrual cycles, altered pattern of
discharge, pain during menstruation and excessive white discharge.
These symptoms were compared not only between the two
populations, but also with respect to the
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Salient Findings of the Study
Comparison of symptoms/investigations in J P Nagar and Anna Nagar
(expressed in percentage) (No. of cases are shown in brackets)
*i
P Value
Anna Nagar
SI No
Symptom
J P Nagar
1
2
Breathless on usual exertion
(49)
Chest pain/tightness
26.08
(36)
Weakness in extremities
(129)
(74)
(97)
35.50
3
87.16
50. 0
65.54
36.95
4
Fatigue
81.08
39.85
(51)
(55)
5
Anorexia
Nausea
66.21
58.10
28.26
16.66
(39)
6
(120)
(98)
(86)
7
8
9
10
11
12
Abdominal pain
53.37
25.39 .
(35)
Flatulence
68.91
25.36
(35)
153)
(21/96)
(16)
(28)
13
14
15
16
Anxiety/depression
(79)
(102)
(114)
(65/141)
(67)
(81)
(99)
(108)
(65)
(12)
(1.79)*
(1.46)*
Blurred vision/phptophobia
77.02
Abnormal distant vision
Tingling & Numbness
42. 0
45.27
54.72
Headache
66.89
Muscleache
72.97
43.92
8.10
14.68
12. 7
Loss of memory for recent events
17
Impotence
Haemoglobin (male) (mean gm%)
18
Haemoglobin (female) (mean gm%)
38.40
21.88
11.59
20.28
42.02
36.23
10.14
0.72
12.70
10.79
(23)
< < 0.001
< < 0.001
< < 0.001
<<0.001
<<0.001
<<0.001
(58)
< < 0.001
< < 0.001
<<0.001
< 0.001
<<0.001
< < 0.001
< < 0.001
(50)
(14)
(01)
(1-35)*
(1.34)*
<<0.001
< < 0.001
<0. 05
<0. 01
< 0.001
3
d
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♦ Standard deviation of means
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theory alone even though pulmonary lesions can cause peripheral
hypoxia and hence muscular fatigue and so on. On the other hand,
the enlarged cyanogen pool theory can better explain the varied
and apparently unconnected symptomatology. It must be
emphasised that both theories are probably playing a role in the
causation of symptoms. However, the ICMR has not tested the
cyanogen pool hypothesis rigourously. It has studied only the
seriously ill, hospitalized patients and concentrated mainly on the
lung symptoms. They do not say whether the non-pulmonary
symptoms (symptoms not related*to lungs) were also relieved by
.
question is whether there is scientific evidence in favour of NTS
therapy and whether there is equally strong, if not stronger,
evidence against the use of NTS in.this situation.
NTS with its specific action is a better therapeutic agent than
the non-specific remedies that are being used for the lung
symptoms. A dominant section of the doctors of Bhopal are thus
guilty of delaying treatment and by not revealing the findings of its
clinical trial, the ICMR too has to accept part of the blame for the
continuing suffering of the victims.
sodium thiosulfate and curiously has not made its findings public.
After a few weeks of controversy the NTS therapy has now
One therefore, may also question whether the cyanogen pool
been accepted but mass detoxification is still being strongly
opposed.
theory is fully valid.
lb rnujst be stressed here that the mfc is not rejecting the
cyanogen pool theory. It is only to point out that the country’s main
medical research pody has failed to be rigorously scientific in
testing its own hypothesis.
Sodium thiosulphate therapy
We have already explained how sodium thiosulphate (NTS)
will help remove cyanide radicals from the body. If the enlarged
cyanogen pool theory has been established, even as one of two
causative factors the victims should receive NTS treatment Some
of the local doctors and beaurocrats availed themselves of this,
after the cyanide theory was proposed, yet the affected people in
the bastis were not given the drug.
The ICMR at a meeting held on on 4 Feb 85, issued
guidelines for NTS treatment. The medical group of Bhopal which
was opposing the treatment, was also present at the meetings,
according to the minutes. Yet they opposed the treatment later with
the argument that they are not convinced of its efficacy. The
question is not of a doctor’s conviction. A doctor’s choice of
treatment cannot be arbitrary. The
’
IS
The trial with NTS is not the only study launched by the
•ICMR. It has sponsored many other studies on the Bhopal victims,
but they lack an integrated approach. Thus lungs, eyes etc., are
being examined independent of each other, by different
investigators and the ICMR is unwittingly lending support to the
first theory, namely, that MIC gas damages only tissues with which
it comes into direct contact. •
What exactly happened to the gas victims?
So many months after the disastrous gas leak, one still does
not know what exactly has happened to those who inhaled the
gases and are still surviving. This is not because all attempts to
unravel the mystery have failed but because an integrated
approach has not been taken to do so. Months after the disaster,
thousands of the survivors• are still suffering from debilitating...^
symptoms which prevent them from going back to work.
The medical community and the officialdom have been .adhoc
in their efforts to render adequate succour to these hapless
victims. A powerful medical lobby in Bhopal have opposed sodium
thiosulfate,, a treatment, with good potential
13
12
Care, Surveillance and Rehabilitation
to the patients. They have no convincing argument for their stand.
The IMA, (Indian Medical Association) the organisation which has
authority over the medical profession, has remained totally mute.
The doctors as well as the ICMR have concentrated entirely on
those who were hospitalised and have not evolved a holistic,
community approach to understanding the problem. The ICMR
3.
rehabilitation are urgently required.
4.
Mass treatment with sodium thiosulphate .'based on ICMR
guidelines should be initiated maintaining good medical
records.
sponsored local studies with exception of the NTS trials have
lacked the rigour and the epidemiological orientation that are
neccessary ’ in arriving at a meaningful understanding of the
5 A surveillance programme should be undertaken to assess risks
to pregnant mothers, unborn babies and new born babies.
There should also be close monitoring of the gynaecological
problems of women.
. problem.
6.
point of utmost significance is that the victims of the Bhopal
‘
Psychosocial assessment and consequent counselling and
It is necessary to have a long term surveillance of lung
gas disaster mostly.belong to the lowest strata ofsociety and are not
function, in view of the postulated damage to lungs and
in a position to fight for their rights, be it medical aid or monetary
resultant lung fibrosis. Similarly, eyes should be examined
compensation.
regularly.
It
is,
therefore,
not very ' surprising that the
7 A comprehensive listing of all gas disaster victims is a long
overdue task necessary for mass treatment, compensation
and rehabilitation. This must be done immediately.
government and its organisations have shown marginal interest in
the after effects. It also reveals a lack of interest among our
scientific community in investigating an environmental disaster of an
unprecedented nature. On the other hand, one can observe the
striking contrast with which all attempts were made to retrieve the
Black Box of Kanishka, whose mid-air explosion resulted in the
death ofJonly 326 persons but needless to remind of the upper
Communication
8.
There is urgent heed to evolve a continuing education strategy
for all health personnel including doctors working in both
government and non-governmental centres. These could be
socio-economic class.
through newsletters, handouts and informal group meetings.
Recommendations
The areas identified are:
(i) sodium thiosulphate therapy;
(ii) identification and management of psycho-social
Research
1.
The research and follow up studies should shift focus from
stress;
(iii) risks to mothers and unborn foetus and need
hospital/dispensary based studies of seriously ill patients to
family/community based ambulatory patients.
2.
for surveillance;
(iv) family planning advice till completion of detoxi
Well designed clinical trials should be further initiated using
sodium thiosulphate as a therapeutic and epidemiological tool
fication;
(v) role of respiratory physiotherapy,
(vi) management of lactation failure; •
(vii) caution against overdrugging;
to further establish .the significant could role it could play in
mass therapy.
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(viii) need for open minded surveillance of high risk groups;
(ix) importance of medical records.
9.
There is also urgent need for dynamic creative non-formal
health education of the affected community through group
meetings, posters and pamphlets .with information and
messages built around their life style, culture and existing
socio-economic situation.
medico friend circle
The medico friend circle (mfc) is a circle of friends with
- medical/non-medical backgrounds who share the common
conviction that the present system of health services and medical
education is lopsided in the interest of the privileged few and must
be changed to serve the interests of the large majority, the poor,
The areas identified are:
mfc fosters a 'thought current’: upholding human values, people
(i)
sodium thiosulphate therapy;
(ii) ongoing research programmes and informed consent;
and community orientation of health care and medical education,
demystification of medical science and a commitment to the
guidance of medical interventions by peoples’ needs and not
(iii) risk to unborn and new born babies;
10
(iv) family planning advice;
(v) respiratory physiotherapy;
(vi) management of lactation failure including low cost .
weaning foods;
commercial interests.
(vii) importance of records and regular check ups;
experiments with the aim of realising the goals outlined above, and
mfc offers a forum for dialogue/debate, sharing of experience and
for taking up issues of common concern for action.
Occupational rehabilitation and compensation: In the ultimate
analysis care of illness, health education, psychosocial
counselling would be inadequate measures if they were not
backed by adequate monetary compensation and urgent
occupational rehabilitation- of the disaster victims. This would
have to be imaginatively done keeping their previous
occupations and the residual disabilities in mind.
For further details regarding mfc BHOPAL STUDY contact—
Ashvin Patel
Coordination
11.
The government machinery alone cannot handle such a
massive task.. The government must adopt a policy of
enlisting the help of all non-governmental agencies and
groups wishing to work in Bhopal. This enlistment must be
active and supportive.
and finally
12.
It is imperative that the victims as well as the entire country
must be provided with all the details of how the accident
occurred, of the nature of the chemicals released and of the
reasons why the detoxification by sodium thiosulphate has
been so badly mismanaged.
.
ARCH
21 Nirman Society
Alkapuri
Vadodara 390005
OR
Anil Patel
ARCH
Mangrd (At & P.O:)
Via Rajpipla
. Dist Bharuch
Gujarat 393 150
(A detailed report of the study including background, objectives,
materials and methods, observations and results, discussion,
recommendations, important appendices including proformas and
references and reading.list is also availalable on request from the
mfc organizational office 326 V Main I Block Koramangala
Bangalore 560034
Price Rs. 8. 00)
?/
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“THE CHALLENGE AHEL1P*
nThe greatest challenge to medical education in our country is to design a
system, that is deeply rooted in the scientific method andyet is profoundly
Influenced by the local health problems and by the social, cultural and
economic settings in which they arise..
We need to train physicians, in whom an Imeresf is generated t&^ork in the
community and who have dte qualities forfunctioning in the community in
an effective manner".
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Since the Srivastava Report, there has been a growing spirit of introspection and some
commiunenl towards reorientation of the curriculum, to suit our own ‘needs’ and ‘socio
cultural realities*.
I
At the national level there have been many devclopnicnls.(3) These include:
t.
Reoricniauon of Medical Education Scheme, 1975
iL
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TCSSR/TCMR Study group report on Health for All: An alternative strategy • 1981 ;4
The National Health Policy 1982
j
iv.
The Recommendations on Undergraduate Medical Education of Medical Council of ;I
India (19&2)
v.
The National Education Policy, 1986
vi.
The development of the Health University concept, and
l
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vii.
i
The draft Ntriional Educational Policy fur Health Sciences (1989)
Within the medical college sector, there have been serious efforts by a few colleges to evolve •
community oriented training strategies based on the MCI guidelines and sometimes going
beyond It, Their efforts have been interesting but of limited impact, due to many factors *
including inadequate faculty msponse and the changing social ethos and value system of the
medical college entrants. The absence of the concept of ‘autonomy* in the medical education
sector in the country, preventing the development of experimenlal alternative curriculum or
‘parallel tracks’ is also an important factor.
Some medical colleges have been involved more recently innelworking around various new ■
directions including ‘epidemiological orienution*, the ‘alternative track* concept, and the :
‘inquiry driven’ approaches to evaluation/innovacion* (3 & 4).
'
Many have been participating in the annual deliberations of the Indian Association for the
Advancement of Medical Education.
The efforts of the National Teacher Training Centres for medical college teachers a UIPMER,
Pondicherry and PGJ-Chandigartt have also been significant(3).
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Outside the medical colkge sector, theie has been experimeniation and reflections on
alternatives. Key among these are,, the ‘Kottayam experiment* (5), the medico friend circle s
‘Anthology of Ideas' for an alternative (6 & 7), the JNU plea for a ‘New Public Health’ (8),
the Miraj Manifesto (9) and others.
Anuraberof innovative cowounity health oriented (raining programmes for health personnel
especially within the voluntary sector have also developed and arc of significance to Medical
and Nursing Education. ‘Similarly outside (he health sector, in the development and informal
Z'-- education sectors, there havecmergcd anumber of ‘atlcmalivc training experiments, that have
pedagogical i nnov a (ions relevant to medical education (10).
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SOME LACUNAE IN THE PROCESS
Alongside the above, evidence of the spirit of introspection and ‘ir.novatian', which could
slimulate change in (he 199Gs, there arc some associated features that are not so healthy and
could be considered lacunae, and even going counter to the emerging process.
Firstly, there is not much interaction or dialogue between the comparlTncntariscd univeree of
government lieaRh services and training cent res f medical colleges (government and private)
and voluntary agencies and other groups interested in alternative medical education. Even
within these compartments) there are divisions and inadequate networking. Groups arc
therefore unaware of each others5 efforts.
Secondly, there has been inadequate publication of the strengths and weaknesses of these
different initiatives. Even though there is a growing mass of ‘grey literature’ - reports and
handouts and circulated papers - these are not easily accessible to the ‘serious medical
educators in Ind ta, who arc therefore not aware of the weal th o f exper icncc i n the country itself.
Thirdly, the innovators within and withoul thesystem have not subjected lheir own ‘innova
tions’or‘reflections’to any type of‘objectiveevaluation’or‘peer group assessment , In some
instance, where this has been attempted, the results are not easily available, for others to learn
and reflect upon.
Fourthly, in the absence of this awareness of the diversity and multifaceted experience in the
country, there is a lendecicy among medical educators to be carried away by 'ideas and ‘expert
advice’ that have originated in other countries - in situations of different socio-economiccultural conditions and in different cducatiorml systems. Some of lhe recommendations and
suggestions are therefore not adequately grounded in local realities and experience.
Finally, there has been inadequate attention given to the traditional systems of medicine and
healing as well as lhe prevalent health culture and folk health practices.
c.
DISTURBING TRENDS
Simultaneously, lhe 1980s have alsoseen the emergence of a large number of disturbing trends
in medical education and health services development in the country, which may have far
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reaching consequences, to the concept of social/commanity orientation of medical
education (3).
These include:
i)
ii)
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IV)
the mushrooming of private high technology diagnostic centres and the concurrcrnt
glorification of high technology, through high pressure advertising in the media,
V)
the unresolved and probably increasing problem of private practice among full time
teachers of medical colleges,
Vi)
the increasing "doctor-drug producer axis’ with 'vested interest* in the ‘abundance of
'
the mushrooming of institutions based on caste and communal affiliations,
the privatization of health care,
illhealth’(ll)
vii)
the rampant corruption that seems to be accepted as routine practice and the increasing
erosion of norms of medical ethics, with resulting increase in medical mal-praciicc,
viii)
the preoccupation of medical educators with illness care in tertiary care cenires, and
the d Lsregard for primary health/communlty heal th care.
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Taken together, they are beginning to have ■‘an inslduous but definitive, eroding effect on the
focus and orientation of health service development in the country as well as the nature of the
human power education* investment of the State.
This growing 'dialsctical Hnsionf bttweefi the utertasing enthusiasm for reform of
medical edncaliofi towards greater social relevance
commaaity omentniiou in
the f9S0s, hd/h all its inadequacies and the sunuitanenusfy growing (rends towards
prtvalizrfofi,commgrtialisnfan and high-tech tertiary care form the background
scenario for the CHC study which is described in Mbtcqucnt chapters*
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2. BASIC PREMISES OF THE STUDY
9
The basic premises of the study were the following:
A.
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RECOGNISING SECTORS OF INNOVATION
There arc adeast four sectors of innovation from which stimulus tor reforms in medical
education can and have emerged (18):
o
The Expert Sector
i)
Starling from the Shore Committee Report of 1946 lilt the recently circulated, draft
outline of the National Education Policy for Health Sciences (Bajaj Report - 1989)
there have been a series of expert committees in India offering ideas and recommenilalions of grea t relevance to the Indian 8ituatjon.( 13, 11,14)
JO
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ITte Medial College Sector
A few medical colleges have made sc rioiis efforts to operationalise some of the expert
‘ideas' and rccornmcndaltons and some have gone further to evolve their own
community oriented training strategics. Much of this reform is within the framework
of the ‘structure* and ‘function’ stipulated by MCI.
The ‘medical college’ sector includes ideas and recommcndatinns put fonvard by
professional associations nt their annual meetings and also covers much of the
material that has been regularly presented and discussed at the annual meetings of the
IAAME and published in (he Indian Journal of Medical Education.
The 'Expert Sector’ and lhe *Medical College 5ec/or' would together
■yr-' '• <S-’-constitute wliat we would like to term as Orthodox expertise’.
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Since (he 1970s a large number and variety of innovative community health oriented
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ira iningprogrammes for d i fferent types of hea I th personnel have developed, especially
within the voluntary sector. Many are geared to training or reorienting doctors and
nurses (produced by the orthodox system) towards communfty health oriented work;
Many others train ‘lay people’ (non-doctor, non-nurse) iri community health work
(15). Alarge number of ^altemalivetrainingexperiments'supplementing these efforts
have also emerged in other sectors. While these may appear to.have developed in a
‘separate universe\ there is growing recognition, that their approaches and methods
have great significance for professional humanpowcr education in the country (10).
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'The emduate with phcexperience’
There arc a large number of young graduates of the existing medical education system
who have worked in small peripheral rural hospitals, primary health centres and
community health projects and have had to creatively adapt their own inadequate
education to the ‘professional challenges’ and ‘emotional demands’ of community
oriented healthcare. Most of these'creative tensions’and‘appropriate responses’and
ideas are waiting to be systematically tapped and explored.
The 'Voluntary training sector' and the 'graduate with PHC
experience* would together constitute, what we would like to
term as the ''alternative9 expertise,
NEED FOR DIALOGUE AMONG SECTORS
The second premise of the ‘ interactive study ’ was, that while the above sectors of ‘ i nnovation’
have, separately and taken together, a lot of interesting ideas io offer, to all of us, who seek to
reform medical education, there is inadequate documentation and reporting and inadequate
networking and dialogue.Hence this expertise lies relatively unknown within sectors and
between sectors. Medical college based innovators know little of what each other are doing;
the voluntary sector trainers have little dialogue even among themselves; the graduates in the
periphery are seldom contacted for feedback; and therefore there is a‘gross' lack of awareness
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of the wealth of experience avaitaWc in ihc country itself* Unless all these ideas, suggestions,
experiments and innova lions arc available logcihcr in some sort of compUaiion/pubtication
there is lilllc chance of a cross fertilization of ideas and for dialogue between the innovators
and the enthusiasts of all the sectors. It is now more than clear (hat any form of alternative
medical education or experimental parallel curriculum can emerge only if attempts arc made
lo bring the orthodox expertise lo dialogue with alternative expertise and evolve an integrated
strategy.
C.
i
FACULTY DEVELOPMENT - A NEGLECTED ISSUE
The third premise of the study, which has greatly determined its focus and scope, particularly
in the context of lhe ‘end products’ is that the * Faculty’of a medical college arc very important
for any reform process. Faculty development has however been, the single biggest casualty in
the Indian medical education scene. There has been a lui of rhetoric and some lip service to
faculty development but ’ faculty development and training' is al the bottom of lhe priority list
of medical college leadership. Teaching in a medical college is still not considered an
independent and important enough 'vocation' and tends to be still relegated to a sort of
•appendage’ skill or al besi an unavoidable task, not requiring much Special effort or
preparaiion.
If reform In (he 1990s has to have relevance, rigour and collective commitment, then
developing # core group of faculty jn every medical college committed profegsjorjQyy to
medical educalkm is an urgent necessity and this study was primarily oricnicd to supporting
that task.
We have tried to build some ’structure’ and a framework towards this ’faculty development
process*. The availability of faculty role models in the institution are crucial for inspiring
students towards more community oriented and socially relevant vocations In medicine. This
task can no longer be ignored.
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t4CaIii< by whatever na/nt, th e ne ed Isfor a new breed o[physician, who
has a broad understanding of human biology, who is imbued with the
ingredients ofrural andperi-urban societies and their way oflife, who
can communicate effectively with the patient's family regarding the
nature of the ailment, who can address himself to preventive aspects
in the homes, who will be an effective leader of health workers, and
who will use his knowledge to stimulate other community building
programmes.
We need in effect, a social biologist. Mass public hea Ith and hospital
patient care, however well developed, cannot fill this gap, ”
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3, EVOLVING THE OBJECTIVES
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The Step# in the Process
The objectives of Lhe study, based on the premises described earlier evolved through 4 steps.
9
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iv)
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A project proposal was drafted in January 1990 and circulated to the Advisory
Committee, Peer group and a group of selected resource persons in the country.
(Appendix 2)
Several comments, reactions, suggestions were received and were considered by the
researchers,
At the firstrncciing oi’ the Advisory Commiiicc in May 1990 ail the suggestions were
considered and discussed. A modified set of objectives^ keeping in mind limitations
and constraints especially of time fnimewojk, were evolved.
As the project evolved and the field visits and interactions took place, and feedback
from respondents and peers came in some of these objectives got further modified In
terms of focus, priority a nd significance.
This process symbolised the interactive aspect of the action-research,
B,
The Fine! Objectivea
The Key final objectives of the study were:
i.
To document descriptively/analytically - key recommendations
I experiments I innovation I experience in medical edu catiorc
2.
To review key alternative training experiments to identify
issueSj perspectives} ideas;pedagogy relevani to medical educa
tion*
J.
To buildan A nthology ofIdeasfrom a sample of recent medical
graduates with primary/peripheral health care experience.
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A.
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A multipronged data collection methodology was used that included both ‘classical’ and
‘Interactive* approaches. These were as follows:
. a
LITERATURE REVIEW
Identification of key experiments/innovalions, experiences and ideas was done through an
expensive literature search which included the following components.
o
o
a.
b.
c.
IJtory Reference
While reference to several professional journals were made, the key focus was on a
detailed search th rough the Indian Journal of Medical Education from the late 1960s
to date.
Eroiggt Announcements In Bulletins and Journals
Several bulletins and journals published by professional and the ‘voluntary’
i.
sector, as well as a few daily newspapers were contacted for announcements
about (he project
Peer contribution
i?
<1
Some ‘peers* provided substantial information and materials.
□
LETTERS TO MEDICAL COLLEGES
B,
a.
b.
c.
c,
f.
Letters were sent to the I^ans/Principalsand Professors of Community Medicine of
125 Medical Colleges in (he country in June - July 1990. (Appendix 3 & 4)
Reminders were sent in January and March 1991.
C3
0
All the responses received were followed up by corrcspondunceelicitingfurthcrdeiails
about the initiatives, experiments and curricular changes described.
LETTERS TO COMMUNITY HEALTH/DEVELOPMENT TRAINERS
Letters were sent to scl eci group of Community Health and Development Trainers in
a.
October 1990, (Appendixs 5)
be
Reminders were sent in January 1991.
a
□
i
c.
Many trainers sent annual reports and training reports and further details wherever
required, was elicited through ongoing correspondence,
d.
Informal discussions were also held with some of the trainers with whom the CHC
team had contact due to ongoing linkages.
The CHCdocumentation unit already had substantial material onmany programmes.
c.
D.
&
a
u
SURVEY OF MEDICAL GRADUATES WITH WORK EXPERIENCE IN
PERIPJERALRURAL HOSPITALS AND HEALTH CARE PROJECTS(10]
A preliminary proforma was developed by the researchers after a group discussion
a.
with a few doctors who had worked in peripheral rural hospitals and were presently
9
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to networking, the approach to research was a oomblnationof ‘classical’ as well as interactive
(See Table II).
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TABUE II
O
Research approaches In the Study
o
o
Cltsska !/Es ta blLsh ed
*
6
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O
o
o
o
□
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o
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o
Interactive
Literature Review
Peer Group correspondence
and meetings.
Letters to Colleges
(with reminders)
Field visits to colleges and
group discussions with faculty/
interns/
*
Lecters io Trainers
(with reminders)
*
Correspondence with medical
College respondents and
Community Health Trainers.
Questionnaire Survey
(Graduates)
While ‘class leal * approaches helped to standardise proced uresa nd bring in the required rigour,
lhe interactive approaches helped to increase the senseofparticipation and involvementamong
respondents as well as often helped to tap the ‘affective domain' as much as the ‘cognitiveTn
the data collection process.
Very often we could find out what people felt about things not only what they thought Many
negative impressions and often more reflective responses were picked up by this method. Also
different perspectives on the same programme especially from ‘organisers’ as well as
‘participants’ were explored. All ihis would not easily be possible through an objectivised
standardised questionnaire In the final analysis combination of methods helped to gel a wider
qualitative impression of the diversity of innovations.
uThe purpose of medical education is not to produce Nobet Prize
winners but to provide doctors for health services, who will meet the
health needs of the country in which andfor which they are needed" >
WHO Reg4onal Committee for South East Asia
12
□
6
o
o
■o
If
“ ■ ?
56*
2
CHAI GOLDEN JUBILEE EVALUATION STUDY
AT THE . FIFTIETH MILESTONE
A
II
J
Evaluative feedback from members concerning
the Catholic Hospital Association of India (CHAI)
June 1993
Thelma Narayan,
Assisted
Tomy Philip,
A
I
Johney Jacob
by-. Xavier Anthony
3
h
J
J
Society
Community Health Cell
-For Community Health Awareness, Research and
No. 326 , Fif th Main, First Block,
Koramangala
Bangalore .-r *560 034
Action,
■a
. $
$
, <3
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2.
AIMS AND OBJECTIVES
0
o
o
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r
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o '
o
o
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o
o
The overall aims of the entire study into
‘component of ‘feedback from members' fits,
undertake
1. ■ To
an
analytical study
reflection
on
the
Catholic
Hospital Association o-f
India
during
decades. focussing particularly on
the last -five decades,
the
last twenty five years and the present.
2.
To
explore
possi b 1 e
roles
the
Catholic
Hospital
Association
of Ind ia could play in the
future,
in
the
context
of
the
needs
of
its
members,
the
national
the voluntary health sector and the hea1 th
apostolate of
1.
o
o
To elicit information and -feedback -from CHAI
members
on :
a)
their
involvement and nature
o-f
in terac tion
c)
d)
e)
Q
O
Q
the Church.
The specific objectives concerning this aspect of .the study
as given in the project proposal (5) are given below:
b)
o
which this
particular
were as -follows;
2.
with CHAI;
their expectations from CHAI in relation to
own activities;
7 '
their
views regarding the
appropriateness
adequacy of CHAI's activities;
their
and
their views regarding factors contributing to the
gap between expected and observed actions; ■
their suggestions regarding alternate measures to
be adopted to fill in the gap.
To
determine the views of members and of
a
se1ect
group of individuals (panelists of the Policy
De 1 phi
Method),regarding
the possible future role of
CHAI
with particular, reference to:
its mandate,
i)
ii )
its role in the broader Indian scene,
ii i) the role it cam play in Asian and other countries.
A few changes were made.
Factors contributing to the gap between
expected and observed actions were not explored specifically with
this
group.
This was covered to some extent
during
interviews
with people who were more closely involved with the
Assoc iation,
Similarly,
the broader Indian scene and the role, that
CHAI
can
play
in
Asian and other countries was taken up
in
the
Delphi
Method.
Q
-3■
!
o
■■
Ii
t
-
g
3.
METHODOLOGY
A
i
1
3.1
Tha project proposal
Vattamattom,
SVD,
with
Fr.John
discussions
Based
on
draft of
the
□f
CHAI,the
first
idea
Executive Director
in
September
by
Prof . P . Ramachandran
writ ten
study
was
Dr.C.M.Francis
and
responded
to
by
was
1989.
This
storming
session
in
After
a brain
Dr.Thelma Narayan,
of
the
Advisory
1991
at which
members
all
February
first
Committee and the Study Coordinator were present the
was
written
in
March
1991.
This
was
draft project proposal
the Board, all Departments of CH-AI
circulated to members of
Modifications were made based on
and to 144 other persons,
The
reading.
ihe
final
■Fur ther
the
responses
and
after
written
was
in
the
overall
study
project proposal
for
Oc tober 1991.
3.2
I
A
Sampling
study
of
For
the
purpose
purpose of this detailed evaluative
constituent
its
CHAI,
a 20
per
sample of
per cent random
of
(institutional) members was selected. The membership as
ou r
formed
October
1991
consisting
of
2,2/0 members
sampling framework.
Individual associate members (who have
no voting rights) were not included in the study.
, and
institution
The
sample
was stratified for size
of
The
membershi
p
region of the country where they functioned,
to
size
size.
.
One
divided
into two categories according^
was
comprised
This
/
included those with 0 - 6 beds,
category
included
category
member institutions.
The second
1 ,590
of
with more than seven beds. This group consisted
those
stratifying
by
680 member institutions. The rationale for
oT
types
size
was
that size was indicative of different
institutions ,
health/
medical functions performed by
the
care
namely involvement in primary and secondary levels^o^
with
respectively.
It was hypothesised that institutions
and
these
different-functions would have different
needs
different expectations from CHAI.
K
I
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3
3
■I
;
j
-4-
c
o
o
i1
o
o
o
o
o
For
States
and
stratification by region. the twenty-five
wprp
of
the
country
seven
Union
Territories
(U.T. )
t he
divided
into two broad categories, based on the levels
of
well known health indicators.. The
two
ind ica tors
cer tain
were
the Infant Mortality Rate (IMR) and
the Crude
used
Rate
(CDR).
The Infant Mortality Rate
is
wide 1 y
Dea th
as
being
a sensitive indicator
of
the
health
accepted
and level of living of a population.
It is also
a
sta tus
measure of the health delivery system of an area / country,
is also considered
a
fair
The
Crude Annual Death Rate
.Statewise
data
index
for comparative
purposes;
These
the IMR and CDR are available.
are collected by the
is considered to be
Sample Registration System (SRS) which
u
o
o
the most reliable
Q
in
the country.
was 87
The
goal
for the Infant Mortality Rate
for
1990
goa 1
Crude
/
1000
live births per year, and the goal for
the
year .
(Annual)
Death
Rate
for 1990
was
10.4/1000
per
the
During
the
planning phase of the study, 1.987-88
was
Therelatest year for which published data was available.
was
achievement of goals for 1990 already in 1987-88I
fore
Union
the
cut
off
point
for
the
study.
States
/
taken
as
that
achieved the goals for IMR and
CDR
for
Terri tories
laid
down by the National
Health
Policy
(of
as
1990 ,
health
1982) were placed in one category, namely of better
The number of
or better health status.
member
indicators
institutions in this category were 1,555.
o
Q
a
Q
O
reac hed
Those States / Union Territories which had not yet
States/
goals were placed in the second category of
these
poorer
Territories
of poorer health indicators
or
Union
this
status.
The number of member institutions in
hea1th
the
in
The States/Union Territories
c a tegory were 715.
two categories are given as follows.
O
o
o
D
-5-
>
0
(I
SttLr SISK
Better Health Status
Poor Health Status
(1,555 member institutions)
(715 member institutions)
1.
2.
3.
4.
5.
6.
7.
Q.
9.
10. Meghalaya
11. Mizoram
UOci
12. Nagaland
Haryana
13. Punjab
Himachal Pradesh
Jammu and Kashmir „14. Tamil Nadu
15. Tripura
Karnataka
16. West Bengal
Kera 1 a
17. All the
Maharashtra
Union Teritoriss
Manipur
(Andaman and Nicobar Islands,
Andhra Pradesh
1.
Arunachal Pradesh
Assam
Bihar
Gujarat
Madhya Pradesh
Orissa
Rajasthan
Sikkim
Uttar Pradesh
Z .
3.
4.
56.
7.
g.
9.
Chandigarh,
Daman'and
4
1
J
1
Dadra and Nagar Haveli,
Diu,
Delhi,Lakshadweep
and Pondicherry.)
10.6 / 1000/ year and
CN,B:
Andhra Pradesh which had a CDP of
also
were
10.5/1000/year
Meghalaya
with
a
CDR
of
available
The IMP
not
included
in this category,
and
all
Tripura
,
Meghalaya
for Nagaland, Manipur, Goa,
into
this
They were categorised
the Union Territories,
the CDR
was
the CDR.
For Mizoram even
group
based on
a
sma
11 .
It has as small
----- .population and of
not
avai lable.
i
ts
Because
institutions.•
number
of
member
it
was
the other~North Eastern States
similarity
to
category empirica11y - 3
included in this
u^Ln^t
tuations/problem s and
This
broad ■categorization,
that the differing health situations p
11
was
was done so people could
be
taken
into
account.
requ
i
red
,
needs of
that the type.of health interven 10ns
hypothesized
work
,
and
approaches in medica 1 /hea1 th
health system
the prioritization and
of the government and
level
and
functioning
and needs of
the
in th...
Th. work re.pon.e.
be
different.
would differ in
expectations
member
CHAI
result in
felt that
it
wou 1 d
This
services.
of
CHAI
CHAI
■from
useful to study
the
using
this
also
would
the utilisation
1
4-,•
m-f
of C^prvices
services of uhh i
and
members
¥
p1
?
f
a
1
9
criteria.
H1
0
i9
:¥
-6-
II
i
tfi
<1
o
J
0
0
Distri bution
o
o
o-f member shi p
7 Beds
1,010
537
1,555
Poorer Hea1 th
I nd ica tors
572
143
715:
1 ,590
600
2,270
Total
o
o
o
0
o
o
o
Tota 1 .
Better Hea1th
Indicators
Pistribjutipn o£ the sample
e
More than
_____ ______________________________________ _______________________________________ ’___________
o
o
--- ----- ■---- :-------feHA
0-6 Beds
o
o
o
and;.size o-f insti tut ion
■---------------------------------------------------------------------------------------------------------------- '4
I
a
req £ on
by
by
region and size of -institution
6 beds
More than
7
beds
Total
I
Better Health
Indicators
204
108
312
Poorer Health
Indicators
114
29
143
Tota 1
318
137 . .
455
In
the report the two categories according to
region
are
referred to as regions with better health status and poorer
health status (of people) respectively.,
3.3-
Interview Schedule - the instrument -for data collection
Data collection was
personnel
(decision
institutions.
• A |
done
through in terviews with key
makers)
in the
selected
member
An
interview schedule was developed as the instrument
for
data
collection.
Part-A
was identical
to
the
mailed
questionnaire that was administered to a 11 members in order
to gather data regarding the ac tivi ties/prof i le o-f
health
related
work
being done by member institutions
of
CHAI.
Part-B gathered feedback' about the various aspects of CHAI.
There
was
a
special note
for
Diocesan
Social
Service
Societies.
The
interview schedule was pilot tested by members of
the
study
team.
This was done in 14 institutions.of which
12
were
in
Karnataka and 2 in Kerala. They
included
large',
medium and small institutions and a Diocesan Social Service
Society.
Necessary changes were made
prior to printing.
-7-
0
o
o
-
■ "7
. •
I i
I
3.4
Investigators
(interviewers) :
A
participated
in
the
volunteer
investigators
Forty
institutions
in
by undertaking field work to visit
study
Thirty-nine
were
the 20 per cent sample for the interviews,
scholastics in the final years of their formation/ training
They
become priests
priests
and one was
a
priest.
were
to
become
suited
motivated,
reliable,
highly
educated
and
well
suited
to
reliable,
member
institutions
of
CHAI
,
interact
with personnel from t------------ Some had
previous
who
were also all religious personnel.
exposure to research.
Cl
was
This
A
five
day training was conducted for them,
five
of
group
done
twice,
as
there
were two
groups.
One
twice,
Mysore
in
Capuchin
and Franciscan scholastics were based
and
were
and
another group of Jesuit and Diocesan scholastics
Mandya
based in Delhi.
The priest from St.Thomas Mission,
during
the
group.
Topics
covered
joined
the
Mysore
the study, an
the
objectives/purpose
of
training included :
activities,about
CHAI
and
its
various
introduction
use
as
used
in
research
studies,
techniques of interviewing
of
the
schedules
(proformas)
including
explanations
schedu1es
regarding
all
the
used.
Seven
all
the technical terms that were
<
see
background
papers
were
given
to
them
(see
Appendix
I).
papers
■and
trial
interviews
in
nearby
Mock interviews (classroom)
using
the
interview
member
institutions
were conducted
held
regarding
the
experience.
schedule and discussions
Thus
41
member
institutions were covered
by
the
trial
interviews.
Of these 25 were in Kamataka
Karnataka,, 6 in Delhi,
3
Of
in
Haryana
and
7
in
Uttar
Pradesh.
These
were
.member
Uttar
Pradesh,
7
and
Data
institutions who were not
not in
in the 20 per cent sample.
from Part-A of these forms has been included along with the
in
analysis pf the mailed questionnaire,, which is reported
member
CHAI
by
of
health
work
done
hea1 th
the
'Profile
I
■
t
r
■ -1 *
i. ,"
-0
i
J
IL
institutions'.
holidays
in
during
field
work was completed durjng
the
The
extensive
1991
and
May-June
1992.
It
involved
December
circumstances
travel 1to remote areas,often under difficult
problems of
terrorism,.wiId
participating
animals
etc.
Two letters were written
to
r~
member institutions informing them of the purpose» and dates
to
reach
of
the visits and requesting information of how
how
the
membership
department
them.
Available information from t----- --------we
were
unable
of
CHAI
was also used.
Inspite of this
we
were
the
and
to
get
information
about
some
institutions
in
forma t ion
and
in
formation
investigators
just used local sources of
their sense of adventure to arrive at the institution.
including
interstate conflicts,
Ia
I
-0
r
i
J
ia
V ..
-8-
c
a
a
O-
11
o
Logistics
of
working
out
routes,
purchase
of
journey
the
tickets etc, was done mainly by the investigators with
help of the study team and the CHC team.
o
o
o
o
e
Study team members conducted supervisory field visi ts to
were
interviews
South
India
when
th^
few
institutions in
being conducted.
completion of the fieldwork, debriefing was held in
and individual sessions to share overview impressions
and to collect the filled proformas, settle accounts etc.
After
group
Q '
3.5
o
o
o
o
o
o
Mai led Questionnaire
of
807.
questionnaire was sent to the remaining
A
mailed
to
was
institutions
(1,815).
,
The
first
purpose
member
related
medical/hea
1
th
information
regarding
the
collec t
work of all CHAI constitutional members.
There! ore * Par t
A
schedule
were
the
mailed
questionnaire
and
interview
of
the
key
put
to
The
second
purpose
was
identical.
entire
the
to
questions
regarding
CHAI
evaluative
and
The questionnaire was pretested,, modified
membership.
were
reminders
members
in
December
1991.
Two
t
mailed
to
also sent at .an
3.6
The overal1
interval of a month each.
process
of
the purpose, aims and broad areas to be
their
for
the study was sent to all members
proposal
before
information and comments
c.—.. —— —
- - the final project
was written.
This .was mailed with the circular sent by the
informed
The membership was also kept
Executive Director,
about
about the study by the Executive Director, senior staff of
-•/
A
summary
by
covered
o
o
o
(3
o
o
CHAI
)
and
the study
team during
3.7
1991 Annual
Convention,
There
was
Data analysis
The
data was coded and entered into computers, This vias
time consuming task.
Data entry was also cross -checked
a
by
the study team.
The
da ta.
the
D—base
III-*- was used for the analysis of
and
:
'
3
Evening
College
Data
Processing
staff of St.Joseph's
the
out
helped
the
study
team
in
writing
Computer Centre I
in
other
proq rammes and commands necessary for analysis and
__
Tiechnical problems that arose.
o
-9-
()
the
and subsequent circulars,
reg iona1 meetings
scope for interaction at all these points..
1}
J
n
o-F
viruses were a major problem as a number
Computer
work
.
practical
students used the same systems for their
schedules
v
The team also had to fit into their class
much
examination
schedules etc.
However,
we received
the
support and
and cooperation and without this rea y help
analysis would not have been completed in time.
3.8
The Advisory Committee to
the Study and study process
ro 1 e
supportive
The committee
played a very active and
committee
the
of
through out.
It met four times during the period
out.
interactions
study.
There were however several
informal'
and correspondence.
Members also gave very valuable
comments on all the reports.
{
fl
I
Ir->.
I
[
t
' b
1'
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■is<3
Ua
1a
s
i
-10-
0
a
Ia
a
11
('3 •/
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- 2
■
o
O
TWO THOUSAND AD AND BEYOND
. .
*
..
?
&
O ■
o'
CONTEXTUAL
I
O
■
IMPORTANT
FOR
LEVEL ISSUES
AND
POLICY-
THE
FUTURE HEALTH RELATED WORK
OF THE CATHOLIC HOSPITAL ASSOCIATION OF INDIA
o,
o
o
Findings of the Policy Delphi Method of Research
o
o
Dr. Thelma Narayan, Johney Jacob
o
1
o
«□
Advisory Group
Dr. C.M.Francis, Prof. P.Ramachandran, Dr. Ravi Narayan
o
o
Community Health Cell
Society for Community Health Awareness, Research and Action
326, Fifth Main,. First Block, Koramangala
Bangalore 560 034.
)
o
■I 1
3
LIST OF PANELISTS
SI. No.
01
02.
03.
04,
05. .
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
2 2. .
2 3.
2
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35 .
36 .
37 .
38.
39 .
40 .
41 ,
42,
43.
44 ,
45 .
46 .
47.
48.
49.
NAME
Mr. Desmond A.D'Abreo
Prof. Alfred Mascarenhas
Prof V.Benjamin
Dr. Daleep S.Mukarji
Prof. B.Ekbal
Fr. Claude D’Souza, SJ
Dr. Prem Chandran John
Fr. George Lobo, SJ
Dr. Hari John
Mr. S.Srinivasan
Dr. Sulochana Krishnan
Mr. G.Kumaraswamy Reddy, IAS
Mr. A.K.Roy
Dr. R.Parthasarathy
Dr. Esther Galima Mabry
Dr. Rajaratnam Abel
Mr. Averthanus D'Souza
Dr. Jacob John
Dr. P.Zachariah
Dr. Gerry Pais
Mr. Alok Mukhcpadhyay
Dr. Abhay Bang
Fr. S.Arockiaswamy, SJ
Prof. R.Srinivasa Murthy
Dr. B.M.Pullimood.
Prof. Grace Mathew
Ms . Sujatha De Magry
Dr. Qaseem Chowdhury
Mr. P.O.George
Prof. E.P.Menon
Prof,.(Sr) V.j.Kochuthresia
Fr. Joseph Thadathil
Fr. Theo Mathias, SJ
Mrs. R.K.Sood •
Dr. L.N.Balaji ‘
.
Francis Houtart
Dr. Marie Masceranhas
Prof. H.R. Amit '
Sr. Francesca VAzhapilly
Prof. C.A.K. Yesudian
Fr. Harshajan Pazhayattil
Dr. K.V.Sridharan
Drv N.S.Chandra Bose
Dr. P.N. Ghei
Dr. Ashok Dayalchand
Rev. A.C.Oomen
Mr. Ba bu ^Mathew. Dr. Mohan ■Isaac
Ms . Sakuntala Narasimhan
PLACE
Mangalore
Bangalore
Bangalore
New Delhi
Th iru vanant ha pur am
Bangalore
Madras
Pune
Madras,
Baroda
New Delhi
Hyderabad
Bangalore
Bangalore
Bangalore
Vellore
New Delhi
Vellore
Vellore
Bangalore
New Delhi
Gadchirbli
New Delhi
Bangalore
Vellore
Bombay
Bangalore
Bangladesh
Kalamassery
Bangalore
Kalamassery
Thiruvananthapuram
Jamshedpur
New Delhi
New Delhi
Belgium
Bangalore
Canada
Sitapur
Bombay
Trichur
Bangalore ________ _
Delhi
Delhi
Pachod
Vellore
Bangalore
Bangalore
Bangalore
q
q
I
4
T
Ill
[i
4c
i J
7
0. i>
4
a>
oi
CONTENTS
67
Page No
o. ’
1.
I
2<
3.
4.
5.,
O
6.
6.1
6.2
o
o
o
07
The Study Process
08
Findings - Contextualising the work of CHAI
11
Findings ~ Contextualising the work of CHAI
Major health
1
'
.
probiems
and issues likely in
during the fifteen
----—i years ahead
in
26
India
Findings _
Important policy issues concerning
in the future
J
CHAI
Basic Premises of Health Work
35
36
cS^rSsponrio11 E*Obl*mS in the-country that' CHAI
39
6.3
Components
Promoted
42
6.4
Broad Strategies of intervention
6.5
Constituencies/Groups for Focus of Activities
6.6
Redefining Roles in the Present and Future Context
6.7
Organisational
Functioning
7.
Conclusions and Recommendat i ons
8.
o
The Policy Delphi Method
Predicted economic, social and political
trends
the country and their impact on health
o
o
05
?•
i
o
o
Background
Bibliography
of Health Care and Health Action.
Aspects
important
to
be
46
for
Effective
50
54 .
56
59
64 •
4 1
?
5
t?
1. BACKGROUND
c
-H
A
I
in
partnership
with
P
a
D n
E e looks
L 1 ahead
P i
H s
I t
s
i
★ situated in the broader
IT
context of the situation
in India
for a
meaningful
role
I
V
6
★ relating to the health
problems and issues
likely in the next 15
years
★ identifying priority
areas
in its work and its
functioning.
The Policy Delphi Method of research was an important component
of the CHAI Golden Jubilee Evaluation Study. It was employed to
identify broad contextual and policy level issues that would help
CHAI in its planning for the future. Key policy issues and
options are now .available for consideration by CHAI as it plans
its future policy for the next 15 years.
The policy Delphi
method "rests on the premise that decision makers are not
interested in having a group generating decisions, but rather
have an informal group present all the options for their
consideration".’(4)
The method was thus utilised in order to attain the
of the study viz.,
second
■
•
'
3
a
aim
3
(J
•
"To explore possible roles, The Catholic
HospitalAssociation of India could play in the future, in the
context of ..... r the national situation and
the
national health policy, and as part of . the voluntary
health sector.
...
tor....."
(1)
The specific
follows:
objective of the study pertaining to this reads as
fj
"To determine the views of a select group of individuals
regarding the possible future role of CHAI
with
a
a
o
particular reference to:
i. its mandate;
ii. its role in the broader Indian scene, and
iii. the role it can play in Asian and other
countries ” (1)
<3
Regarding methodology, the project proposal stated.
(
"Views of an additional group of 50-75 people outside of
CHAI, from diverse backgrounds (health and non-health,
church and non-church, NGO and government)
will be
elicited.
The ! Delphi technique for forecasting or
futurology will be utilised" (1)
I
Q
43
a
a
11
C)
O I
6
o>
O 1
The needs of CHAI members and their views regarding future
thrusts of their Association have also been elicited • through the
other methods employed in the study.
The issue has also been
raised during discussions with people who have /been/are presently
closely associated with CHAI.
o
1
•Therefore the focus with the Delphi group of panelists was to
explore
in some detail an understanding of the wider national
situation and its impact on health.
This was
a
general
exploration of important socio-cultural-economic-political trends
likely in India in the coming fifteen years that may affect
health.
There was also an exploration of the major health issues
and problems likely to affect people in the country during the
coming fifteen years, This scenario provides the context within
which CHAI will be functioning as predicted or forecast by a
group of people with wide and diverse backgrounds and with a
social concern.
o
o
o
o
o
o
o
o
The method was then used to explore the areas of priority that
need to be considered and taken up by CHAI in its future work. A
wide range of policy • issues emerged from this exercise along with
a debate on some .of the issues.
Once again,
the Pdlicy Delphi Method is not used for decision
making, which rightly is the prerogative and responsibility of
Board
and the Executives of CHAI.
However,
a range
of
possibilities and alternatives are made available for
the
consideration of the policy and decision makers.
In. todays
complex world, this is important if groups want to have an impact
as a- result of their work intervention's and if resources have to
be effectively and efficiently utilised towards the achievement
of the jgoals of the association.
Q
)
o
o
o
o
Q
The methodology
following pages.
used and the findings are
highlighted
in
the
n
1 i
J
7
2. THE POLICY DELPHI METHOD
The Delphi method of research was developed initially in th<=
nineteen sixties, based on earlier experiments.
During its earJv
years it was used primarily for technological
'
Y
forecasting.
particularly in the areas of defence, industry and business"
It
uses several geographically separated experts to make forecasts
about the development of new technologies and their impact and
Iso to estimate the future markets for technologies/coJnodities.
which^ hypothetically takes advantage of both the
naif of the brain and its processing of factual
and the more intuitive right half, generated a
lot
o interest among futurologists in general. rThe
~’
past decade has
seen it being used for a variety of different r--------purposes.
the^USA3 for "blfSsical DelPhi" used by the Rand" Corporation Thus
in
the USA for defence purposes in 1954. and still usedfor
cechnoiogical forecasting.
Modifications have developed to
different purposes as for instance the ’’r
—i-io- Delphi»” and suit
Decision
the
Policy. Delphi”.
The method is therefore still
in
_.i
a
process
of
evolution.
■>
C
o
I
V
The Delphi method is a group
<
method utilising persons with
expertise and experience in the field .
similar to a committee, but is different in tha^!™3
known
functions
a. anonymity is maintained,.
maintained,, thus avoiding identification of
an
opinion with a person.
b. repeated
repeated rounds
rounds of
of questionnaires are used viz.
two to five,
depending on the purpose.
c. the questionnaires not only ask questions,
questions,
but
provide
but
i!O'
sununaries of
or summaries
of
4’
9rO'li’ ■resp°',‘e
"«««« optlons/lssues
e. respondents, are given the opportunity to react to and
differing viewpoints.
The
is
assess
J
3
J
g
7
“ ’
Policy
Delphi Method is utilised for the analysis of policy
issues
"forum and is ]
mtchanism for makin9 decisions. It is'thus I
for ideas
ideas ”,.
Arriving at a consensus is not an objective
though a rating is obtained.
It infact tries to explo-e oobosino
on the various
xu is
forWScorrelatina
1OUviissues
iSSUeS;.
iS tneretore
t^erefore an organised method
r^i• correlatln9
views and information pertaining to specific
react7 areas and for allowing the respondents the opportunity to
that an
It tries
to ensure
to and assess
assess differing
differing View
view points.
points,
options
. on- the table for
consideration!3
°PtlOnS have been
been—
' putP^-.References :
4-
Linstone, H.A. and Turoff. M. , 1975 (Eds)
The Delphi Method
techniques and Applications
Addison - Wesley Publishing Company,
r Reading, Maasaolmsetts
3
a
a
€
a
a
a
a
OI
0)
0)
8 3. THE STUDY PROCESS
o'
After an initial period of getting references and meeting people
to study and understand the method keeping in mind the specific
needs of CHAI for which purpose it was^ being used,
the main
steps followed in the study were as follows:
O»
1. A list of possible panelists (participants in the study) was
drawn up by the CHAI study team, the Advisory Committee and
the CHAI team. . It was optimal to have about 40 panelists and
therefore the first selection was more than double
this
number. .
This included people who had
expertise
and
experience in diverse fields so that CHAI could benefit from a
broad perspective.
Panelists also were chosen from different
backgrounds
viz.,
secular, church
related
(Catholic,
Protestant, Orthodox),
religious, and lay, governmental
and
non-governmental.
A grid was drawn up to ensure represenation
of different disciplines/work streams viz.,
coordinating
agencies,
policy .makers,
medical college
professionals,
(educators of health personnel), 'community medicine/community
health- practitioners, nursing, educationists
(non-medical),
management professionals,, social scientists,
theologians,
communicators, lawyers/advocates, politicians etc.
o*
o'
I .
o
i
<1.
I
o
o
o
o
o
2. Letters of invitation and participation .forms to 108 selected
persons
were sent out in April 1992 giving a tentative time
framework, of the study. 49 panelists agreed to participate as
panelists in the method.
3. They
represented all the different components' of the grid
except policy makers of the government and the
Church
hierarchy.
o
4. The first round of material included a background note^on CHAI
.outlining the type and distribution of its memberhip, its aims
and objectives, organisational structure, the headquarters and
its departments/units, funding thrusts in the 1980s and a few
important points from history. . ’
Q
A brief note about the Policy Delphi Method and the
confirmed panelists was also circulated.
o
o
of
5 . The first round questionnaire was sent along with the above in
May 1992.
The .first question was used to evolve a,group scenario of the
important economic, political and social trends
which many
occur in the coming f if teen •‘years that would have an impact on
This provided the broad
the health status of people in India,
contextual ' picture, generated by the.panelists within which
This
the health work/interventions of CHAI would be located,
issue was not to be explored further.
o
The major health issues and problems of the people of India,
T-h-is— formed
likely in the next 15 years—wa-s-aIso explored.
o
)
o
list
ir
G
l
9
the more specific context to which CHAI was responding in
work.
its
Initial ideas from panelists on what should be the issues that
future woxrk
CHAI
should take up as areas of. priority, in its
during the next fifteen years were also elicited.
Views regarding the role of voluntary organisations in general
This however was not followed up later.
were also explored.
in early Jun e
6. A
reminder regarding the 1st round was sent
responses
(two
and
by
end
June,
we
received
35
(11.6.92)
73% ,
ones came later) i.e, the response rate was
additional
questions viz . ,
summaries
<of the responses to the first two
on
concerning contextual issues were circulated to panelists
27.6.92 and 4.7.92.
issues
regarding priority
ishould-take
*
- - • • ■ up, were used- to
•
- • - ■
second
develop
the
This covered seven
round questionnaire mailed on 4.7.92.
broad areas viz.r
L
o
1
7. Responses to the specific question
that
i.
CHAI
th^t
Basic premises of health work/underlying assumptions>
(perhaps
must be considered by CHAI for their futture work
(_
as a statement of philosophy)
ii . Important
to.
health problems/issues that CHAI
• r.-'
iii .
iv.
Types of
promote.
health
action/health
work
that
could
respond
CHAI
should
Need to clarify constituencies/groups on which CHAI
focus its activities.
(5
9
9
J
Strategies, of work .or. interventions needed to implement it's
objectives and. priorities .
*3
Need for role identification
g
spread
of
all panelists were "requested to respond to the
Thus
rated
that emerged from the first round.
Panelists also
ideas
These
each item using scales that were given for each question,
were regarding importance for most and desirability/necessity for
some.
It
was
also attempted to generate further debate
differences, thafdwere emerging eg:
a.
. -■
should
aspects
or
mechanisms
that
could
be
introduced or strengthened to enable effective functioning.
vii.
kJ
3
v . Organisational
vi.
I
on
areas
-J
I
of
focus of activity primarily towards membership vs a possible
larger role.
.
.
____
0
G
i-
a
c
or
7.3
oj-
b. focus
on
community
based,
j
‘ _1_
health
interventions as <against provisionnon-institutional
of good quality med ical
care based in hospitals and. dispensaries
‘ _j that are accessible
to the poor.
o’
o
o>
OI
o
I
I
I
O,
O
o
o
o
o
o
o
o
I
8. A first reminder :regarding the second rpund was sent in
August.
The same response rate of 73%* (37) was received early
for
the round as well.
9- At this point the study team who were also <
coordinating and
involved with other aspects of the CHAI study
j were asked to
write a discussion
document
*
.
„
„
for
the 49th Annual Convention
to
be held in
October
1992.
m October 1992.
This document drew
drew from all
components of the CHAI Study and was entitled
"Seeking the
Signs
of Times .
it was to be used for regional
and
profession group meetings of CHAI members that
were
planned
during the Golden
— Jubilee
—Lil—j year.
Contextual issues raised in the first round
wee given
chapter ’’Directions from Delphi
in
10. Analysis <of the
*
second round was also made available to all
CHAI members
in
January
1993
r^i^aVgroup matings?
0 aaditi
°nal background note
additional
used for
11. The <complete analysis of the second round was
reported
in
early February 1992. At this stage it was felt that since a
sufficient spread of ideas had been generated to serve the
purpose of CHAI, the Policy Delphi Method was closed with
this round.
12. It was <also felt^that it would be useful to share.the
ideas
generated from the method with the1 members of CHAI,
and to
get members rating of issues that were specific to CHAI,
Therefore
a
modified
version of
the
second
'found
questionnaire was developed with a common rating scale. This
is being given to participants of all the regional meetings.
Thus at'the end of the year
year, befor
before the Jubilee Convention, we
will also have members views about
-- —— these issues which touch on
several crucial areas regarding the work and functioning
of CHAI.
Q
o
o
o
o
o
o
a
■■■
J
.0
0
Q
i
REACfflW HEALTH. TO Tlffi
ORASSROOTS
o
o
o
0
o
THE JAN SWASTHYA RAKSHAK SCHEME
Q
i
0
OF THE
GOVERNMENT OF MADHYA PRADESH
Q
O
I
A PARTICIPA TOR Y INTERACTIVE REVIEW
JULY - DECEMBER, 1997
o
G
0
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 1 8
Fax : (091) - 080 - 553 33 58 (Attn. CHC)
J
a
i**
a
a
a
a
December 1997
■’i?
■i
r’
a
a
a
h
0
o
75
0
o
i.
O
Document the profile of the JSRs in five districts in different regions of Madhya
Pradesh.
ii. Examine the process of selection of the JSRs by the community.
Aiii. Document the content and methodology of training in selected PHCs with a view
to strengthen this process, keeping in mind the skills required for provision of
essential child survival and safe motherhood services at village level.
o
iv. Evaluate the system of examination for certification of the JSRs and suggest
modifications if necessary.
o
o
V.
Document in the randomly selected five districts of the state, the perception of the
local community and panchayats of the services provided by the JSRs in their village.
vi. Examine the functional linkages that JSR have with health staff after training.
vii. Prepare final report to strengthen JSR scheme in Madhya Pradesh.
o
o
o
o
o
o
NOTE
O
J
o
o
o
o
o
At the outset, vve would like to clarify that at the time of Review not a single JSR had
received his registration certificate - a necessary prerequisite to practice as
mentioned in the government orders on the scheme. Because of this, the actual,
practical review of the performance of JSRs in the field was not feasible. Only
indirect information of their assisting or non-assisting in the implementation of
national programmes like immunisation, etc., could be obtained. A study of the
effectiveness of the services provided by the JSRs and their benefits to the
community wjll necessarily have to await some reasonably long time after the
scheme is able to get off the ground. (Items V and vi of the TOR are therefore only
indirectly addressed in the Review because of the local field realities and situation of
the scheme at the time of this Review)
o
o
o
o
o
. 12
r
Q
o
'a
A1
•J
J
G
IIL METHO DO LOG Y' OF REVIEW PROCESS
The development of the methodology for this Review was influenced to a considerable
degree by the purpose and scope of Review and the time-constraint involved in
conducting a state-wide study. The various aspects of the methodology can be broadly
classified as follows:
o
G
G
. G
I. Field Evaluation
i. Identification of levels of administrative set-up;
ii. identification of functional areas of study;
iii. sources of data;
iv. development of instruments;
v. sample size and design;
vi. collection of data; and
vii. analysis and interpretation of data.
O
'C?
Q
2. Peer review of training programme
i.
o
Evaluation of training manual and programme objectives by NGO groups with
prior experience in similar activities.
3. Workshop of interested and key partners on field review report of JSR
Scheme '
i.
o
a
0
Workshop to discuss review findings
By adopting this three step methodology it was felt that inputs of a large number of
individuals could be obtained in short time within the time and budgetary limitations.
3.1 FIELD EVALUATION
G
□
. 0
3.1.1 Identification of levels of administrative set-up
Keeping in view the objectives of the scheme and the operational details evolved for its
implementation, collecting and utilising information from sectors other than health
especially at the grass-root level, was considered desirable. Therefore, the levels of
administrative set-up from where the information was to be generated were decided as
follows:
I.
Organised health services set-up
a
a
.a
a
a) District level concerned with-operattenal details of scheme
b) Primary health centre complex concerned with training and implementation of
scheme at grass-root level.
.
.
;
■
.
.
•
■
•
13
a
a
c
d
c
I 1
n
o
o
~n
C)
II. Link between organized health services and community
o
Jan Swasthya Rakshak.
III. Consumers and their representatives
1) Village level
a) community members
b) community leaders
c) village level workers
2) Block level
o
o
a) Block Development Officers
b) Block Level Presidents
■ I
3) District level
a) Zilla Parishad President/members,
b) CEOs and President of Zilla Panchayat Health Committees.
o
Every effort was made to meet representatives at all the above levels. Though there‘was
no difficulty at the village level, it was’ not always possible to meet representatives at
Block level or District level because of transfers or previous commitments necessitating
their absence from headquarters. Also, as some of the Panchayat representatives in some
places which we surveyed, had left for the Congress convention at Calcutta which was
being held at the same time, we were unable to elicit their views.
o
o
o
o
o
3.1.2 Identification of functional areas of Study
The functional areas or dimensions of the..scheme on which, the review was based are
given below.
These were worked out taking into consideration the status of
implementation of the scheme at the’time of conducting the study and in keeping with the' ‘
objectives and scope of review.
f
i. ' The extent of deviation of the scheme in its actual implementation to date in different
districts;
o
ii. attitude and commitment of J SR to the planned work;
o
o
o
o
o
iii. attitude and perception of community members, leaders and primary health staff
towards the scheme in general and JSR of their villages in particular;
iv. adequacy and appropriateness of medicines and drugs supplied to the JSRs;
v. problems and bottlenecks in the effective selection and training of JSRs;
vi. administrative and logistics aspects.
The functional areas were decided with a view to cover all the dimensions providing
thereby the factual attitudinal assessment of the implementors of the scheme and potential
0
o
o
o
o
14
I
n
I 1
, C’
beneficiaries. These served as guiding principles on the basis of which instruments for
data collection were developed.
3.1.3 Sources of data
The study involved collection of primary data from respondents at various levels of the
health administrative set up, as well as from the community members and leaders. Data
was also collected from secondary sources such as instructions 'and circulars issued at
different points of time and records of district and PHC levels.
* G
o
The categories of personnel were chosen on the basis of extent of their involvement in the
planning or implementation stages of J SR scheme directly or indirectly. The number oi.
respondents in each category and the total number interviewed are as follows:
Q
TABLE 3 : CATEGORY OF RESPONDENTS
Level of administrative
set-up
District
Block
Village
Category of respondents
Chief Medical Officer
C.E.O.
Deputy CEO
B.D.O.
B.M.O.
M.O. Incharge training of JSR .
Block Extension Educator
Male Supervisor.
Lady Health Visitor
Jan Swasthya Rakshaks
Community members
Community Leaders
Village Health Workers
0
Total no. of respondents
2
1
5 "■
9
1
11
11
11
101
u
■
A
20 villages
20 villages
6
3.1.4 Development of instruments
4
After having identified the functional-areas mentioned earlier, different schedules meant
for collection of information from different categories of respondents were developed. In
all, 6 such schedules were developed. (Appendix 6a to 6g). A number of areas were
common to some schedules. They were introduced to obtain information from different
respondents on the same dimensions of the scheme.
a
a
The schedules contained-structured and open-ended attempting to cover knowledge,
attitude and reaction of different levels of respondents. The District and Block level
schedules were in the form of guidelines'and were administered in the form of
semistructured interviews.
15
a
c
i
IJ
-O
7^
€)
o
o
o
o
3.1.5
Sample size and design
The present review was being undertaken mainly to provide midcoiirse corrections and
suggest ways and means to improve the overall performance of JSRs. In the .absence of
any regular monitoring system and because of the logistical limitations even though a
structure was made the process was envisaged more as a qualitative review rather than a
quantitative review. Within this limitation, the diversity and vastness of the state
warranted our obtaining data from as many parts of the state as possible. Keeping in
view the quantum of information to be collected at different levels of administrative set
up within the constraints of time and resources, a multi-stage sampling process was
resorted to. From five regions of Madhy^ Pradesh, two districts each were initially
selected randomly. From these two districts, one was then again selected randomly. In
these selected districts, two PHCs each were selected more on the basis of practical
consideration of time, resources and logistics rather than on the basis of rigorous
statistical requirements. In each of the PHC unit, effort was made to visit at least two
villages to discuss matters related to the scheme with community members and leaders.
While conducting the field survey, we were informed of RCH training being given to a
large group of female “JSRs” under a pilot project being funded by an international
agency at Piparia Block PHC. Since the functions and activities of this group were to be
very similar to the JSRs in other districts, we decided to review the training process at
Piparia Block PHC also. The final list of Districts, PHCs and villages visited are given
below:
TABLE 4 : Districts, Block Primary Health Centres and villages visited during the Review
o
District_______________________ Block PHC_____________________ Villages__________ ___
Vidisha
1. Peepai Kheda . . . *A:.
1. Sunpura
2. Biisran
Bhind
o
0»
D
o
Bilaspur
2.
Gyaraspur
1. .Furtula
2. Mudro Ganeshpur
1.
Phooph
1.
2.
Baralu
Deenpura
2.
Ater
1.
2.
Ater (Hamlet)
Johri Kotwal
1.
Balloda
1.
2.
Chhapra
Bachhao
2.
Pangad
1.
Menhdi
1.
Govind Garh :
1.
Agdal
2.
Sirnior
1.
’ 2.
Kiron
Raj gad
Rewa
Hoshangabad
Piparia
1.
2.
Gadaghat ‘
Alipar Kheda
Dhar
1.
Nalchha
2.
Sardarpur
1.
2.
1.
2.
Panela
Patliyapur
Badadi
Karchi/Ruprel
o
Q
o
□
o
•
16
u
p
770
Below is a short summary of the selected districts.
District Profile:
LA
A District profile of Madhya Pradesh was compiled from secondary sources of data, to
locate the findings from the sample districts in a broader state context.
*
All the selected districts visited except Hoshangabad had a higher percentage of rural
population as compared to the percentage of rural population in Madhya Pradesh.
*
Dhar and Vidisha districts have a lower rural female literacy when compared to that of
the State.
*
Bhind and Vidisha have one of the lowest sex ratios. Due to various causes identified
in various other studies, this does greatly influence the socio-cultural practices
specially gender related in these 2 districts.
f*
*
Except Bilaspur, the CBR and TFR were higher in all the other districts visited.
C3
*
Bhind and Vidisha have a much higher and Dhar much lower schedule caste
population when compared to rural Madhya Pradesh.
c*
r.
Dhar has 59.45% rural population belonging to schedule tribes. Bhind hardly has any
tiibal population. Their percentage is low in Vidisha and Rewa.
State/District •
Total
Population
Percen
tage of
Rural
Popula
tion
Rural
Female
Literacy
Rate
___
o
o
Total (Rural &
Urban)
Rural
4
SC
.ST
SR
CBR
TFR
(1984-90)
(1984-90)
0
Madhya Pradesh
Total
Rural
Urban
66,181,170
50.842.333
15,338.837
Districts_____
Bhind **
Rewa **
Dhar **_____
Vidisha **
Hoshangabad
Bilaspur **
967,857
1,318,172
1,187,702
775,303
920,695
3,148,763
14.55
14.80
15.72
23.27
28.82
4.87
931
943
893
37.2"
5.0
76.82
28.85
19.73
■ 58.92
79.40
84.77
86.86
79.90
72.66
83.00
23.55
22.81
15.64
19.54
26.32
20.92
22.17
15.38
6.85
21.68
16.84
19.12
0.15
13.56
59.45
5.23
22.20
26.33
813
946
960
872
904
990
39.0
40.9
37.2
40.1
38.0
36.7
5.8
5.8
5.1
■0
a
SR - Sex Ratio
SC - Scheduled Caste----- ST—Scheduled Tribe
TFR - Total Fertility Rate
* * Districts visited by Study team
Source : Health Monitor 1994 &. 1995 (FRHS) - Bibliography (18)
5.6
5.4
5.0
0
□
CBR - Crude Birth Rate
I
17
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A
o
3.1.6
O
For the purpose of collection of data, a team of two members visited the various
institutions and administered the various questionnaires to different categories of
respondents and held open-ended interviews as appropriate with the different levels of
personnel mentioned earlier. Discussions were held with‘‘community members and
leaders of identified villages based on guidelines mentioned earlier. Discussions were
also held with JSRs after they submitted their filled up questionnaires to elicit their views
in a group situation.
a
o
A
Methodology for collection of data
A
3.1.7 Analysis and interpretation of data
o
o
o
All data collected was analysed either manually or with the help of the computer and
appropriate interpretations were made from the analysed data. Information was thereby
obtained on the selection process, training process, training manual, examination system,
profile of JSRs and views of various categories of people on the scheme and its
objectives.
o
3.2 PEER REVIEW OF TRAINING PROGRAMME
o
The training manual and programme objectives were distributed to a large number of non
governmental / voluntary organisations with experience in similar activities for their
review and comments. Their comments were analysed, and collated. By this method,
inputs of a large number of individuals (Sec Supplement) were obtained on the scheme.
p
o
o
o
o
Q
O
3.3
J
WORKSHOP OF INTERESTED AND KEY PARTNERS ON
REVIEW REPORT OF JAN
SWASTHYA RAKSHAK SCHEME
After the review in the field, a preliminary report of findings was prepared. This was
presented to and discussed in depth amongst an invited group of participants and key
players, which consisted of representatives from the Madhya Pradesh government, Health
Department, IRDP, District administration, UNICEF-Bhopal, and invited NGOs
(Appendix - 7) at a workshop arranged specifically for this purpose. The comments,
suggestions and recommendations of these group of particip’ants are mentioned in depth in
the section “report of the discussions of interested and key partners”.
Q
O
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o
o
o
D
18
•O
9
v
A STUDY OF
POLICY PROCESS AND IMPLEMENTATION
OF THE
•>
NATIONAL TUBERCULOSIS CONTROL PROGRAMME
.i
IN INDIA
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*1
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Thesis submitted to the Faculty of Science
of the University of London
in fulfilment of the requirement for
the degree of Doctor of Philosophy
o
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by
DR. THELMA NARAYAN
•
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CJ
March 1998
a
a
Health Policy Unit
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
University of London
(3
a
<3
- 42
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4
i 1
I)
S3
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a
CHAPTER THREE
STUDY DESIGN AND METHODS
O
3.1
O
The key questions were:
Research Questions
a) What explanatory factors underlie the perceived implementation’gap of the
National Tuberculosis Programme in India?
O
b) Can these be analysed in terms of policy content, contextual factors,
o
o
policy process and actors?
c) What are the implications for policy from this analysis that can strengthen the
NTP?
o
3.2
o
Using an iterative method, tentative hypotheses (given below) were developed regarding
G
reasons for the perceived implementation gap. They derived from an initial analysis of
o
o
documents, interviews and a brief historical review. They provided direction to subsequent
6
3.2.1
Hypotheses
search and were not designed to be tested or proved/ disproved. Issues identified were
focused on more analytically and ih greater depth during data collection and analysis.
Private For Profit Sector
Governments’ implicit support for the private sector undermined the NTP and public sector,
O
o
♦
While the NTP concerned itself almost exclusively with the public sector, separate
Government'steps simultaneously promoted and supported growth of private sector
health care, from the 1950s onwards. The private sector grew without regulation and
without cognisance of the principles of the NTP. The number of allopathic doctors
o
o
working in the private sector increased from 60.4% in 1963-64 to 73.4% in 1986-87
(FRCH 1990). Physicians of Indian and other systems of medicine are almost all in the
private sector.
o
o
61
o
o
u .
■()
•
•
Utilisation of public sector resources (staff time, drugs, infrastructure) for private
G
practice, including charging for free services, partially reduces access to public sendees
(?
or causes irregular treatment among the poorest.
o
Economic interests of the pharmaceutical industry, of medical professionals and of
O
those concerned with drug purchasing for the public sector play an important role in
these developments. Economic constraints of government due to external and internal
factors are related.
3.2.2
Public Sector Dynamics
Weak States and peripheral institutions, inadequate resources and urban rural dispan ties in
n.
health care provision suggest low Government commitment to the NTP.
•
The State level is crucial to implementation of the NTP (and other health programmes)
o
□
in India's federal system. State Governments however depend on Central Government
financially and technically, and provide inadequate direction, support and motivation to
their employees implementing the programme.
•
Resources (financial, personnel, drugs and equipment) required to achieve the
G
objectives of the NTP were inadequate, especially at sub-district level, from the start of
the programme.
•
d
Peripheral Health Institutions (PHI's) at sub-district level, the point of contact behveen
patients and providers for the majority rural population, are the weakest in the NTP in
terms of capacity to handle this complex programme. Negative staff attitudes to poor
patients and to TB play a role.
•
The historic and growing disparity between medical and public health services for
organised sector employees (large public and private sector industry/services) and urban
areas, as against those forlhe rural poor and unorganised workers, affects the NTP.
•
Economic and class interests probably underlie developments mentioned above with
social relations being reproduced in this sector.
t
a
a
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3.2.3
o
Health programmes backed by stronger interests adversely affected the NTP.
•
o
o
Competing Interests
From the 1950s vertical programmes (malaria, smallpox, family planning/welfare and
immunisation) dominated public health, adversely affecting general health services at
primary care level and the NTP, which was integrated with this. Vertical programmes
had support of the bureaucracy, political leadership (for a major pail of the period),
national elite and international agencies:
o
o
3.2.4
Political Will
Political support to the NTP was inconsistent and counterproductive when coercive.
A
•
After an early phase of central government commitment from 1947-1960s, TB was
O
neglected. Renewed political attention in 1982, included it in the Twenty Point
O
Programme, but with insufficient resources. Introducing targets for sputum examination
at this time resulted in negative consequences.
O
3.2.5
o
The Voluntary/NGO and Peoples' Sector
Marginalising voluntary sector participation in policy limits the balancing influence of civic
society. ' . -
o
•
6
’■
’ .••-
The TB Association of India (TAI) helped place TB on the agenda in the 1940s, a time
when government was responsive to voluntary sector initiative. NGO's subsequent
attempts to raise issues concerning inadequate and irrational tuberculosis care were
unsuccessful in influencing policy change. Since establishing the NTP, NGO role in
O
policy process has been partly marginalised by Government policy makers.
O
Health issues, particularly specific disease problems like TB, are peripheral to peoples’
(3
social movements. There'is thus little countervailing power to the strong interests
mentioned earlier.
i
o.
-63
o
O
.
11
^6
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t>
3.3
0
Aim
To understand underlying explanations for the perceived implementation gap in the
.r
National Tuberculosis Programme of India by undertaking:
a) A historical, analytical study of policy process and implementation at the national level
since the 1940s, and
b) A case-study of policy implementation in one State, at District and Taluk level.
3.4
Q
Objectives
A. National Level Policy Formulation and Development
G
3.4.1 To contextualise the NTP to economic, political and social factors influencing policy
formulation and development.
3.4.2
To review briefly changes in policy content namely problem definition,
o
epidemiological methods used to determine its size and nature, basis of intervention
strategies and their modifications over time.
3.4.3
To study implementation processes (Table 6), including creation of infrastructure
3
(TB specific and general health services), resource flows and to identify roles of key
actors/interest groups and levels of power in implementing the NTP.
o
B. Implementation at State, District and Taluk level
3.4.4
To identify how actors/interest groups influenced implementation.
3.4.5
To study the availability and distribution of resources for the NTP at State, district
and peripheral levels. These include trained staff, training institutions, physical
infrastructure, TB diagnostics and drugs.
3.4.6
To study organisational mechanisms and inter-relationships of the NTP at different
o
a
a
a
a
□
□
levels.
a
64
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6
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3.4.7
To compare implementation processes at taluk level between the public sector and
an NGO which has taken responsibility from Government for the NTP in one taluk. In the
two taluks to study:
a) Staff perceptions regarding the NTP;
c) Perceptions of TB patients regarding their experience of the NTP functioning;
d) Perceptions of elected representatives and informal leaders regarding functioning of the
VJ
o
o
o
o
o
o
general health services with which the NTP is integrated.
3.5
Research Methods
3.5.1
General Approach
. An empirical, historical/longitudinal, in-depth case study of the NTP was undertaken, using
'■ a mix between a bottom-up and top-down framework to study policy process and
implementation. The inductive component studied the functioning of the NTP to understand
explanatory factors for the perceived implementation gap. In . this approach to theory
building, explanations of events are developed through a detailed analysis of those events
(Edwards and Talbot 1994).
An iterative process of policy analysis (Hogwood , and Gunn 1984) was used, with
o
o
progressive focusing of issues around the framework of context, process, actor and content,
leading to newer directions of search. To structure the understanding of policy process, a
framework of implementation factors was developed from the literature, providing a two-
o
o
o
tiered framework of analysis.
Multiple sources ofinformation/ methods ofdata collection used were:
a) semi-structured/ in-depth interviews (with checklists);
b) review of internal documents, records, published reports, media reports;
c) observations of implementing agencies at local, district and state level.
o
Interviews were unstructured, open-ended, with respondents picked not by statistical
methods but because of their knowledge/ status (Yin 1982).
A multi-level sample was drawn from the following administrative and political units: local/
village, subdistrict or taluk, district, state, national and international. Respondents
o
65
o
H'
<I
T'
comprised TB patients, elected representatives, private practitioners, government personnel
o
including peripheral health workers, PHC medical officers, DTC staff, state and national
programme managers, and personnel representing international agencies.
0
Validcition of findings was done through triangulation (use of more than one source of
o
information /method tor data collection). Triangulation, used in inductive research, involves
O
taking multiple, often three perspectives on a phenomenon/ event (Edwards and Talbot
1994). Different types of data (qualitative and quantitative) and data collection methods can
Ci
reveal different aspects of reality. Additionally triangulation can use different investigators,
study the problem over a period of time, and/or use different theories/ perspectives to
interpret a single set of data (WHO Mental Health Div. 1994). Most commonly mixed
0
CJ
triangulation is used. It is also used as a method of checking reliability in qualitative
research. Because of the complexity revealed by the process one major data collection
method is primarily used, while others provide supplementary evidence. In this study, the
□
main method for the district and sub-district levels was interviews, while for the historical,
<5
national level it was review of documents.
A Research Assistant, a sociologist, with experience of survey research (in medical and
o
developmental/social topics), w.as trained’ to conduct semi-structured, in-depth interviews
with patients, elected representatives and peripheral health workers. He belonged to the
area, was familiar with the local dialect and established a good rapport with respondents.
o
The checklist of questions was double translated into Kannada (the local language). Pilot
0
testing of interviews with PHC Medical Officers, Health Assistants, TB patients and elected
Q
representatives was done. Patients were interviewed at_their homes and health personnel at
the health centre. A 10% sample of patients were re-interviewed 4-6 months later to check
reliability. About half of the interviews with TB patients were tape recorded, as testing
showed non-interference with flow and. quality of interviews, with patients essentially
Q
telling their story and nothing to lose or gain. Regular debriefing sessions with the research
a
assistant were held. Many related valuable observations and perceptions picked up during
Q
the extensive fieldwork were shared. At other levels (e.g. some governmental personnel) it
a
a
was found that sometimes even making notes during the interview caused respondents to
41
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66
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o
o
o
There was a need to release emotional tension that accumulated during intense encounters
Q
with suffering. Sharing, meetings, writing (the research assistant is a poet) helped, but a
hesitate. To achieve maximum recall in these interviews (two-thirds of the total) notes
were written as soon after the interview as possible, and on the same day. This
necessitated time scheduling as writing up took a little longer than the interview.
deep imprint remains.
O
o
o
o
o
o
o
o
o
3.5.2
Sample
Sampling commenced with listing:
J
•
key policy makers involved in the NTP over time at national and state level;
•
representatives of interest groups; and
•
key actors at local level (patients, doctors, health workers and elected representatives).
A non-probabilistic sampling approach was used. Snowball or chain sampling (Edwards
and Talbot 1994) helped select additional respondents. The initial sample provided names
of many knowledgeable about/involved in the NTP. These were, prioritised and numbers
limited due to time constraints and logistics.
Selection ofstate, district and taluks were as follows:
1.
State'. Karnataka, one of 25 States in India, with a population of 44.8 million (1991
census) was selected. With reference to national standards, indicators show that it has
o
average levels of socio-economic development and that the NTP performs moderately
(ICORCI 1988). The researcher was based in the capital city Bangalore, in the Community
o
o
o
o
Health Cell, an NGO resource centre which provided the study infrastructural support. The
National Tuberculosis Institute in the city provided much information.
2. District'. Mysore district, one of twenty districts in Karnataka state, with a population of
3.1 million (1991 census) was selected. It has an average index of development and
moderately developed health services. It is larger than the average district. It was chosen
because NTP services for an entire Taluk had been taken over by an NGO and this could
provide a point of comparison for identification of implementation factors. Positive
o
o
o
67
(j
experiences would demonstrate that in spite of contextual constraints, implementation was
attainable within a socio-cultural situation. .
<?
3. Taluk (sub-district administrative unit): Implementation was studied in 2 of 11 taluks
0
in Mysore district: a) Heggade Devana Kote taluk (210,000 population), an average taluk
o
with a mix of public, private and voluntary sector services and the countrywide pattern of
■o
the NTP being run by the government. This was socio-economically the poorest taluk in the
a
district.
b) Yelandur taluk (population 70,000) had the same mix of services, but a voluntary
organisation had taken responsibility for provision of TB services for the taluk from the
state government since 1991. Reasons for this, processes of implementation and outcome of
NGO intervention were studied.
Patient Sample: Lists of TB patients were obtained from the District TB Centre, Taluk
General Hospital, voluntary organisations and Primary Health Centres. Selection criteria
were:
•
equal numbers of men and women, though prevalence of disease is 2/3rd in men and
l/3rd in women - to identify gender discrimination, if any, in programme functioning;
9
geographical spread of patients in villages throughout the taluk i.e. remote and near the
headquarters town; rural urban mix;
.
economically and socially disadvantaged patients;
drop-outs from treatment;
♦
3
3
O
O
o
o
0
a few children and patients with extra-pulmonary TB;
o
patients from above backgrounds treated by public and voluntary sector.
G
A mix of the most powerless were consciously chosen. There was no statistical analysis as
(J
this is a policy process study, focusing particularly on political dimensions.
A sample of elected representatives from local government at Gram Panchayat (village
level) and Zilla Parishad (district level), for their perceptions regarding the functioning of
□
■3
the public health services with which the NTP is integrated. Public health comes under their
C3
68
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6
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purview of responsibilities. Members from socially disadvantaged groups and women were
o
o
o
o
chosen
3.5.3
Specific Research Methods for Different Levels pf Study
a) National Level
•
Documents for the historical review included administrative and research reports,
evaluations, journal articles and books. It involved gaining access, reading and re
0
reading, identifying themes regarding context, content, actors and processes followed by
a process of analysis by sub-themes, synthesis and interpretation (sources in Annexe 2
O ■ I
and bibliography).
•
o
o
o
o
Semi-structured interviews with 62 policy makers and senior researchers involved
historically and currently with the NTP/RNTP and 23 respondents from international
organisations (list in Annexe 2). Repeat interviews were necessary and useful.
Attending national level meetings provided insights and opportunities for discussions
with a wide range of people with different views and perspectives (list of meetings
attended in Annexe 2).
b) State, District and Taluk Level
o
o
•
Interviews with key actors and interest groups (lists in Annexe 2, checklists of questions
in Annexe 3):
- 90 TB patients;
o
o
- 22 elected local government representatives and 8 staff members from the Zilla
Panchayat office;
- 70 implementors from the front-line upwards (health assistants, doctors, voluntary
organisation staff, district level staff); and
o
-11 private practitioners and visits to pharmacies in the two taluks.
J
o
o
•
Answers to relevant questions raised in the State Legislative Assembly;
•
Media coverage- TB and health service coverage in a local language (Kannada) district
newspaper were reviewed.
•
Records from the National TB Institute concerning the District;-
o
□
o
69
i 1
G
•
Records from the State Directorate of Health Services and TB Control section; and
•
P.ecords from the District TB Centre and the voluntary organisation.
3.6
(
0
Limitations Of The Study
The researcher fell’ ill towards the end of the fieldwork resulting in some curtailment of
o
State level and organised sector data collection. In retrospect, the Erythema Nodosum that
developed were early signs of TB. Later supraclavicular lymph node enlargement led to a
o
biopsy, diagnosis and six month therapy with rifampicin, pyrazinamide and isoniazid during
the writing up phase. Cardiac shadow enlargement during treatment and growth of lymph
nodes at the end of treatment added anxieties. Hence analysis was supplemented by a
personal experience of the disease under study, adding an unintended emic perspective.
Efforts were made to reduce possible ‘researcher bias’, reported in policy studies -as
researchers becoming co-opted 'by the unit of observation as advocates or critics (Williams
1982). Awareness of researcher subjectivity in data collection and interpretation influenced
by personal values, professional background and experience was maintained in order to
limit it.
Selection and recall bias among respondents is a well known factor. In this study repeat
O
interviews and validating interviews helped reduce this. The inherent complexity of the
o
problem and adoption of a wide ranging approach necessary for policy analysis resulted in
G
certain issues not being followed up.
Efforts were made to minimise limitations by using multiple methods, divergent sources of
information, pilot testing check lists and practising interviewing.
Though the private sector is an important actor in TB care in India, issues concerning it
were minimally addressed as the study focused on the policy process and implementation of
Q
0
<2
Q
public policy. It therefore provides a partial picture. This is an area for further policy
- analysis.
’3
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70
£1
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A REVIEW AND CONSULTATION REPORT ON
6
O
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o
o
o
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BB awn MHBK MB
PARTI-THE STUDY REPORT
JULY-NOVEMBER 2001
COMMUNITY HEALTH CELL TEAM
O
O
BANGALORE
SUPPORTED BY DFID, NEW DELHI
O
Q
o
o
Prof Mohammad
Dr Shyam Ashtekar
Dr Shashikant Ahankari
Amulya Nldhi
Dr Dhruv Mankad
Dr Abhay Shukla
&
Dr Ravi Narayan
o
Q
□
o
j
-.1 1
0
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
O
PARTS: MATERIAL AND METHODS
0
THE CHCELL TEAM
o
The CHCell team consisted of consultants working in the field of primary care. The team had following members:
1. • Dr Ravi Narayan
2.
Dr Dhruv Mankad
3.
Dr Shyam Ashtekar,
4.
Prof Mohammed
5.
Dr Abhay Shukla,
6. ’
Dr Shashikant Ahankari,
7.
Shri Amulya Nidhi
O
O
0
Preparatory visit
Two preparatory visits were conducted. The first, by Dr shyam ashtekar in March’2001, This
was an interview with RGM officials. Health dept and a filed visit to PHC/CHC and JSR villages and a
Bengali doctor. The purpose was to understand the likely tasks and nature of the JSR programme.
o
o
This helped to build a rapport and also to frame the TOR. Concept of the study was shared with the
RGM CH.
The second visit by the team members (Dt Rajgarh, block Khllchipur) came about in July 2001.
During this.visit the team observed some training sessions, met working JSRs, trainers. Health
o
officers, RFWTCs etc. This gave the team a feel of the programme. It also helped frame actual
methods and questionnaires. Logistical planning was done after this visit.
3
Sufficient time was allocated between each visit to internalize the issues. Email exchange on
G
methods and. questions helped sharpen the study tools.
Selecting districts
The main aim of the review exercise was to consult various stakeholders. Since, JSR Scheme
was implemented all over Madhya Pradesh, the team decided to visit various places to collect relevant
<3
information.
Following the preparatory visit's experience, sample districts were selected purposefully based
<3
on the following three criteria:
•
□
Human Development Index
Region representation
•
Q
Tribal population
Feasibility was another factor considered. Since the stakeholders are present at the district, block and
a
a
a
village levels, samples of all the three locations were essential. In addition, RFWTCs were also
32
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0
6
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 20p 1
O
O
selected because curriculum designing, TOTs and the manual had major contributions from the
G
faculty.
Considering these criteria, we studied the following
•
o
o
6 districts, 2 blocks per districts, 1 CHC and PHC per block, 2 villages per CHC/PHC
3 Regional Family Welfare Training Centers
Some changes were made after consulting Dr Agnani, RGM. He was asked for his opinion
about the better districts in the JSR Scheme. The purpose was to look at what innovative, best
G
practices were implemented and initial problems solved.
O
After the deliberations among the team members and RGM 6 districts were selected based on
)
HDL The blocks, the PHCs and the villages were to be selected in consultation with the CMHO of the
selected districts. Districts, blocks and villages visited by-the teams are:
G
o
o
o
o
o
o
o
o
District
Barwani
Block
Name
Silavad
No
2
Villages________________
Name______ ____________
Seganva, Avali, Rehaguri,
Bhutkira, Devall, Shely, Warla
No
6
Team
No.
1
Sendhwa
Bagh
Dhar
Dhar
Jabalpur
Satna
Guna
Bhopal
Dhamnod
Kukshi Nalcha
Barela
Majholi______
Nagod,
Suhawal
Majhgawan
Maiher
Aron
Raghogad
Bairasia
Phanda
Timeframe
5
2
Bagadi, Bagadi phata
Dhamnod,
All, Lonera, Patllpur
2
4
2
Kalgodi, Barha
Pipariya, Khabra______ ;
Umari Patelan, Sanwalia,
Kothi, Hiroundi
4
3
4
3
Salaya, Mlana, Shirsee,
Nandner.
4
4
1
5
2
Gandhinagar
:
The study was started in July 2001 (initial exploration); the field investigations done in
September 2-27 and analysis took another 8 weeks. The logistics for visiting selected Districts was
decided on the assumption that the team would cover the selected locations and the stakeholders in
G
districts 3 days. One buffer day was allowed to complete the logistics or for communicating among
the teams for any changes.
O
Sources of Data
The evaluation involved all the possible stakeholders at each level. A list was prepared and
they were clubbed as a Group based on their interaction level with the JSR Scheme, their stake level
o
.33
o
o
11
G
0
REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
6
and their interests in the actual functioning of the Scheme. The number of respondents with their
■: I
Groups is:
0
.9
Level
Stakeholders
District, Blocks
Collector, CEO, Chairperson ZP, Janpad, members of JPSS
O
Village
Community, GP, GSS, Teachers, Users
District, Block CHCs , PHCs
CMHO, DHO, BMO, MOPHC
o
District, Block, PHCs
RFWTC, Trainers, Training I/C
Block, PHCs, Villages
ANM, MPW, Supervisors
Villages
AWW, TBA, Trainee or Practicing JSR
Block, PHCs, Villages
Pvt Med Practitioners, Bengali Doctors, Practicing VHCs, Pharmacists
All the levels
NGO, Journalists
~~
ISSUES COVERED
G
Scheme /Selection
Gender, Education/ Other social factors, Distance factors, Non clinical Role, Who selected?
Training/T/JSR
Venue, Schedule, Method and Content, Changes, Trainers, TOT, Manual
Work-content
G
Tasks, Illnesses, referral &workload. Records & reports, NHP, Use of medicines & skills,
Problems/suggestions
Community
O
Links, NHP Linkage, GP/GS/GSS, Links with PMP, Users, PHC, Supervision/Referral, Feed back/Report,
Economy, Fee/Income, Honorarium, Depot holdership.
&
Data Collection Methods
a
a
a
This is a qualitative study, doing an in-depth inquiry of the programme over a small sample.
Intensive consultation was done on the methods and samples. Interviews, observations, FGDs were
the main instruments. Ail narration are recorded on field diaries and some photographs and
documents also collected.
□
Interviews
The main objective of the evaluation was to consult the stakeholders of JSR Scheme. It was
43
decided to have Focus Group Discussions with the Groups identified and direct interviews with
individual members. A set'of issues addressed while interviewing the respondents was prepared. An
- •
exhaustive list of questions related to each Group was prepared as given in Volume?.
■a
□
Opinion Poll: '
a
a
Since the interviews would give the qualitative information about the trends among the
geopolitical levels, it was decided to collect opinions from the key informants representing the
34
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<Y7 -
6
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REPORT OF CHCELL STUDY OF JSR SCHEME OF MADHYA PRADESH: September -December 2001
Groups. A questionnaire was designed with 3 questions focusing on their suggestions. The
respondent should be involved in the JSR Scheme. See Volume?
JSRs' perceptions;
.
The JSRs are the pivots around which the Scheme has evolved. Their perceptions, opinions, experiences and
knowledge form the main plank of the study. This was the outlook of the Evaluation Team. An exhaustive
questionnaire was designed for Trainee JSRs and the Practicing JSRs. (PI See Volume?). Total of 204 Trainee
JSRs and 22 of Working JSRs have responded. (The Working JSR actually means one who has taken training
o
o
o
o
o
o
o
earlier. The nomenclature comes from the process-the PHC/CHC MO was asked to name any working JSR in the
area, hence the name working-JSR Some of them are not actually not working as JSRs)
Case Studies:
The family background, social milieu, their operational area, and their links with the various
health care providers and with the community form the basis on which the JSR model can be built up.
Profiles of Practicing or Trainee JSRs give insight to these aspects. See Volume?.
Case studies are
presented.
Consultation in the group:
At the end of each leg the team held discussions and at the end of the field study, the 4
members sat at Bhopal for two days discussing various concerns and issues investigated. The
exercise is presented in a table format. It was then circulated on email and finalized. The last- •
consultant added his remarks on email.
o
o
o
. .
Study of documents
Documents of the JSR scheme, mainly Govt, orders and books published were studied.
ANALYSIS AND REPORT
O
.
The response sheets from JSRs were rendered into standard phrases evolved on perusal of
sheets. For instances responses to the question "what is your dream" evoked answers like want
o
to become a doctor, do daktari in village, run a clinic, dortor-yase banoo etc. These were
converted into the key phrase "become doctor". This rendered the data treatable in Excel format.
o
o
.
The major challenge was in interviews. The consultants evolved together a free-list of questions
for each category of respondents, which was used as guiding list for.interviews. Each consultant
J
into a word format converted the field diaries in a 4-Column table style (issue-subissue-responseremark). The statements were again combed by one researcher, split into issue-wise rows and
o
o
o
o
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then sorted by category. This gave us a bunch of responses.from various respondents on each
issue. Scanning this enabled us to write the major opinion, variants and nuances. This was used
in writing the results and discussion. The full text was shared with all the team before finalization.
.
Two consultants studied the JSR manual and a separate review is enclosed.
35
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GOVERNMENT OF KARNATAK.X
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Districts : 27 Districts
Disadvantaged:- Lower class and Caste
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speculation but , demand close attention at the earliest for policy review and
implementation. .
Health is a state subject, and it is. the responsibility of Government to ensure a'n
equitable distribution of minimum and adequate health care that is accessible to the
whole population.
Considering the inadequacies in terms of infrastructure and
relatively poor health indicators, there is a need to understand the disparities in the
health and health care services, in the state.
*
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OBJECTIVES:
The goal of this study is to highlight the extent of disparities that exist in health and
health care facilities between districts in the state and within the districts and to
suggest steps to be taken to reduce these disparities.
The objectives of the study therefore include:
'»
1. To determine the disparities in Health determinants^
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2. To determine the disparities in Health status
3. To determine the disparities in Health Care resources allocation.
4.
To determine the disparities in Health Care utilization.
5.
To determine the most disadvantaged districts in Karnataka to evolve and initiate
more focussed projects in these districts.
.
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^ NatlOna/ TubQKulosis Control Program: Action Plan, Govt, of Karnataka,
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Given the constraints of time available only quantitative data' that is available from the
following secondary sources on various characteristics was collected.
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Multi Indicator Cluster Survey - 1998 - UNICEF
Rapid Household survey under RCH project, Karnataka State - 1999
Human Development Report, Karnataka State - 1999
Directorate of Health and Family Welfare Services, Govt, of Karnataka
Sept.2000
ICDS - Women and Child Development Department Report - Nov. 2000
Census of India 1991, Karnataka State District Profile 1991.
Rural Development Panchayati Raj Department, Statement on Delow Poverty
Line Families, Govt, of Karnataka
Data was checked’for its quality and quantity and regional disparities were assessed
on the basis of available data on indicators in following essential categories:
(Annexure— I)
>
>
>
>
>
Health Determinants
Health Status
Health Resource Allocation
Health Care Utilization indicators and
Over all indicators
Each indicator in the above-mentioned categories was standardized and algebraically
added for each district. The total was re-standardized and a composite index as
Standardized “Z” Score was obtained for each district, which gives the relative position
of the districts on the scale in Karnataka State.
It has been observed in many studies that lower class and caste suffer with
disproportionate burden of diseases and mortality. Different types of morbidity and
rhortality have 'different patterns with respect to the age, sex and social class. So to
assess the equity with respect to these characteristics, it is necessary to get the
primary data in disaggregated form at various levels right from taluk to state level.
However, disparities in health on the basis of class, caste, age, sex and the religion
could not be assessed, as data does not exist in disaggregated form for districts of
Karnataka.
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HEALTH DETERMINANTS INDICATOR .
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Prevalence and level of poverty * -1998
Educational levels * -1991
Adequate sanitation and Safe water coverage * - 1998
Housing *-1991
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HEALTH STATUS INDICATORS
i
Under five year mortality rate * -1991
b. . Nutrition of children * - Nov. 2000
c.
Maternal mortality ratio: Not Available
d.
Life expectancy at birth: Nbt Available
Incidence & Prevalence of relevant infectious diseases *-1999
e.
f. % Infant mortality ratio: Not Available
s- ■ ' Child mortality (1-4 years): Not Available
a.
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HEALTH CARE RESOURCES ALLOCATION INDICATORS
a.
Per capita distribution of qualified personnel in selected categories eg.,
medical officers: physician, obstetrician, paediatrician, surgeons &
paramedical workers. * - Sept. 2000,
J
12
b.
Per capita distribution of services facilities at Primary, Secondary and
Tertiary levels. * - 1999
h.
Per capita distribution of total health allocation and expenditure on
personnel and supplies as well as facilities: Not Available
□
IV.
HEALTH CARE UTILIZATION INDICATORS
a.
b.
c.
d.
Immunization coverage * - 1998
Antenatal Coverage-* - 1998
Percentage of births attended by qualified attendant * -1998
Current use of contraception *-1998
^ Indicators used in the present report
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Draft for Discussion Only
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Title .
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Review of Externally Aided Proj ects in the
Context of their Integration into the Health
Service Delivery in Karnataka
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Author
Ravi Narayan
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Dr. Ravi Narayan, M.D. (AIIMS), D.T.P.H, (London), D.I.H. (U.K.)
Community Health Adviser - Community Health Cell
367 'Srinivasa Nilaya', 1st Main Jakkasandra
Koramangala, Bangalore - 560 34 INDIA
Telephone/Fax: 5525372
E-mail: sochara@vsnl.com
O
Date: March 2001
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3
APPENDIX -1
o
Project Proposal
G
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Review of externally Aided Projects
in the context of their integration into the
Health Services Delivery in
Karnataka
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Content List
1. Introduction
2. Objectives
3. Methodology
4. Budget
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5. Project Outcome
6. References
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7. Appendices
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9
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1. Introduction
Since mid 1990's, Karnataka Government has negotiated and received grants / loans from
International Funding Agencies for an increasing number of Health related projects.
These have included IPP - 8, IPP-9, KHSDP, KFW, RCH, .Prevention of Blindness,
RNTCP and other projects. These externally aided projects have their particular focus
and framework and operational strategies to support and enhance both quantitatively and
qualitatively different aspects of the Health Sector development. Each of them has had
various mid term and concurrent reviews and some of them are currently reaching the end
of specific phases. The Karnataka Task Force in Health while reviewing these projects
informally in their discussions and deliberations have raised some important questions for
review.
o
o
n
0
1.
"What are the learning points from each of these projects"
ii. How can they be integrated into the health system incorporating beneficial
o
points and avoiding distortions?
.
What
are
the
issues
for
consideration
of
sustainability,
accountability
and
iii.
transparency" (1)
o
o
This project proposal is a short-term initiative to explore some of these issues
qualitatively as a preliminary to perhaps a larger study at a later date.
O
O
Community Health Cell is a technical Community Health and Public Health oriented
policy research and training group that has reviewed external, aided projects in the past.
Four policy initiatives are relevant to this study.
1) Review of health projects in India supported by Misereor / Germany. (7)
2)
Review of Health Partnership of Memisa in Netherlands.
(6)
3) Review of partnership in Health (Cebemor Netherlands Government) (5)
4)
1Policy
_reflections on World Bank Activities in India - (see references) (3)
o
Q
2. Objectives of Study
o
1.
The study will review all the externally aided projects not just individually but in their
collective context and relation to the Primary Health Care and Public Health system
development in the state using a SWOT approach.
More specifically it will look at
a. The Strengths of each project and the positive learning experiences.
b. The Weaknesses or difficulties encountered in each project.
c. The Opportunities that have been created or exist to enhance primary and
public health care system development in the state.
d. The Threats or distortions that may have been inadvertently caused by. the
project assistance to the health sector or'that may be caused during the process
of integration.
53
o
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Some specific questions are in Appendix one, though a more structured approach will
emerge after the literature, review.
(-
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3. Methodology
The time frame work of three months is too short to evolve a rigorous data based,
quantitative approach to project design and therefore a more qualitative approach that
will focus on a participation, interactive process is being suggested rather than an expert
external review the method suggested will try to make it a collective learning experience
for all concerned. Each project will be requested to allot atleast one project statf to be
part of an evidence collecting, evidence sifting; and evidence collecting exercise.
O
The steps of the process will be
A. Phase one 15th September - 15th October 2000
i \
i.
ii.
Literature Review of all .project proposals and mid term/ concurrent reviews and
aide memoirs.
Informal discussions- with all project leaders and support team to clarify the
nature and process of review and seek required support and participation (As a
half day interactive workshop together, tentative date 10th October 2000.)
B. Phase Two -15'th October - 30th November 2000
i.
ii.
iii.
Qualitative interviews with Directors and staff of each of these projects and with
a small representative sample of other stake holders including medical officers ■
and other staff. (Some visits outside Bangalore will be required)
Interactive participation workshop, with representatives of all the projects to
address the issues of sustainability accountability etc. and all those issues, which
are common to.all projects and derive from phase one review, (atleast two, to be
discussed at A. ii)
A questionnaire survey of some key aspects relevant to the study to be filled up
by each project as 'evidence contribution' to the review.
(i
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C. Phase Three - 15th November - 15th December 2000
1.
ii.
iii.
Integration of all the data/evidence from phase one and phase two
processes into a project analysis document.
Circulation of this document to all concerned with a weeks time
framework for replies.
Incorporation of all comments / suggestions and final editing of a
document to be submitted to KTFH hopefully not later than 15th October 2000.
4. Budget
A budget proposal to support the study and including costs of Researchers, other
assistance, office support including photocopying, computer facilities, postage.
Q
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□
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54
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107
9
stationery, travel of research assistant and co-ordinator of study and some supportive
costs Tor three interactive workshops is included in Appendix Two.
O
o
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O
O
o
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The study will be undertaken by Dr. Ravi Narayan of CHC supported by a full time
research associate for 3 months and drawing upon short-term '.research assistance fram
some other members of CHC team on a flexi-time basis.
Some elements of the study / review are complementary to the project proposals of
Mr. Vinod Vyasulu of Centre for Budget and Policy Studies, Dr. Ramesh Kanbargi of
ISEC; Mr. As. Mohamed of SJMC and Dr. Pankaj Mehta of Manipal Hospital and so
their involvement in some aspects of the study will be operationalised through informal
interaction at no additional cost.
Finally to make the short term process more cost effective and efficient .under the
circumstances - close co-ordination with the project leaders will be established so that
some aspects of the study including the interactive aspects can be linked to any ongoing
schedule of meeting/training programmes or midterm/concurrent reviews so that
opportunity costs are enhanced.
5. Project Outcome
A project report highlighting a SWOT review of the External Aided Projects and Policy
guidelines for integration, sustainability and future projects of this type.
6. References
1. Topics for Action Research Studies identified by Task Force ( a KTFH handout)
2. Comprehensive Health, Nutrition and Population services development initiative in
Karnataka (An idea draft from CHC)
3. Comments on Case Study of World Bank Activities in the Health Sector in India (A
CHC policy reflection)
4. A Guide to sector-wide approaches for Health development - concepts, issues and
working arrangements (Andrew Cassels) A WHO/DANIDA/DFID publication.
5. Programme Evaluation-Basic Health Services India (cebemo / icco/DGlS), October
1994. (CHC) T
6. Partners in Health - Challenges for the next decade: A process renew of the Indian
Partnership of Memisa - 1989-1994, (October 1994. CHC)
7. Promoting Health in India: A process review of the Indian Partnership of Misereor,
December 1994. (CHC)
55'
;■
O
las
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APPENDIX - II
O
Some Issues and Questions to be addressed in the Review Project by
Literature Review and Interactive discussions.
A Check List
0
1. Descriptions of each project including year of starting, period, focus, objectives,
components, programmes, budgets, reviews, etc.
2. Was the ‘problem analysis’ and the ‘problem solution’ comprehensive or selective?
If selective then factors used for prioritization? or selection of strategies?
3. How does the project support,
a) Health System Development ?
b) Primary Health Care?
c) Public Health?
n
.
,4. How is the project funded?
a) Direct or indirect
b) Loan agreement/conditionality
c) Repayment
d) Budget components etc.
o
5. What has been the experience of
a) financial management
b) disbursement
c) expenditure •
d) delays
.
e) shortfalls, etc.
Q
O
u
Q
6. Is the project funding leading to distortions in spending priorities?
7. Are a reliance on projects perpetuating long-standing budgetary imbalances;
implications on existing state health budget etc.?
8. Are there diversities in accounting/auditing procedures?
9. Strengths, Weaknesses, Opportunities, Threats of each project including those
identified by mid-term reviews.
10. Are there problems, of
a) Project flexibility
b) Overdesigned
a
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0
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56
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c) unnecessary long lead time, preparation delays
d) Slow rates of disbursement
e) Complicated procedures
f) Any other managerial/operational problems.
11. Are there areas of overlap / duplication with other projects?
a) HMIS
b) TEC
c) Training
d) Staffing
e) Others
12. Are projects creating islands of excellence in
i an otherwise under funded sector?
O
o
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13. Who drives the project?
a) ' State Health Directorate
b) Funding partners
c) ' External consultants
d) Others
14. Are there problems of:
Ownership
i)
Leadership
ii)
Intersectorality
iib
Implementation
iv)
Monitoring and Evaluation
v)
Any other areas
vi)
• -
15. How do the projects perform in the context of some policy imperatives:
a) Equity
b) Gender sensitivity
c) Regional disparties
d) Partnerships
NGOs
i.
Private sector
ii.
Academics-Research
iii.
Others
iv.
----- e) Accountability including corruption and political interference
f) Community involvement and partnership
g) Decentralization and Panchayatiraj
16. Do multiple projects make it difficult for the government to develop and implement a
coherent health policy for the health sector as a whole?
17. What has the project done in the context of sustainability?
57
-.11
I
11'^
3
Integration of EAP's in Health Service Delivery
Karnataka
CONCEPTUAL FRAMEWORK (4)
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a) State need
b) Funding partners
c) External Consultants
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inal
a) System
b) Financial
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Some
d
Issues
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for Integration
n«
aj Corruption
b) Political
Interference
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a)
HMIS
b) IEC
c) Training / CME
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Financial Issues
a) Budgets
b) Finaneial gystem
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GLOBAL PUBLIC PRIVATE
INITIATIVES (GPPIs)
a
based on a case study of the
O
Global Alliance to Eliminate Lymphatic
Filariasis (GAELF)
o
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UNDERSTANDING
in
O
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Karnataka State, India
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,
by
Mr. Naveen I. Thomas
Dr. Thelma Narayan
October 2004
Community Health Cell
359 (Old No. 367), Srinivasa Nilaya
Jakkasandra, I Main, I Block
Koramangala, Bangalore —560 034
Karnataka state, INDIA
In collaboration with the WEMOS-GPPI study team
WEMOS Foundation, P. O. Box 1693
1000 BR Amsterdam
The Netherlands
u
111-/
G
9
i
G
CONTENTS
A cknowledgements
Executive Summary
3
3
4
3
O
PART -1
1. Introduction
2. Objectives
3. Methodology
4. Definition of Global Public Private Initiatives (GPPls)
0
5
6
6
7
«'A
9
PART-II
5. The Global Context and GPPls
7
6. Global Alliance to Eliminate Lymphatic Filariasis (GAELF)
6.1. Epidemiological Profile
6.2. Evolution of the GAELF
6.3. Intervention Strategy
6.4. Work done by the GAELF
6.5. Constituents of GAELF and their role.
8
. 8
8
9
10
11
V.-Z
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PART - in
7. The Indian Context
7.1. India’s health situation
7.2. Indian healthcare market
7.3. Health system
7.4. Health expenditure
7.5. Drugs and pharmaceuticals
12
13
14
15
16
18
8. The Karnataka State Context
8.1 General Information
8.2. Karnataka health indicators
8.3. A comparison
8.4 Population stabilization
8.5. Health gains
8.6 Health gaps
8.7 Equity in health and health care
18
19
19
20
21
21
22
23
9. Filariasis and Filariasis Control in India
9.1. Background
9.2 Causative organisms
9.3. Filariasis control in India - a historical review
9.4. National Filaria Control Programme (NFCP)
9.5. Revised control strategy
9.6 Organisational set-up
23
23
23
23
25
29
30
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10. Filariasis and firariasis control in Karnataka
10.1. Filariasis in Karnataka
10.2. Organisational set-up in Karnataka
10.3. Process of implementation
o
o
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/I
31
31
33
35
PART - IV
11. Critical Issues in regard to GA ELF
12. Conclusion
13. Recommendations
41
46
47
O
REFERENCES
49
o
o
ANNEXL'RES
Annexure 1: Health in Karnataka -Some Statistics
Annexure 2: Newspaper Report on MDA in Karnataka
Annexure 3: Abstract of Cochrane Review on use of Albendezole
51
56
57
LIST OF TABLES
Table 1: Differential in Health Status among the States.
Table 2: Selected Health Indicators of Marginalised People in India
Table 3: Health Infrastructure
Table 4: Availability of Doctors and Hospital Beds per Lakh of Population
Table 5: Indian Health Expenditure
Table 6: India’s Per-Capita Expenditure on Health
Table 7: public Investment on Health
Table 8: Country Public expenditure on health as a share of the GDP
Table 9: Comparison of the Private Expenditures on Health
Table 10: Number of Drugs under Price Control
Table 11: General Information Regarding Karnataka
Table 12: Karnataka Health Indicators
Table 13: Comparative HDI and GDI Ranks
Table 14: Health Gains
Table 15: Health Infrastructure
Table 16: Demographic Indicators
Table 17: Differences in the Levels of Infant and Child Mortality ’
Table 18: DEC medicated salt trials in India
Table 19: Population protected-under NFCP-andrthe'set-up as on April 2003
Table 20: Epidemiological situation and prevalence of mf
Table 21: Filaria Institutions Functioning In Karnataka State
Table 22: Population at Risk and Protected Under the NFCP
Table 23: District-wise Incidence of Filariasis in Karnataka (Year: 2001)
Table 24: District-wise Incidence of Filariasis in Karnataka (Year: 2002)
Table 25: District-wise Incidence of Filariasis in Karnataka (Year 2003)
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LIST OF FIGURES
Fig 1: Chart showing the changing microfilarial rate in Karnataka
Fig 2: Chart showing the changing number of mf and disease cases
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We thank the communities, especially those living with filariasis, who cooperated with us and
helped us to know more about the impact of filariasis and filariasis control (or- the lack of it) on
their lives. This report is dedicated to them, and prepared with the hope that highlighting the
issues concerned will improve the health.systems, thereby benefiting their lives.
A whole range of people have been interviewed and many others have given their valuable
suggestions and comments regarding the GALEF programme and filariasis control. It would be
too numerous to list them out here. Our heartfelt.gratitude to all of them.
Mr. S. J. Chander from Community Health Cell (CHC) was involved in some of the field visits.
We thank him for his contribution to the study.
We specially wish to thank Prof. D. Banerjee, Dr. C. M. Francis, Dr. Rayi Narayan, Dr. Daisy
Dharmaraj, Mr. Poddar, Dr. Sampath Krishnan, Dr. Venkateshwara Rao, the staff of Department
of Health and Family Welfare, Government of Karnataka, the staff of National Institute of
Communicable Diseases, Delhi and from the National Filarial Control Unit, who greatly
contributed to this Study by their inputs. A host of other Government officers too contributed
their valuable time and provided information. We thank them for their support.
We greatly appreciate the efforts being made by WEMOS to work on GPPIs and health. Mr. Jose
Utrera and everyone from the WEMOS team were very supportive during the process of the
Study. We thank them for their support and co-operation.
Mrs. Noreen Hoskins and Mrs. Deepu Shailaja helped in secretarial assistance, compiling and
filing the various materials related to GPPI and in the final preparation of report. We thank them
and the accounts and office team of CHC for their valuable assistance.
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October 2004
Dr. Thelma Narayan •
Mr. Naveen I. Thomas
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4
EXECUTIVE SUMMARY
; ;GPPIs
’ may 'be good,‘ the
' 5 case study the Global Alliance to Eliminate
While the intentions of
Lymphatic Filariasis (GAELF) raises many questions. GAELF has been driven strongly by a
very
try small group of international players. Even at the global level there is unevenness between
WHO and the companies on the one hand and national government representatives on the other.
The possibility of getting some additional funds and technical support may override other factors
in decision making. On one hand GAELF helped to bring the issue of filariasis back on the
health agenda of the government, however on the other hand, the means advocated by the
Alliance are debatable.
Some of the other arguments against the GAELF are that, there appears to be a decline in the
mf+ve prevalence rate over time in India. Therefore, before embarking on an ambitious and
expensive Mass Drug Administration Programme, the risks and benefits of this approach needed
to be carefully considered. Secondly, problems of much wider public health significance such as
anaemia, under-nutrition of under-fives and low birth weight are not even addressed. Access to
mental health services and rehabilitation is extremely limited. Hence prioritisation was necessary.
A proper costing of the MDA approach was required — not just of the drugs but of the entire
exercise. The filariasis control programme, with MDA as a one-stop solution has turned out to be
programme-oriented approach, rather than a community and person-oriented one, which has
resulted in the lack of ownership and participation of the community. The programme has also
turned a blind eye to the needs and problems of the people who are already suffering from
filariasis. In addition, vector-borne disease would continue to exist as long as mosquitoes were
around. The GPPI has unfortunately only concentrated on providing drugs as the solution leaving
the cause untouched. The Government machinery at the field level was not involved in planning
and designing of the MDA activity, which affected the planning and implementation. The co
administration of Albendazole with DEC has been resisted by senior officers of the Government,
and a recent Cochrane review also has reportedly not shown any positive effect of adding
Albendozole to DEC. GAELF is making the two-drug regimen conditional to any support even
for a research study, raising the question of its own interests — in filariasis control or in its major
partners. One of major problems of the drugs is the anaphylactic shock experienced by some
people who take the drug, due to the microfilariae present in their body. It is also known to be
teratogenic in early pregnancy. When a drug administration is done on such a mass scale, it would
be difficult to identify women in their early stages of pregnancy. Some of the other problems are
related to lack of choice, adverse impact on the public health system, poor implementation
thereby defeating the purpose, dug industry manipulation, questionable partnership and lack of
accountability
Some of the key recommendations are that, following the WEMOS study of GPPIs in the health
sector, it is important to have a presentation and discussion with key decision-making staff from
across the World Health Organization. The process of discussion, debate and dissemination of
research findings should happen among all stakeholders at international and national levels. A set
of core values need to be identified and made widely accepted as a framework for global public
po.licy action, including strengthening community participation, respect for local health traditions
and systems of medicine and respect for the basic human right to health and health care. The
public health systems needs to be strengthened with local capacity building for public health.
Increased research and advocacy on GPPIs in health is required. There is a need for greater
openness towards alternative approaches .to public health problems with affirmation of diverse
locaUolutions.
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PART I
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1. INTRODUCTION
The past few years have seen a rapid rise in the number of Global Public Private Initiatives
(GPPIs) in the health sector. This policy phenomenon has grown dramatically in order to
.reportedly address major public health problems particularly in the so-called developing
world or the South countries. GPPIs have been characterized by WHO as a means .to bring
together d set of actors for the common goal of improving the health of populations based on
mutually agreed roles and principles. This sounds quite harmless, but may be simplistic and
misleading. Some consultative process between major actors have taken place in the GPPIs
studied. However consultations have been fairly restricted to a small circle of international
players, that include WHO, multinational companies, other multilateral agencies, major
foundations, and some representatives of government. All this has occurred for the sake of
the public good. However, participation of the public and public health’ professionals and
implementers has been remarkably low or absent. There is an inadequate evidence-base to
suggest that this new policy-approach being applied on such a large scale results in positive
or intended impacts. There was a need to know the effects of this policy-approach on the
public health problems that are being addressed; on the health systems through which they
function; and on the health rights of people particularly the poor. An inter-country
collaborative study was initiated by WEMOS to fill in this gap.
While the intentions of GPPIs may be good, the case study the Global Alliance to Eliminate
Lymphatic Filariasis (GAELF) raises many questions. GAELF has been driven strongly by a
very small group of international players. Even at the global level there is an unevenness
between WHO and the companies on the one hand and national government representatives
on the other. The possibility of getting some additional funds and technical support may
override other factors in decision-making. Doubts about inadequacies of the technical
component of the approach were muted and even dismissed. The capacity of national health
systems to undertake such an exercise was.not adequately thought through. Dissent was not
seriously considered. A variety -of methods were used to influence decision-making.
Consequently a narrowly focused, rigid, vertical, top-down, strategy was adopted.
The positive-impact of the Global Alliance to Eliminate Lymphatic Filariasis (GAELF) was
that it has helped to bring the issue of filarias is back on the health agenda of the government.
However the means advocated by the Alliance was debatable.
There has been a long-standing debate on the use of Mass Drug Administration (MDAs) to
tackle the problem of filariasis. The wisdom in using the drug on such a mass scale has been
questioned in various forums, and in public debates generated by the government s plan to
introduce MDA. Another issue that has come up under public scrutiny is the introduction of
Albendazole with DEC. The public debates have brought out a lot of issues concerning denial =
of rights, due to implementation of the GAELF supported filariasis control programme. Some
of the key rights denied are the Right to Life, Right to Know, Right to Informed Consent and
the Right to’Health Care. The denial of these rights affect decision-making at all levels. In
addition, the programme also has an impact on the local drug industry' and functioning of the
public health system.
Some of the other -problems identified by this study questions the very nature of the
partnership. The partnership is seen to be only a theoretical one, where the coalition is too
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diffused and the partners highly unequal so to bring any meaningful interaction. The
deficiency in the partnership process has caused the programme to be context-blind,
programme-oriented and lacking in accountability.
2. OBJECTIVES
General Objective: To study the influence of the Global Alliance for the Elimination of
Lymphatic Filariasis on the National Filariasis Elimination Programme in India and its
implementation in selected sites in Karnataka, with particular reference to the fulfilment of
the Right to Health and Health Care of people, particularly the poor.
Specific Objectives:
)
1. To study the content, organizational structure, financing and operating mechanisms of the
GAELF and the National Filariasis Elimination Programme in India.
2. To study its linkages with the general health services and primary health care in
Karnataka state.
3. To study its implementation in selected districts of Karnataka .with a focus on access,
equity and sustainability, and a special focus on those in need of care.
4. To study all the above, using a framework of the right to health and health care as
enshrined in international covenants and in the Indian national constitution and legal /
ethical guidelines.
,.
5 To identify conflicts of interests if any, and to identify how they are mediated /
negotiated.
3. METHODOLOGY
1.
2.
3.
4.
5.
6.
7.
)
)
)
Participation in two workshops for synchronisation of concepts, methods to be used and
discussion on preliminary findings.
The health and health care situation in India and Karnataka was outlined through updated
secondary sources of information / data.
A policy analysis of GAELF and the National Filariasis Elimination Programme was
done through interviews and a study of documents.
The implementation of the programme at the state level was studied by field visits to
health institutions in the periphery (Sub-Centres, Primary Health Centres and Community
Health Centres) wherein discussions were held with providers, patients and the
community. Discussions / interviews were also held at the taluk, district, state and
national programme unit and with other officials at the Directorate of Health Sei vices.
Document review and interviews were done at the national level and with experts from
the Vector Control Research Centre, Pondicherry. Health system professionals from
academic institutions and NGO resource centres were interviewed. Links were
maintained with the ongoing Right to Health Care Campaign of the Jan S^-asthya
Abhiyan (People’s Health Movement in India)
The methodological tools, guidelines and framework of analysis used by other
participating countries and organisations for the GPPI study were utilised.
Principles of Research Ethics were maintained.
■a It»
. I
CHC
First Draft
Grey Literature Review on CPHC
) Draft Synthesis of grey literature from select Asian countries about Comprehensive Primary
Health Care (CPHC) experiences
n
1. Introduction:
D
yi. Paragraph on overall project (to be provided by Ottawa ^tub^
Obis paper provides a narrative synthesis of literature pertaining to Comprehensive Primary Health
Care (CPHC) experiences in select countries of Asian region. Totally 77 studies (See Annexure.No.l.)
pertaining to CPHC experiences of 12 countries (Bangladesh, India, Indonesia, Iran, Lebanon, Nepal,
^man, Pakistan, Philippines, Sri Lanka, Thailand and Vietnam) including 2 studies pertaining to
'CPHC experience of multiple countries of Asia that met the inclusion criteria of our research analytical
Damework are included in the review process. Out of the allotted 14 Asian countries, the present study
does not cover experiences in 3 allotted countries (Bhutan, Malaysia and Palestine) and includes a
^Audy on one country (Oman) which was not in the original list of allotted countries.
Q.
Methodology for the review process:
‘fhe studies for the review and narrative synthesis were drawn from two sources and undertaken by two
(•Jifferent teams:
1. Grey literature review undertaken by team at Community Health Cell (CHC) based in
Bangalore in India
2, Published and indexed literature review undertaken by the team at Flinders University and
i)
South Australian Community Health Research Unit, Australia
21. Search strategy:
.
O
1.
The CHC had agreed to undertake a review of grey literature on CPHC experiences in 14 countries in
Oie Asian region. Information was collected about health programs and projects in the 14 countries that
used or were using ‘‘Comprehensive Primary Health Care (CPHC)” approach in their work using the
following methods:
of the books, articles, academic and non-academic periodic and non-periodic
3 1. Review
publications and unpublished materials in the library of CHC
inventory of contacts of people and projects working on CPHC was prepared based on more
u 2. An
than 25 years of rich and long networking experiences of Dr.Ravi Narayan and Dr.Thelma
Narayan. An e-mail request was sent out to the organizations and individuals with a request for
3
materials from their projects for the review process. Remainder emails were sent and follow-up
telephone calls made to non-respondents thrice during the study period (June 2007 to May
2008). Leads on further contacts provided by the originally contacted people were also
followed up.
.
3. An e-mail request for literature on CPHC experiences was also sent out to people who had
agreed to be regional/country resource people for the project and listed in the project proposal
as researchers, research users and institutions.
Q
□
^Tie team based iin Australia undertook the published and indexed literature review using the database
India, Bangladesh, Bhutan, Nepal,'Pakistan, Sri Lanka, Lebanon, Palestine, Iran’ Philippines, Indonesia, Malaysia,
Thailand, and Vietnam
3
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.4 1
Grey Literature Review on CPHC
First Draft
CHC
provided by the University of Ottawa (912 references).
(
PJ
2.2. Inclusion and exclusion of the studies in the review and narrative synthesis:
The grey literature review till date includes materials obtained from the above mentioned process, noplater than May 2008. During the Level-1 of grey literature review;process, the title and abstract^
(whenever available) reviews was undertaken using the research analytical framework provided by thd /
U liversity of Ottawa. The final selection of the articles for full review was based on the information
obtained from the abstracts/title depending upon the set criteria. The studies/documents identified ai
meeting
eeting the research inclusion criteria in Level-1 were included in the full text review process i.e/v
L|vel-2 of the literature review process. Finally, 35 studies were included in the full text review (See
Annexure No. 1.)
from the original published and indexed literature database of 915 articles, a total of 42 articles mel*
the set criteria of Level-1 and were included in the Level-2 of the literature review process. 11 of these
42 were commentaries and did not qualify for inclusion into narrative synthesis. (See Annexure No.2.).
In total, 77 literary pieces covering CPHC experiences of 12 countries (see TableNo.l.) were reviewed
using analytical framework of the project. 66 of the reviewed 77 studies contributed to this narrativO
synthesis and 11 studies that were commentaries were excluded from the narrative synthesis (See
Figure No.l).
I
(
Table.No.l. Country of studies included in the review
Indexed
Total
Literature Review Studies
_______ 2_______
6
26
_______ 11
4_______
7_
Iran
Grey Literature
Review
4
15
3
_______ 4
|
Lebanon
1
________ 0_______
Multi-country
Nepal
Oman
Pakistan
1
' 1
3
1 •
________ 3_______
________ 0_______
________ 8
________ 2_______
4
1
11
2
Country
Bangladesh
India
Indonesia
Philippines
________ 2
<
a
6,
1
1
Sri Lanka
1
________ 0
1
Thailand .
1
5
6
Vietnam
1
4
5
Total Studies
35
42
77
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12^
CHC
First Draft
Grey Literature Review on CPHC
)
Figure No.l. Steps of literature review
a
^GREY LITERATURE REVIEW
INDEXED LITERATURE REVIEW
Level 1
<0 Review of titles and abstract using
I
research analytical framework
Level 1
Review of titles and abstract of
published and indexed literature
database using research analytical
framework (n=915)
A
?
r
13 Studies not
!
matching set
i
criteria
zx_
±
Studies
matching set
criteria
Studies not
matching set
criteria
Level 2
No further
analysis
.
Studies
matching set
criteria (n=42)
3
J No further
I.
□
analysis
Full review of the literary
papers using research
analytical framework
(n=35)
Level 2
■ . Full review of the
studies using research
analytical framework
(n=42)
3
t)
Studies
that are
commentaries
(n=ll)
3
O
□
3
□
Q
No further
analysis
1
NARRATIVE SYNTHESIS
(n=66)
3
5
J
3
-“3 -
Studies
•other than
commentaries
' 0=31)
Z
Grey Literature Review on CPLiC
First Draft
CHC
i I
t
2.3. Limitations of the reviews undertaken:
S'
Any research into the effectiveness of CPHC is a monumental process owing to the diversity of the
understanding and practice of CPHC and we are certain that we have not included all relevant an
appropriate literature on CPHC in this review process. The practice of CPHC is more common than
that is reported. Formal documentation of the effectiveness of CPHC programs is not very commd
and many of the published literature are not widely available. Furthermore, many CPHC programs a^
more practice oriented than research oriented, evidenced by their reporting mechanism. In addition^
many reports are published in local languages which further limit the already meagre number
studies on CPHC initiatives available for review process. Moreover, many CPHC initiatives have beer,
reported as “slices” rather than “whole” posing immense challenge in integrating the various reports c*
the same initiative to obtain the whole picture compromising the process of drawing lessons learnt
Also, there are no databases containing a comprehensive documentation of CPFIC publications limiting
the review process. The whole review process is further complicated by the immense complexity of tb-^
interventions involved and the dearth of research methods to adequately conquer the complexity o
both the process and outcomes of CPHC initiatives.
Besides, grey literatures on CPHC do not exactly qualify as research studies with rigorous study desi^
and systematic analysis. Hence, they are more qualified to be known as reviews. Even though many oj
the country’studies are classified as “narrative synthesis”, they do not fit exactly into the framework c-«
“narrative synthesis” in the way it is defined currently. At the same time, it appears that there has be|
a dearth of research studies on CPHC post 1980. In addition, it looks like most of the studies have been
undertaken in severe resource, time and trained human resource constraints leading to compromise fstudy methodology. As a result of all these factors, the robustness of the evidence and therefore tl;
interpretation and the analysis vary. Additionally, full review of all the CPHC literature available
CHC team was limited by time and human resource constraints.
Moreover, the indexed literature review was faced with the challenge of finding relevant articles on CPF&
within the scientific literature database, as most of the interventions reported were highly selective P&
(SPHC) interventions. The articles that had some relevance to this research project seem to be publish
nhostly in the period from mid 1990s to now. We speculate that the relative absence of scientitic article.'
describing the whole CPHC programs seem to have been limited due to the constraint of word • limit A,"
absence of a dedicated journal for reporting CPHC.
As a result all the drawbacks mentioned above, the literatures that have been included may possib1'
provide a partial view of the available evidence. Nevertheless, we are confident that this review 11
been able to capture a relatively comprehensive and robust evidence of CPHC effectiveness within
limitations mentioned above.
(
■ However, it should also be borne in mind that there are varied forms of knowledge generation and the
grey literature chronicles real life experiences in a rich text format from which there are import,
lessons to be given to the world.
V
It as also appears that there is lack of adequate development of research methodologies on GPHC a
lack of political will and financial resources that have hampered the full implementation of CPHC a!
have affected the development of research methodologies. AVe dare say that the practice of CPHC
movedfar ahead compared to the research of CPHC. One of the roles of research to inform policy a
practice can therefore be questioned. This provides an opportunity to develop newer research metH
■
■
.
.
r
-4-
C
CHC
First Draft
Grey Literature Review on CPHC Jnd also closer links between practitioners, people, policy makers and researchers. This may improve
(fhe potential synergy between research implementation that would help accelerate the achievement of
the “health for all” goal. There is a vast research gap between policy and practice of CPHC and
jsearch into this important area. Lack of research funding and low priority by policy makers and
national research bodies may also be a reason for the limited research conducted in CPHC in the Asian
Tegion.
Qur grey literature review experience of CPHC in Asian region has some important lessons for us
-namely:
> It is a time consuming, labor intensive but worthwhile process to collect widely scattered and
little known but important studies and reports that are not indexed
O
> Persistence and rich networking are of prime importance in collecting grey literature
3 > The studies and reports in the grey literature arena often use a mix of methods and analysis
process in field conditions and hence may not follow rigorous scientific, quantitative evidence
collection methods
Many of the valuable experiences regarding CPHC, especially the experiments by
NGOs/CSOs as well as overview of country experiences, that have not still entered the indexed
literature domain or internet domain, have rich and valuable lessons to inform the practice q>f
)
•CPHC in the world. Hence, grey literature review must be an integral part of any exercise jn
o
synthesizing evidence on CPHC
> There is a need to further develop and refine research methodologies to study CPHC as a
3
■strategy to work towards “Health for AU”
> Grey literature, offers better possibilities for reporting “whole CPFIC” initiatives since it is Jrt
constrained by the “length limit” and “evidence only” policies of peer reviewed journals. We
found that grey literature is much more comprehensive than journal articles in terms of
O
covering. CPHC initiatives in their “wholeness” including contextual factors., full description
3
of the CPHC intervention including experiential narration which id often very rich and
valuable but by-passed in the peer reviewed journals
‘o
Brief history ofCPHC in Asia:
-The Asha region has a long and rich history of efforts to develop pro-people and community based
health carehystems which relates to freedom struggle of Asian countries from their colonizers. There is
Qi a way an aspiration of Health for All as articulated in .Bandung Conference in Indonesia in 193 6,
Sokhey Committ^report (a sub-committee on Health of the plaiming committee of Indian National
-Conference formed iKanticipation of Independence from colonizing British) in India in 1939 and
^hore Committee report hr^ndia in 1946. Furthermore, many NGO programs like Deenabandhupuram
project started in South. Indiadnl 946 were fired by similar, aspirations and tried to actualize it locally.
Jn addition, NGO led Jamkhed Cbnrprehensive Rural Health Project (CRHP) in the'Maharashtra state
of India started in 1970 and one Indoheman project in central Java run by Dr Gunawan Nugroho were
Matured in “Contact”, a bimonthly publication of the Christian Medical Council of the world council
of churches based in Geneva, in the 1970s''as, pioneering community health projects. The Jamkhed
-'-CRHP was also featured in the landmark publication “Health by the People” edited by Dr Kenneth N.
jJewell.inJ972, which greatly influenced the 1978 Alrha^Ata conference and declaration.
(Jfhe early articulations (e.g. Bandung Conference 1936, Bhore'Goinmittee 1946) were broad in scope
and aspirational. They linked health to development, saw the gaps in'health care and saw the need for
Community based care. They evolved in response to the situation with severe resource constraints
_^human, material and financial) and were based on the available knowledge and-technologies at the
< '
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> Research for change
Just listen: research and activism
can walk hand-in-hand
The goal of Health for All is underpinned by health systems
research, but the subject is still ignored, says Ravi Narayan
Completing his three-year term as.co-ordinator of the Global Secretariat
of the PeOple's;..Health :Movernen’t - before it-moves.to the MiddleiEast - .
activist researcher Ravi Narayan, a member of the Foundation Gbuncil of
> RHN: Can you first tell us a little of
your background?
RAVI NARAYAN: In the 1980's, after
WHO’s 1978 declaration of Health for
All by the Year 2000 at Alma Ata, many
■ people were working for Health for All;
but NGOs, government, and researchers
were all boxed up in their own little
worlds, not talking-to-each other, not
affecting each other.
So four or five of us in Bangalore, Indiastarted the Community Health Cell
(CHC) - now the functional unit of the
Society for Community Health Aware
ness, Research and Action.
It's a multidisciplinary group of profes
sionals, based initially in Bangalore, but
now in many parts of India. We all.
helped to build an interface between
these three groups - NGOs, govern
ment and researchers - and amongst
other things we built a People's Orient
ed Health Movement in India.
Some of my colleagues and I were very
deeply involved the first international
People's Health Assembly in Bangla
desh in 2000, and I was invited to con
tinue to build such coalition in other
places since 2003. That explains to
some extent even my role now on the
Foundation Council of the Global
a J0f**
Ravi Narayan leading the People's Health March
at the Second People’s Health Assembly at
Cuenca, Ecuador, 22 July 2005 - carrying the
banner of the local Ecuadorian National Health
Committee.
Forum for Health Research: my con
cern is to build linkages and dialogue.
> RHN: You were also Professor of
Community Medicine in Bangalore,
and an Overseas Lecturer for the Lon
don School of Hygiene and Tropical
Medicine. What research did you pur
sue?
RN: Well.I was very involved with some
pre-Alma Ata primary health care strate
gies - health coopeTatives - and also in
the tea plantation, communities’of
G
c
o
South India. There we e/olved some
thing called the comprehensive labour
welfare scheme.
These experiences and ideas con
tributed to.primary health care thinking,
and made the Indian Government very
enthusiastic about being a signatory of
the global Alma Ata Declaration when it
came about in 1978. We had started all
these in 1974, so we felt very endorsed
.by the Alma Ata declaration itself.
> RHN: So these were effectively
action research projects, were they?
iW !
a
a
RN: Yes, this was action research. We
ran India's first health cooperative
which was when we transplanted a
health function to a milk cooperative in
rural India, in Karnataka. The Indian
Council of Medical Research selected it
as one of the 14 alternative approaches
to health care in 1976.
The second thing that I did was to set up
a small occupational health unit, which
focussed on agriculture. I did a very
large study on tea plantation workers in
South India, looking at potential occu
pational hazards. It was probably one of
the largest studies on agricultural communities in the world.
Tea plantations are geographically
well defined, so one can study health
system development and epidemiologi
cal needs in a closed community.
So they're ideal for research; but they're
also very useful and constructive,
because you're dealing with the planta■ tion management - and by giving them
evidence of what is happening you can
try and build health systems -.hat are
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more responsive to the needs of planta
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At CHC we also researched TB in a very
(3
3
tems research and social determinants
• research in all health programmes.
disadvantaged part of our state, looking
> RHNrVour . research
at the social determinants and the
health system issues that were making ■
connected with pressure for change.
the TB programme unsuccessful.
seems
closely
RN: I am an activist researcher. I am
concerned about two global trends
The world was then moving to the
O
ties, I will try and push for health sys
which I feel at present seem counter to
new approach called DOTS - directly
the whole issue of looking at social
observed treatment, short-course. But
determinants and health systems and I
in the social milieu of India, particularly
hope the Global Forum in Cairo in Octo
in the disadvantaged rural areas, with
ber will help to shift the balance a bit.
our health systems being as they are,
we felt DOTS would not be adequate.
One is that donor funds still look at TB,
It was too biomedical and techno-man
malaria and HIV/AIDS as single vertical
agerial.
disease programmes. And no doubt they
are very important diseases but if you go
3
Our study was done by Thelma Narayan,
a little behind them, all three of them,
present.y the Coordinator of the. CHC,
you find health system issues and social
O
and presented at the Global Forum for
determinants, which are cross cutting.
3
9
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9
Health Research in Tanzania in -ZOO?,
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9
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positions...
> RHN: I see, that is the point.
strategies or equity, gender, stigma or
RN: There is a reason for that. There is
poverty or whatever, they affect all
three and it's important for the donors
also to allow for projects that look at
cross cutting, health system and social
nants, TB programmes would not really
determinant themes'rather than individ
increasing evidence all over the world in
a lot of research, which is at present is
not mainstream, but marginal, some of
it from respected academia, not all from
People's Movements and Civil Society
ual disease or health problems.
campaigns, that the existing vertical top
. get far.
down single disease strategies don't .
We're quite thrilled with the fact
We hope that the WHO Commission on
that health systems research has now
Social Determinants of Health will make
became a very important theme of the
a breakthrough on that.
And they don't work because these
larger determinants h'ave not been
The second trend is that there are
looked at adequately. And even groups
like World Bank regularly generate data
on these issues but sometimes tend not
to use them.
WHO - and I was honoured to be a
member of its Task Force on the topic.
We felt that in recent years some.of the
early research that we'd done, which •
mainstream research had now become
groups like Gates Foundation who still
are looking for drugs and vaccines and we've been trying to suggest that
work.
existing drugs and vaccines that we
have, and good ones at that, don't
. reach the people they are supposed to
Now health systems research and social
reach. And so there's absolutely no
determinants research are well recog
nized - and now we have a whole
WHO Commission on Social Determi
nants with which many of us are also
guarantee that you will be able to
reach them with the new ones unless
working closely.
spent on finding why existing drugs
some of the funds, 10% maybe of the
money, spent on research, is also be
The CHC basically focused on public
9
able evidence, not just as ideological
social, economic, cultural and political
factors that determine the success of
the TB programme. And we felt that if
biomedical researchers don't look at
health system issues and social determi
and vaccines don't reach the people.
o
look at social, economic, political and
cultural determinants also as research
So whether you talk about development
mainstream.
9
RN: Well, I think that's only partly true
and I tell you why I say that. We need to
where we showed a whole range of
was considered in a way marginal to
O
Speaking at the welcome ceremony to the
People's Health Movement In Canar, Ecuador,
before the Second People's Health Assembly.
For example, the World Bank has
enough data to show that user fees
don't work anywhere, if you use access
for poor people as an indicator. It's
maybe very good for a health system to
generate some funds but if you use that
as an obstacle for poor people to access
whatever you want to distribute or pro
vide, it's definitely not a good idea.
So what would we call this? Economic
health challenges and their social deter
> RHN: Right, I understood. But let me
minants and the health systems needed
be devil's advocate. Isn't the principal
feel researchers must look at all the data
to address them. So you can understand
factor in this failure to reach the
and use the Cochrane Foundation type
why we are so thrilled with what's now
needy really political and economic?
happening at an international level —
and as a Global Forum Foundation
It's not so much to be challenged by
research, as to be challenged by polit
ical and community action.
of approach asking, is there really evi
dence? [See "South African Cochrane
Centre", this issue pp 28-9].
continued on page 24 >
Council member and in other capapi-
evidence or an ideological position? I
I
8MW
> Everybody is also pushing public-pri
vate partnerships. There is no evidence
than that public private partnerships
support primary health care or public
.health goals. So why are we pushing a
major policy shift in this direction?
Where are public health programmes or
primary health care programmes which
are public-private partnerships, and
which are working towards the Health
for All goals? Because when you get pri
vate sector coming in with a profit
motive, it will shift priorities.
I feel in some of the new official roles
I'm going to play, in the Global Forum
Foundation Council, the Public Health
Foundation of India, and on the Editori
al Board of the British Medical Journal,
I'll be able to provide or locate this sort
of evidence - and to use hard evidence
to challenge the system. So it's not only
the strength of people on the streets, or
people demanding health for all as a
right - but evidence that is also today on
our side.
>RHN:That's the point you were mak
ing at the Global Forum in Mumbai in
2005 and I was very struck by that. But
what do you mean by saying that this
research is somehow not mainstream?
Where is it being published?
1
RN: Well, it is being published, as reports
by organisations, or in journals, but only
oh the sidelines. Let me give you one
example. Some years ago I was asked by
the Karnataka government, because
they set up a health task force in the
state, to look at externally funded proj
ects. I looked at a combination of about
12 externally funded health projects.
Karnataka, as you know, has a 55 million
population, about the same as the UK.
I’il use hard evidence to
challenge the system - so
it’s not only the strength
of people on the streets.
RAVI NARAYAN
that coming to a state with each fund
ing agency negotiating with the state
with its own evaluation procedures,
and its own schedules, the health sys
tem gets disintegrated. So most of it
is unsustainable, because there are
twelve systems rather than one inte
grated system.
Now this was reported and it helped
Karnataka government make a deci
sion. The 2001 WHO Commission on.
Macroeconomics and Health, chaired
by Jeffrey Sachs, had a group, which
looked at international funding, and
they know about my study. It is included
in the references - but unfortunately
they didn't take the recommendations
seriously, just mention it in the reading
list. If they'd actually gone into that data
they wouldn't have made some of the
recommendations they did. But groups
like the Global Forum for Health
Research, by facilitating researchers
with such data available in the annual
Forums, will slowly begin to change the
balance.
c
c
and your stress will come down that's
something you can sell.
So part of what you just asked was a
clue, that research in those fields is not
adequately funded because a lot of
our funding is now coming from
industry and we don't have independ
ent research from government bodies
and from other networks that will look
at health systems and social determi
nants. There's no money in that.
c
Another problem is that a lot of
researchers who understand health sys
tems often also do a loti of single dis
ease type of research - because that's
the way they can get some funds. And
then they go to meetings, which are
also single disease oriented.
So nobody is discussing health systems!
VVhereas if you actually went and lis
tened to a conference on malaria and a
conference on immunisation anc a con
ference on TB, you find all of them are
saying 'we are not able to transfer our
ideas into the field because of health
system issues, social determinants'. But
then they won't research it! rw h
C
o
c
Q(
>RHN:So there may be two issues
there. One may be that there's not a
critical mass, as such, of research and
another might be that it's being
ignored for ideological reasons?
There were World Bank-, DFID and
UNICEF programmes in TB, malaria and
other diseases. The study looked at
what these externally funded projects
did to government health systems.
We asked, through a participatory,
interactive process: what do they do to
sustainability and integration? Two
very important issues.
RN: Yes - I think they both are impor
tant. One is that most of the money is
getting more and more linked to indus
try, and industry wants products, they
don't want processes - which they can
not own at some time and sell in some
way. Now I understand that that's the
way drugs and vaccines will develop.
But if you say after studying noncommunicable disease, that what you
have to now do is to change people's
lifestyles, you can't sell that easily. At
the most you can produce a little manu
al on healthy living or something.
My study showed that vertical pro
grammes, when you have twelve like
But commercially that's a bit limited,
whereas if you say that you take this pill
.;..aeblei!nq.;healt^r3nbvthPV«<
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Pushing the international health research agenda towards
equity and effectiveness
7)°4; 364:1630-31
David McCoy, David Sanders, Fran Baum, Thelma Narayan, David Legge
r.as Health Movement,
Zo'^munity Health Cell,
».ore, India (D McCoy,
'S, F Baum, T Narayan,
DLegg?)
Despite substantial sums of money being devoted to
health research, most of it does not benefit the health of
poor people living in developing countries—a matter of
concern to civil society networks, such as the People’s
Correspondence to:
orDavidMcCcy
Health Movement.1 Health research should play
1
,.^xyx.demon.co.ulc
influential part in improving the health of poor people,
not only through the distribution of knowledge, but also
by answering questions, such as why health and health
care inequities continue to grow ,
2^
increased global wealth, enhanced knowledge, and more
J
effective technologies.
Previous Editorials in this journal, and other reports,
o
J______ -1______ J
o
3
9
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9
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9
o
1 -
1
1
.
.1
.
*•
that the 10:90 gap—whereby only 10% of worldwide
health research funds ;are allocated to the problems
responsible for 90% of the world’s burden of disease,
mainly in poor countries—needs to be reversed. Second,
that greater emphasis should be placed on research in
the social, economic, and political determinants of ill
health, relative to clinical and biological research. Third,
that tire barriers to the transfer of knowledge from
research
bee overcome.
The W into
Tn policy
P r and
7 practice
PlaCtlCe need to
t0?
OVerCome'
The 10.90 gap largely represents a fiindmg gap shaped
by commercial interests, and inadequate funds being
provided through the public budgets of poor countries,
development assistance grants, charitable foundations,
and non-govemment organisations who have an interest
and a mandate to invest in public or non-commercial
SS oTpaoTpeO0npTteted “ addreSSing
applied to the question of why the cancellation of the
odious debt of many poor countries has not been
forthcoming, why many rich countries’ development
assistance still falls short of the UN’s 0-7% gross
domestic product target,8 and why bilateral and
multilateral
trade agreements continue to be
unfavourable and even punitive towards the poorest and
sickest ‘people. Third,- ----------------moreIJresearch
is needed into the
X4UCV4CV1 111LO me
deS^n and fina?cillg °{systems and basic services and
into how these factors determine access to good quality
care and other health inputs (eg, water and adequate
nutrition). As health systems become increasingly
effects of the liberalisation, segmentation, and
commercialisation of health-care systems is essential.
These three points complement the call for more
research on why available and affordable technology and
knowledge are not used, for example, to prevent millions
of children from dying of diarrhoeal disease and acute
respiratory infections. Appropriate research- would
mmwic
me maimy
indicate now
how the
mainly social
social and
and political
political barriers
barrii to
^Plication of existing technologies might be overcome
application
This achievement could be aided by country case studies
J ‘
’•
7
that combine an analysis of the political economy of
poverty and ill health together with the health systems
factors that help or obstruct access to effective health
care. Such research would bring together political and
____
social scientists, uu<um
health cLuuiMmsrs
economists, public health
pr:feSSiOna13society organisations.
To promote the transfer of knowledge from research
Part of the solution to'addressing this overall deficit in into policy and practice, several issues should be
funding includes continuing with current efforts to
examined. Presently, there is a research culture and
increase development assistance, hasten the cancellation
incentive system that encourages researchers to be more
of unfair debt and reform unjust trade structures. But
concerned with publishing their results in academic
we also need creative thinking and bold action around journals than with ensuring that their research leads to
new proposals, such as raising funds through an improved policy and practice. Furthermore, policy
international authority that is able to effectively tax makers and programme implementers in developing
global corporate profits,5 or applying levies against global countries are either sceptical about the value of research,
financial transactions (eg, the Tobin tax).6-7
or do not have the skills to appraise and use new
• With respect to research on the
f social, political, and information.9 The scarcity of capacity in the public sector
economic determinants of health, we draw attention to has been further aggravated by
steady brain drain of
three points. The first is the need for more research into
capable health professionals to richer countlies or from
the effects of globalisation on poor
j
’ ” and growing the public sector to the domestic private or non
health
health inequities, and on the development of proposals
government sectors (including the health research
to reform tlie current global, political, and economic sector).1®/
institutional order. In addition to research on more
These difficulties could be overcome by changing the
effective mechanisms for global resource redistribution, incentive system and allocating a greater share of health
research should focus on how health equity can be research funding to academic and non-government
protected from the market failures . of economic research institutions in poor countries that work closely
globalisation and __the__pperation of transnational with policy makers, health managers, service providers,
commercial interests. Second, we want more research and communities. This allocation of funding needs to
www.thelancet.com Vol 364 October 30,2004
ViewF--
f
be complemented with more investment in developing
research capacity within the health systems of poor
countries.
;/Research geared towards practical health systems
development is also often qualitatively different from
research that is geared towards the imperatives of
academia and the medical industry. For example,
research on the efficaq'- of interventions in a controlled
environment is different from that on the practicability
of applying effective interventions in the real world.
More action research that involves service providers can
help to bridge the gap between research and
implementation, and ensure that research is embedded
within the day-to-day realities and constraints of under
resourced health-care systems. The use of participator}'
research methods can also help poor communities
shape health systems to meet their needs.’1,11?
Research findings are also more successfully
implemented when researchers include mobilised
citizen constituencies.11 Successful implementation is
aided first by ensuring a vigorous community of civil
society organisations with a mandate to keep a watch on
health policy development and implementation; second,
by use of research funds to actively foster the capacity of
these organisations to change the commissioning and
priority setting for research; and third, by including civil
society organisations in research production and
encouraging partnerships that link them with academic
researchers.14
Finally, the imbalance in power between researchers
in rich and poor countries must be bridged. Many
academic and non-government institutions in more
developed countries benefit disproportionately from
the meagre research funds that are focused on poor
health in developing countries. This imbalance is in a
context where academic and research institutions in
leveloping countries are struggling to gain their own
funding and find it difficult to retain good staff.
Practical ways of addressing the inequities within the
•health research community might include mapping
out the distribution of research funds for health
problems between research institutions in rich and
poor countries, documenting the obstacles to the
development of research capacity in developing
countries and conducting in-depth case studies of the
health-research funding policies and patterns of
selected donor and international agencies.
Global conferences and summits on health research,
such as the two that are due in Mexico this November, by
themselves are unlikely to substantially affect the
challenges we present. The current pattern arid use of
health research shows the balance of prevailing global
power, perspectives, and interests. Redressing
the
imbalance
will
require
consciousnessraising, mobilisation, and pressure at many different
__ppbits in the global health research system and in
health-care systems more broadly. Pressure for change
c
■
'i*
#
c
i
n
i
e
Figure: People's Health Assembly rally, Dhaka, Bangladesh, 2000
will need to be exerted at all levels and by many different
actors. The Peoples Health Movement is committed to
being increasingly influential. .
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
•D McCoy was funded by the Global Equity Gauge Alliance to attend a
WHO consultation on health research that contributed to the final
production of this article.
References
I
Peoples Health Movement http://www.phmovement.org (accessed
Sept 21,2004).
2
The Lancet Kickstarting tire revolution in health systems research.
Lancet 2004; 363:1745.
3
The Lancet Mexico, 2004: research for global health and security.
Lancet 2003; 362:2033.
4
Global Forum for Health Research. 10/90 report on health research
2003-2004. Geneva, Switzerland: Global Forum for Health Research,
2004. http://www.globalforurnhealth.org/pages/index.asp (accessed
Sept 21,2004).
5
Tax Justice Network. Declaration of die Tax Justice Network, 2003.
http://www.taxjustice.net/e/e_declaration.pdf (accessed Sept 21,
2004).
6
Stecher H. Time for a Tobin Tax? Some practical and political
arguments. Great Britain: Oxfam, May 1999. http://www.oxfam.
org.uk/what_we_do/issues/trade/downloads/trade_tobintax.rtf
(accessed Sept 21,2004).
7
Michalos AG Good taxes: the case for taxing foreign currency
exchange and other financial transactions. New York: Duncan Press,
1997.
8
Labonte R, Schrecker T, Sanders D, Meeus W, Fatal indifference: the
G8, Africa and global health. Cape_Town: University of Cape Town
Press, 2004.
9
Lomas, J. Using Linkage and exchange to move research into policy
at a Canadian Foundation. Health Affairs 2000; 19:236-40.
10 Padarath A, Chamberlain C, McCoy D, Ntuli A, Rowson M,
Loewenson R. Circulation or convection? Following the flow of
health workers along die hierarchy of wealth. EQUINET: Network for
Equity in Health in Southern Africa, 2003. http://www.gdnet.org/cf/
search/display.cfm?search=GDNDOCS&act=DOC&docnum=DOCl
2980 (accessed Sept 22. 2004).
II Winter R, Munn-Giddings C. Action Research as an approach to
enquiry and development. In: A handbook for action research in
health and social care. London: Roudedge, 2001; 9-26.
12 Martin K, de Koning K, eds. Participatory research in health: issues
and experiences. London: Zed Books, 1996; 1-18.
13 Minkler M, Wallerstein N, eds. Community-based participatory
research for health. San Francisco: Jossey-Bass, 2003.
14 Sanders D, Labonte R, Baum F, Chopra M. Making research matter:
a civil society perspective on health research. WHO Bulletin
(in press).
G
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6
TOWARDS AN APPROPRIATE
MALARIA CONTROL STRATEGY
Issues of Concerns and Alternatives, for action
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The Expert Group and main contributors:
i.
Dr. Ravi Narayan, MD, DTPH (London), DIH (UK), Coordinator/Secretaiy, Community
Health Cell, Society for Community Health Awareness, Research and Action, Bangalore.
2.
Dr. P.N. Sehgal, MBBS, DPH, FISCD, FAMS, Consultant, Voluntary Health Association
of India, New Delhi, ex Director National Institute of Communicable Diseases, Government
of India.
3.
Dr. Mira Shiva, MBBS, MD, Head, Public Policy Division, Voluntary Health Association
of India, New Delhi.
4.
Prof. Amitabha Nandy, MBBS, DCP, MD, Department of Parasitology, Calcutta School
of Tropical Medicine, Government of West Bengal, Calcutta.
5.
Dr. Rajaratnam Abel, MBBS, MPH, Head, RUHSA Department, Christian Medical
College & Hospital, Vellore.
6.
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Dr. Sunil Kaul, MBBS, AVARD-NE, (Association of Voluntary Agencies for Rural
Development - North East) Jorhat, Assam.
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Voluntary Health Association of India
40, Institutional Area, South of IIT,
New Delhi-110016.
Society for Community Health Awareness, Research and Action,
Community Health Cell 367, ‘Srinivasa Nilaya’, Jakkasandra,
1st Main, 1st Block, Koramangala, Bangalore-560 034
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24.
MALARIA RESEARCH CHALLENGES
3
The National Task Force on Revised Strategy for control of Malaria (1993) has reiterated the
‘ -’importance of Research back up for Malaria control and has recommended that “Need based laboratory
Qand field research directly linked to local demands for malaria control activities, generated by district
micro plan should be supported at the national and regional levels.”
Olt then highlights areas of research which include epidemiology, chemoprophylaxis and antimalarial
treatment, clinico parasitology, entomology, parasite characterization, socio-medical aspects of malaria,
Ofield operational research and health services research. It also highlights specific issues in each
ir^of these areas and suggests some initiatives to build this dimension of malaria control strategy further
We fully endorse these recommendations and feel that a much more concerted and serious effort
,-.must be made to operationalise the comprehensive suggestions. However, we have some concerns
■ and suggestions that would reinforce the recommendations of the task force and perhaps complement
.it as well.
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24.1 National Malaria Research Network
First, we recognise and appreciate that researchers in institutions like MRC and its
field stations, VCRC, NICD, NIHFW and others have been doing research that is relevant
and exploring ideas and alternatives that are of significance to the programme. However,
their links and coordination with NMEP are somewhat adhoc and the relevance of the
investigations are not always central to the emerging operation/research and field research
needs of NMEP. We believe that the coordination between NMEP and these National
research institutions and centres should become integral to the future programme
but the committee/network formed for such an integrated purposp should also pull in
expertise of researchers from medical colleges and health policy research groups in
the voluntary sector and the non-governmental sector. The network need not be a
bureaucratic initiative but an informal network of experts that share ideas, brainstorm
and guide and coordinate research, exploring new challenges and preventing duplication
of efforts.
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The NMEP has an opportunity of making the NMEP- ODA linked Surat Malaria
project as the focus of such an informal networking. The historical Nara ng wal
project brought together not only collaborating institutions but a larger network
of policy makers and service providers, to regularly consider the findings of the
study and dialogue on their applications and implications had a major impact on
MCH services in the country. A similar process could be initiated in Surat and
this would have a wider qualitative impact of the project.
24.2 Dissemination of Research Findings
“ 3
1.
While most of the research being done, does get published in National and international
journals and also presented at national and international conferences, there is urgent
need to disseminate the significant findings and salient features of ongoing projects
in a more active way to all those individuals, project and for a concerned with Malaria
as an important public health problem. A bulletin for this purpose or some_other creative
communication strategy could be an excellent initiative for government-Volag
collaboration. It is equally important that key findings get translated into guidelines
for action and these' are transferred to the field through operational manuals and
information booklets and even to the community through effective health education.
The challenge is to keep ‘research’ and ‘action’ in a dynamically linked situation.
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a research network;
a creative research bulletin; and
collaborative projects between government and non-government sector especially
in operations research, action research and socio epidemiological, and £i_eld testing
of appropriate techniques and technology and effective lab to field programme >yd[
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make existing research efforts more cost effective and relevant.
Operational Research
Malaria control programmes need to develop the capability to
undertake applied field research on issues of direct relevance to
control objectives. Such research should be conducted by health
personnel with assistance from research institutions and other groups.
The objectives and design of operational research projects should
be established within countries and should be closely tied to the
particular problems identified during planning, implementation and
evaluation of control programmes at all levels. Those who will
have to implement decisions made as a result of the research should
be closely involved in the research process, so that they are
committed to its conclusions.
The research should address not only the efficacy and costeffectiveness of specific interventions, but also related areas that
influence them and other components of programme and management
activities.
These will include capabilities for effective
epidemiological response; community perceptions of malaria and •
treatment practices; the effectiveness of referral systems, the
implementation and effectiveness of antimalarial drug policies; career
structures; the impact of migration and of ecological and
environmental changes on malaria; training and health education
for staff and communities; and programme evaluation.
vi
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Source : WHO Technical Report Series 839 page 50
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MEDICAL JOURNAL OF INDIA
S
VOL. 10, NO. 4, 1997
155
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Medicalizing Health Research to Suit the Market
The World Bank’s 1993 World Development Report Investing in health imparted, in
its first-ever endeavour, a new orientation to health and the provision of health care
to the people of need-based countries. The report set the.pace for pushing up health
on the agenda of national governments and ‘packaging’ health care as a commodity
that can be traded like any other, for a. price. The reorientation was also aimed at
promoting the private sector, as in business and industry, to let it reap the benefits of
curative medical technologies developed in tlie West. Thus, it was reasonable to
expect the world’s so-called conscience-keeper in health matters—the World Health
Organization (WHO) which evolved and promoted revolutionary concepts such as
Essential Drugs andPrimary Health Care, to set things right by way of a rejoinder. The
1996 report of the WHO ad hoc committee on health research relating to future inter
vention options—Investing in health research and development—behQS the expecta
tion. It is not a rejoinder but an extension, in large part, of the World Bank’s report.
This should not come as a surprise as the brains behind both the reports appear to be
the same, with a greater sprinkling of experts from the ‘target’ countries in the WHO
report. Two of the authors are indeed from the WHO: the Director, Tropical Diseases
Research, and the Director, Division of Child Health and Development. The target
countries are, of course, the low- and middle-income nations who are expected to
tackle the ‘multiple and complex health needs ahead of them’ in a manner this report
prescribes.
Expectedly,, the report is rich with data well presented in 31 boxes, 54 text figures
and 102 text tables spread oyer 8 chapters together with a summary, 3 appendices and
9 annexes. Besides presenting commonly available well accepted data on health, the
report attempts to justify these by overquantification using DALY—(Disabilityadjusted life year); the use of which is debatable.The concept of DALY, in vogue since
its authentication in the World Bank report, has not been subjected to the close
scrutiny that it deserves.
The four key challenges ahead for health researchers and planners identified by the
report are: (i) traditional threats to maternal and child health from infectious diseases,
malnutrition, and maternal and perinatal conditions such as unsafe childbirth and low
birth-weight; (ii) a continually changing threat from microbes particularly those causing tuberculosis, pneumococcal infections, malaria and the acquired immunodeficiency
syndrome (AIDS); (iii) emerging epidemics of non-communicable diseases; and
(iv) inefficiency and inequity in provision of health services. While there may be an
agreement on the nature of challenges recognized by the report, the responses to these
challenges appear to be influenced disproportionately by the technological fixes
devised (or to be devised) by the West. The historical fact that the West successfully
tackled almost the same challenges less than a century ago chiefly through non
medical interventions seems to have been forgotten.
It/is worth emphasizing that almost all the ‘best buys’ the report advocates for
tackling the challenges are of a ‘biomedical’ nature and will have to be ‘sold’, essenfrally by the rich to the poor countries. The chief ‘best buys’ include vaccines for
malaria, pneumonia andAIDS ; diagnostics for sexually transmitted diseases; DOTS
(directly observed treatment short-course) for tuberculosis; and sequencing the
genomes of major pathogens—a very tropical disease research approach.
156
THE NATIONAL MEDICAL JOURNAL OF INDIA
VOL. 10, NO. 4, 19^ ;
The questionable assumptions the report makes in giving confident projections-^
disease burden get concealed behind the impressive pie charts which attract the
reader’s attention. Obviously the report’s focus is ‘disease’ and not ‘health’. It
considered the burden of disease measured in terms of DALYs for selected conditions
and then estimated the reduction in that burden assuming that currently available
strategies and technologies were optimally applied.The report also assumes that new
magic interventions could well be developed if money is provided. It is comm- ;
knowledge that many of the tools for effective control of the major microbial and
parasitic infections and infestations have been with us for decades. However, it is tH
top-down, centralized, unresponsive, techno-managerial oriented public health system
and the exploitative, unaccountable private health system which havd been the majf 1
obstacles in providing the benefits of the available knowledge to the people. Persis
tence of tuberculosis, resurgence of malaria, revisiting of plague, acute respiratc
diseases and diarrhoea continuing to be the top killers are all vivid pointers to the
broken health systems alienated from the people.
,a
No one questions the importance ofcontinuing relevant and appropriate biomedical
research. But it is difficult to accept the assumption that all the required intervention'
could be successfully developed by western scientists if unlimited resources are made
available to them. This, the report believes, could provide the ‘final’ansv/ers to co
tinuing microbial threats! Ihe World Bank and WHO would be well advised to trace
the history and costs of research that went into development of a vaccine for lepros*?
before wisdom prevailed upon us that a vaccine for leprosy is not the ‘best buy’; the
better use of already available drugs would be much more bene ficial. While thq
report has succeeded in stating the complex health problems facing humanity, it has*
not provided analytical insights into the origins and the genesis of our failures, so*
essential to formulating appropriate solutions.
G
The report almost entirely ignores (except in a paragraph in the preface) the wel]^
known pillars of health—food, clean water, sanitation, education and sound economic'
status; factors which work through multiple channels to influence health.The author^
also assume that we live in an apolitical world. Research into peoples’ varied cultures
and other systems of medicine such as ayurveda and yoga, so important in view of th^.
impending steep rise in the burden of non-communicable diseases, diseases of ageing*
and mental disorders in particular, or homoeopathy—widely accepted and used in the
West itself—do not receive any mention.
2
The report does a commendable job of drawing attention to tobacco—a risk factor
for some 25 diseases—and the general non-appreciation of the scale of its impact oC
global disease burden. It warns that for every 1000 tonnes of tobacco produced, about
1000 people will eventually die and that no single disease is expected to make suciy^
a giant claim as this one risk factor. The world’s largest tobacco exporter is the USA.
The recent example set by the USA administration of forcing tobacco companies tC
pay a large, yet token price, in terms of total tobacco sale profit for the enormous
damage they have done to their own people could have been commended if it waO
accompanied by.a ban on the pushing and promoting of tobacco to poor countries—
a gesture of some concern for the lives of non-Americans also. Obviously the repofcassumes the unchallenged dominance of the globalized market economy for the next,,
quarter century, regardless of a rapidly changing world which is questioning it. *
The World Bank report advocated ‘cost-effective’ strategies. These have already,
led to large cuts in the budgets for health in the public sector resulting in an increas^
in inequalities in access to health care. Offering medical technology to those who can
pay for it seems to be the only cost-effective approach to the Bank. Unfortunately th£’
WHO report fails to recognize that the greatest challenge today to the health of the
people in poor countries (and of poor people in rich countries) is the market approaclV
to health and health care.
In defining prime areas for health research and development, the report ignores thd
reality that health is the core of human development and hot simply a techno-mana-^,
gerial intervention of delivering a variety of ‘packages’ addressing select problem!
of different groups of the same population (sick child package, family planning
u
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'.f'JONAL MEDICAL JOURNAL OF INDIA
VOL. 10, NO. 4, 1997
157
ahties and projected plans and
strategies.
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technology can be exploited and furthp H
i
ensure how best current medical
plea for increase in funding of^reseaXn t7oS d
11 “ henCe a
West since ‘the conduct of research and d X dlSCaSeS ln the ,aboratories of the
countries is commonly hampered by brain-dmin”X^oX™’"'6"001116
n‘. H. ANTIA
.
M- W. UPLEKAR
1 he Foundation for Medical Research
Worli
Mumbai
Maharashtra
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Resurgence of Malaria
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However, there is increasing evidence that the malady is deener
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138
THE NATIONAL MEDICAL JOURNAL OF INDIA
VOlL 10, NO. 4, l
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. promote mefloquin as the new ‘wonder drug’. Studies presented recently atanatioK
seminar have highlighted the role of chloroquin in inhibiting haem-dependent protein
synthesis i n the parasite, the implication of which is that increasing the dose of chldfX
qum (a cheap, effective, and adequately available remedy) would probably overcome
the resistance problem rather than costly alternatives.4 The dangers of overuse af.L
misuse of mefloquin have also been highlighted in a recent report.5
Similarly, while personal protection measures are important in the short term
recent efforts by international public health.agencies.to socially market ‘insecticide
treated mosquito nets’ (ITMNs) as a ‘magicbullet’ are likely to be counterproductiG
This will divert funds and attention to a top-down, vertical distribution and marketing
programme when community-oriented and integrated bio-environmental approachej
perhaps more sustainable. An IDRC/WHO publication6 has also cautioned thm
ITMNs may not be easy to implement and sustain on a large scale in routine healm
interventions; and this advise needs to be heeded.
A recent independentexpert group has taken a broader social-economic-culturapohtica approach to epidemiological analysis and identified a host of interesting
issues whichhavecontributedtotneresurgenceofmalaria.5These incl Jdemalariogerk'
development strategies the inadequate involvement of voluntary alenices general
Pra(;nll°ners °' fhe community in the national programme; the increasing loss opublic health skill and competence at various levels of the health care system- the
increasing corruption and political interference in health care decision-making- th •
confused dialectics of centre-state responsibility in health and the decrease in health
care expenditure. Other studies taking broader socio-epidemiological approaches aQ
idcntjfying factors such as migrant labour and agricultural development.7-9 Recognition
of the need for this shift is only very recently getting some emphasis in international
research reviews.10
The time has come for health policy planners to move away from narrow biomedi j
cal approaches seeking technological fixes to a much broader social and communityoriented paradigm shift in research, problem analysis and action initiatives. In th£>
absence of this, malaria and the re-emerging communicable diseases will continue to
represent not only a failure of our public-health system but also of our research
methods.
a
REFERENCES
1 CommunUv'T1 °r
MiniS,ry °f Health an<1 Family Welfare""'"-I »'■
Community Education Booklet. National Malaria Eradication Programme, New Delhi, 1996.
z John J1. An Indian point of view. Lance/ 1997-349-31-42
’ SSSSSSHXSSKSS-
4 andZher^rnn^
a^mher .rop.cal
drU8r78e,S 'he ma,ar,al Parasite- Attracts ofthe third nationalseminaron malaria
University Grants Cotnmission/Bangalore Universi.y/Society of Applied Gencticsy
5 ^'/SM CHn
v7ir<"* m
malaria con.rol stralesy:
action. New Delhi:Voluntary Health Association of India, 1997.
6 HafthOrgSonJ 996.‘Eny D°"
A
melhndfor
of concern and a’temarlm for
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malaria deaths IDRCAVorld ’
J
A- RT
Satl'a-iit S' Verghese S- JosePh A- Malaria a"d mgrant labourers—Sociotj—
p demtological inquiry. Economic and Political Weekly 1997;XXXII (16) 19 Apr
■
^cadeeseS7nfVR’ VTaraghaVan D- A«^alarial policy in the Madras Presidency: An overview of the early J
decades of the twentieth century. Med Hist 1992;36:290-305.
OB
9 referX0;^3" u* Epi<^,nio,08ica, Pa,terns associated with agricultural activities in the tropics with special
Agrlcu-ntS
7
10 far PaV00 d MaClean M’ Davies C‘Maluria research: An audit ofinternational activity Prism Report No 7 Unit
for Policy Research in Science and Medicine. London.The Wellcome Trust. Sept 1996
RAVI NARAYAN
c . Community Health Cell£
Society for Community Health Awareness Research and Action '
Ko ramangala
Bangalore ji
Karnataka
c
$
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SEA-MAL-230
DRAFT
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I Guidelines for Implementation
of Roll Back Malaria at
District Level
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World Health Organization
Regional Office for South-East Asia
New Delhi
June 2003
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Guidelines for Implementation of Roll Back Malaria at District Level
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•
Other Medical Officers
«
Paramedical staff
•
Additional personnel who might be called in an emergency
(g) Provide initial and
Response Team
a
c
refreshertraining at regular intervals for Epidemic"
Q
•
Ensure district specific training manuals and schedules are developed.^
and ready
u
•
Lay out clear, step-wise procedures
<
•
Rehearse procedure? frequently.
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(h) Increase access to early diagnosis, prevention and treatment lor epidemic
affected areas
b
1
I
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II
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'■f
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•
Sensitize community to seek early treatment
•
Reinforce malaria control activities by all health staff
•
Establish partnership
private sector
&
Explore the use of rapid diagnostic test where available
•»
Update antimalaria drug policy periodically
with
Non-Governmental
organizations
and
C
Identify disadvantaged population.
(i)
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Provide additional and extended support to disadvantaged population ir£
drugs and materials for the poor and marginalised living in:
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• Remote areas
•
Hard to reach areas
•
Isolated areas
•
Inaccessible areas
(
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So that they are better prepared to handle sudden epidemics.
4.6
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Research and Development
(a)
Facilitate research on malaria at the district level in the following areas :
•
O
Knowledge - attitude - practices - behaviour of people in rural, tribaL
and urban areas.
■
-
Focus on Health practices and Health seeking behaviour for
Malaria type fevers and symptomatology.
.
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□
(b)
\u;
Study rPotential
mobilization of
of the
the community,
ulci nidi role
loie i/ involvement
involvement and
ana // or
or mobilization
community organizations, Panchayats (Village level elected bodies), general
practitioners, alternative systems of medicine and folk health practitioners,
voluntary agencies, and projects and networks of development
environment and women's groups.
)
o
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(c) Review critically the role, training, and process
process of
of monitoring
monitoring and
and
continuing education of village based health workers, community level
resources persons, village guides etc.
O
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(d) Study the evolution and operationalizationi of community based
approaches and alternatives to malaria control exploring viable, feasible
sustainable options and strategies of malaria control in response to the
diversities and disparities that one finds at the community level.
o
J
(e) Evaluate scientifically traditional systems of medicine and Folk medicine
practices to prevent/cure malaria as available in the respective area.
o
•
Use quantitative and qualitative research methodologies
•
Evolve multidisciplinary research advisory groups and study teams
including resource persons from public health, entomology, clinical
pharmacology, social sciences, anthropology, traditional systems of
medicine, etc.
•
Use more interactive, participatory and decentralized approaches that
validate local practices and uses.
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Health Research
for the
Millennium Development Goals
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A report on Forum 8
Mexico City,.-16-20 November 2004
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prepared by
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Chapter 2: Knowledge and power
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There has been a continued emphasis on the.need to improve knowledge for health research, but in an
D editorial in The Lancet shortly before the Mexico City meeting another part of the problem was highlighted:
"The abysmal lack of knowledge about how the health systems of the poorest countries can or should be
v ; improved," the editorial said. It called for the establishment of a new health systems research specialty, one
that is supported by affluent nations and integrated within the policy and health systems of less developed
nations. The specialty should focus, it said, on narrowing the know/do gap and creating a culture where
policy and practice derive from evidence. "The specialty should also draw on what useful research has already
been done in other disciplines, such as in the social, behavioural and organizational sciences." These themes
0 echoed through the meetings in Mexico City.
J) Basic research has no value for health unless it is translated to human gain, began Mark Walport, Director
of the-Wellcome Trust, in the opening plenary on global perspectives. The mission of the Wellcome Trust is
O "to tester and promote research with the aim of improving human and animal health." Its first objective is to
enhance the knowledge base.
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Illustration 7. Wellcome Trust expenditure in tropical medicine research
1999-2002 (-.£300 million)
120,000,000
------- --------------------------------—______________
100,000,000
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Presented by Mark Walport in “Wellcome Trust and the Millennium Development Goals"
I
O The Trust's huge malaria expenditure of nearly £100 million between 1999-2002 demonstrates; one effort
to deliver on MDG 6, starting in'.the community, proceeding to research and continuing to development of
policy, practice and products to deal with disease. As one of the world's largest medical research charities,
the Wellcome Trust supports more than 5000 researchers at 400 locations in 42 countries. In 2003 the Trust
launched a new division, funding university and strategic translation awards focused on technology transfer.
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Walport described Wellcome Trust Centres in Vietnam and Malawi and offered the Africa Centre in KwaZulu
Natal in South Africa as an example of a community-based approach to understanding the long-term
impact of the HIV/AIDS epidemic. The Trust made 193 tropical medicine training and personal awards
etween 990-2002 to aid training of future leaders, and has supported clinical and field research aimed at
• understanding and controlling diseases in the context of the less developed countries of the world. Public
private partnerships, he said, will get the new drugs through the pipeline. He also noted that if local people
don't have some of the responsibility for the funding, they don't feel they own it.
G
O
The advantages that foundations have in global health research, Walport explained, are that they can be
independent, apolitical, take a long-term view and be good partners for governments, universities, health
departments, NGQs and local communities.
f?
What foundations can't do is substitute for good government," he added. They also.cannot enter into
open-ended funding commitments, work without financial commitment from other partners or work
without consent.
Research can offer insight into the consequences of population change and its impact on health in resource
poor countries, he explained. It can provide a reliable evidence base to support policy- and decision-making
°n the best use of scarce health-care resources. But he added that research agencies must avoid imposing
a ridiculous burden of regulation" or believing that one size fits all when it comes to solutions. He believes
foundations and agencies have a responsibility to identify and fund the best researchers and the best science,
that which addresses the most significant questions through the best methods.
I
Alan Bernstein, President of the Canadian Institutes of Health Research (CIHR), pointed out how well
positioned his country.i§ to contribute the knowledge needed to improve the health of populations and
to strengthen health systems. "We have consciously decided to take our gifts of history and geography to
develop a wider, global sense of community and citizenry," he said. Canada, he added, has a broad-based
and recognized research community that is linked to strategic networks, a federal government committed to
investments in science, and a foreign policy agenda that promotes partnership. He quoted Canadian Prime
Minister Paul Martin: "We are a knowledge-rich country. We must apply more of our research and science to
help address the most pressing problems of developing countries."
It is my opinion and the opinion of many others that knowledge is very important," Bernstein said, "yet
what may be more important is how this knowledge is used - scientific evidence should lead to policy
and practice, and that is why we are here today." He called attention to the WHO report Knowledge
for Better Health and cited three of its key points that entrenched in the foundation of the CIHR:
i. Every country should have a national health research system that focuses its energies on •
health problems of national interest, especially those that will strengthen health systems.
2. Biomedical discoveries cannot improve people's health without research to find out how to
apply them.
3. Health systems must interact with health research systems to generate and use relevant
knowledge for their own improvement.
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Specifically, CIHR's approach to health research includes a problem-based, multidisciplinary and networked
9 approach. Strategic approaches must be built on scientific excellence and, he emphasized, bridge "the gap
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between what we know and what we do." Science and research coupled with knowledge translation is the
best way forward, he said.
"At, CIHR,
we
have created .environments
that bring- together
.
,
------ researchers,
--------------- , policy-makers, health-care
professionals, government, private sector and the public. Each team defines the research agenda and follows
t rough with its application into policy and practice - basically the knowledge creators and the knowledge
users come together facilitating the use of this knowledge."
He described Canada's Global Health Research Initiative established as a result of growing concerns over
■f. .the health status of less developed countries. It represents a partnership between Canada's development
Q agencies, its health research agency and the federal department of health. This multi-partnered initiative is
aimed at developing practical solutions for the health and health-care problems of the developing world
•). Many of these global solutions will also provide valuable information on how to address these issues in
Canada. Examples include providing high quality primary care for controlling epidemic diseases, such as HIV/
J AIDS, and preventative programming to reduce sexually transmitted diseases.-
0 Through Canada's experience with Severe Acute Respiratory Syndrome (SARS), Bernstein said, the Canadian
public has become more aware of health threats and issues in other countries. "Understanding these
O 'upstream' forces and their health impacts on vulnerable populations in low-, middle- and high-income
<5 countries is critical to optimizing the future health of Canadians and all global citizens."
Bernstein stressed that the importance of better understanding North/South partnerships and how to target
them. Access to research information must also be improved, not only within a single country "but also on a
j global level between countries." he said. He strongly endorsed international clinical trials registration to share
knowledge and increase public confidence in science.
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Illustration 8.
•••> Clinical Trials Registration
“(Clinical trials) are one of the main sources of medical knowledge, yet information about these
trials is difficult to find... Information is even more difficult to find about neglected diseases that
disproportionately affect poor and marginalized populations."
Press Release, WHO/23
• July, 04: CIHR announces that all CIHR funded RCTs register in an international
registry (ISRCTN).
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• September, 04: International Committee of Medical Journal Editors requires trial
registration as condition of publication.
• October, 04: Cochrane Colloquium in Ottawa issue "Ottawa statement", a proposal
for international-registration of human trials at inception.
i
Presented by Alan Bernstein in “Canada’s Global Health Research Initiative: A Partnership in Response
to the Challenges of Global Health"
"Canada has an <opportunity
, ,
and responsibility, to help close the gap in health research capacity between
y high- and low-income countries/' he concluded... "If the world seriously addresses the major causes of
mortality and poor health in the developing worldI, we might well envision dramatic reductions in premature
mortality and a better future for humanity."
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Harvey rineberg, President of the US Institute of Medicine, grounded the discussion with a very practical
point on health research: it should be used not only to discover new things but also to find better ways
to use what is known. The second part of this aim is relatively under-invested, he said, but it holds great
promise. Using the great success of the McDonald's fast food chain as an example, he said that the genius of
iuS foundci, Ray Kioc, was not in the invention of the hamburger but in the standardized ability to deliver it
simply and efficiently. However, Fineberg suggested the equation should be read both ways: "We also have to move from action to knowledge."
i7
He endorsed transparency in research in the regulation of health trials, and the public's access to the results
of studies and trials. "It is not a matter of academic freedom to convey the results but a matter of public right
to know," he said, adding that there has been a "dramatic accumulation" of registries of clinical trials by the
American Medical Association, Canadian Institutes of Health Research and others.
Fmeberg praised television, radio, print and Internet attempts to raise the profile of health research and its
social impact, thereby improving public understanding of health research to assure an ongoing commitment
of resources. If the conference in Mexico could.identify the core needs of health, research, if it could ensure
capacity building, then it would promote the cause of global health, he said.
Illustration 9.
Why care about the role of research? i
%
1 Science is both a collection of ideological beliefs and an agency for liberation. As an agency
for liberation, it substitutes democracy for political and religious authority.
Demanding evidence for statements of fact and providing criteria to test the evidence, it
gives us a way to distinguish between what is true and what powerful people might wish
to convince us is true. “
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Tesh SN., Hidden Arguments: Political Ideology
& Disease Prevention Policy. London: Rutgers University
Press. 1989. p. 167
Presented by Jonathan Lomas in It Takes Two to Tango: The Importance of Joint Knowledge Production for Research Use’
Managers and policy-makers, not just clinicians, save or harm lives, declared Professor Jonathan Lomas,
Executive Director of the Canadian Health Services Research Foundation. That is one reason to care about
health systems research, he added, another is because research evidence helps build consensus, a primary
objective of the health system manager or policy-maker.
He illustrated the difference managers with teamwork training can make: after emergency-room staff in nine
southern US hospitals received teamwork training, clinical error rates were reduced from 30.9% to 4.4% over
a 12-month period.
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He traced the history of the increased use of knowledge and research from the passive 1960s ("an acutely
naive period") when journals primarily were used as a source of knowledge, to the 1970s, when an era he
called 'push" began, with a strategy for dissemination largely based on practice. He described the 1990s as
a push harder era, with implementation through diffusion by journals and through high-tech routes. But
after 30 years of research in this area, Lomas said, "we still lack a robust, evidence-base^te-inform decisions
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about strategies to promote the introduction of guidelines or other evidence-based measures into practice."
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The "push era" approaches were driven by the research world, while the rnew era of "partner and pull"
approaches are driven.by the health system, with ongoing linkage and exchange, he explained.
o Lomas used scurvy to illustrate the importance of linkage between policy-makers and researchers (See S.R
Brown Scurvy, Thomas Allen Publishers, 2003):
o
In 1601, James Lancaster showed that lemon juice eliminated scurvy among sailors but it wasn't until 1747
that James Lind's research confirmed that finding. It was only in 1795, 194 years after the discovery, that the
British Navy first used citrus juice for its sailors. In 1854, 253 years after the discovery of the treatment for
scurvy, the British Board of Trade began to use citrus for sailors in the merchant-navy.
Lomas suggested reasons for the long know/do gap:
• there was poor institutional memory and communication;
D
• it was contrary to vested interests (of the military) to implement the information;
o
• the concept was a major challenge to the accepted scientific wisdom of the time;
0
• there were simply inadequate links between those doing the research and those who could
implement the results.
The key to research use, Lomas believes, lies in interpersonal links that are spread through the life of a study
and which establish collaboration. Two-way communication between researchers and decision-makers not
only facilitates the use of research but also builds trust.
(
"How much research that we do actually focuses on health equity?" asked Gita Sen, Sir Ratan Tata Professor
and Chairperson of the Centre for Public Policy, Indian Institute of Management at Bangalore. Despite decades
Q of studies, she said,. there
- - - is4 an absence of broad research on women's health beyond reproduction, and little
attention paid to multiple effects of poverty, gender, race and caste. "We should look carefully at what is
being done," she advised. At one end of the spectrum, she suggested, is the research done on poor, African,
black women and on the other end is a large body of information on rich, Anglo-Saxon white men.
&
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What research gets done is not a simple matter of researchers' choice, Sen said, and asked: "What determines
if research generates winds of change or if voices are left crying in the wilderness?" She suggested that the
0 public sector needs to enter more partnerships with the private sector and develop research beyond that
which is profit-oriented.
$
□
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We need gender to get mainstreamed to keep it from getting marginalized," she continued. But she
warned of the possibility that gender sometimes gets "mainstreamed out of existence - it is everywhere and
nowhere."
I
The field of gender and health equity is still largely the province of women. Sen said, and that should not be
the case in science. Young women researchers, more often than their male colleagues, face the limitations of
money and access to information,' she added. On the whole, Sen said, institutional politics of publication must
also be addressed and improved.'
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Sen viewed the other side of the equity coin as power: "the technical, risky and all-pervasive" element that
governs the lives of most humans, including health researchers. The dynamics of power, she said, are profound,
sometimes subtle, and work at many levels - from door-to-door politics to the sophisticated application of 0
technology. She cited the case in which a researcher arrives in a village with informed consent forms without
building rapport or trust in the community "and so nothing happens." She also cautioned that "informed consent" may be no more than a formality and should not be considered a guarantee against abuse. -
Power comes into play not only between researchers and the researched, but also among the researchers
themselves and in the translation of research into policy, Sen added. While abuse of power is usually recognized
by those affected, she said that it is not acknowledged or buffered against at the institutional level
□
The question of political will
The subject of political will was raised repeatedly at the Mexico City meeting, beginning with the opening
remarks by Ilona Kickbusch calling for a binding global agreement on health.
Andres de Francisco, Deputy Executive Director of the Global Forum for Health Research, presented figures on
research investments for HIV/AIDS, malaria and tuberculosis. The order of magnitude of research investments
appears to be around US$1.4 billion for 2002: about US$1.2 billion for HIV/AIDS vaccines, anti-retroviral drugs
and microbicides, US$45 million forTB and. US$126 million for malaria. So for these three diseases, which
collectively accounted for almost 12% of the global burden of disease in 2002, the average R&D spending
was about US$8.4 per DALY. This only amounts to less than one tenth of the average US$73 per DALY spent
globally on all health research in 2002.
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The complex world epidemiological picture makes it extremely difficult to measure the size of the "10/90
gap" quantitatively at the global level. However "the relationship between investments and disease burden
€
has been used as a symbol of a gross inequity in health research funding," de Francisco said. "Priority setting
should ideally be evidence driven, and tracking priorities and funds for health research allow the identification
of research areas which are under performing. Investments in research on. these three diseases clearly show a
failure, possibly reflecting a lack of political will.".
>
-*
Illustration 10..
• HIV/AIDS
- vaccines (IAVI estimate)
US$ 549 million
• ARV drugs (assumed similar) ' —[USS 550 mWoftf-microbicides
US$.143 million
• Malaria
US$126 million
• TB
US$ 45 million
$
(0
Total
US$1.4 billion
US$ 8.4 per DALY
Average global expenditure, all BoD USS 72 per DALY
Presented by Andres de Francisco "Financial Flows, Priority Setting and
the “10/90 gap“ in Health Research"
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Mary Anne Burke, Health Analyst/Statistician, Global Forum for Health Research, explained that the US $106
□ billion
spent for total health research and development comprised 44% from the private sector, 48% from
public sector, and 8% from the private not-for-profit sector. But investment, she showed, is dominated
o the
by a few countries, foremost of which is the United States, with 49% of all health R&D expenditures. Japan
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contributed 13%, the UK 7%, Germany 6% and France 5%. She pointed out that contributions from lowand middle-income countries were largely unknown or unaccounted for, but most
of the increase from the private sector clearly came from high-income countries.
Illustration 11. Global distribution of public and private
health R&D exenditures 2001
Spain
Denmark
Belgium
Austarlia
Netherland 1%
Switzerland 2%
Italy 2%
Sweden 2%
Canada-3%
6%
United States
\
Germany
6%
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Japan 13%
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Presented by Mary Ann Burke in "Monitoring Financial Flows for Health Research 2004"
Source: Monitoring Financial Flows for Health Research 2004, Global Forum for Health Research
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"Most of the spending done by high-income countries in high-income countries was in generating products
tailored to health-care markets of high-income countries," she said. A small portion was carried out by lowand middle-income countries and an even smaller portion was funded by high-income countries but carried
out in and for-the benefit of low- and middle-income countries, Burke said that even a small shift in budgets
of low- and middle-income countries to allocate more money for health research that addresses urgent
health needs of their populations could make a big difference.
(
“It's a question of political will and priority-setting," she said. "For example, in the 1990s India's health R&D
budget could have been more than quadrupled if money being invested in space R&D had been shifted to
investments in health R&D."
---------- ---------Srinath Reddy, Chair of the Department of Cardiology at the All India Institute of Medical Sciences,
speaking about the role of policy-interventions in chronic disease, observed simply: "Medicine is politics on a
grand scale. He said health policy must be scientifically credible, not made in isolation; he emphasized the
importance of public-private cooperation. India, he said, is a prime example of a population moving from low
to high risk in terms of cardiovascular disease. It currently leads the list of countries in terms of years of life
lost due to CVD and by 2020 is projected to have a CVD rate 94% higher than the US in terms of lives lost.
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In another very different area, Rochelle Sobel explained that the "good news" about road crashes is that^
t ey are predictable and preventable. Political will and commitment to road safety are what are needed for a
national road safety plan. The research community can provide the data and demonstrate interventions, she
said, but it takes political will to implement them.
Ronald Labonte, Canada Research Chair, Institute of Population Health, Canada, told a session on financial
flows and priority setting that while more research is needed, the greatest threat to global health equity is ‘
i e disparity in power. "All diseases have two causes, pathological.and political," he said, "and global health
research is unavoidably political." Speaking about the G8 group of industrialized nations, he said the health
systems contributions from these nations, which account for about half of the world's economic output and <
export amount to only 4% to 8% of total official development assistance. "Political will at the top only rises
when .demanded from below," he observed. The problems are not insurmountable, he continued they are
political.
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He was critical of G8 and World Bank programmes for developing countries and called on the G8 to cancel
the Third World s debt and help establish a Global Health Compact "for the greater global good."
<3
Access to knowledge
In a parallel session, Luis de la Calle, a member of the Mexican Commission on Macroeconomics and Health,
described knowledge that is especially crucial to the health sector as one of the best examples of fpure public
good. He pointed out, however, that the creation of new knowledge might require large fixed costs that
can create obstacles to technological progress in the absence of regulation. Without intellectual property
protection, incentives to conduct research are diminished because costs associated with research cannot be
recovered.
Illustration
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12. Relationship between knowledge and intellectual property rights
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Public and private good considerations
Public good:
patent requires
publication
Knowledge
IPR
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Research
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Public good
Drugs
Public good:
1 improved
/ public health
Presented by Luis de la Calle in"Ideas on how best to promote
knowledge creation “
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De la Calle'described the "tension" that exists between the protection of intellectual property rights and
he ere at.on of a temporary monopoly that results in higher prices than would be available in a competitive
H
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lmP°rtance- he said- that the government weigh the role of knowledge in curing
illnesses and prolonging or improving quality of life, keeping in mincUhatthe optimal level of regulafcmivthX
which maximizes the quantity of knowledge utilized in the market. He referred to recent amendments Mexico
had made to its laws to strengthen intellectual property rights (IPR) and the incentive to conduct scientific
researc (e Reglamento de Insumos para la Salady el Reglamento de la Ley de la Propiedad Industrial').
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Health Research for the Millennium Development Goals
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While it is important to protect a product produced through scientific research to make it a business
proposition worth pursuing, the optimal level of intellectual property protection in a given society is up for
debate, de la Calle admitted.
This topic is one of the targets under the MDG 8, to develop a global partnership for development: "In
cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing
1
o
De la Calle made two points: the optimum level of protection varies by product and is not the same for
countries at different levels of development.
)
o
I
The countries that reap the great benefits from intellectual property protection, he said, are those that are
farthest along in terms of economic development. Conversely, the lower the level of development, the less
interest a country will have in protecting intellectual property rights.
3
3
3
He made several suggestions on how to encourage knowledge creation while ensuring that treatment
costs are affordable to the consumer..These include reducing costs of developing new drugs by making the
regulatory framework more efficient, government subsidies for clinical tests and reducing legal costs.
la Calle proposed another mechanism to promote research and encourage innovation: open-source, where
□ De
research findings are shared on the Internet. This requires the donations and participation of researchers who
volunteer their time and whose discoveries are not patented. It also allows awarding drug development
contracts to the company that offers the lowest price, resulting in lower prices for the users. "If it were to be
successful it would contribute substantially to improving the quality of life of the world's poorest populations,"
he said.
3
O
3
3
From a grassroots perspective ...
Ravi Narayan of the People's Health Movement provided a civil society perspective on the huge imbalance
between the small percentage of global health research resources and the health problems of the majority
of the world's people that they address. He noted that in India today, health care is the second basic cost for
people after food and water.
z/ A major challenge for researchers is to decide what evidence for health problems is crucial and significant, ’
Narayan said, adding that social, economic, cultural and political factors are not given the importance that
they are due. Researchers are trained to consider biomedical factors: clinical, epidemiological and techno
3 managerial. He suggested that "people-oriented" perceptions be substituted for these "professional"
perceptions in a paradigm shift that he believes is the single most conceptual challenge to address the
Millennium Development Goals and the "10/90 gap."
I
In a "plea on behalf of the people for a sense of balance", Narayan said social determinants like poverty,
gender bias, conflict, stigma and social exclusion must be considered in assessing evidence on disease.
3
“Whose evidence are you taking?" he asked. “The governments', the academics', the industries', the NGOs'?
- or also, the community, peoples' organizations, the socially excluded?
“
- ------ — -
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"Who decides on the implications of funding? The government? The industry and market forces? International (j
funding agencies? The World^Bank and WTO and their alliances? Or also, the people, peoples' organizations
and peoples' movements?"^/
0
He cited a case study on the use of bednets in the Mandla community, made during a period when 1200
of the 2000 people surveyed were outside the bednets at the peak mosquito biting time. Those who were
inside, he said, were either too tired to use the nets or did not understand how to use them. "The people are r
sharing evidence with the malaria programme bednet researchers about poverty, survival, marginalization and
other social determinants," Narayan explained.
I
"What is our interpretation?" he asked. " Should it be social marketing and health promotion of bednets for
malaria to keep them inside - or poverty alleviation in the context of sustainable development and responsive Q
primary health care to make the programme more accessible, relevant and affordable?"
(I
Illustration 13.
••MheMDGsandtbe^O^fepe^v^^
Approach
Biomedical deterministic research
Participatory social/ community research
Focus
Individual
Community
Dimensions
Physical/pathological
Psycho-social, cultural, economic,
political •
Technology
Drugs/vaccines
Education and social processess
Type of service
Providing/dependence
creating/social marketing
Enabling/empowering autonomy
building
Link with people
Patient as passive beneficiary
Community as active participant
Research
Molecular biology
Pharmaco-therapeutics
Clinical epidemiology
Socio-epidemiology
Social determinants
Health systems
Social policy
Presented by Ravi Narayan in "Health Research: MDGs and the 10/90 Gap"
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The shift in health research that Narayan envisions would move the focus from the individual to the
community, towards more consideration of the social, economic and political factors and with emphasis on
the educational and social processes. "A social vaccine is closer than the AIDS vaccine," Narayari concluded.
The People's Health Movement should be a force to "pull along" the funders of health research as well as ’J
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The idea of a 'social vaccine' - or a 'vaccine against
poverty'- has been the subject of discussion among
public health professionals for a long time. A social
vaccine implies social change, not just a social
intervention. The concept includes crosscutting and
holistic initiatives and programmes for enhancing
action within communities and health systems to
address the social determinants of health. Speakers
in Cairo called strongly for researchers to look more
closely at social determinants of health, keeping in
mind that health is a fundamental human right,
and inequities should not be tolerated. They
acknowledged that while areas of science such
as genetics have the ability to deliver miraculous
advances to conquer disease and repair the body,
millions of people fail to have access to even basic
healthcare and remain trapped by poverty and
deprivation.
The session on a social vaccine reminded
participants of the long tradition of public health
that has recognized the fundamental importance of
social interventions. More than once reference was
made to the Alma-Ata Declaration of 1978, which
stated: "The attainment of the highest possible
level of health is a most important world-wide
social goal whose realization requires the action of
many other social and economic sectors in addition
to the health sector."
3
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Illustration 18. Bring us back a vaccine against poverty
o
id.
ii
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• In there any vaccine against poverty?
• What about injustice and inequity?
Presented by Arturo Octavio Quizhpe Peralta in
"Social vaccine: hope and alegremia"
o
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Source: Cartoon by Alexandre Soroukhan (1944) in Nancy Elizabeth Gallager's
^9ypt S Other War: Epidemics and the Politics of Public Health (Contemporary
Issues in the Middle East)", December 1990
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Illustration 19.
of
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More than malaria, TB and HIV/AIDS, people
Narayan, however, cautioned that 'social vaccine'
who have worked at the community level say it
Interventions may tend to concentrate too much
is inequality, poverty, exploitation, violence and
on changing the individual's behaviour or go
injustice that are at the root of ill health, stated
too far towards changing existing social norms.
Ravi Narayan, Community Health Adviser, Society
More emphasis should be put on changing health
for Community Health Awareness, Research and
and social policies, he said. Additionally, while
Action, India. He underscored the importance
of tackling the economic, social aiad political
determinants of health through promotion of
health as a human right. Taking tuberculosis as
interventions like those proposed by UNESCO and
ILO have tried to address the broader issues, they
are often still limited to interventions in the HIV/
AIDS arena. They should be extended to the spread
an example, he referred to a study showing how
of most diseases and to the continuing ill health
a deeper social understanding of the disease
of the poor and marginalized in every community,
could move beyond vaccine and drug distribution
he said. He advocated using long-term solutions
to motivation and empowerment of the patient
focused on the deeper determinants within society:
through counselling and building the skills of
autonomy. In his own recent work on HIV/AIDS,
Narayan has predicted that the shift to enhance
research towards a social vaccine will be a much
more comprehensive response to the disease. It is
gender, disability, war and conflict, mental health,
malnutrition’and social exclusion. These, he
concluded, would be a vast improvement over the
usual interventions that tackle health issues purely
from a bio-medical framework. If the research
also an approach that requires new partnerships
community takes up the challenge of developing
between medical/laboratory researchers and the
a social vaccine, there would be a paradigm shift
public health researcher/activists.
along the lines shown in the table below.
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Approach
Biomedical deterministic
research
Participatory social / community
research
Focus
Individual
Community
Dimensions
Physical / pathogical
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Psycho-social, cultural,
economic, political, ecological.
.<1
Technology
Drugs / vaccines
Education and social processes
Providing / dependence creating I
Enabling / empowering
social marketing
autonomy building
Link with people
Patient as passive beneficiary
Community as active participant
Research
Molecular biology
Socio-epidemiology
Pharmaco-therapeutics
Social determinants
Clinical epidemiology
Health systems
Type of service
■(
Social policy
____________
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Presented by Ravi Narayan in
"Towards a social vaccine - challenges
for research*
Source: Narayan R., Health Research:
MDGs and the 10/90 gap 2004
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Although Vincent Bwete, Lecturer at the Uganda
Martyrs' University, was pleased to see health
promotion as a major theme in Cairo, he still
considers it a neglected area. He noted in his theme
report that many of the presentations and research
papers were concerned with combating disease.
Referring to comments made by the Egyptian
Minister for Population and Health, Bwete said:
"It has been proved beyond a reasonable doubt
that even emerging and re-emerging disease, in
addition to the traditional communicable diseases
and maternal conditions, affect the poor most." He
maintained that evidence of the social dimensions
of health was not brought out well by health
researchers in the Cairo meeting.
He pointed to evidence presented by Arturo Octavio
Peralta, Professor of Paediatrics, Faculty of
o Quizhpe
Medical Sciences, University of Cuenca, Ecuador,
described some devastating outcomes for the
o who
most vulnerable: the world's children. This, Bwete
is often due to an imbalance between medical
o said,
and social factors that have to be considered in
o
□
designing health-promoting interventions to avoid
shifting mortalities from communicable to noncommunicable disease conditions. He cited Peralta's
discussion of how lack of social interventions, such
as physical exercise and recreation, result in the
children of wealthier families becoming obese.
Presentations made in Cairo sometimes
concerned fairly small groups of people, often in
communities that are the objects of research but
are geographically remote. Doris Cook, Manager,
Aboriginal Ethics Policy Development, Canadian
Institute of Health Research, reported on a
project designed to develop ethics guidelines on
health research on aboriginal people. The project
recommended that the relationship between
researchers and the community be formalized with
an agreement describing the expectations and roles
of each party. Cook, an aboriginal, emphasized
the importance of respecting culture. For example,
aboriginal children are often raised by elders in
the community. A researcher unaware of the social
^.Handicapped is not a problem,
<3
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a plea for a social vaccine.
e.g., mosques don't have wheelchair ramps.
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3
every eight seconds a child dies due to a
water-related disease
air pollution contributes to 2.3 million
cases of respiratory insufficiency in
children each year
40 million children live on the streets of
Latin America and three-quarters of them
have addictions to solvents and glue
852 million children have insufficient
food.
3
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it's just that the public makes it a
problem. 5^
Not only poverty but other forms of inequity,
such as a country's external debt, militarization
and injustice, are formidable health barriers in
developing countries, Peralta said. He, too, made
3
||
Health equity research
context may think that aboriginals abandon their
children, but the practice is traditional and helps
elders remain active, useful and autonomous in
their communities. In the same session on health
equity research, Lenore Manderson, Professor,
Psychology, Psychiatry and Psychological Medicine.
Monash University, Australia, used extracts from
conversations to demonstrate how different
individuals living in Southeast Asia identify with
their disabilities. She quoted a Malaysian woman:
"Handicapped is not a problem, it's just that the
public makes it a problem. Sitting in a wheelchair
can be very, very annoying. It makes you feel very
institutionalized. Every handicapped person has a
different problem; institutions are not equipped
to deal with them." Manderson said that negative
identification with impairment is particularly
-pronounced4n Islamic countries where there is no
building infrastructure for people with disabilities,
Peralta focused on the huge toll that poverty
takes:
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Combating
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FflRJJIll 10
---------------- Cairo, Egypt
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Kathryn Church, Consultant for the Pan American
Health Organization in El Salvador, described a
participatory assessment process in El Salvador
that helps local communities design maternal
and newborn health promotion interventions.
She explained that this is just one tool to be used
to empower local communities, and especially
women, to assess their situation and develop
needed plans and interventions for maternal and
newborn care. In a paper concerning Maori health
research, Clive Aspin, Senior Research Fellow, Nga
Pae o te Maramatanga, University of Auckland,
New Zealand, presented a framework designed to
maximize health equity for the indigenous peoples
of New Zealand. The findings were projected to
inform health research development in other
countries, aiming at the goal of equity for other
indigenous peoples.
In the effort to build health and health equity,
evidence of the extent and impact of inequities
and what works to reduce them is crucial, she says,
"but evidence is not enough." She stressed the
importance of research on the underlying causes
of the statistics. She drew' data from studies of
aboriginal Australians who live, on average, 18
years fewer than other Australians, and are more
likely to have range a range of illnesses including
infectious diseases, cardiovascular diseases and
diabetes. They also suffer more injuries, more
suicides and are more likely to be imprisoned. But,
Baum observed, the Aborigines also have suffered
great dispossession; they have’lost their land and
frequently their culture. Awareness of the evidence
and putting forward policy solutions supported by
the evidence should logically lead to action - but
often does not, she said.
Advocacy for a change from a medical model of
healthcare to a more comprehensive approach was
echoed by several speakers and participants. But
the arguments emphasizing social determinants
of health were generally qualified to underscore
the need to strike a balance with existing clinical
services, not to undermine.them. Some urged
public health officers to become involved in matters
that affect health but are beyond the traditional
health sectors, such as the prevention of war and
civil society capacity building for human rights
advocacy. Another area of concern was the need
to re-orient health workers to be aware of their
own biases and how patients may be affected.
•Leila Adesse, Project Director, Ipas Brazil, gave an
example in a paper relating to gender violence,
health and human rights. Clinicians, she said, may
unwittingly stigmatize expectant mothers who
choose not to abort a baby affected by a genetic
disease or malformation.
She described the "blocks" to hearing the evidence:
cost considerations that are used to avoid equity
arguments, a focus on neo-liberalism that does not
support a social vaccine for equity, and an emphasis
on individualism that contends that individuals are
primarily responsible for what happens to them,
including their own health. She likened the cost
argument to that for prolonging slavery - many in
England and the USA in the 19th century believed
they could not afford to abolish the trade, a view
opposed by abolitionists on the grounds that it
was contrary to the principals of social justice and ■
humanity. A social vaccine will require a political
will and a vibrant civil society to advocate a better
balance in social and economic-considerations,
Baum said. It is a difficult approach to implement
because the public health perspective may be
complex and hard to grasp. But there is evidence
that social interventions are effective, she said, .
even though more research is needed. One of the
requirements, she added, is for public resources
from taxation to make a social vaccine possible.
Reflecting that civil society has always played
a crucial role in arguing for structural solutions,
she said it would need to take a strong role now
to lobby for social interventions. The alternative,
Evidence is not enough
"What good does it do to treat people's illnesses,
then give them no choice but to go back to the
conditions that made them sick?" asked Fran
Baum, Head of the Department of Public Health at
Flinders University, Australia and member of WHO's
Commission on the Social Determinants of Health.
L
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□
r
Baum, said, is a world that is increasingly unjust and
unhealthy for the majority of its people.
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Illustration 21. Social vaccine research
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High
Presented by Fran Baum in "Vaccine or values? Achieving global health and justice"
o
The importance of resilience
o Imam. Nuwayhid of the American University of
3
Beirut, Lebanon, described how the violence in
Lebanon in July 2006 took a great toll: 1,200 people
dead, over 4,000 injured, one million displaced,
3 30,000 homes destroyed and 200,000 homeless.
About 50% to 60% of the healthcare facilities in
were not functioning, he said. Roads ando Lebanon
bridges were destroyed, the country's airports
J
Q
Q
3
targeted. Hundreds of thousands survived in
crowded unhygienic environments with minimum
health impairments after being moved to shelters
in schools, offices and public gardens. Water, food
and sanitation all became major problems. Yet,
he said, the most striking thing for public health
professionals in the aftermath of the war was
that there was no disorder or social, unrest. When
the hostilities ceased, the displaced went back
to their neighbourhoods and towns. He quoted
David Shearer, UN humanitarian coordinator for
Lebanon:
"To my mind, the most intriguing thing about this
large-scale migration was just how orderly and
without incident it was.. What other country could
experience such a mass movement of its citizens
in the heat of war and have virtually no incidence
of hunger, malnutrition or deadly disease? In my
experience^ it's simply unprecedented."
Nuwayid said the main message they drew from
the experience was that the affected population
had been subjected to a social vaccine that
I
contributed to its resilience and protected it
against a breakdown that would have been a
rational reaction to events. However, he observed,
a more fundamental social vaccine is needed that
addresses the root causes of war and other humanmade catastrophes.
i
He defined resilience as the trait that enables a
person to "bounce back" in a healthy state from
very stressful situations. Among the characteristics
that contribute to resilience are the capacity to
face reality, the ability to find meaning in hardship
and the readiness to improvise solutions in difficult
circumstances. In addition, he said "hardiness,"
social support and deeply held belief systems are
important. He credited previous recent experiences
with wars and conflicts for preparing the population,
as well as the "compassion" of Lebanese people and
their Shiite subculture. He said that Hizbollah and
its associated NGOs had provided encouragement
during the war by appealing to a set of deeply held,
shared beliefs that had supplied social support. He
criticized humanitarian aid policies for stereotyping
individuals as being "vulnerable" and war-affected
I
3
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3
T'.E R M I N A N T S
of
Health
I
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Combating
disease
and
promoting
health
.
FOIHlIllIO
------------------- Cairo, Egypt
populations as being inevitably "traumatized."
In most cases, he believes that standardized
emergency public health interventions have been
implemented without adequate consideration of
Low- and middle-income countries (LMICs) account
for more than 85% of the world's six million people.
"Identifying research capacity for mental health in
such a large context is daunting," said Saxena, ' yet
the affected populations.
it is becoming ever more important to assess gaps
and resource requirements. Even if one allows for
the limitation of the identification strategy of the
study, an inescapable conclusion is that there is a
virtual absence of mental health research capacity
(<5 identified researchers) in half of the LMICs in
Latin America, Africa and Asia."
However, Nuwayid acknowledged that some
public health professionals predicted that, had the
war continued a few weeks longer, there would
have been a complete breakdown. "The orderly
behaviour of the displaced during the war was, in
some ways, an artificial construct," he admitted. He
made it clear that the concept of a social vaccine
in the case of war is praiseworthy only if it does
not become an alternative pattern of dealing with
adversity and disease. "Public health professionals,
especially global health organizations, need to be
involved in preventing war and not only in reducing
its effects," he said. "A social vaccine must be seen
as a momentary solution as we wage our own war
for social justice."
Mapping mental health research
Mental illness accounts for about 12.3 % of the
global burden of disease and is expected to rise to
15% by the year 2020, by which time depression
will disable more people than AIDS, heart disease,
traffic accidents and wars combined. The belief
that mental health is a greatly neglected area
within public health in developing countries
was documented in results of a survey reported
by Shekhar Saxena, Coordinator, Evidence and
Research, Mental Health and Substance Abuse,
World Health Organization, Geneva. The survey,
done jointly by the Global Forum for Health
Research and WHO, was unable to identify mental
health researchers in 31 of 114 low- and middle
income countries and fewer than five researchers
were identified in 26 countries. Of the 4633
identified researchers, 914 responded. Three
quarters of respondents stated that policy-makers
were not involved in the planning and conduct of
mental health research. Research priorities were
influenced by personal, burden-of-disease and
funding issues rather than in response to policy
makers' requests.
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Three quarters of respondents
stated that policy-makers were
not involved in the planning
and conduct of
mental health research.
<1
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In a discussion following the report of the findings,
Vikram Patel, Reader in International Mental Health
and Wellcome Trust Senior Clinical Research Fellow,
London School of Hygiene and Tropical Medicine,
United Kingdom, observed that in South Asia
there is a growing acceptance of mental disorders
as a "major cause of suffering." He also reported
that less than 10% of mental health research is for
children and yet children there make up 45% of
the population. Some of the discussants suggested
that mental health research might be integrated
into primary care. Among those was David Ndetei,
Professor of Psychiatry, University of Nairobi, Kenya.
Speaking in another session, he illustrated the
.grim reality of poor availability of mental health
professionals in many parts of Africa and Asia with
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another statistic: more than 680 million people, he
said, have access to less than one psychiatrist per
million of population.
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' Population (millions) '
Number of psychiatds.s
.J
• Uganda
1:1,1,872,700
20.6
11
• Tanzania
1:2,681,800
29.5
11
3
• Kenya **
1:514,200
56
• Rwanda
1:7:700,000
28.8
7.7
O
• Nigeria***
1:1,021,000
102.1
101
• Ethiopia
1:5,336,300
J
• Zambia
1:4,700,000
58.7
9.4
11
2
• Zimbabwe
1:4,140,000
11.4
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• Malawi
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9.6
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• Mauritius .
1:122,200
1.1
9 (all government) ’
• Cameroon
1:3,475,000
13.9
4
• Ghana
1:1,636,300
18
11
• Congo Brazzaville
1:2,900,000
of whom were trained in the United Kingdom in a
programme developed with the help of the British
government. Since 1983 Kenya has trained a total of
50 psychiatrists locally. "However, this number is still
very negligible considering a country population of
31,500,000 people," Ndetei observed. "It is unlikely
that in the foreseeable future Kenya will have a
psychiatrist/population ratio equivalent to that in
Europe and North America." Kenya must look at
other options to deliver mental health services,
he suggested, including increasing the mental
health component in the training of nurses and
occupational therapists as well as medical students.
This could boost the number of professionals
capable of managing most psychiatric conditions
at the primary health care level.
Challenges, including the "brain drain"
9
10
1:9,600,000
J
Q
1
Mohammad Abdur Rab, WHO Representative in
Sudan, in a plenary discussing future challenges,
spoke candidly on the subject of brain drain, a topic
that had surfaced in other sessions. "We are all
aware of the weak capacities for health research
in the developing world," he said/ "yet over 20,000
9
9
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■IE RMINAUTS
OF
HEALTH
1
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** Only one medical
school training
psychiatrists
*** More than 10
medical schools training
psychiatrists
Presented by David Ndetei
in “Quantifying the
treatment gap for brain
disorders in developing
countries"
Source: World Population
Data sheet publication of
Population Reference Bureau
Washington DC, 1997
qualified doctors in Africa left the continent in the
1990s. The number is surely larger now and a, similar
picture prevails all over developing countries. The
challenge Is really simple - how to bring them
back? The post 9/11 world has further restricted
opportunities for training in the West, particularly
for countries in the Middle East. The challenge is
how to find alternate solutions to compensate for •
the shrinking opportunities."
Nobody must be left out.
Abdur Rab described two revolutions: the first
transformed public health through new knowledge,
linking disease with environment and hygiene; the
second has led to advances through innovation and
technologies to better ways of disease prevention,
diagnostics and therapy. Sadly, he said, those two
revolutions left out over a billion people, mostly
from the developing world. Now, unravelling of
the human genome structure has ushered in a third
revolution and this time, he says, "Nobody must be
left out."
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Chapter 2 - Innovation and its impact
r)
t/en Lopman, Research Associate, Department of
-^fectious Disease Epidemiology, Imperial College
London, United Kingdom, showed how verbal
^jitopsy was adapted to measuring AIDS mortality
in two areas of Tanzania and Zimbabwe. Lopman’s
Qam worked with two cohorts, one in Kisesa Ward
Cape, South Africa, presented PHC’s historical
background to the roundtable participants, setting
the stage for the discussion of how to approach
current challenges. They quoted Margaret Chan,
Director-General, WHO, to illustrate the critical
link between PHC and universal access to health
jn Tanzania where HIV prevalence in 2001 was 8.3%
~/i.d the other-in Manicaland in Zimbabwe where
care:
^prevalence was 20.5%. The important point was
i.iat for both groups, the HIV status was known
the patient before death. Workers wiio were
Trained to identify the symptoms of AIDS patients
,^jd verbal autopsies shortly after the deaths.
'Lopman defined the ‘gold standard’ in the AIDS
£"^aths as a person who had been HIV positive at
a previous survey based on antibody testing, had
0t been injured or in an accident shortly before
death and, if it were a woman, had not had an
Ostetric-related death.
Primary health care’s rejuvenation
kJ
PtiC, the backbone of the health care system,
rias resurfaced on the global agenda and, while it
/'■juld not normally be considered ^n innovation,
Vis being re-evaluated in light of the innovations
best way to ensure sustainableiiiiffpfgVgi ^Jfi
meats in health outcomes, and the b.;st
guarantee that access to care will be fair”
Margaret Chan at ths International Conference on Health for
Development in Buenos Aires, Argentina 16 August 2007
Sanders observed that most articles and papers
on PHC do not consider broader determinants of
health, intersectoral collaboration or community
participation. Roundtable participants raised
a number of questions about these areas and
suggested ways to handle emerging challenges as
well as employ new technology. The participants of
the roundtable proposed some research priorities
for PHC, which will be published by the Global
Forum for Health Research.
'^d technologies that have become available and
/vnich may change the way it is employed.
“After Alma-Ata, what happened to primary health
Don Matheson, Director of International Relations,
^Jiistry of Health, New Zealand, opened a
oundtable discussion on the relevance and promise
(3 PHC remarking on its striking rejuvenation.
care?” someone asked in a session on child health
equity, chaired by Zulfiqar A Bhutta, Professor and
Chairman, Paediatrics and Child Health, Aga Khan
' University Hospital, Pakistan. There was agreement
that there is no unique solution to ensuring equity
of care through strengthening PHC. However, Luis
After emphasis on PHC had disappeared for
3ny years, he said there is again strong political
commitment for it. Globally, he added, it is seen
r? a vehicle for social cohesion; he interpreted
h^s as a reassertion of the Alma-Ata agenda that
Mcused on health equity. Until recently, Matheson
PHC has not matched these political drivers
>ut now that it has regained attention, there is
C3Srea^ opportunity to take advantage of the
"enewed political agenda.
T
------------
Ravi Narayan, Community Health Advisor, Society
J' Community Health Awareness,/ Research
nd Action, India; and David Sanders, Director,
^xmool of Public Health, University of the Western
Huicho,
Professor
of Paediatrics,
Universidad
National Mayor de San Marcos, Peru, suggested, “it
is timely to revisit the issue of comprehensive PHC,
to gather reliable information on whether it may
actually allow universal and equitable coverage
with health interventions that lead to substantial
and sustained improvements in child health.” He
reviewed important successes of PHC, particularly
in the 1980s, which, he said, was fundamentally
'due to political will to meet universal basic needs
and active social participation. In all the reviewed
countries,. he said concrete strategies were
established with clear targets to reduce inequities
in the allocation of resources for PHC.
o
3
gS-IDO
LSI 31J
37
7
rJ J
Equitable access: a report on Forum 11
I1
G
CHAPTER 3
policies to enhance health system performan
“The results of NHA estimation in Nigeria, v/ .
covered the period of 1998-2002, startled 1
with some'revelations,” he told participants J
example,^out-of-pocket means accounted^
Zeroing in
on health systems
almost two thirds of total health expenditure
That obviously exposed ouii national htf’’
system as a severely inequitable one.” Eq't
in the health system, Fakeye continued^
critical for ensuring better health, especially
the poor. He recommended institutionalize...
of community health insurance schemes ar
guaranteeing quality services for all segmC
of society.
Health systems have come under scrutiny as
global health problems gain recognition in an age
of massive investment in health and research.
There has never been so much activity devoted
to health - and yet the MDGs for health still
appear beyond reach. Stephen Matlin observed at
the beginning of Forum 11 that there is growing
awareness that health systems, essential for
research and the delivery of health care, will
increasingly be required to deal with the growth
of chronic diseases throughout the developing
world. This comes in addition to coping with
infectious diseases. He underscored the need for
robust, well-rounded health systems that are also
well managed. These are absolutely necessary,
he said, for health promotion and prevention
before illness strikes, and support when people
become ill.
In the opening plenary, Tolu Fakeye, speaking
for Adenike Grange, Federal Minister of Health,
Nigeria, proposed measures to facilitate equity
in health systems in developing countries.. He
spoke of the relevance of health research to
design and improve health systems and of the
need to continue building and using research
capacity.. “A minimum package of health services,
especially comprising the health-related MDGs,
should be determined and all efforts should be
made to ensure they are provided universally,”
he stated. He announced that a provisional
package would soon be presented for adoption
by the health authorities of all his country’s
states and the federal capital territory of Abuja.
_He..called for national health acco-uftt-s-^NHAs) to
{I
In a session later the same day, Van G*
Professor of Health Management, Pe.fa
University School of Public Health, Chij
explained
how
the
Commission
on
Soc
Determinants of Health was set up in zoojT
improve equity in health through stimulatin
action on social factors. By broadeq'
knowledge and facilitating debate on the caus
of ill-health, it was hoped that knowlefj
would lead to action, she said. The commissi'"
works through promoting knowledge on soC
determinants of health; advocacy amon.
policy-makers, institutions and society; ac^
to integrate knowledge into public policy; a
by supporting institutional leaders on issfrt
concerning the social determinants of heaUI
WHO set up nine knowledge networks to info
on prospects for action on social determina^-,
- of health, including one on health systems.
1
Lucy Gilson, Professor, Centre for Health Poliv
University of the Witwatersrand, South AfrC?
presented the findings of the Commissio
Health Systems Knowledge Network. She be(
with a summary: “The available evidenci
published and perhaps most importantly
experiential, clearly shows that health syste
can promote health equity, but all too often,M
we know, they exacerbate health-inequity.” j
forces that entrench inequity, she said, indue
• commercialization and^globalization
• ,neo-liberal health reforms
• organizational culture, including gender j
inequity.
estimate the financial resources used for health
“All of these forces embed inequity and
strengthening health systems we have to th'&
and how they are spent, in order to develop
about how to tackle these forces as well
40
Chapter 3 - Zero.'ng in on health systems
0 -
i
Jhat we need to do within health systems.”
first thing that must be done, she said, is
ft recognize that the p.ublic sector plays the
Qimary role in working towards health equity
and should be strengthened to achieve that
( Jhction. Of course, she added, “Politics always
matters to health and health equity.”
She named areas that the network recommends
strengthening: leadership and processes
f^jt leverage inter-sectoral action, practices that
enable engagement and social empowerment,
ppvisions and financing aimed at universal
coverage, and revitalization of PHC. Referring
rj policy development on the national level,
she commented, “It is not good enough to
tj?^ement the new interventions in the most
resourced areas; it is critical that the least
(^acitated areas are strengthened enough to
.iriplement interventions that can address health
Mblems.” The report, Gilson says, argues that
more is needed than technical analysis - it
Ms there is a need for political action and
^o-mmitment. Research needs to be supported
o/communities and health workers; it needs
How to measure what is not clear
Measuring access to health services has been
elusive. “Even though access to health care is
frequently identified as a goal for health care
systems, what is meant by access often remains
unclear,” commented Sylvie Olifson-Houriet,
Health Economist, Global Forum for Health
Research, who was a rapporteur for the session on
‘Framework for measuring access’. Stephen Birch,
Professor, Department of Clinical Epidemiology
and Biostatistics, Centre for Health Economics
and Policy Analysis, McMaster University, Canada,
agreed that there is no consensus on the meaning
or measurement of access to health care. He
stressed that a conceptual framework is important
to guide analyses of health care systems and
to inform policies. After discarding a number of
definitions he thought insufficient, he suggested
that the most appropriate might be represented
by the equation:
(...) Access equals empowerment to
benefit from health care.”
p£jbe persuasive to public managers; and it
eeds to be credible and focused on elements
need to be understood and strengthened,
he concluded.
3
n the same session, Ritu Sadana, Coordinator,
JJiity, Poverty and Social Determinants of
ealth. Evidence and Information for Policy,
Oo, and Amit Sengupta, Joint Convenor,
People’s
Health
Movement,
India,
agreed
Whatever definition of access to health care is
used, he said, needs to be transferable across
cultural, economic and geographic settings.
Birch also provided a framework of access
based on separate dimensions of affordability,
availability and acceptability. Once the definition
is clarified and the different dimensions of access
I
are understood, the barriers to access can be
identified, Birch said.
rdt several knowledge networks are calling
04a push for alternatives, “not business as
^al.” Sengupta said that that evidence from
knowledge networks shows that radically
irfferent strategies on howto make a difference
^Jpealth are needed. Today there is no longer
e excuse that the tools and approaches do
exist, he said. He suggested, a framework
F three core values to inform the knowledge
)em and to translate knowledge to action.
.ie values, he said, are equity, the right to
<4lth and empowerment. “Empowerment
Jiot just knowledge,” he explained. “The
■^neous notion that, we empower somebody
e^S}° 56 abandoned- We do not empower
ybody, what perhaps we can do is create
^bling conditions around which people can
npower themselves.”
3
A financial assessment
-A session on the financing of health systems
drew many participants to hear Diane McIntyre,
Associate Professor, Public . Health and Family
Medicine, Health Economics Unit, University
of Cape Town, South Africa, share highlights of
a recent Global Forum publication. ‘Learning
from experience: health care financing in lowand middle-income countries’ she said, seeks
to pinpoint problems that are repeatedly found
in health systems around the world. Noting the
growing consensus that health
systems should
be universal, providing-all-cftizens with adequate
health care at an affordable cost, the author
remarked,
In the medium to long term you can
O
3
41
I
I 7^
Equitable access: a report on Forum 11
c
I t
.
have much greater impact and reduce differentials
countries spent more on health budgets, a pro-poorf'
if you progressively pursue universal coverage.
distribution of primary health service could narrow the
“My preference is to head firmly in the direction
of universal coverage, but in the allocation of
resources, pay greater attention to the poor.” A
core principle of an equitable health system is
financial protection, she said, ensuring that no
one will be impoverished or have their livelihood
threatened because of the high cost of care. Health
systems that meet these expectations demand the
child mortality gap between the poor and better off.fl
The .project she?described also aimed to determine
whether pro-po'or basic health care might slow the pace of overall achievement, since the multiple^
....
health cafe problems of the poor might require extra "j
work to alleviate. Focusing on immunization data,
from 47 developing countries, Kruk found that the x
creation of cross-subsidies, she explained, from the
wealthy to the poor (paying according to ability to
pay) and from the healthy to the sick (collecting
benefits based on need). Both taxes and health
and the rich was associated with the smallest total
drop in under-five mortality. Indeed, the distribution
most oriented towards the rich was most effective,
resulting in the largest drop in mortality.
insurance are key prepayment mechanisms at the
core of health care financing, she said.
“As health spending rose, mortality among poorL
fairest distribution of immunizations to both the poor
children did not fall as fast as among their better■
j
My preference is to head firmly in the
direction of universal coverage, but in
the allocation of resources, pay greater
attention to the poor.”
off counterparts, despite the substantially higher
baseline rates of child mortality,” Kruk said. “This
suggests there is a trade-off between equity and
overall achievements” in health care coverage of
V
developing country populations.
c
McIntyre cited several success stories in health care
To reduce inequities, pro-poor health strategies
financing in low- and middle-income geographies,
including Costa Rica, Sri Lanka and the Indian state
of Kerala. Despite relatively low income levels, all
three boast high life expectancy and score well
on other indicators of health. “What’s common'to
all of them is a strong commitment to the public
funding of health services,” she said. Sri Lanka,
may need to be accompanied by additional
improvements in education, nutrition levels
and water sanitation to make the greatest 0*
difference, Kruk said. Her findings elso suggest
researchers should carefully review what policies £
were undertaken by a handful of countries
(including Colombia, Egypt and Turkey) that have C
which relies primarily on taxes for funding, offers
accomplished the difficult task of both reducing
extensive geographic coverage of hospital care.
The vast majority of the population uses public
sector hospitals. Costa Rica has taken a slightly
different approach, pairing mandatory insurance
with tax funding. “Sometimes people think
mandatory insurance will decrease the need for
tax funding. But on the contrary, Costa Rica felt the
overall mortality and improving equity.
The research/policy interface
need to increase taxes to subsidize the national
Richard Horton, Editor-in-Chief of The Lancet, in
health insurance contributions of the poor.”
a discussion of current challenges for improved
policies. He said this recognition had led to a U
reassessment of the role of a medical journal
and to a change of direction for The Lancet <
A medical journal has the potential of being
a catalyst between -the research community
and the policy community, Horton explained.
4
It can promote an exchange and create a solid
Tax funding is essential, she concluded. She
proposed earmarking 15% of national budgets for
the health sector - a target suggested by African
leaders in 2001 in Abuja, Nigeria, for LMICs. She
also listed health insurance, especially mandatory
insurance with a single risk pool, as a key part of
an integrated funding mechanism.
Margaret Kruk, Assistant Professor,
Health
Management and Policy, University of Michigan
School of Public Health, USA, examined whether, as
42
1
<3
Research is a massively neglected force in
<
policy-making and global health, observed
research foundation through peer-reviewed,
published articles. It has the ability to amplify
and distil messages for policy-makers, moving 3
beyond the academic community to draw in
civil society.
i i
Fi
Chapter 3 - Zeroing in on health systems
I
■lAncisco
Becerra-Posada,
Director,
Academic
Learning from policies and products:
HPV-HIV vaccines
>greement and Dissemination, Health Research
Pwicy Directorate, Ministry of Health, Mexico,
weed, adding that each country should look for
Introducing a session on policy coherence for
ts own catalysers. He pointed out that a country’s
product development and access, Chair Carlos
Qearchers should understand the responsibility
Morel, Scientific Coordinator, Oswaldo Cruz
Foundation, Brazil, noted that when PDPs were
first created, not much thought was given to the
next step: access to the products. Now, that issue
is being discussed intensively, and knowledge
can be gamed and exchanged from a number of
hey have to their funding agencies and the power
Jiir publications have to shift policy. The role
they have in the transfer of knowledge is very
;C^)ortant, he said.
CiJshmi Lingam, Professor, Centre for Women’s
experiences and products.
Sadies, School of Social Sciences, Tata Institute
it Social Sciences, India, remarked that health
^icies talk to other policies. She raised some
questions: Are doctors being trained to look
jsocial determinants of health? Are medical
schools looking at recognized evidence? What do
v )earchers see as their priorities? Can we have
Robert Hecht, Senior Vice-President, Public
Policy, International AIDS Vaccine Initiative, USA,
explained that the human papillomavirus (HPV)
causes cervical cancer, the most common form
of cancer for women in the developing world.
Globally it results in over 270 000 deaths each
icademic research with a human face, research
ivlt recognizes issues of power and equity? More
year; half a million new cases occur each year
questions emerged during the discussion period:.
•» To is The Lancet accountable to? How do we train
^nd equip health scientists so they have a broader
understanding of the political environment? Who
pts the groundwork for debate - the researchers,
. biiticians, the public? .
He addressed policy coherence in two ways: first,
through the introduction of vaccines for HPV and
attempts to achieve coherence across the range of
policies needed to bring the vaccine to adolescent
girls and women in developing countries; then,
with regard to the opportunity for learning
O
across vaccines, specifically to apply what has
been learned from HIV to the HPV vaccines and,
^‘alth policy frameworks was the topic of one of
four sessions at Forum 11 where the Council
on Health Research for Development (COHRED),
'jjtzerland, made an effort to stimulate
iscussion of how national health research
3^)tems could support important ‘ objectives.
"OHRED also coordinated sessions on innovative
JJnmunications, equity and health system
analysis in the Western Pacific. In the session
Jt addressed equity, the role of civil society
as highlighted as extremely important, with
discussants calling for more people-centred,,
^n^iity-oriented research agendas. Case studies
om Costa Rica, South Africa and Tunisia reflected
(j^jimon concern for equity in health research
system development and policy development
‘ s
t as .
J|l as in priority-setting nicthodology. Health .
research can help address equity by making
^^ible inequity, participants agreed.. Now that
ealth equity is getting attention, they said it
lOtime to capture the momentum and push for
n^itical commitment to action.
with almost 90% of them in the developing world.
conversely, collecting knowledge gleaned from
the HPV vaccines to employ when an HIV vaccine
becomes available.
There are two new vaccines against HPV currently
on the market. Hecht said they are highly effective,
safe and provide protection for at least five years,
perhaps longer. Working with PATH, IAVI has
focused on introducing the HPV vaccines through
country demonstration projects. He remarked
on the similar social, economic, political and
operational challenges presented by vaccines for
HPV and HIV. These include the health systems
challenge for delivering a vaccine for adolescents
and a series of economic issues on how to pay
for it.. The HPV vaccine has the potential, he said,
ofchanging the paradigm of interventions being
available in rich countries far before they are
accessible in the developing world.
Global barriers to
access of HPV and
HIV
vaccines include the very high vaccine prices
and insufficient global political support for
the vaccines. (At US$ 120/dose in a three-dose
3
43
J
•I
t y
Equitable access: a report on Forum 11
r
-------- r?
a
Fig 15. Some issues/challenges common to HPV and AIDS vaccines;
<11
IBMw&sF'!*
ggpttg
■ ’•W’ •
fe’
Adolescents:
^certain
Financing
i8ssa&,,
RIP
-
lip
Delivery /
■
ic:
Gender
c
Presented by Robert Hecht in “Introducing HPV vaccines in the developing world: bridging reproductive health and the global
response to AIDS .
&
r
treatment in the USA, HPV is far beyond the
reach of many of the people who need it; the
manufacturers have said the price would be lower
in developing countries.) At the country level,
there are other barriers, including fears about the
vaccines, lack of national leadership support and
the absence of a proven vaccine delivery strategy
for adolescents. For each of the barriers, there
has already been a response developed and
Hecht described several. He suggested that the
vaccines could be coupled with existing child
or adolescent vaccines and/or medications. The
HPV vaccine also4could serve to introduce other
sexually transmitted infection control programmes
in developing countries and would complement
adolescent and women’s screening and treatment
programmes. However, there remains the common
challenge of integrating both vaccines with
existing prevention programmes, not replacing
existing prevention options.
In a session on improved health systems, many
questions were raised about the gap between
policy and research. A theme began to emerge
around the need-forstrong community engagement
in applying research to influence health policy.
Adnan Hyder, Assistant Professor, Departments of
44
International Health, Health Policy and Management ’
Johns Hopkins Bloomberg School for Public Health",
USA, reviewed a number of factors that may affe^f
how health systems research contributes to policy.
These include: societal norms that influence botC
processes and expectations; the informal usage of
health systems in a particular place, as opposed tt?
in theory; and perceptions of science and its value
within a given community. He suggested it is wortfl
considering some key questions:
• Is research critical to improving policy decisions
made in health systems, especially in LMICs?
• Do decision-makers operating in the sphere
”
of health systems value and demand research C
evidence for improving their decisions?
Q
Ejaz Rahim, Member (Social Sector), Planning
Commission, Ministry
of Planning
and|
Development, Pakistan and since November
2007 Pakis-tan’s new Minister of Health, asked^
from the policy-maker’s point of view: “Can
every statistic be considered research?” Rahim
laid out a series of other questions, including^
How .does health fit into a nation’s social*
agenda? Is there an annual research plan at the country or even global level that can be linked
to development objectives?
?
c
-i /
■ •
tA—
O'
?
Chapter 3 - Zeroing tn on health systems
■
G Pannenborg, Senior Adviser for Health, Nutrition
?nd Population, World Bank, drew attention to a
fSiactical consideration: the health ministries in
d^/eloping countries typically lack a director of
^search, or at least one able to exercise any real
IQver. Another problem is that national statistics
gathering bodies are underdeveloped, so statistics
Orelatively unreliable or lacking altogether. Within
nations, Pannenborg proposed forging tighter links
Oween decision-makers in ministries of health and
hose in research institutes. But he acknowledged
uK.Jt another problem concerns translating global
scientific findings to the national level. “Many’
buntries have N1H syndrome - not invented here,”
Pannenborg. He explained that if research was
ndt done within a given country, decision-makers
Qy be sceptical about whether it is relevant to
□cal conditions. One possible way to win stronger
^"jking for putting research into practice at
le policy level is to link universities of a given
Qeloping country more tightly with government
rircles, extending even to the municipal level.
□
question was raised in this session by a
AUicipant working in research who pointed to
recurring phenomenon that complicates efforts
bridge
ho ridge the gap between research and policy:
-li^gh levels of bureaucratic turnover. He cast the
Qblem as
“NMB - not my baby,” explaining:
Hjen new policy-makers come in, they’re not
Doking for continuity. The people in power are
^VVMIIIII
more concerned about their particular
;enda and less about the long-term strategies
0 goals that predecessors may have their
3mes associated with.” Agreed Hyder: “That
fundamental question. Do we establish
slationships with institutions or personnel? We
.Anow we need champions, people who can
£.e legislation and get it implemented.” But he
dtfed that often, those policy-makers do
not
long-term tenures.
’lety
Narayan, Public
for Community
Health
Health
Consultant,
Awareness,
jarch-^d Action (SQCHARA), India, offered a
Jssible solution for contending with this lack of
^^tinuity. Researchers can establish credibility
th community groups that will continue to
\^s for health reforms even as bureaucracies
lange. Narayan added that the media can have
Jeful role as an outside monitor to ensure that
yearch does not become captive to a biased
Mical agenda,
We need global initiatives to earmark
resources for HPSR [health policy and
systems research],” said Green, citing
a related need for “a greater voice in
low- and middle-income countries in
agenda setting.”
In a different session, Andrew Green, Professor,
International Health Planning, Nuffield Centre for
International Health and Development, University
of Leeds, United Kingdom, described how scientists
can use research findings to shape policy. First,
they set priorities for research, conduct it and
disseminate the results. Then, in a step that Green
said is little understood, they filter out the most
important findings and amplify those most relevant
to policy-makers. Only then can policies be made.
He noted that priorities are often set by international
agencies and philanthropic organizations in the
‘ North that rely
/ on ‘expert opinion panels’. In
practice, Green said, this may mean the developing
countries themselves are not involved in setting
the research agenda, so they miss an opportunity
to develop their own internal capacities. “We need
global initiatives to earmark resources for HPSR
[health policy and systems research],” said Green,
citing a related need for “a greater voice in low-,
and middle-income countries in agenda setting.”
He said that until the research culture makes a
shift from this traditional orientation, countries
themselves must develop mechanisms, to set
their own research priorities, perhaps led by their
ministries of health and. assisted by the national
health research councils.
China’s health system reform
TangShenglan, Health and Poverty Adviser, Health
System Development, WHO Representative Office,
Beijing, outlined efforts to reform health systems
in China, a process that has been underway for
more than two decades but
— --- ------------ 1 was given renewed
emphasis at the recent Communist Party
Congress. “Despite China's spectacular economic
growth, the slowdown of improvements in public
health has occurred concomitantly with a rise in
disparities in health outcomes between urban
and rural populations," Tang said. According to
”
account studies, he said, out-ofpocket payment for health care from individuals
rose from 20% in 1980 to 54% of total health
1
)
45
i 1
Equitable access: a report on Forum 11
C
expenditure in 2005. He attributed difficulty and
inequity in access to health care to the rapid
increase of medical care costs and the inadequate
coverage by health insurance. He described
Chinas various health insurance schemes: three
Wl 111
types of urban mainstream social health (two of
which require co-payments and deductions), the
new Rural Cooperative Medical Scheme (RCMS)
and Medical Financial Assistance (MFA) for the
poor, elderly and disabled. Not all those who are
eligible for MFA, however, automatically receive
benefits and they must go through a complicated
procedure of application, Tang said. The annual
use rate in 2004 was much higher in RCMS areas
(3-4o/°) than in non-RCMS areas (2.2%) but, in
i
II
b
“In some urban areas people wait all night to register
at the hospital", said Wu Jong.
Source: www.phoenixtv.corn
Health policy-makers attach high importance to
these problems, she explained, and to illustrated
the commitment of the government to changing
the situation, she described the framework olO
China’s health system. It consists of essential
health care, basic health insurance, an essential^
payments, which the poor frequently cannot
afford. Although 685 million people (78%) of the
drug system and a public hospital, management e
system. The government’s priorities are the^
rural population is estimated now to be covered
by RCMS, the financial protection offered by it
and the urban health insurance schemes is very
limited. Tang concluded:
country’s major health issues, she said, those;.
resulting in the highest burdens of disease. Other
priorities are cost effectiveness, emphasizing/j
proven interventions; economic affordability^'
• Inequity in population coverage remains a
based
health insurance systems.
• Most benefit packages focus on catastrophic
diseases, require fee-for-service payment and
may not be cost-effective.
• Low-income groups are disadvantaged when
seeking services and benefits because they
cannot afford co-insurance payments and
deductibles.
Looking ahead, Tang said the healthy economic
growth in China over the past three decades has
provided the government with a financial base
for universal health care. It is critical for the
government to reform the current health care
schemes to provide basic care for all, he said.
t
Slip
general, the rich everywhere had a much higher
hospital admission rate than the poor. The
new RCMS has failed to change the pattern of
inpatient services among different income groups
because it requires deductible and co-insurance
serious issue both in the urban and, rural
„
©I I | (
“Let me show yyou something,” said Wu Jing,
Researcher, Center for Health Statistics and
Information,. Ministry of Heath, China, as she
began presentation of China’s new National
Essential Health Services Package (NEHSP). She
showed photos of people in urban areas waiting
all night to-register-at a hospital and an elderly
couple using traditional treatments because they
could not afford to see a doctor.
46
on
national
revenue
capability;
andrM
equity, she said. The proposed NEHSP addresses
essential public health functions, public health'^
services and clinic health services that employ
1.52 doctors/thousand people and i.06 “nurses/^
thousand people and utilize 235 types of western
drugs and 128 traditional ones. The estimated Q
cost of the proposed NEHSP is 169.3 billion RMB
(US$ 23 billion), of which 53% will go to essential (
public health functions. Wu said confidently that
the total cost is both politically and financially^
feasible for China. The proposed plan has been
sent to the Ministry of Finance, she added, and
further adjustment on data and methods will be p
done. The next steps will include collaborating
with related experts to carry out implementation (J
design (see Figures 16 and 17).
<
I j .
Chapter 3 - Zeroing in on health systems
T
o
a
government and the United Kingdom’s Department
for International Development. Its aim, he said,
(NEHSP)
-
.
.. f
—J- -—
:a,¥)mic feasibility
IS;
china's GDP (Gross domestic product)'
;'tcrease rate >10%
\nina public revenue: ¥ 3542.3’billidn
f’iEHSP cost <5% of the public revenue
spited by Wu Jing in “A national essential health services
rkage”.
□
was to explore suitable mechanisms for protecting
the poor through Medicaid and to improve access
to health care for the poor by increasing health
care utilization and removing financial burdens. It
was designed to assist national and local policymaking on Medicaid and to provide community
based medical assistance by offering a wide
range of health care services in four cities. UHPP
Medicaid greatly increased utilization of health
care in Shenyang and Chengdu during a project
between 2001 and 2004, and greatly reduced
both inpatient and outpatient expenses per visit,
he reported. The goal of the programme was not
r
money, he stressed, but rather access of the poor
to health care. The programme’s impact on primary
tjurban poor in China have been long ignored,”
ted Meng Qingyue, Director, Center for Health
aLJgement and Policy, Shandong University,
lina, in the same session. “When you talk about
Cloor, the sense is that they are located in rural
^as,” he said. Take a closer look at the details,
i Wvised. The urban poor include people with no
support or income and no working ability, as
.a as people without permanent jobs or income
'c^yhose who are poor as a result of bankruptcy.
s amounts to 22 million people, or about 5Q>f China’s total urban inhabitants. However,
Bng also called attention to the magnitude of
Cjowing problem of.rural migrants who have
led the urban poor *- an estimated 120 to
lOmiUion people. A survey by the Ministry of
il Affairs shows that 50-60% of poor urban
Jeholds are created because people needed
pay for illnesses; a similar survey shows that
^te for patients who should see a doctor, but
4o do so, is over 50%. The urban poor are
drained by access to many resources, not only
care in community health centres was especially
positive and resulted in huge increases in visits,
examinations, consultations and immunizations.
Local governments have supported the Medicaid
programme and the mechanism developed
in programme has been used by the central
government. It needs now to be coordinated with
other schemes. Meng emphasized that it is just one
of the significant systems for protecting the poor.
i
Fig l7.
Essential pubUc health services
China’s proposed NEHSP
1
9 Categories (52 items)
: .v‘ ’•
• Routine health information management
• Vaccine
• Infectious disease control
• Maternal and children health care
• Elder health care
• Chronic diseases control
• Mental health care
• Family planning
• Health education (the spread of knowledge)
care, he said.
Qsc
scribed the Urban Health and Poverty Project
HPP). a. project co-financed by the Chinese
Q
Presented by Wu ling in “A national essential health services
package”.
s
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47
I
, i i
/•^cr
1
THE BAMAKO CALL TO ACTION ON
RESEARCH FOR HEALTH
' I
Strengthening research for health, development, and equity
FROM THE GLOBAL MINISTERIAL FORUM ON RESEARCH FOR HEALTH
BAMAKO, MALI, NOVEMBER 17-19,2008
c>
Wu the Ministeis and representatives of ministries of health, science and technology, education,
foreign affairs, and international cooperation from 53 countries ,
(
Following regional consultations on research for health in Algiers, Bangkok, Copenhagen, Rio
de Janeiro, and Tehran,
Gathered in Bamako 17-19 November 2008 hosted by the Government of Mali.
a
WE RECOGNIZE THAT
a.
1.
We must continue to build on and sustain the progress made since the Mexico Ministerial
Summit on Health Research in 2004;
I
2.
Research and innovation have been and will be increasingly essential to find solutions to
health problems, address predictable and unpredictable threats to human security, alleviate
poverty, and accelerate development;
c
0
3.
The global research for health agenda should be determined by national and regional
agendas and priorities, with due attention to gender and equity considerations;
/
4.
Greater equity in research for health is needed: only a small proportion of global
spending on research addresses the health challenges that disproportionately affect the poor,
marginalized, and disadvantaged;
c
<1
5.
The nature of research and innovation for healfhjmprovement,..especially in the context
of the United Nations Millennium Development Goals, is not sufficiently inter-disciplinary and
inter-sectoral; there is a need to mobilize all relevant sectors (public, private, civil society) to
work together in effective and equitable partnerships to find needed solutions;
c
J
a
Algeria, Angola, Bahrain, Benin, Brazil, Burkina Faso, Cameroon, Canada, Cape Verde, Chad, Congo, Denmark,
France, Guinea Bissau, Indonesia, Iran, Iraq, Ireland, Japan, Libya, Malawi, Mali, Mauritania, Mexico, Morocco,
Namibia, Nepal, Netherlands, Nigeria, Norway. Paraguay, Philippines, Poland, Portugal, Rwanda, Senegal,
Seychelles, Sierra Leone, South Africa, Sri Lanka, Sudan, Sweden, Switzerland, Tanzania, Thailand, Timor Leste,
Trinidad and Tobago, Tunisia, Uganda, United Arab Emirates, UK, USA, Zimbabwe
(
1
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11.
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□
6.
There 'is often
misalignment between funders, governments, and other organizations in
relation to research for health;
7;
Strong national commitment to science education at all levels of the education system is
ciitical to success in research for health and to the advancement of societies;
8.
Funding for research for health, especially in low- and middle-income countries, is
difficult to secure, but there are considerable societal returns available as a result of that
investment. This is especially true in times of economic crisis; now is the time to invest in
research for health;
9.
There are ongoing international efforts in the areas of public health, innovation, and
intellectual property, which need to be fully implemented in order to ensure more equitable
access to interventions.
o
.J
GUIDED BY THE BAMAKO PRINCIPLES OF LEADERSHIP, ENGAGEMENT AND
ACCOUNTABILITY,
’
o
WE CALL FOR ACTION BY
3
National governments
D
■
To give
priority to the development of policies for research and innovation for health,
especially related to primary health care, in order to'' secure ownership and control of their
research for health agendas;
1.
(.)
□ •
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3
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3
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3
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3
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2.
To allocate at least 2% of budgets of ministries of health to research;
3.
To improve capacity in institutions, ministries, and throughout systems for the
implementation of research policies, including: identifying national research priorities;
responding in a timely way to unpredictable health threats; providing a conducive environment
for development of a strong research culture; ensuring technology transfer; improving education
and training of researchers; integrating research for health within health systems; translating
research into action; and evaluating the impact of research for health;
4.
To develop, set, and enforce standards,, regulations, and best practices for fair,
accountable, and transparent research processes, including those related to ethical review and
conduct, product development and manufacturing, quality and safety of patient care, the
registration and results reporting of clinical trials, and open and equitable access to research data,
tools, and information;
5.
To promote knowledge translation and exchange through the application of effective and
safe interventions, evidence-informed policies, policy-informed research, and publication and
effective dissemination of research results, including to the public, taking into consideration the
diversity of languages and advances in information technology;
V
2
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11
10^
a
6.
To develop mechanisms and tools to enable effective inter-sectoral, inter-ministerial, and
c
inter-country research collaboration and coordination to address complex health challenges;
c
7.
To strengthen the efficient collection, storage, and sharing o^ reliable health information
and data according to international standards, to ensure utilization of the existing bodies of o
knowledge, and to develop skills for local data analysis and its use in policy development,
c
planning, monitoring, and evaluation;
o
8.
To strengthen research capacity and build a critical mass of young researchers by
developing and including curricula on research methods and research ethics, especially but not
exclusively for students of health sciences; and to stress the importance of scientific research in
secondary and tertiary levels of education;
f
Appropriate institutions at the regional level
''J
9.
To assist countries through international collaboration and where there is an identified
need to build and strengthen research for health capacity;
•
10.
To work through regional alliances to advocate for research, establish networks of
researchers and regional centres of excellence, ensure coherent and sustainable funding, improve
education and career opportunities in research and research management, and strengthen
harmonization of regulation and ethical conduct;
o
c
c
J
All partners and stakeholders
c
11.
To harness the potential of research by drawing on new sciences, emerging technologies,
and social and technological innovations, to address priority health challenges;
12.
To implement the recommendations of the WHO Task Force on Scaling Up Research and
Learning on Health Systems: namely, 1) mobilize around a high-profile agenda of research-and
learning to improve the performance of health systems; • 2)' engage policy makers and
practitioners in shaping the research agenda, and using evidence to inform decision-making; 3)
strengthen country capacity for health systems research backed up by effective regional and
global support; 4) increase financing for health systems research and learning;
13.
To implement the recommendations from the WHO Commission on the Social
Determinants of Health, especially those related to health equity;
■
•
*
.
14.
To promote and share the discovery and development of, and access to, products and
technologies addressing neglected and emerging diseases which disproportionately affect lowand middle-income countries;
i
9
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15.
To ensure civil society and community participation in the entire research process, from
priority setting to the implementation and evaluation of policies, programmes, and interventions;
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and to support civil society in advocacy to key decision-makers, including politicians, for
increased investment in and commitment to research for health;
Funders of research and innovation, and international development agencies
o
16.
To better align and harmonize their funding and programmes to country research and
q .' innovation for health plans and strategies, in line with the Paris Declaration on Aid Effectiveness;
(2)
n
O
□
o
17.
To better align, coordinate, and harmonize the global health research architecture and its
governance through the rationalization of existing organizations, to improve coherence and.
impact, and to increase efficiencies and equity;
18.
To invest at least 5% of development assistance funds earmarked for the health sector in
research, including support to knowledge translation and evaluation as part of the research
process, and to pursue innovative financing mechanisms for research for health;
19.
To increase,and sustain support for national research and innovation systems for health —
in particular research institutions - in low- and middle-income countries, and to ensure support
for ongoing initiatives developed in response to the Mexico Statement;
□
Multilateral agencies, together with Member States and partners
o
20.
To ensure that WHO streamlines the architecture and governance of its research activities
and effectively implements in unison both the strategy on research for health and the Global
strategy and plan of action on public health, innovation, and intellectual property;
o
21.
T° promote research for health within UNESCO as an important inter-sectoral, issue in
capacity building and in policy advice provided to. governments in education, the sciences,
culture, and communication;
3
22.
To urge the World Bank Group and regional development banks to deepen and expand
their research for health activities as part of their economic and operational research programmes,
with particular emphasis on health systems research and innovation, and national science and
technology capacity building;
J
□
J
23.
To evaluate the effectiveness and value of the four-yearly ministerial fora prior to
convening a further high-level inter-sectoral forum to discuss global research for health priorities;
24.- To explore the feasibility of establishing. November 18 each year as a World Day of
Research for Health.
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A Gall for Civil Society
Engagement in Research
for Health
□
We - the authors of this Call to Action - are a group of civil society
organisations that, through our work, demonstrate how research leads to
o
action for change. We. play key roles in all aspects of the research process
and conduct ground-breaking research involving multiple sectors and
)
disciplines focusing on neglected research areas. We believe that research
needs to move from health research to research for health. Our
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experience is proof that civil society organisations are indispensable to
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achieve this change.
3
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This document is the result of a consultative meeting held in Denmark (23-24 October, 2008)
organised by CIAM, COHRED and OBL, and co-funded by the Wellcome Trust and the organisers.
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A Call for
foT~
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Preamble
The goal of research for health is beller health for
This document - or blueprint - presents key
all.. Reaching this goal is possible with (he
strategies and recommendations to strengthen
involvement of the stakeholders in health that
represent the rich spectrum of sectors and
disciplines, including civil society organisations'
(CSOs). Civil society organisations are a missing
voice in the successful move from health
research to research for health.
the role of CSOs in research for health. It was
Civil society organisations:
developed by a group of CSOs to:
• Emphasise the value an^ importance of CSOs
in research for health; ;•
•' Define appropriate strategies to increase CSO
engagement in research for health;
• Inform the discussions at the Bamako
Ministerial Forum on Research for Health,
• Drive, participate in and conduct, research
and participate in developing a post-Bamako
that embraces health in its broadest sense,
including the determinants of healt h and
h eal th -rela te d i n eq u iti es;
• Can hold all stakeholders accoumablc lor the
commitments they make towards icscarch
for health;
action plan that will include greater civil
society engagement in research for health.
The strategies, based on the perspective of
CSOs, outline die steps necessary to involve
CSOs in helping achieve better health for all
• Can increase the skills and capacity of
through research. The recommendations focus
local actors, enabling them to respond
on all stakeholders in research for health - that
effectivly to national and international
is, government, academia, funding institutions,
priorities and demands;
• Provide missing viewpoints and cultural
perspectives to research for health;
• Translate research for health into action lor
health; and
• Disseminate research findings to a wide
audience of stakeholders in health using
more accessible and most appropriate formats
such as stories and narratives.
development partners and CSOs committed to
research for health.
1 We define civil society organisations us orgnuisutions iJvil arc nut for
profit, operate between the state and the public, represent or serve
population groups, and arc guided by the principle of social justice. Our
fiKiis is on those organisations with an interest in research for health, and
in usihg research to assess health determinants, influence health policies
and improve health outcomes. While acknowledging the diversity of CSOs
and the challenges of representativeness.' we believe that CSOs represent
and build alliances with community based organisations and community
groupings, and that their contribution to-research for health has a positive
impact on the population al large.
Recommendations from civil society organisations
to all stakeholders in research for health
We call on all stakeholders to:
1. Acknowledge the importance of research for
4. Provide funding which is long-term and
improving health for all, .and to recognise the
contribution CSOs can make to^suppoi t the
broad scope of research for health, with a
focus on health development and equity.
participatory processes, build their
institutional capacity, and becoming a strong
partner in developing and implementing
research strategies at local, regional and
global levels.
3. Create environments at national and global
levels in which CSOs can exercise their
legitimate roles in research for health,
through providing financial, inli asti iniuiul
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llexible, based on fair-contracting principles,
thus strengthening CSOs to engage in
2. Build and nurture partnerships with CSOs
around common concerns on national and
global priorities in Research for health, and to
base these.partnerships on the principles of
mutual respect., fairness, inclusiveness,
transparency and trust and with a multi
discipline approach.
e-
5. Value additional and creative means of
communicating research, using a variety of
channels and languages, and to. acknowledge
the role CSOs can play in raising awareness of
research, in increasing engagement in research,
in transforming research findings into action,
and in communicating this to the public, thus
helping build public trust in research.
■i
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6. Jointly, identify indicators and
development and institutional capac irv
methodologies for evaluating the impact and
building support to CSOs.
contribution of all stakeholders, including
CSOs, in research for health.
A Call for Civil Society Engagement in Resea:. I t for Health - Input to the Global Ministerial Forum on Research for Health
■1
F
11 o
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Blueprint'for strengthening the role of civil society
organisations in research for health
1. Advocate for greater involvement of civil
society organisations in research for health:
• Civil Society Organisuii<>iis
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process, identify capacity building needs
based on areas of interest, and develop
arguments based on sound evidence and
knowledge; (b) deeper awareness of the
and implement capacity building plans
concerns ol the public i.n how these match
up with the policies and agendas of
government, academia, funding
institutions and development agencies.
2. Establish and strengthen partnerships and
networks for civil society engagement in
research for health, with:
• Government and Academia
Establish and strengthen' partnerships
between government institutions?
academia and CSOs based on mutual
respect, democratic principles,
transparency and inclusiveness.
“ Funding Institutions and
Develop111ent Age 11ciex
Strengthen interactions between funding
bodies and development agencies to
increase involvement, of CSOs in research
for health.
• Civil Society Organisation'.
Establish and strengthen networks
between CSOs based on common themes,
supported by international and global
CSOs, to: (a) amplify ihe voice of the
3
O
public to influence policies, strategies and
agendas of government, academia,
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organisations in local, national and
international environments:
• Civil Society Organisations
strive towards a) excelling in integrity and
political independence, b) exercising social
idevance and inclusiveness, c)demonstrating transparency, accountability
and professionalism in administrative and
financial management, and d) delivering
quality services and products.
5. Increase civil society organisations’ access
to research funds
• (hivernnient and Academia
Incorporate CSOs in research projects,
where appropriate.
• Funding Bodies and
Development Age ncies
Increase availability of research funds to
CSOs by harmonising and aligning
funding principles and practices.
6. Create a national and international demand
for research for health
• Guvermnent and Acadeinia
Include a research component in all
health-related development projects, and
establish systematic mechanisms that will
make research findings available in a
language and format accessible to the
general public on a timely basis.
funding institutions and development
• Funding Institutions and
agencies as they relate to research for
Development Agencies
Encourage the inclusion ol a research
between CSOs on all aspects ol research
for health.
3. Strengthen the capacity of civil society
organisations to participate as full partners
in research for health:
component in health-related development
projects, and provide funds to promote
dissemination of research findings in a
language and format that is accessible to
the general public on a timely basis.
• Civil Society Organisations
• Gove-) inn ent. Academia: 1 imdmg
Instil udons and Dove lop-mem AgenciesSupport the development <il independent
institutional and huiiian capaCily to enable
CSOs represent an independent Voice in
research for heal-th. '
•
>
based on the identified needs.
4. Increase the credibility of civil society
health; and (b) promote collaboration
(3
<3
Define areas of interest in the research
CSOs can advocate based on: (a) rational
values, objectives and motivation of
government, academia, funding
institutions and development agencies; (c)
respectful dialogue and communication on
the practical and accurate needs and
‘O
• Civil Society Organisations
.
•
■ I?
Include a research component in all
health-related development projects, and
promote translation of research
knowledge to actionable knowledge
thereby highlighting relevance tv day-
today living situations.
/&c; 1
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I
SEA-CD-190
Distribution: General
I
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Application of
Epidemiological Principles
for Public Health Action
I
Report of a Regional Meeting
SEARO, New Delhi, 26-27 February 2009
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12.
Conclusions and recommendations
Virasakdi Chongsuvivatwong*
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The participants of the Regional Meeting on Application of Epidemiological
Principles for Public Health Action, held in the WHO Regional Office for
South-East Asia in New Delhi from 26 to 27 February 2009, recognized that
in view of the challenges posed by the recent economic crisis, climate
change, emergence of new infectious diseases, rising burden of NCDs and
tire continuing problems of high child and maternal mortality, there is a need
to strengthen the culture of epidemiology in the South-East Asia Region.
■
The scope and reach of epidemiology, which is an integral part of
public health, must be expanded to include the study of social, cultural
economic, environmental, ecological and political determinants of health'
and constitute the keystone for use of evidence .for development of public
health policy It must be used not only to plan, but also manage and
evaluate public health programmes. In order to address the old as well as
the new challenges to public health, epidemiological surveillance and
response capacity must be further strengthened in Member States, with a
sufficient number of trained epidemiologists, the support of public health
laboratories and use of information technology (e.g. open source software
that provides a common language).
I
§
ii
A greater level of interaction is needed between epidemiologists and
social scientists including for development of new methodologies in a
multidisciplinary manner and to bring in the concept of socioepidemiology. Such an approach will help in moving beyond health
problems per se to new complex social and human developmental
challenges such as the current crisis and threat to public health posed by
the global financial meltdown and climate change.
■
■
Training in epidemiology in medical and public health schools should
be skills oriented or field-based, with teaching-learning methodologies
based on learning by doing. Imparting epidemiological skills and an
analytical approach to problem-solving is imperative, at all levels of the
health services - from national to state/province to district and primary care
levels. Epidemiological capacity, however, does not lie in medical schools
and schools of public health alone but also in so-called alternate sectors
' Professor of Epidemiology, Prince of Songkla University, Thailand
Page 41
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Report of a Regional Meeting
such as management and social science institutions, professional •- J
associations and civil society, which also need to be tapped in a spirit of p
partnership in order to address the various health dimensions.
a
o
Recommendations
Member States should:
>
Promote and strengthen the use of principles of epidemiology
and of quality epidemiological data for formulating national
policies/strategies and managing health programmes;
>
Invest in and establish a recognized career path for f*
epidemiologists
and
public
health
specialists with
a *
skills/competency profile at all levels of health services;
>
Build capacity of the national health staff at al! levels of health <
service delivery including those working in national disease
control programmes in effective application of epidemiological K
principles for evidence-based public health action;
>
Develop and/or further strengthen networking among national
institutes and centres active in epidemiology, and harness their
expertise for promoting and protecting public health and for (J
sharing information for action;
r
•
>
Enhance teaching and training of epidemiology in the
undergraduate
medical/nursing/dental/laboratory/veteririary
courses, with emphasis on quality, in order to instil
J
r
epidemiological thinking in students;
■
>
*
>
"
I
Foster better collaboration with environmental, ecological and
social scientists to understand the influence of these factors on g
diseases and to apply this knowledge for planning, programme
implementation, monitoring and evaluation; conducting special
surveys such as demographic health surveys at regular intervals
could help in generating data relevant for this purpose;
Collaborate and support utilization of existing epidemiologyrelated capacity available in each country, not only in medical
schools and schools of public - health but also in the so-called
alternate sector such as civil society, professional associations,
Page 42
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Application of Epidemiological Principles for Public Health Action
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and management and social science institutions. Similarly, use
laboratory inputs and information technology in improving
epidemiological analysis; and
□
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3
>
Organize, in collaboration with interested partners and
stakeholders, a regional conference to enhance the visibility and
relevance of epidemiology in the South-East Asia Region and
advocate with policy-makers on the critical role of evidence for
public health action, at all levels of the health services;
>
Provide technical support to Member States in building the
capacity of national programme staff in epidemiology and
application of its principles for programme development and
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management;
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WHO should:
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Consider organizing annually a national epidemiology seminar to
share information on and experiences in epidemiological
research and training initiatives under way in the country.
>
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Continue to facilitate networking and partnerships among
institutes active in conducting epidemiological training or
research both in medical schools and schools of public health,
and in the so-called alternate sector, and provide a forum for
sharing of information and expertise within the Region;
Prepare and
epidemiology
consensus;
>
o
?■
share with Member States standard/uniform
training materials, and protocols based on
?•
I
Assist Member States in the formulation and implementation of
research that could determine the influence of social, cultural,
economic, environmental, ecological and political factors on
disease epidemiology and delivery of and access to health
interventions, and in better translation of such epidemiological
evidence to the policy and programme context;
o
i
■
Develop various short (1-2-week) epidemiology training courses
that are participatory, interactive and field practice-oriented for:
health programme managers so that epidemiological data
)
are used to plan, monitor and evaluate public health
o
programmes;
Page 43
A
SWi-
♦
1
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Report of a Regional Meeting
a
medical/public health school students through FETP-typ
training methods to engage them in the application^,
epidemiological principles td field investigations;
laboratory specialists to enhance a stronger involvement ar
constant collaboration between public health laboraton’
and epidemiologists;
nongovernmental organizations to encourage them to u.
epidemiological principles in their programmes; and
journalists and community organizations on kommunicatC
epidemiological information/data as an evidence base f<
public health action.
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Montreux Statement from the Steering Committee of the First
Global Symposium on Health Systems Research
From November 16-19, 2010, 1,200 participants from over 100 countries gathered ir.
O Montreux, Switzerland for the First Global Symposium on health systems research l
Under
the theme science to accelerate universal coverage the Symposium reviewed state-ofo the
art research and discussed strategies for strengthening the field of health systems
Q research.
After five days of keynotes, plenaries, concurrent sessions, satellites and informal
discussions and debates, the Steering Committee recognizes that there is an enormous
kJ energy to move forward with a further agenda of action reflecting the spirit and
commitment that brought us to Montreux from Mexico and Mali. This agenda includes:
o
1) Bringing this symposium to fruition by electronically preserving and disseminating the
intellectual products and knowledge discourse, ensuring their appropriate archiving and
creating channels of innovative communication.
2) Creating an international society for health systems research
^rearing an international society for health systems research, knowledge and
O innovafon,
which under the umbrella of science to accelerate UHC , will take forward the
0 collective opportunities identified by participants in Montreux with the ainToTlbuUdmg
greater constituency, credibility and capacity for■systems’^^ch^ healS gTo^a'l'ly. ’
3) Articulating a further agenda of improvement and action related to research on
systems for health
a.
___
j and lend suPP°rt to regional and national efforts to strengthen health
a:.^e VISlbll
!ty
systems research;
b. Work with the priority agendas related to the recently agreed UNSG strategy on
O maternal, neo-natal and child health; and the upcoming UNGASS related to NCDs to bring
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more
health
accelerate
n x effective
,
x -i. x- systems strengthening to 2?2
_!_._x-! universa| hea(th coverage;
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bubons from the global scientific community to establish norms,
J standards and practices to strengthen the foundations for health
— •—•- • •
■ 11
1 U1 I systems research
related to the production, translation and reproduction of knowledge for health systems
including: 1) the terms and typologies of research; 2) the range and appropriate use of
methods measures and instruments; 3) criteria for evaluation of strength of evidence and
. sJXt H« SyH,heK S; 4) msobal"sms f°r b"^ing the gap between demand an"
° t <■
h HSR and enhancing its translation to policy; and 5) opportunities to strengthen
research capacity through core curricula, and courses, clearer career paths and
y supportive institutions;
)
Joint oPborfunities for collaborative research and knowledge production across
different disciplines, sectors, stakeholders and geographies.
L) 4) Gather for a Second Global Symposium on Health Systems Research in 2012 or 2013 to
S_eC°?d Global Symposium on Health Systems Research in 2012 or 2013 to
j evaluate Progress, share insights and recalibrate the agenda of sciences accelerate
universal health coverage. China has kindly offered to host such a symposium
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Beijing Statement from the Second Global
Symposium on Health Systems'Research
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3 November, 2012
Beijing, China
o
From 31 October to 3 November, 2012, 1,775 participants from
over 110 countries gathered in Beijing, China for the Second
Global Symposium on health systems research. Around the
theme of inclusion and innovation towards Universal Health
Coverage (UHC), the Second Symposium reviewed state-of-the
C
art research and discussed strategies for strengthening the field
c
of health systems research.
b
Over four days comprising nearly 200 program events including
I
keynotes, plenaries, concurrent sessions, satellites, posters, films
a
and informal discussions and debates, the following action points
I
related to the inclusion and innovation themes have emerged:
• In our endeavor to achieve UHC, we must ensure the
centrality of social and gender equity. UHC is not only a
health system's task but a societal goal that requires
inclusion of diverse actors, different types of knowledge and
innovation across local, district, national, regional and global
contexts.
• Effective inclusion recognises the paramount priority of the
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collective development of indicators that can be used to
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monitor countries’ progress towards the goal of UHC, as
well as being used by civil society to hold governments
o
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o
accountable. Such measures must be relevant to local and
national contexts, first and foremost, and amenable to global
comparisons.
• Most urgently, local capacities for critical health systems’
analysis is required for individual countries to understand
what aspects of their health systems (in terms of service
delivery, financing and governance) require change so as to
make real progress to UHC with equity.
» The social, methodological and technical innovations shared
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in this Symposium provide a well-spring of knowledge and
an enormous opportunity,provided they can be appropriately
integrated to bring about systemic change to accelerate
progress towards UHC.
Key ideas for action that have emerged related to the objectives
of the program include:
• The cutting edge of health systems research should be
advanced by supporting analysis of politics and policy;
community action interventions; fiscal innovations; equityoriented health metrics; and longitudinal methods to capture
dynamism and long-term impact of interventions.
• Symposium participants want more research on: social
inequalities in health, including urbanisation and ageing;
social exclusion; governance; and the balance of sectors,
including informal, private, and public.
• The development of social science methodologies, health
metrics and monitoring and evaluation systems in a
balanced manner should be encouraged in order to.
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appreciate the complexity of health systems, policies and
implementation processes and capture their historical
origins, current status and future long-term impacts.
»
Other innovations that warrant support include strengthened
data surveillance systems; better documentation of financial
flows at all levels; nesting research and incorporation of
knowledge uptake in research design for improved
monitoring and accountability, including by communities, in
implementation of UHC.
Knowledge translation should be facilitated by developing
communities of practice and trust between researchers,
practitioners and policymakers; drawing from multiple
sources of knowledge and evidence, including real-world
experiences; strengthening open-access databases; and
enhancing South-South exchange of innovations to achieve
UHC.
• Long term and public financing for public research
institutions for health systems research is desired. Interest
groups and partnerships should be supported for various
forms of training in health systems research, that include
■ communication, values, power relations and context analysis
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as capacities at all levels.
We note with pride some accomplishments of key milestones
committed to in Montreux, 2010
a
1. The launch of the WHO Strategy on Health Policy and
Systems Research represents a significant step forward for
the field. It calls for increasing the relevance and utility of
Health Systems Research by making it more demand driven.
It suggests options for action by member states to embed
research into decision-making to ensure that HPSR is
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grounded in political realities and at the same time, the
grounding of policy processes in evidence and science.
2. The creation of a first international society for health systems
research. With more than 1400 members and 11 newly
elected board members, Health Systems Global held its first
Board and Annual General Meeting and began on its path to
catalyse and convene its membership to strengthen the field
of health systems research in the pursuit of more just and
. equitable health systems.
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3. Furthermore to meet the expectation, clearly expressed in
Montreux, that HSR inform policies more systematically,
participants contributed to the first meetings of the global
consultation on health in the post-2015 development agenda
as part of the United Nations Secretary General’s High-Level
Panel process. Understanding how to build on the MDGs,
address emerging issues, measuring new goals, and linking
these to accountability mechanisms relevant to each country
requires continued contributions by the health systems
research community.
In support of the Symposium themes and recommendations,
funders expressed broad support for the establishment of a new
Q
mechanism, a Research Consortium for UHC (RC UHC), to
improve the coordination of resources to accelerate the
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knowledge and know-how for universal health coverage. With a
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committed core of funders and a clear agenda for research, the
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development and operationalization of RC UHC will be finalised
and launched in 2013.
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In 2014, we will gather for a Third Global Symposium on Health
■
.
1
Systems Research to continue to evaluate progress, share
o
insights and recalibrate the agenda of science to accelerate
universal health coverage. Following a call for proposals,
applications from South Africa and Canada, are being reviewed
by the Board of HS Global with a .decision expected by the end of
2012.
o
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Approved by the Executive Committee of the Second Global
Symposium on Health Systems Research
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C.)
THE ‘SOCIAL VACCINE’
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Reflections on a new metaphor to strengthen
policy action on the social determinants of health
□
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Editor
Dr. Ravi Narayan,
Community Health Adviser,
Community Health Cell, Bangalore, India
o
D
(In Dialogue with
Session Panelists, respondents and PHM
colleagues)
a
3
Based on
Special Plenary, Forum 10,
Global Forum for Health Research,
Cairo, November 2006
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CONTENTS
1. The Social Vaccine - Background paper for Forum 10 Plenary
2. Vaccines or Values? Achieving global health §nd justice - some
insights from commission on Social Determinants of Health Paper by Dr. Fran Baum
. 3. Can we count on a Social Vaccine in War and Peace - Paper by Dr.
Iman Nuwayhid, Chadi Cortas and Huda Zurayk
O
4. Watching to die or playing to live? Childhood Malnutrition arid
Social Determinats - paper by Arturo Quizhpe
f *
5. HIV and AIDS : A challenge to People with Disability in Africa.
Determinants for vulnerability of Persons with Disabilities to HIV
and AIDS - paper by Babirye Kwagala Betty
6. Power to the People : Returning the control of our. lives (and our
health) — Paper by Vikram Patel
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7. Social Vaccine - a metaphor to revitalize the public health research
and advocacy community — A report of Plenary session on ‘Social
Vaccine’ at Forum 10 by Dave McCoy
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8. Social vaccines to resist and change unhealthy social and economic
structures: why we need them and how they would work — Fran
Baum et al (A paper submitted to BMJ for its Policy and Analysis
Section)
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Appendices
ALL PPTs
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1. TOWARDS THE CONCEPT OF A SOCIAL VACCINE
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(Background paper for Double Plenary Session on ‘Social Vaccine’ at Forum 10
Cairo, 30th October, 2006
Contents
1. Recognizing social determinants of health
2. Recognizing social approaches to tackling health
challenges and public health problems
3. The concept of a ‘social vaccine’ and its future
4. The research agenda towards the study of social
vaccine
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I. Recognising Social Determinants of health
The People’s Charter for Health that emerged at the first People’s Health
Assembly in Savar, Bangladesh, in December 2000, noted that 'inequality,
poverty, exploitation, violence and injustice are at the root of ill health and the
deaths of the .poor and marginalized’. It also emphasized that 'health is a social,
economic and political issue and above all a. fundamental human right’. In its
detailed call for action it suggested a six point programme which included:
■ health as a human right;
• tackling the broader determinants of health - economic, social and political
challenges;
■ environmental challenges
■ war, violence, conflict and natural disasters
■ A people centred health sector
■ People’s participation for a healthy world
Very significantly, it is the first comprehensive consensus health document that
suggests that action for health has to move beyond the biomedical approach
focusing on drugs and vaccines to a more comprehensive social approach (1)
The People’s Charter for Health echoed and endorsed the Alma Ata Declaration,
an earlier global consensus document which in 1978 had also affirmed that
''health is a fundamental human right and that the attainment of the highest
possible level of health is a most important world wide social goal whose realization
requires the action of many other social and economic sectors in addition, to the
health sector’(2) .
The importance of actioni on the social determinants has been suggested in the past by
several health professionals and expert committees.
In 1981, the Indian Council of Social Science Research and the Indian Council of
Medical Research in their Health for All strategy in India, outlined a prescription for
Health for All, which included such a broad concept of health action.
They
emphasized the need for a mass movement to reduce poverty and inequality and'to
spread education, to organize the poor and underprivileged to fight for their basic
rights and to move away from the counter productive consumerist western model of
health care and replac? it by an alternative based in the community(3)
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Echoes of this broader social action are seen in the writings of public health
professionals and epidemiologists in the late 1980s. In a detailed epidemiological
socio cultural and political analysis of Health and Family Planning Services in India,
Professor Banerji noted that: "Health service development is thus (a) socio-cultural
process (b) a political process; and (c) a technological and managerial process, with
an epidemiological and sociological perspective’ (4). Extending this idea further, in
1989, Community Health Cell in India proposed a paradigm shift in health action
from a biomedical approach to a social, community approach, which also moved
focus from ‘drugs and vaccines’ to education and social processes (5)
It is
important to emphasize that a case was being made not for a biomedical versus a
community / social model of public health but for the broadening of the orthodpx
biomedical approach by the inclusion of a social / community / societal dimension.
The late Professor Rose (1992) after decades of extensive epidemiological research
wrote that 'the primary determinants of disease are. mainly economic and social and
therefore its remedies must also be economic and social. Medicine and politics
cannot and should not be kept apart’ (6).
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Many researchers have since explored the social factors as determinants.of disease.
Studies on mental health have shown associations between risk of mental disorders
and poverty and also factors such as experience of insecurity and hopelessness, rapid
social change and the risks of violence and physical ill-health. (7). Studies have
shown gender disadvantage and reproductive health risk as factors for mental
disorders in women (8).
Other studies have shown interconnectedness between women’s health and life
concerns, including physical fatigue and psychological stresses of living in poverty.
The studies have suggested that Economic, social, psychological, and physical
determinants come together in women's bodies
This study has recorded that
“ Women's evocative words underline emotion and its connection to bodily health,
emotions that are a lingering response to the horrors of war and a reaction to the
daily degradations ofpoverty". (9)
2. Recognising social approaches to tackling health challenges and public health
. problems
In 1998, in a comprehensive public health policy analysis of the problem of
tuberculosis and tuberculosis programme in India, Narayan. T, (10-13) suggested
different levels of our understanding of the ‘‘determinants of disease' and
hypothesized that "determinants at different
levels needed different levels of
solutions and control strategies (See Table 1).
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She emphasized that the recognition of the new and deeper social paradigm would
move our understanding of TB beyond vaccine and drug distribution, to include
components that enhance awareness, motivation and empowerment of patient through
counseling and-autonomy building skills. Finally, such a programme would-then —
locate action in a multidimensional and multisectoral mosaic impacting on all aspects
of the problem. Without specifically calling it a ‘Social Vaccine’, it was suggested
that the programme would include an increase in health budgets and funds foi TB
control^ poverty alleviation programmes focused on marginalized peoples, housing
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and planned urbanization programmes; occupational safety focused on high risk
individuals and high risk occupations; personal and social support to affected peoples
and their families - particularly those from the marginalized sections; and initiatives
to address social and economic inequality and injustice. It was emphasized that such
a broad based social societal oriented model of a health programme for tuberculosis
would then ‘strike at the roots of the problem and not fritter away resources in
superficial biomedical reductionist strategies that have a limited imoact on the
disease ’ fll).
Table 1
Tuberculosis and Society - Levels of Analysis and Solution
Levels of Analysis of
Causal understanding
Solutions / Control
_____ Tuberculosis_____
_______ Strategies______
Surface
phenomenon Infectious disease / germ BCG, case-finding and
(medical and public health theory
domiciliary chemotherapy
problem)______________
Immediate cause
Under-nutrition / . low Development and welfare
resistance, poor housing, - Jncome generation /
low
income / poor housing
purchasing capacity______
Underlying
cause Poverty / deprivation, Land
reforms,
social
(symptom of inequitable unequal
access
to movements towards ' a
relations)
___________ resources
more egalitarian society.
Basic cause (international Contradictions
and More just international
problem)
inequalities
in
socio- relations, trade relations,
economic and political etc.
systems at international,
national and local levels
Source: Narayan, T. 1998(10)
In a series of annual conferences at Sir Dorabji Tata Centre for Research in Tropical
Diseases, Bangalore, researchers have explored the research challenges of social and
community determinants of Malaria, Diarrhoea, Acute Respiratory Infections (ARIs)
and HIV-AIDS and have recognized that the evidence on these determinants will help
to evolve new social and community approaches to tackling these major public health
challenges (M-17). In each of these papers, a comprehensive analysis of the social
determinants of these diseases has been attempted and it has been suggested that
research on these problems should move beyond the biomedical quest of new drugs
and vaccines and include social; economic, political and cultural action that may
prevent the problem or reduce the incidence. Table 2 summarizes diagrammatically
an approach to studying all the determinants at different levels shown in the form of
concentric circles, taking the HIV/AIDS paper as the example (17).
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Tabic 2
Research Challenges on the Social Determinants of HIV/AIDS
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RESEARCH CHALLENGES ON THE SOCIAL DETERMINANTS OF’HIV/AIDS
)
SOCIAL ASPECTS OF
DISASTER
NATURAL & MAN-MADE
MIGRATION / DISPLACEMENT
DEBT
CRISIS
&
Conflict
Non
Human
Primate
Models
WTO I TRIPS
Ethics
and
Patient
Rights
HIV -1
Vaccine
OCCUPATION
HEALTH
ANOSAFETY
MVA Based
Vaccine
Preventive
HIV Vaccine
War
c
Class / Caste
& Gender
Poverty /Equity
Microbicides
Tissue
Pathology
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Opportunistic
infection
Visceral
leishmaniasis
Therapeutics
Vaccine
Community
Mobilization
MACRO ECONOMIC POLICIES I
INTERNATIONAL HEALTH FINANCE TRENDS
Access
to PHC
HIV seropositive
monitoring /
HIV
Virology
ARV
Therapay
HIV Drug
Sexuality/
Resistance
Sexual
Behabiour
and
norms EROSION OF
Fungal
PUBLIC
Infection
HEALTH
SYSTEMS
Preventive Measures
(Now
including condom
Economic
Paradigms)
Stigma and
Discrimination
Laboratory
Monitoring
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PRIVATIZATION / COMMERCIALIZATION.
-OF HEALTH CARE
Source : Narayan, R, et al (17)
In Table 3, three of these papers;highlighting the determinants to be researched and
the solution and control strategies to be evolved have been summarized. Could some
of these strategies constitute a ‘Social Vaccine’ approach to the problem?
Table 3
Socio-epidemiological analysis of key communicable disease
Malaria (14)
• Malariogenic
.development
Migration
patterns
• Environmenta
1 / Ecological
changes
Determinant *
s
• Poverty
/
To be
inequality
researched
community
knowledge
and attitude
• Health
care
providers
(KAP)
•
‘Resistance’
’ Diarrhoea (15)
• Poverty,
. .. inequality
&
social
marginalisation
• Migration
/
■ displacement .
Ecologically
hazardous
and.
unsustainable
development
• Development
strategies without
health
impact
assessment
• Economic policies
that downside /
Access to Primary
• Health Care
•
Stigma
discrimination
•
Sexual behaviour
& norms
Social conflicts
•
Erosion of public
health-system-----Commercial izat io
n of health care
Inadequate
•
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&
•
•
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HIV-AIDS (17)
• Poverty / equity
class/caste
&
gender
•
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of
public
health system
(system
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(.)
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o
3
Health
impact
assessment
and response
• Health care
for migrants
• Eco-sensitive
development
• Poverty
alleviation
• Equity
focused
health
strategies
• Health
education
• Reforms/
strengthenin
g of public
health
system.
•
Some
solutions /
Control
strategies
(SOCIAL
VACCINES?
)
e
commercialise
public
health
system.
Commercial izatio
n of health care
including
unethical
prescribing
occupational
health and safety
• WTO/TREPS
• Migration
<&
displacement
• Natural & man
made
disasters
and debt crisis)
Tackle
poverty • Life
skTiT
and
education
for
marginalisation
youth as healthy
Poverty
and
responsible
alleviation
sexuality
programmes
• Local level peer
Environmental
education
for
and
health
informed
and
campaigns
separate
Health
discussion
impact
on
assessment
sexuality.
of.
development
• Strengthening
study
primary
health
Pro-poor
care access■ for
women
economic policies
and
marginalized
sections of social
Countering
commercial
of • Community
other of health
organization and
care
self-help . groups
to
strengthen
access
and
treatment.
• Positive people’s
network
to
empower, enable
and
monitor
programme. ______
Source : Narayan, R (14, 15, & 17)
In the latest paper in this series on HIV/AIDS, Narayan. R has specifically noted that
'there is a paradigm shift required to enhance research towards a ‘social vaccine' •
which will be a much more comprehensive response to HIV/AIDS problem ’(17)
In an earlier paper, at the Mexico Forum 8, there had been a plea for a change in the
focus of research from biomedical deterministic research to a more participatory
social 1 community research that would focus on education and social processes rather
than only drugs and vaccines (see Table 4). It was concluded that A social vaccine
for AIDS is closer than the AIDS vaccine' if such a shift in health research could take
place (18).
Table 4: The MDGs and the 10/90 gap : a PHM perspective
3
3
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Approach
Focus
Dimensions
Technology
Type of
service____
Link with
people
Research
/
Participatory
social
community research
Community______
cultural,
Psycho-so.cial,
economic/political
social
Education
and
Dings / vaccines
processes________
/
empowering
Providing / dependence creating Enabling
/ social marketing_____________ autonomy building
active
Community
as
Patient as passive beneficiary
participant
Social-epidemiology
Molecular biology'
Social determinants
Pharmaco-therapeutics
Health systems
Clinical epidemiology
Social policy
deterministic
Biomedical
research____
Individual
Physical/ pathological
Source: Narayan. R (15)
It was emphasized that this paradigm shift also require new partnerships between
medical / laboratory researcher and public health researcher / activist. The quest for
the social vaccine arising out of research activities in this new paradigm is an exciting
prospect for the future.
3. The concept of a ‘Social Vaccine’ and its future (19)
Origins
Though the origins of the ‘social vaccine’ concept is not clear, its use can be traced
back to the counselling and psychological studies stream. The California Task Force
to Promote Self-Esteem (1990) described ‘self esteem’ as a social vaccine or a
dimension ofpersonality that empowered people and inoculated them against a wide
spectrum of self-defeating and socially undesirable behaviour (20).
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The concept of ‘social vaccine’ was also used in other areas like de-addiction and
control of addictive substances like tobacco and drugs. Public opinion was seen as a
powerful social vaccine that effectively precludes certain behaviours in the fight
against tobacco and drugs. (21)
4
HIV/AIDS
0
In the field of HIV/AIDS, the ‘social vaccine’ concept came to be used in the 1990s
where it referred to a comprehensive package of preventive education, promotion of
contraceptive use and edification ofcommunities. This approach was used in Thailand
to suppress HIV infection rates and was cited as a model to be emulated (22).
However, the concept of ‘social vaccine’ was variably. used even in the field of
HIV/AIDS. It varied from using it to refer to prominent personalities and traditional
leaders interacting with people ‘dying of AIDS’ (23) to ‘prevention and control’ (24)
to ‘sex education’ (25) to ‘education’ in general (26) to ‘multi-dimensional response’
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involving elements such as ‘preventing social exclusion, protecting incomes and
social security schemes, and promoting solidarity with people with AIDS.’ (27)
Education and Social Vaccine
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There are two issues here—one is the use of ‘education’ as social vaccine, and the
second is the use of social vaccine in educational settings like the use of school-based
risk reduction strategies. The spectrum of use of the former varies from ‘sex
education’ (25) to ‘life-skills training’ (17) to ‘use of education as an empowerment
and developmental tool’ (26). The latter has also been studied in detail and various
institutions and education systems have come up with packages to deal with the issue.
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Social Vaccine as a ‘Vaccine’
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The social vaccine can be both a metaphor and a ‘real entity’. This .dimension was
reviewed in an interesting paper, which uses the framework of clinical vaccine
development, use., effectiveness and evaluation to examine the ‘social vaccine’
construct. The author calls on social sector policy makers and planners to learn from
vaccine developers and makes a few recommendations drawn from his observations
of vaccine development. They include; increasing investment in good quality social
science/education. research; developing an assessment methodology and a more
comprehensive means, of reporting on HIV prevention; applying cosNeffectiveness
analysis for social/education HIV/AIDS interventions; strengthening the quality and
coverage of delivery systems; maximizing HIV prevention coverage of target
populations (28).
The ILO and ‘Social Vaccine’
The ILO’s work on social vaccine was scaled up after the Regional Tripartite
workshop organized by ILO and UNAIDS in Windhoek, Namibia, in October 1999.
The workshop noted HIV/AIDS as 'the most serious social, labour and humanitarian
challenge that is currently threatening every African country's economy; a
developmental crisis, causing discrimination in employment and the social exclusion
of People Living With HIV/AIDS (PLWHA); a scourge that brings additional
distortion to gender inequalities, and increases the numbers of orphans and
incidences of child labour9.. It advocated for a 'social vaccine' that promoted social
inclusion, solidarity, and income and job security (29).
The Future of ‘Social Vaccine’
The wide spectrum of the use of the term ‘social vaccine’ and its adoption at the
highest levels of social action reflects the potential use of this construct. However, the
inability of the ‘social vaccine’ concept to become more wide-spread in its use and
impact points to some basic structural deficiencies in its construct as well.
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Examining the usage of the concept mentioned^ earlier, we can draw a few
observations about the construct of the term ‘social vaccine’:
• The usage of the term ‘social’ in almost all the cases mentioned above are
limited to the basic understanding of ‘social’ as ‘living together in
communities/'and tries to make use of that aspect in its intervention.
I
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The interventions concentrate too much on the behavioral aspects and try to
make use of the ‘society’ in either changing the individual’s behavior, or woik
towards changing the existing social norms, fighting stigma, etc. Not enough
emphasis has been put on health and social policy levels of such change.
Interventions like those of UNESCO and ILO try to address the broader issues
involved, but they are still limited to interventions in arid around the arena of
HIV/AIDS. It fails to recognize or tackle these broader social determinants as
factors that affect the spread of most diseases and are crucial to the continuing
ill-health of the poor and marginalized in every community.
• A major problem in public health responses today is the verticalisation 6f
interventions often to the detriment of other issues being tackled in the health
field. The interventions listed above also fall into the same trap by focusing
solely on the control of one problem while ignoring all other related health
issues. Social vaccines need to be constructed as a vaccine for protectinjg
society against a large number of problems simultaneously — a systemic
response, not a vertical ‘magic bullet’ response!
• Many of these interventions also follow the cause-effect model and find an
intervention that tackles, the immediate cause of the disease or problem, bdt
does not bring about a long-term solution. Social vaccine can be more
effective, if they focus on the deeper determinant.
•
While these are a few challenges that may affect the long-term viability of the social
vaccine, the interventions listed above are certainly a vast improvement over the usual
interventions that tackle health issues purely from a bio-medical framework.
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4. The research agenda towards the study of social vaccine
The Special Plenary at Forum 10 will look at the concept and construct of social
vaccine’ beyond the HIV/AIDS focus to other health challenges as well. This includes
other communicable diseases like TB & malaria, and social determinants like gender,
disability, war & conflict, mental health, childhood, malnutrition, and social
exclusion. The panelists and respondents and contributors from the floor will help to
evolve the Research agenda to take this concept of the ‘social vaccine forward. This •
section of the paper will evolve by the end of the Special Session incorporating all the
ideas and suggestions during the presentation of the paper and discussion.
Finally, to summaries this short review on the ‘social vaccine’ concept, one could
conclude with an evolving definition:
"‘A social vaccine can be defined as, Actions that address social
determinants and social inequities in society, which act as a
precursor to the public health problem being addressed . While
the social vaccine cannot be specific to any disease or problem, it
can be adapted as an intervention for any public health response.
The aim of the social vaccine is to promote equity and social
justice that will inoculate the society through action on social
determinants of health ”(19).
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Two developments in the 21st century are imporUnt for further development of a
concept of ‘social vaccine’. The first is the People’s Charter for Health (1) which was
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a civil society consensus on action towards a series of health and social policy issues,
which can be constructed as ‘social vaccines’. The second has been the launch of the
WHO Commission on Social Determinants on Health (CSDH), which is now bringing
together all the evidence that will help us understand the need for ‘social vaccines’
even more. The commission has to be challenged to move beyond collecting
evidence for social determinants , which is a very significant and important step
itself, but also to use this opportunity of the dialogue between the commissioners, the
knowledge networks, the facilitators of the civil society evidence and others, as
stimulus for evolving action on these social determinants as ,a ‘social vaccine’
construct. As Prof. Fran Baum has noted, ‘z/the People’s Health Movement and the
CSDH are . successful in picking up the baton from the earlier Health for All 2000
movement they may form the vanguard of a successful movement for a socially just
and healthier world in which policy decisions are driven primarily by this vision
(Health for All) rather than by decisions that maximize profit for a small elite (30).
The concept of a ‘social vaccine’ or ‘a set of social vaccines’ at the. core of such a
movement may just be the idea which captures the imagination and energy of the
World Health Organization and the global network of researchers to make this
happen. We hope the.Session at Forum 10 helps towards this paradigm shift.
References
i.
□
(J
□
Q
3
Q
3
3
3
Q
□
People’s Health Assembly (2000), People’s Charter for Health, People’s Health Movement Global
Secretariat, Bangalore (www.phmovement.org).
2. World Health Organisation, Primary Health Care : Report of the International Conference on Primary
Health Care, Alma Ata, USSR, September 6-12, 1978, Geneva, WHO, 1978.
3. ICSSR/ICMR (Indian Council of Social Science Research / Indian Council of Medical Research) (1981),
Health for All : An alternative strategy, Pune, Institute of Education
4. Banerji, D. (1985), Health and Family Planning Services in India - An’Epidemiological, Socio Cultural
Political Analysis and a Perspective, Lok Paksh, Delhi.
5. Community Health Cell (1989), Community Health in India, Health Action, 2, 55-2, Health Action for
All Trust, Secunderabad.
6. Rose, G (1992), The strategy of Preventive Medicine, Oxford, Oxford Medical Publications, pp 1-H38
7. Patel, V and Kleinman.A (2003). Poverty and common mental disorders in developing countries
Bulletin of the World Health Organization 2003, 81 (8), p609-615.
8. Patel, V et.al., (2006). Gender Disadvantage and Reproductive Health Risk factors for common mental
disorders in women, Arch Gen Psychiatry, 2006;63:404-413
9. Zurayk H et al (2006). Beyond Reproductive Health : Listening to women about, their health in
disadvantaged Beirut neighbourhoods, (paper from Inter-disciplinary Research Project on Urban Health
Centre for Research on Population and Health, American University of Beirut, Lebanon).
10. Narayan, T (1998). A Study of Policy Process and Implementation of the National Tuberculosis Control
Programme in India. Doctoral Thesis, London School of Hygiene and Tropical Medicine.
11. Narayan, T & Narayan. R (1998). Educational approaches in tuberculosis control : Building on the
social'paradigm. Chapter 21 in Tuberculosis - an interdisciplinary Perspective, Eds, Porter, JDH &
Grange J.M., Imperial College Press, London.
12. Narayan, T (1999) A violation of citizens rights. The Health sector and tuberculosis, Issues in Medical
Ethics, Vll (3) July-September,’1999.
13. Narayan T(2002),
■
Global Forum for Health
Research, Forum 7, Arusha.
14. Narayan, R (2001). Beyond Biomedicine: The Challenge of socio-epidemiological Research in ‘Trends
in Malaria and- Vaccine Research - the current Indian Scenario’. Eds. Raghunath D & Nayak R
Proceedings of the Second Sir Dorabji Tata Symposium, Tata McGraw Hill, New Delhi, 2001.
15. Narayan, R. (2002). The Community Health Paradigm in Diarrhoeal Disease control in Diarrhoeal
Diseases: Current status. Research Trends and Field studies. Eds. Raghunath D & Nayak R, Proceedings
of the Third Sir Dorabji Tata Symposium, Tata McGraw Hill, New Delhi, 2002.
16. Bhan, Anant (2003). Public Health aspects of Acute Respiratory Infectious in Trends in Respiratory
McGraw Hht
20^^^
Pr0Ceedin8S °f ,he F°urth Sir
Tala Symposium.
171
Ra,In£?l<ris,lna J and
S (2006).- Towards the Social Vaccine determinants of
HIV/AIDS, panel discussion report in----------- . Eds. Raghunath D & Nayak R, Proceedings-of the Fifth
Sir Dorabji Tata Symposium, Tata McGraw Hill, New Delhi, 2006 (being published).
U
18. Global Forum for Health Research (2004). Health Research for the Millennium Development Goals -}■ A
report on Forum 8, Mexico City, November 2004, quoting Narayan. R’s paper ‘Health Research:MDGs
and the 10/90 Gap’, p29-30.
19. Thomas N.I. (2006). Towards a Broader Understanding of Social Vaccine : A Discussion Paper based
on a internet search and literature review. (CHC handout)
20. Walz, Garry R. ‘Counselling To Enhance Self-Esteem’. ERIC Digest. January 1991. Available at
http://www.ericdigests.org/pre-9219/self.htm Accessed July 16,2006
21. Antonio Maria Costa. Opening Remarks to the Commission on Narcotic.Drugs. United Nations Office
on Drugs and Crime (UNODC). March 7, 2005. Available at http://www.unodc.org/unodc/speech 200503-07 l.html. .Accessed July 16.2006
22. Ministr)' of Foreign Affairs, Japan. Japan's Initiative in the Fight against Infectious and Parasitic
Diseases.
University of Toronto Library G8 Information Centre. July 2000. Available at
http://www.g7.utoronto.ca/summit/2000okinawa/infectious.htm. Accessed July 15, 2006
23. Greg Harris, ‘Social Vaccine holds promise for AIDS crisis; University of Calgary OnCampus Weekly,
November 26, 2004, available to http://www.ucalgary.ca/oncamous/wccklv/hov26-04/aid.s-jnhtin://\v\v\v.ucal.carv.ca/<)nciiinous/\\cckly/iK)y26-04/<>i k N-ihafrica.html. Accessed July 15,2006
24. Ofeibea Quist-Arcton. ‘Ghana: Aids Treatment Plan Begins In January’. AH' Africa Global Media
(Interview of Professor Sakyi Awuku Amoa, Director General of the Ghana Aids Commission).
November 30. 2003 Available at: http://allafnca.com/stories/20031 1300172.html?page=6. Accessed
July 15,2006
25. UNESCO Bangkok. ‘Sex Education: a Social Vaccine Against HIV/AIDS for Young People in Lao
PDR’. UNESCO Bangkok Newsletter-Issue No. 4, August 2005. Available at
http://\v'wfw.unescobkk.org/index.php?id=3266 Recessed July 15, 2006
26. Education International. 'UNGASS: Education is Ute social vaccine for HIV and AIDS’. Child Rights
Information Network (CRIN). May 31, 2006. Available at
http://www,crin.org/resources/infoDetail.asp?]D==8466. Accessed July 16, 2006
27. International Labour Organization (1LO). ‘In search of a "social vaccine"’. World of Work. No. 32,
December 1999. Available at http://wvAv.ilo.org/pubiic/english/bureau/inf7magazine/32/aids. htm.
Accessed July 17, 2006.
28. David J Clarke, The Education Response to HIV/AIDS: The ‘Social Vaccine’ as Metaphor and Reality.
Commonwealth
.Education
Partnerships
2004.
Available
at
http://vvww.15ccem.com/15CCEM/files/CEP2004/33EDUCAT.pdf . Accessed July 17,2006
’
29. International Labour Organization (ILO). HIV/AIDS and die World of Work - 1LO Response.
September
2005.
Available
at
http://www. ilo.org/public/english/region/afpro/harare/areas/protection/hivaids.htm
Accessed July
17,2006
.....•'
30. Baum Fran (2005). Who cares about health for all in the2Is* Century?, J. Epidemiol. Community Health
2005; 714-715 doi: 10.1136/jech.2005.035113.
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Civil Society Engagement in Health Research
Thelma Narayan,
Centre for Public Health and Equity (CPHE)
Society for Community Awareness Research and Action (SOCHARA)
Bangalore
& People Health Movement (PHM)
22nd October 2008
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1. Introduction
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The Community Health Cell which a group of us initiated in 1984 and where I was based for
25 years, started with the premise of building and strengthening a community health
movement in India working a lot with NGOs and field groups. The founding group earlier
held faculty positions in the department of Community Health in a leading medical college
in South India. Over the years working linkages were built with a number of NGO’s,
federations and networks. Over the years as our understanding of underlying health
determinants deepened we became actively involved in the evolving Peoples’ Health
Movement where the engagement both with social movements and with the state
increased. Since 2006 we are also trying to foster a Public Health Movement in public
' health education. In 2008 on the occasion of the silver jubilee of.CHC, the Centre for Public
Health and Equity was established by SOCHARA to take forward the health policy and
research work, along with continued support to earlier work in an advisory capacity.
With our academic background, since the 1980s in our new civil society base we continued
teaching research and practice of Community Health but with a clear focus on contributing
consciously to social change processes. Some of the studies that we were involved with
include:
•
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As conveners of the Medico Friend Circle we supported community based studies
after the Bhopal industrial disaster taking the findings back to people.
A study of the social relevance and community orientation of undergraduate
medical education using multiple methods was conducted and followed up with the
State Health University, government and some educational institutions over the
years.
We undertook the golden jubilee evaluation of one <'
"
'large voluntary sector
of the
health networks with 2500 health institutions spread across India. As part of the
Policy Delphi study of future trends was done in 1991-92. A questionnaire and field
visits to a 2020 sample of 400 institutions were done by trained investigators.
Follow up discussion meeting were held with 13 sub-groups among the
membership arid with, regional groupings. The Association changed its name and
Constitution with a greater focus on community based work.
A health policy analysis of policy process and implementation factors was
undertaken as a doctoral study using the National TB program as a case study.
This fed into our subsequent work with state governments in Karnataka, Orissa,
Madhya Pradesh, and Chhattisgarh and with the federal government through the
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National Rural Health Mission which was launched in 2005. This also led to a twin
pronged approach of strengthening the PHM and engaging with the WHO.
• ■ We have supported environmental health studies through a loose network that
emerged around 2001. Team members continue to work in this area.
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• ‘ Other international studies that we collaborated with included a study by WEMOS in
the Netherlands on global public private initiatives in health. Currently we are the
Asian hub for a study on "Revitalizing Health for All - Learning from
Comprehensive Primary Health Care”. This study is funded by the Teasdale Corti
project with the co-principle applicants being in the Universities of Ottawa and the
Western Cape. It has a strong PHM presence of persons from the PHM Research
Circle.
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All the studies were done based in the non-state civil society sector which offered a lot of
freedom. Links have always been maintained with government, academic institutions,
NGOs and a number of individuals. What we consciously did not get into was publishing in
mainstream journals by and large (though there have been some publications). We
published reports for circulation locally where decisions and action were required. We have
also introduced local language publications.
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As mentioned earlier as an understanding of the underlying determinants of health and
determinants of inequalities in health deepened we become actively involved in the first,
People’s Health Assembly in Savar, Bangladesh, as an alternative to the World Health
Assembly which was open only to state representation. The first PHA had around 1400
participants from 75 countries and adopted the Peoples’ Health Charter (see
www.phmovement.orq). The Charter has spontaneously translated into around 50
languages including.Braille and is also taught in some postgraduate public health schools.
We subsequently were deeply involved in the People's Health Movement globally,
nationally and at state level, hosting the global PHM secretariat from 200^-2006.
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Within India we are currently involved in a large scale pilot testing of community monitoring
of the health system with a network of organizations with active support and institutional
legitimacy and mechanism provided by the National Rural Health Mission of the Ministry of
Health, Government of India, from 1999-2002 through the task force on health and family
welfare setup by the commissioned stretches which helped shape our recommendations.
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2. Enablers and barriers to civil society engagement in health research.
•
•
Visionary, progressive, leadership in the civil service and the political establishment
(which in our case in India is a democratic system) has provided very valuable
policy space for health research by civil society and its follow up. When-there is
mutual trust and respect and time and effort are made on both sides a positive
synergy has developed. This enabling environment can be consciously built by
groups who have an equity oriented, inclusive approach.
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However the sustainability of these arrangements can be fragile and short term.
Lobbies, and competing interests are always present. In environmental health
research this has led to court cases, setting up of counter expertise and other
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attempts to influence the policy process. However all of this is positive as it leads to
a larger public debate.
If researchers see themselves only in their professional capacities as knowledge
producers then the studies get limited to publications, bookshelves and do not
influence policy and political' processes. Skills within the research teams or
•
organizations for participatory,
engagement are required,
(.)
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□
Status quo factors which sometimes include professional associations, research
councils particularly from a biomedical background, and other procedures that may
be bureaucratic are often barriers to the progress of engagement. Different
strategies have been attempted to overcome this and the pathways of change
could in themselves be an area of study. •
Funding institutions and mechanisms.can play a significant role in broadening the
focus of health research to research for health, development and equity.
•
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National health' research policies could provide a framework through which
institutional strengthening for research for health could occur in a manner that can
include civil society actors.
Development of institutional capacity and human resources in research for health
• need to be prioritized with a time frame. This effort should be focused both on the
public sector and civil society- developing strong public-public partnerships. •
• Privatization of health /medical research with a strong focus on clinical trails, is
draining trained human resources with research capacity. Attractive salary ■
packages, perks and working conditions and the absence of a social perspective is
resulting in a significant imbalance.
•
•
Social -cultural and economic factors privilege status and a life style whereby the
brightest and best are drawn into international bodies and business/industry in
health research. An internal and external brain drain among researchers is more
active and present than that among health practitioners where the brain drain from
lower income countries and populations is also significant. The focus of health
research also gets skewed.
•
Peer pressure and aspirations play an important role in career choices by young
researchers.
•
The provision of funds, mechanisms for professional support and legitimacy as well
as institutional mechanisms to strengthen capacity and ability for sustained work by
civil society based researcher will bring in fresh perspectives from community
based work.
•
While qualitative research, inter-disciplinary and trans-disciplinary research,
participatory action research and ethical issues in research are gaining ground they are still relatively marginal. This needs to be reversed and balanced by pro
active policy measures. Involving civil society research into the research main
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communication
An evolving system of engaged researcher’s interacting and working with policy
makers, practitioners and civil society changes the knowledge production and
utilization process. Information and communication technology when coupled with
oral group communication at community level has been very much more positive in
bringing about change in knowledge, attitudes and practice.
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stream and the policy discourse also needs to be legitimized and mainstreamed
while maintaining autonomy and creativity.
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3. Message for Bamako.
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a) Decisions and strategies should be encouraged by global and national policy making
bodies to recognize, legitimize and establish concrete mechanism to involve civil
society research /researchers to participate in research and policy process.
b) Developing institutional capacity to manage research and to strengthen human
resources for research for health, development and equity in civil society should be
given greater priority with earmarked funding.
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These steps would help to further enhance both understanding and action to address the
underlying determinants of health and the determinants of health inequality in our inter
connected world.
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Revitalizing primary health care: how can
epidemiology help?
Ravi Narayan
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A recent guideline in a declaration (I) made by the Consultation on the Application of Epidemiological
Principles for Public Health Action,, organized by the WHO Regional Office for South-East Asia in
February 2009, states that, “The scope and reach of epidemiology which is an integral part of public
health must be expanded to include the study of the social, cultural, economic, ecological and political
determinants of health and constitute the keystone for use of evidence for development of public ’
health policy.” This guideline summarizes the main point of this paper that explores the shift in the
paradigm of epidemiology which is required if this discipline has to support the revitalization and
renewal of primary health care that is taking place today.
In 1978, when the Alma Ata Declaration (2) was announced, the focus of epidemiology was on
vaccine-preventable diseases, tuberculosis, mother and child health, environmental.sanitation and other
diseases, primarily communicable, often described as the diseases of poverty and underdevelopment.
Epidemiologists, in the early years of the primary health care (PHC) era, focused on communicable
diseases and maternal and child health problems,with a more orthodox approach ofwatching mortality
and morbidity trends of these problems, resulting in single-disease approaches and programmes. While
the Alma Ata Declaration also emphasized new concepts such as equity, appropriate technology,
intersectoral development, community participation and health as a right, the true significance of 1
these radical concepts was lost among public health practitioners, policy-makers, epidemiologists and
researchers in those days.
□
In the years that followed, noncommunicable diseases, including cardiovascular diseases, diabetes,
mental health, and occupational/environmental health problems emerged as newer priorities. These
newer, more complex challenges led epidemiologists to identify broader determinants like lifestyles, ■
behaviour, individual and collective risks and other such factors, that led to more broad-based health
promotion and risk amelioration strategies.
)
Today, the primary health care-challenges at. community level in .a country like India include
agrarian distress exemplified by both growing childhood malnutrition and farmers’ suicides; economic
downturns that affect primary health care systems; and climate change,, war and social conflicts and
other disasters that affect the broader context in which primary health care systems are developing
and need to be sustained. These require epidemiologists to be able to study factors such as poverty,
inequality, exploitation, violence and marginalization and make epidemiology relevant to the new
challenges. It will require a shift towards a new paradigm.
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What is this new paradigm in epidemiology and what is the evidence required to study and
understand this new context? To answer this question, I share in this paper three short reviews that
will illustrate the challenges to epidemiology today, especially in the context of community-based
comprehensive primary health care.
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The first is a gradual evolutionary journey of the Centre for Public Health and Equity, Society
for Community Health Awareness, Research and Action (SOCH ARA),'’Bengaluru, India, trying,
over two decade, to understand this epidemiological complexity in both situation analysis and
health programme response. This journey was a study, a reflection and action experiment at the
interface between the public health system and the community.
•
The second is a brief overview of some of the emerging dialectics within epidemiological thinking at
the theoretical level as it grapples with the increasing complexity, moving from the epidemiological
understanding of disease to the epidemiology of determinants and structures in society.
The third is a brief outline of some recently published key documents that are beginning to
reflect this paradigm shift in public health and epidemiology.
•
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Finally, 1 shall illustrate through a lew evolving diagrams how epidemiology can metamorphose to
be more supportive of the current policy imperative of a revitalized primary health care system.
The journey towards a new paradigm
I
We began our journey into understanding the community-based challenges and framework of primary
health care in the pre-Alma Ala years in the department of community medicine in a medical college
in south India. We worked at the community level using health cooperatives, local health workers and
partnership strategies with the government and the community to enhance the goals of primary health
care (3,4). This led to expanding the range of primary health care activities to preventive and promotive
services, appropriate technology and development activities. We were, however, constantly faced with
the dilemma before most PHC workers, realizing early in their action-response that the biomedical
response was inadequate for a more complex social/community context of the PHC challenge. Cough
. syrup as treatment for a patient with chronic cough is inadequate for the cough which may be linked
to poverty, injustice, lack of protective facilities at home and work, myths, social exclusion and other
■ factors that may be important determinants of the chronic condition.
We were inspired by the work of two professors whose research work symbolized a shift from a
biomedical paradigm to a socio-epidemiological paradigm.
Prof. D. Banerji of Jawaharlal Nehru University, New Delhi, worked in 17 villages in India, in
the 1980s, visiting them year after year to understand their experiences and perceptions of health
and health services. He concluded that, “Health service development is a social-cultural process, a
political process, a technology and managerial process, with an epidemiological and sociological
perspective” (5).
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Similarly, Prof. Geoffrey Rose, an illustrious epidemiologist at the London School of Hygiene and
Tropical Medicine, well-known for his work on salt and hypertension, wrote a treatise after a very
successful career in teaching and practising epidemiology that, “The primary determinants of disease are
mainly economic and social and... medicine and politics cannot and should not be kept apart” (6).
0
One of our team members used the approach of these two professors to study tuberculosis as
a community health problem. In this doctoral study, over 200 patients who had been labelled as
‘defaulters’ of the TB treatment programme in rural districts of Mysore in Karnataka, were interviewed
to understand tffe processes leading to the default. Many social, economic, political and cultural factors
were identified which distorted theTB programme. From all the evidence gathered, a new framework
of the understanding of TB and its causation was hypothesized, which covered different levels of
analysis and each level of analysis, leading to a different level of control strategy (Table 1). The study
also made a critique of the .recently introduced directly observed treatment, short-course (DOTS)
programme from a socio-epidemiological point of view, identifying its limited biomedical focus and
. suggesting a community-based reorientatioiTrFrom DOTS to community-oriented treatment service
(COTS) was the suggested paradigm shift (7, 8).
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Table 1: Researching levels of analysis and solutions for TB: a common health problem
Levels of analysis of
tuberculosis
Causal understanding of
tuberculosis ,
Sblutions/Control strategies.for
luberc-.il.i-is ■
Surface phenomenon (medical
and public health problem)
Infectious disease/germ theory
BCG, case-finding and
domiciliary chemotherapy
Immediate cause
Under-nutrition/low resistance,
poor housing, low income/ poor
purchasing capacity
Development and welfare income-generation/housing
Underlying cause (symptom of
inequitable relations)
Poverty/deprivation, unequal
access to resources
Land reforms, social movements
towards a more egalitarian society
Basic cause (international
problem)
Contraindications and inequalities
in socio-economic and political
systems at international, national
and local levels
More just international relations,
trade relations, etc.
Source: Narayan T, 1998
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Many researchers of PHC constantly identify such social, economic, political and cultural
determinants in their studies but fair to interpret their significance or integrate this evidence into an
evolving solution. For example, an excellent study (9) on bednets use in a malaria programme among
adivasi (tribal) people in Mandla, Madhya Pradesh, identified that 60% of the people were outside the ■
bednet at peak mosquito biting time due to survival tasks linked to their economic activity. A follow
up over six months of those who used the net identified many cultural, economic and climatic reasons
for the non-use of nets. The evidence that has been gathered by the epidemiologists of the malaria
centre was an excellent social evidence, indicating poverty, survival, marginalization and cultural
determinants that affected the decision-making process of the adivasis. Unfortunately, the researchers
used this evidence in a more orthodox way, interpreting the evidence as factors to be included while
social marketing the use of nets to the affected population rather than using the evidence to link bednet >
programmes to women’s health cooperatives, income generation and community empowerment
initiatives, as has been done by civil society groups in Orissa and other states.
It is a challenge for epidemiologists to- move beyond superficial epidemiology that focuses in an
orthodox way on the biomedical aspects of a health problem and therefore results in techno-managerial
programme solutions, to a deeper assessment and measurement of social, economic, cultural, political and
ecological evidences that will enable them to look at deeper determinants of ill health like poverty, gender
bias, conflicts, stigma and social exclusion. They should evolve social and community interventions
to respond to this larger framework of understanding. Many health professionals who look at these
deeper social determinants and social solutions are often labelled as health activists, whereas they are
actually socio-epidemiologists who look at the determinants of an unhealthy society in a holistic manner
rather than just disease and individual ill health. Prof. Denis Burkitt (well-known for the epidemiological
description of Burkitt’s lymphoma in Africa) described this dichotomy in the 1970s by creating two
categories of public health professionals - “floor moppers” and “tap turners off — and two categories
of public health researchers - “intracellularists” studying the molecular basis of disease and health in their quest for new drugs and vaccines and “balloonists” studying the determinants at community and
societal levels (Fig. 1). These are the types of future epidemiologists urgently needed with special skills
and social sensitivity to support PHC challenges at community level.
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Fig. 1: What sort of researcher do you want to be?
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In 2000 , SOCHARA was an active participant in a gathering of primary health care enthusiasts,
public health professionals, epidemiologists and health and social activists from 75 countries, who
had gathered in Bangladesh for the first People’s Health Assembly, to assess and explore why the '
Health for All by the Year 2000 goal had not been achieved. The People’s Health Charter (10), which
evolved as a situation analysis and an action manifesto, presented a new epidemiological framework
for public health professionals and policy activists. It reiterated that, “Health is a social, economic and
political issue and a fundamental huin’an right”, and that, “Inequality, poverty, exploitation, violence
and injustice were at the root of ill health”. Based on this new socio-epidemiology, it prescribed
actions that tackled the economic, political and social challenges of health; countered war, conflict,
disaster and environmental health challenges; and promoted a people-oriented health care based on the
rights paradigm. Since 2000, two alternative world health reports - Global Health Watch-I and Global
Health Watch-II - have provided the socio- epidemiological evidence to back this new framework of
health and health action (11). Professors and researchers from all over the world have contributed
their evidence and analysis to these documents and reiterated the challenges of the multidisciplinary
evidence that epidemiologists must begin to measure and analyse to support public health policy.
Presently, SOCHARA is a part of a global initiative collecting evidence on comprehensive primary
health care (12). A study is being done on six projects in India, Bangladesh, Pakistan and Iran to
look at gender challenges in primary health care, the role of health workers (the Accredited Social
Health Activist of the National Rural Health Mission in India and the behervaz in Iran), the role of
community mobilization and empowerment, and the multiple approaches to urban primary health care.
This research partnership will try to take its epidemiology into social, economic, political and cultural
determinants to widen the understanding of PHC. This is an urgent policy imperative in line with the
Bamako Declaration, which encouraged greater partnership between civil society and academia.
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A brief overview of debates and discussions on new eras and new paradigms of epidemiology in
scientific literature since the mid-1990s, shows that the dialectic towards a deeper framework for
epidemiological analysis is also emerging in academia.
. An interesting paper (13) published in 1996 identified the shift in the paradigm of epidemiology
to four phases - the sanitary era, the infectious disease era, the chronic disease era and the ecoepidemiology era - and described the paradigms for each era, the analytical approaches during each era,
and the preventive approaches that emerged as a result of this understanding and analysis (Tabic 2).
Table 2: Future of epidemiology eras and paradigms
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Era
Paradigm
Analytical approach
Preventive approach
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Sanitary1
Miasma
Clustering of morbidity and
mortality
Drainage and sanitation
Infectious disease1
Germ theory
Lab isolation and experimental
transmission
Vaccines and antibiotics
Chronic diseases1
Black box
Control risk factors
Eco-epidemiology*
Chinese boxes
Risk ratios of exposure to
outcome
Analysis of determinants and
outcomes at different levels
Socio- epidemiology2
Multilayered/
Multicentric circles
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political and ecological
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Source: ‘Susser M, Susser E, 1996; ’Narayan R, 2006; Baum F et al. 2009
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Social vaccine and
community empowerment
through CPHC
More recently, a group of socio-epidemiologists has built an understanding inspired by the Alma
Ata Declaration and the people’s health charter, evolving the concept of the ‘social vaccine’ and the
epidemiological analysis that is required to understand and evolve it (14, 15).
Another interesting paper in the mid-1990s has compared traditional epidemiology with modern
epidemiology and identified the increasing problem of the directions in which modern epidemiology
has progressed, which has the focus on the individual, organ, tissue, cell and molecule; on the clinical
trial; a positivist, epistemological approach, and a reductionist epidemiological strategy with an
increasing focus on the individual rather than the collective (16). What is interesting about this paper1
is the call it makes to ‘go back to the epidemiology of John Snow’. This traditional epidemiology was
public health-oriented and population-based, historical and cultural in its context of study, linked to .
the paradigms of demography and social science: realist in its epistemological approach and focused
on population-based interventions. This paper makes an earnest appeal that, “Epidemiology must
reintegrate into public health and must,rediscover the population perspective”.
The challenge today is to move beyond all the focus on molecular biology, clinical and vaccine
trials, biotechnology, genomic imprinting and stem cells research, to socio-epidemiology, behavioural
science research, political economy studies and ethnography so that the research agenda is more
balanced and the translation of evidence into policy and action is more comprehensive and evidence
based (Fig. 2).
In many ways, the new socio-epidemiology described more recently has a somewhat similar
framework to what this paper describes as traditional epidemiology, except for the fact that the new
determinants are not only social, economic, political and cultural but also structural - in society rather
than in populations and individuals.
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South-East Asia Regional Conference on Epidemiology
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Fig. 2: Developing a research and advocacy agenda for primary health care
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A plea for balance
Molecular biology
Clinical trials
Vaccine trials
Immunology
Biotechnology
Genomic imprinting
Stem cell research
Socio-epidemiology
KAP studies
Policy studies
Behavioural sciences research
Political economy studies
Participatory research
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Recognizing the naw paradigm
Many recent documents at the global level are beginning to recognize both the limitations of the
current dominant epidemiology and also exploring some of the complexity of public health systems
and policies, including the challenges of revitalizing PHC.
The World Health Report 2008 has again placed primary health care on the global agenda. It has very
strongly brought into public health thinking the issues of social justice, right to health, participation
and solidarity (17). This report emphasizes that public health researchers and system developers
must now focus the evidence on universal coverage, service delivery, public policy and leadership
reforms. It also talks about mobilizing .organizations, imagination, intelligence and ingenuity for
supporting system development. All this requires new research evidence like the epidemiology of
social determinants and societal structures.
The Commission on Social Determinants ofHealth (CSDH) (18, 19) also places social determinants
of health on the map of epidemiological and public, health research. It reiterates that evidence should
come from multiple disciplines and multiple methodological traditions. Ohly with that sort of creative
cross-fertilization one can bring rich and diverse evidence base for today’s complexity. The report
mentions with great clarity that, “Evaluations of social determinants of health interventions require
rich qualitative data in order to understand the ways in which context affects the intervention and
the reasons for its success or failure”. It supports all evidence as important and not just randomized
controlled trials (RCTs) and laboratory experiments, and suggests various upstream determinants
such as socio-economic context and position, differential exposure, vulnerability, health outcomes
and consequences as important issues for study.
The Global Health Watch Report 2008, which is also called the Alternative World Health Report
from civil society, on the state of global health, says that people’s health is safest in people’s hands (11);
therefore, the objective is to empower individuals and community with knowledge and skills for
achieving good health. Civil society needs to strengthen their efforts with epidemiological evidence.
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The consensus emerging more recently from a wide range of sources is that:
•
•
•
there is a need to revitalize primary health care;
the evidence base should have a much broader focus on upstream determinants;
new models and paradigms are required, one of which should be to involve communities in
evidence-gathering and system development.
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Building the new epidemiology - step by step
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SOCHARA has begun to work step by step to change the focus of epidemiology from biomedical
determinism to a broader social analysis. This is necessary to tackle the complexity of health and
health care challenges at the primary health care level. In recent years, SOCHARA has tried to create
a diagrammatic model that constructs this complexity in concentric circles or boxes to emphasize that
this is not clinical versus public health versus social/structural analysis but is actually a complexity
that enhances problem-understanding and challenge as the analysis gets broader and more societal.'
This diagrammatic model (Fig. 3) shows the primary health care model surrounded by the biomedical
determinants, then surrounded by the public health factors and challenges, and then further surrounded
by the social, political and cultural determinants.
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Fig. 3: Towards a new epidemiological analysis for primary health care research
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Social-Economic-Political-Cultural determinants
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The diagrammatic model can be constructed by identifying through literature review all that is
known about a primary health care problem at the three levels-biomedical (clinical and pathological);
public health; and societal (social, economic, political, cultural determinants).
In diarrhoeal diseases, the public health box focuses on poverty, malnutrition, personal and
community hygiene, unsafe water supply and inadequate sanitation, inappropriate feeding and weaning
practices, and contaminated food as well as fly/vermin breeding. The broader social determinants
include inequality and marginalization, migration and displacement, inaccessible and unaffordable
PHC, unethical drug promotion, disasters - natural and man-made - and so on (20). Through this model
one can widen the lens to give the larger determinants the same sort of rigour in both quantitative and
qualitative evidence-gathering as one does to the immediate causes.
Using this new model, a recent analysis of the vector-borne diseases highlighted problems from
animal husbandry,' forestry, wildlife, sports, international travel, urbanization, labour migration,
inequality, marginalization, new economic policies, unsustainable development, privatization
etc. (21).
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These models have been presented in various national and global; forums to encourage
epidemiologists and researchers to move to a much more social-oriented research. This overall shift in
our understanding of primary health care problems and public health challenges is also now represented
in a diagrammatic way to encourage a shift in the emphasis in research and action from a biomedical
model to a social /community model of health research and system building (22) (Table 3).
37
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Table 3: New public health/epidemiology: the paradigm shift
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Focus
Individual
Community
Dimensions
Pliysical/Pathological
Psychosocial, cultural, economic,
political, ecological
Technology
Drugs/Vaccines
Education and social processes
Type of service
Providing/Dependence-creating/Social
marketing
Enabling/Empowering/
Autonomy building
Link with people
Patient as passive beneficiary
Community as active participant
Research
Molecular biology
Pharmaco-therapeutics
Clinical epidemiology
Socio-epidemiology
Social determinants
Health systems
Social policy
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This paradigm shift involves at least six elements:
•
A shift in focus from individual to community.
•
A shift in dimensions from physical and pathological to broader psychosocial, cultural,
economic, political and ecological dimensions.
A shift in technology from drugs and vaccines to education and social processes.
A shift in the type of service from social marketing and providing models to enabling,
empowering and autonomy-building processes and initiatives.
•
•
•
A shift in the attitude of people from patients and/or passive beneficiaries to people and
communities as active participants.
•
A shift in research focus from molecular biology, pharmaco therapeutics and clinical
epidemiology to socio-epidemiology, social determinants, health systems- and social policy
research.
This paradigm shift is just beginning to be recognized in the recent literature. When it takes place,
then the quest will move to social vaccines that will begin to tackle some of our.key primary health
care problems and public health challenges at a much broader level.
There was some concern when many of us recently began to use the concept of ‘social vaccine’
to describe actions against the social detenninants of disease. Many public health researchers felt
that vaccine wds a biomedical terminology and we may inadvertently biomedicalize the action on
social determinants. However, it was also felt that it was a good metaphor and that social vaccines
would actually protect people from the commodification of health and health care. This will be a new
terminology for prevention and promotion and probably excite the imagination of primary health care
and public health policy activists and professionals.
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The task ahead
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There is an urgent policy imperative to make epidemiology relevant to primary health care by an
active dialogue between public health professionals and epidemiologists and PHC action initiators
and civil society activists. This dialogue would result in a lot of cross-fertilization of ideas and
experiences, building on the ongoing micro and macro experiments in our countries. Many interesting
new experiments can be initiated.
3
•
Will epidemiologists learn how to measure equity? How to do class and gender analysis?
’
Will epidemiologists work with lay people to give them the tools of epidemiology ? A lot of
work has been done recently in the environmental health movement in India where lay activists
are collecting evidence for environmental epidemiology and community action.
•
Will epidemiologists work with the National Rural Health Mission and give serious
methodological direction to new initiatives, such as community monitoring, social audit and
people health watch?
5
This is the epidemiology of the future and a more definitive answer to the question raised at the
beginning of this keynote paper - how can epidemiology help primary, health care services.
0
Conclusion
□
Epidemiology will help the revival of primary health care if it accepts the following directional
changes:
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•
Moves from medical colleges and research laboratories to community;
•
Includes the social, economic, political, cultural and environmental analysis in epidemiological
studies;
•
Introduces the equity, rights and gender analysis;
•
Involves the community not as objects of research or as sources of data but as participants in
evidence-gathering;
•
Understands evidence of social determinants as evidence for social and public health action.
This is the challenge before public health professionals and epidemiologists today. This is the
challenge of the Alma Ata Declaration. And this is the challenge of the Bamako Declaration.’
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Commission on Social Determinants of Health. Closing the gap in ageneration: health equity tlfaaigh
action on the social determinants of health. Final Report of the Commission on Social Determinants of
Health. Geneva] World Health Organization, 2008.
(19)
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Narayan R. Health-Development-Agriculture-Environment: New Linkages and New Paradigms (challenge
of arbo viruses in India). In: Raghunath D, Rao DC, eds. Arthropod-borne viral infections current status
and research. New Delhi, Tata McGraw Hill, 2008, pp 409-416.
Narayan R. What evidence? Whose evidence? Who decides? Challenges in health research to achieve the .
MDGs and respond to the 10/90 gap. In: Beverly PS, ed. Health Research for the Millennium Development
Goals. Forum 8 Mexico, Geneva, Global Forum for Health Research 2005, pp29-30. Available from:
(
20?0]/WWW’8'Ob?IfOrUm,iealth‘Org/COnten^dOWnl°ad/527/3384/file/sI4835e pdffAcCeSsed 5111 Apri’
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An external evaluative study of the
STATE HEALTH RESOURCE CENTRE (SHRC)
and the
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MITANIN PROGRAMME
A state-wide health sector reform initiative and
community health worker programme in
Chhattisgarh State, India
Final Report
December 2005
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COMMUNITY HEALTH CELL
el. 080-2553 1518, Telefax: 080 - 25525372 Email :chc@Sochara.org
Mandated and supporteel by:
The Department of Health and Family Welfaire, Government of Chhattisgarh
&
Action Aid, India
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Section I
The State Health Resource Centre (SHRC), Chhattisgarh
Origin, Role, Review of Achievements
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1.
Introduction
This section deals with Objectives two and three of the Terms of Reference of the
external evaluation namely to “Evaluate the SHRC role in strengthening key
aspects of the public health system in Chhattisgarh'.
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1.1. How far has SHRC been able to achieve its goals and objectives and to carry
out the role defined for it as a part of the reform agenda, including the Sector
Investment Programme (SIP) milestones?
1.2 Study the SHRC impact ds an additional technical capacity for the DHFW
GOC.
ill
7.3 Review partnerships made and managed by SHRC with civil society
initiatives in the context of the Milanin programme and other policy
initiatives.
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1.4 Review SHRC contribution as <an academic group through research
activities, publications, andfellowship/internship programmes etc.
1. 5 Review significance of the institutional arrangement of SHRC in the public
health and health system context of Chhattisgarh.
2. Evaluate SHRC as an institution and make recommendations for its future.
2.1. Review the following aspects and recommend steps to strengthen them
further.
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a) human res(furce management and development policies and
procedures.
b) institutional structures, mechanisms and social arrangements.
c) governance and accountability systems.
d) financial systems.
2.2. Make overall recommendations for the SHR.C" (Ref: Terms ofReference).
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Methodology
2.
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A sub-group of two members of the evaluation team focused on the SHRC I
component. Methods used included:
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A detailed document review — see Bibliography.
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Interviews and discussions were ]held individually with key participants from
different stakeholders and in groups witli some field coordinators."
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Seven districts were visited - Rajnandgaon; Durg; Raigarh; Bastar; Dantewatia;
Ranker; Dhamtan, seeing health institutions at different levels - district
hospitals, CHCs, PHCs, health sub-centres. Discussions were held with health
personnel, NGO team members; prashikshaks and Mitanins
We were
accompanied by field coordinators. (See list for details and annexure for caSe: studies).
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T5?/33. C1°Se interaction with the subgroup of the evaluation team studying
the Mitamn programme so that perspectives and findings were shared and
integrated.
There were two meetings of the whole evaluation team - in March 2005 in
Raipur for planning and in end May 2005 in Bangalore to discuss findings.
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3. Pi ofile of Health and Health Care in Chhattisgarh
This brief profile developed from secondary sources is being given in order to
contextualize the health interventions that evolved in the new state. Expectations
objectives and achievements from the SHRC, the Mitcmin programme and
initiatives to strengthen the health system need to be viewed in this context ’
3.1. Introduction
The health status of a population reflects the set of prevailing social, economic
and political conditions. Health indicators that are used to describe the health
status of populations draw particularly on mortality (death) and morbidity
(sickness) data as the most gross indications of levels of .wholeness and well
being. Though they are limited in capturing many important aspects of health
and life, particularly the qualitative aspects, they are often the only indicators
available. Standardization and comparability across population groups are
important features that help in assessing how far a society and its government
have progressed in realizing citizens rights to health and health care. These rights
and entitlements are enshrined in many national and international documents and
agreements. Availability, validity and quality, of data depend very much on the
efforts and resources invested in developing health information systems. This
section utilizes available standard secondary sources of information. It describes
the administrative units within which public health services function; the health
care services available; and the health status of people in Chhattisgarh with brief
comments from a evaluative, recommendatory perspective..
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6. Study Objectives of the External Evaluation
These were developed in March 2005 and are as follows:
B. Evaluate Key Processes Regarding:
Preparation, Selection, community processes, Training of Trainers
(TOT), training, Follow-up and Panchayat involvement,
Evaluate supportive systems as planned, in comparison to what was
implemented, trying to understand variations and reasons for
difference / change,
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Logistic supplies including training materials and drugs,
Referral systems,
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Fundflows,
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Continuing education.
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B. Study outcomes in terms of the following:
Health education and improved public awareness of health related
issues.
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Improved responsiveness and utilization of public health care
services, with equity.
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Community action and participation for health and development.
Access to immediate relieffor common medical problems.
Wo men’s health empowerment and increase in women's access to
primary health care.
Linkages with gram panchayats and enhanced capacities of local
panchayats for health planning and programme implementation.
-th6 different m°dels used ot implement the programme
SWOT prmiples, focusing on flexibility, participation, equity"and effect on
outcomes.
D. Gender analysis of various components of the programme.
E. Identify the programmatic challenges faced by the Mitanin programme.
F. Make recommendations for further strengthening of the programme.
G. Draw out lessons from the Mitanin programme that could feed into the
proposed ASHA programme (Accredited Social Health Activists) of the
National Rural Health Mission (NRHM) of Government of India.
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1. Methods and study sample
Qualitative techniques
IS: ■
Given the Terms of Reference (TOR), the very short notice for a team to. be put
together, and the time and resources available, the evaluation team decided to
undertake'a rapid evaluation study using qualitative approaches. It was decided that
the evaluation would draw on perspectives of the 4 main groups in the program
namely: a) the Mitanins’, b) the community or Gramwasis, c) the support system—
the public health system and the prashikshaks, d) the planners’—the SHRC.
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To capture the first three perspectives it was decided to study what we termed the
“Mitanin Unit”. This consisted of a village - all the Mitanins of the village who
were contactable; the people of the village; the Prashikshaks; and the Angamyadi
worker and ANM (female health assistant) where possible. In each block we also.
met the PHO medical officers, and NGO staff team who ran the program (in case of
an NGO run program). We thus tried meeting a cross section of persons in the
village or ‘Mitanin Unit’ to get an indepth understanding of what was working or
not working, rather than covering a particular percentage of Mitanins.
While it is important to quantify the achievements of the training in terms of
knowledge and skills, we felt that we would rather look at the way the program was
actually perceived by the various stakeholders to understand the ground reality of
the programme. However even in this predominantly qualitative approach, we have
tried to make the exercise representative by selecting the sample of Mitanin Units
from various districts and phases of training, and doing the study with six plus two 1
researchers.
The sample
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Given the nature of the state, and the different phases the program was implemented
in, as well as the different administrative arrangements found in different blocks,
we chose a stratified random sample. The steps that we followed were :
Chhattisgarh was divided into North, Central and South Zones, after discussions
with SHRC staff, Government and NGOs working in the state.
The North comprised of the following districts - Koriya, Sarguja, Jashpur, Raigarh,
Korba, Janjgir and Kawardha.
The Central Zone districts were - Rajnandgaon, Durg, Raipur, Mahasamund, and
Bilaspur.
1 The Milanin study was primarily done by six researchers, while two other researchers .ho w
SHRC also added their observationsfrom districts visited by them.
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The Southern Zone districts included Dhamtari, Ranker, Bastar and Dantewada.
In each region the blocks were classified into three groups, depending on the phase
of implementation of the project.
1. The pilot phase blocks.
2. The first expansion phase - Phase I.
3. The second expansion phase - Phase II.
Since the pilot phase was totally run by NGO’s, and the second expansion phase
was less than a year old in some places it was decided to give greater weight to
blocks, in the first expansion phase. Thus from each zone the selection of blocks
was: One block from the pilot phase;, two blocks from the first expansion; one
block from the second expansion phase.
All blocks were being assigned numbers and the study blocks were chosen by using
the table of random numbers from tire eligible set of blocks after due stratification
as described.
Totally 12 blocks were selected from the total sampling frame of 146 blocks.
The 12 blocks in the study
Pilot phase
First expansion
Second expansion
(Phase I)
(Phase II)
Blocks sampled /
Nagari
Sarangarh
Pandriya
selected
Nawagarh
Lakhanpur
Gurrur
Podioprada
Churra
Durgkondal
Marwahi
Dhamtari
Lohandiguda
Blocks completed
Nagari
Sarangarh
Pandriya
Nawagarh
Lakhanpur
Balod
Podioprada
Churra
Gurrur (Partly)
Marwahi
Dhamtari
Lohandiguda
Doundi
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Kurudh
During
curing the
me study
siuoy the
me blocks
diocks of
or Durgkondal
Uurgkondal and
and Gurrur
Guinur were not completed. In their
place Balod, Doundi and Kurudh were visited ie 14 blocks were covered. These last
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minute changes in plans were made to offset the effect of any tutoring of the Mitanins
preceding the interviews (as we discovered that our questionnaires had reached some
selected blocks).
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Once the team reached the chosen block / block head quarters the following procedures
were broadly followed:
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At the block level 2 PHCs were chosen based on accessibility (one inaccessible and
one easily accessible).
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At each PHC a list of villages was drawn up and at least two villages were randomly
chosen (by chits). Sometimes villages on the way to chosen villages were also visited
especially if the target of 3-5 Milanins were not reached in the chosen villages.
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Panchayat leaders / ex-panchayat leaders (as the program was started during their
time)
The Mitanin(s)
The Anganwadi worker / ANM if possible
Villagers gathered in some common place and through house to house visits,
. visiting houses both near and far from the Mitanin’s house in the same Para.
> Members of the health committees or the women’s committees as the case may be.
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> Prashikshak (trainer).
At each village a questionnaire / checklist was used to collect information from the
various stakeholders that we met.
Development of the questionnaire / checklist
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A questionnaire schedule for each stakeholder was developed and used mainly as a
checklist to guide our discussions in trying to understand the various perspectives. The
questionnaires were semi- structured (options provided) and partly open ended.
The questionnaire was developed in a step wise fashion .after careful study of the
internal evaluation just completed, the objectives of the program and the operational
objectives as defined in the internal evaluation. Based on all these the broad domains
were agreed upon. These included : Conceptual basis of the program; Selection of the
Mitanin; Training; Support to the Mitanin; Interaction with the public health system ;
and Outcomes such as health education, home visits, community level activity, gender
enbowerment etc.
For each of these domains we listed assumptions and then fashioned a question that
would capture the essence of the information we wanted. Members of the team went on
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three pilot field visits to gain a feel for the program before actually making the
questionnaire. These include a meeting with Mitanins at Gunderdehi, a two day visit to
Manendiagarh and interaction with Mitanins, NGO activists as well as Field
coordinators, and observation of the field coordinators meeting and training. The
finalized questionnaire was field tested in the village, of Baital in Doundilohara bfock of
Durg.
The CHCB team consisted of the following members; Thelma Narayan, Shyam
Ashtekar, Sunil Kaul, Deepti Chirmulay, Shashikant Ahankari, Rajani Ved, Rakhal
Gaitonde, Amulya Nidhi, (and two assistants Vinay Vishwanatha and Naveen Thomas).
All except Amulya Nidhi and Naveen are doctors. All the team is experienced in the
area of public health, and community health including training of community health,
workers. Brief biodatas of the investigators are given in an appendix. The SHRC study
team consisted of Dr. Thelma Narayan and Dr. Rajani Ved assisted by Mr. Naveen
Thomas. Other members made the Mitanin team, coordinated by Dr. Shyam Ashtekar.
The SHRC study team also met mitanins in groups, as also prashikshaks, DRPs etc but
did not use the questionnaire.
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The Final Sample
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By the end of the field investigation the Mitanin team' study interviewed :
> 96 Mitanins
> 495 villagers (Gramwasi)
> 19 Prashikshaks
> 31AWWs/ANMs
> 8 Doctors
Apart from this the whole team met nearly. 300 Mitanins in groups, besides trainers
and almost all the field coordinators in groups. While these group meetings did not lead
to questionnaires being filled they contributed richly to the narrative and case-study
data that the team built up.
The mitanin study team finally traveled to 14 blocks in 9 districts. In all we visited 60
villages.
Secondary data sources
Documents listed in the bibliography have been used as secondary sources of
information along with newspaper clippings and photographs given by SHRC. A film
made by SHRC on the Mitanin programme was also viewed by the teams. All the
training material (seven books) was perused.
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Analysis
Data analysis was quantitative and qualitative.
Quantitative
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The questionnaire-responses were subjected to the following analysis:
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The primary data entry was done on Excel spreadsheets. These were sent to one of] the
evaluators who merged the various tables, and after running logic checks, proceeded to
analyze the data using the software package EPI INFO 2002 (CDC Atlanta).
The data was initially presented as cross tables on the entire .data and then stratified by
Phase of implementation and the administrative arrangement. These stratifications were
done to see the emerging trends in the data due to the phases and the administrative
arrangements;
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Qualitative
The qualitative data was analyzed at two levels,
> At first evaluators wrote out narratives of their experience and reports of
meetings, focus group discussions, quotes and case-histories.
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stakeholders according to the blocks, studied the emerging trends and wrote
block wise reports.
The emerging trends and results of the qualitative, as well as the quantitative data
analysis were discussed at a meeting in Bangalore 30^ and 31st May 2005. where most
of the evaluators met and shared their individual assessments. This helped a lot to make
sense of both the qualitative as well as the quantitative data.
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General comments on methods
While collecting the data we have contacted and gathered perspectives of all the
stakeholders of the programme - the planners, the support structure / implemented, the
key functionary - Mitanins, the beneficiaries
Gramwasis and other village level
functionaries. We have asked each about their assessment of the programme, the work
by the Mitanins and any suggestions for improvements.
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We lave juxtaposed analysis and comments in this presentation to help make
convenient reading.
Using a quantitative mind set the study deals with a relatively small samole of 96
still^The numb
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phaSeS’ eaCh Category becomes smaller '
still- The number of respondents in other groups (support staff) is even smaller
owever the study adopted an mdepth qualitative approach. We rely on geographical
spread of the study, depth of the enquiry and eight different researX'brinX ta
most similar findings as our corroboration. We have therefore felt comparatively safe
oncusions made regarding the programme as per the study objectives.
s^ection^1 rghVb0Ut the Mitanin Programme (and health sector strengthening in
section-II) denve from our collective understanding based on all aspects of our
involvement in the evaluation - discussions with a very wide variety of people field
visits, observations of events and processes, and reading a large number of documents
ana reports.
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9. Limitations of the Study
This study has to be read and understood bearing several limitations in mind:
The evaluation was undertaken at very short notice by eight resource persons from
different parts of the country. The time to undertake the evaluation was short. A
suitable qualitative methodology was therefore selected, with experienced
evaluators. We had to do with a fairly small sample of Mitanins. However we have
taken care that the sample is well spread out and representative.
Budget constraints prevented us from visiting the areas for a second time for any
further research, which is often necessary for qualitative studies.
The short notice, of just 15 days to put the study team together and initiate work,
meant that different researchers had to plan their visits during different time slots.
This reduced the possibility of adequate common time together for fine tuning the
enquiry-instruments and approaches. However use of emails, and mobiles helped us
bridge the distances and gaps. An unbudgeted meeting was held to discuss
preliminary findings. Further discussions though required could not be organised
through a meeting.
There is no systematic MIS data on the performance of the health system for 2 \2-3
consecutive years even on the website of GOC. It is therefore difficult to attempt
impact/outcome analysis of the programme.
There is no data on what Mitanins do as tasks in the community, nor do the
Mitanins keep any monthly record of activities. The study can not deal with this
aspect within the timeframe of this evaluation study. Therefore even ‘output’
measurement could not be attempted in this study.
On the other hand even the public health, system does not keep any systematic
records of what the Mitanin does in terms of referrals, blood slides, drug-dispensing
etc. For instance very few referral slips were found in the health institutions and
these did not tally with the number of referrals said to have been made. Therefore it
is difficult to estimate the quantum and quality of interaction between the Mitanins
and the health system. The Mitanin is expected to assist in many tasks and it is.
difficult to measure this without systematic records. This study is therefore unable
to measure quantum and quality of interaction between the health system and the
Mitanin programme. The same is the case with her interface with the Anganwadi
/ICDS svstem.
Study team members shoulder major responsibilities in their respective
organizations. In future concerned authorities need to plan evaluations well in
time, as the evaluations are vTitten into the Mitanin project proposals right from the
beginning. Last minute hasty work reflects on the overall project management.
Confounding factors
In the pilot areas and indeed in several other blocks other development and women’s
empowerment initiatives are underway in the form of SHGs and NGO activities. All
these have an effect on the levels of awareness and empowerment of the communities
and women. In any study of this kind, these can not be separated.
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10. A Four Perspective analysis of the Mitanin study
This study was done with the following
four perspectives taken into
consideration—a) the community, b) the planners, c) the mitanins, and d) the BRPDRT and health system staff. The accompanying figure at the end of this section
presents the four perspectives in which some overlap is assumed. How did the
study findings conform to the four perspectives? Given below is a brief overview.
A.
The Community (Gramwasi)
At this stage of the programme, the community is aware of the programme,
but does not find the programme useful enough. A small proportion of the
community needs and expectations from the programme are satisfied as yet.
Drugs and medical relief is only part of the list. The bigger problem is how the
planners perceive the community needs and expectations. The panchayat and
gram sabha are inadequately involved in implementation of this programme.
B. The Planners perspective
The primary concerns such as achieving ‘all women mitanins and coverage’
have been met in this programme. The issue of low costs without long term
liabilities are also met. However the increase in both demand and supply side
factors of the health system are yet to be met. The health system linkage is
yet to be well established. The programme is launched and training of
variable quality has taken place at different levels in most parts of the state,
but follow up health action at a larger scale is yet to begin, and hence many of
the concerns are not tested. Although all of them are legitimate concerns for
any planner, some of them may be self defeating. For instance, the low cost no
liability principle actually, means the scheme is disposable and is not built to
last. The planners need to really take a hard look at what has been achieved in
terms of addressing health and health care needs, by this programme once the
54,000 Mitanins are in place and fully trained.
€. The Milanins
It is evident that the Mitanins’ primary concerns for remuneration, proper
drug supply and support are not yet met at this stage of the programme. Many
of them complained about the amount of time spent by them. Their learning
need is partly satisfied, but needs to be further strengthened in stages later.
There may be higher and enlightened needs like self-actualization, gender
issues, and participating in or building up a women’s movement, and. But
the programme is yet to reach this stage. Since the primary concerns are yet to
be met, the planners and managers need to work on basic issues and priorities
first.
D. The Support System
The health staff, AWW, the FCs, BRP and DRPs are the main support
systems of the Mitanin programme. The health staff is concerned about the
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adversarial role of the Mitanin. Their primary interest is in making their own
work easy. Many of them see this possibility -like bringing children for MCH
clinics or treating malaria fever. The AWW is yet to be officially involved.
The BRP - DRP support system is struggling for its own survival. It is quite
possible that health staff may be concerned about Mitanins work affecting
their private earning from medical services. The medical officers did not feel
fully involved in the programme, but were generally supportive about the
programme. However several of them were skeptical about the role of the
Mitanin programme.
The four perspectives offer important insights about the why and how of the
programme. Some of the concerns may be contradictory and opposing. The
programme planners’ major job is to augment areas of strength and address
and engage the major concerns of each perspective. The planners in this case
have to look at all the three 4other’ perspectives beyond their own. In a true
participatory spirit, the different concerns have to evolve and find spaces.
; Failure to adequately address and engage the different concerns will create
aberrations. Analyzing these systematically:
■ . The neglect of the Mitanin perspective may result in high attrition,
reducing the programme to a mere paper scheme.
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The neglect of the community concerns may reduce the scheme to a
sarkari one where people will largely bypass it arid look for.other help
(like RMPs)
The neglect of support staffs concerns may hurt the support structure
and linkages with the public health system. The first major job is to get
over the adversarial engagement and find a groove for cooperation and
collaboration.
And none of the planners concerns, however lofty and justified as in this case,
can materialize without answering the genuine concerns of the three other
stakeholders. It may need self reflection on the part of planners and all the
other constituencies regarding survival issues of Mitanins, the BRP-DRPs; the
issue of reasonable drug supply; sendee orientation, with replacement of an
adversarial engagement by a cooperative one. For this to happen, the planners
may have to change some assumptions.
We believe that generating a perspective-analysis is an important pail of this
study, rather than only generation of rates and ratios from surveys. This is the
true purpose of a qualitative study of a programme as complex as that of the
Mitanin. The programme can undertake mid- course correction and the fourperspective analysis could provide a systematic basis to move forward.
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The Four Perspectives
needs)
Primary medical services
Preventive and promotive care,
National
Health
programmes
Quality of care
Promptness,
including FP, RCH,
Good behavior.
No irrational private practice
No exploitation.
AYUSH inclusion
Health information,
\
Gender, equity concerns
Linkages, referral support
Costs, sustainability, durability,
Low cost
Programme feasibility,
• • Administrative liability,
Linkages • with the public health
Time,
Wages-remuneration,
Supplies, support
Respect,
More learning
system
Demand generation for services and
Supply of services at grassroots
safe- hassle free
Quality of care,
Supports, links
Legal safety, feasibility
Political misuse
Should be an ally, not adversary
Feasible-selection,
implementation,
logistics, monitoring
Generate community's cooperation and
response
NHP friendly
- Media
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