Jyoti Gupta : Strengthening Public Health Systems: for Human Rights and Development of Communities
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- Jyoti Gupta : Strengthening Public Health Systems: for Human Rights and Development of Communities
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Strengthening Public Health Systems:
For Human Rights and Development of
Communities
Learning and experiences during the
Community Health Fellowship Programme
Of :
Dr. Jyoti Gupta
e-mail: jyotiji_2802@rediffmail.com
Community Health Fellowship Programme
Community Health Cell (SOCHARA), Bangalore
CONTENT
1. Prologue
2. Introduction
3. Placement at State Health Resource Center (SHRC)
The Public Health System: Its components
Chhattisgarh
The State Health Resource Center
The Mitanin Programme - Approach to Community Health Action
Objectives of the Mitanin Programme
The Mitanin
Programme Structure and Operational Guidelines
Reflections
Need for the Mitanins or any CHW programme
Mitanins – Their potential and …their future.
4. Placement in Prayas
PRAYAS – a profile
Land rights of the tribal – Issue of land alienation
Health Committee
Integrated Population & Development Programme
Workshop on declining child sex ratio
“Jan Swasthya Sashaktikaran Abhyan”.
Health Insurance?
My activity calendar in Prayas
5. The organization - Samavesh
6. Epilogue
2
PROLOGUE
Basic principle of science is that it evolves only against the background knowledge
of previous experiences; i.e. new learning is based on previous understandings.
*******
I am a medical graduate, being trained as a clinician to practice medicine – study
symptoms in a patient, give a diagnosis and accordingly prescribe a therapeutic regimen
and advice care. Studying the biology of a human body and what causes it pain will catch
fascination of any human… and that is where we are held up for 5-6 years …trying to
‘study’ the (biological) science of pain and discomfort… (in Humans!)
There is a huge institutional set up to teach us this scientific discipline, and similarly to
deliver these services. A thought of how these huge institutions were built & functions is
also alluring – but then we understand, that there are professional and organizational setups in place that work to serve and to co-ordinate such ‘Community Life’. There are people
fulfilling their individual roles for smooth running of this ‘community life’.
…Ok so to identify our roles in the society we were forced (!?!) to go to schools, to learn
skills for fulfilling social responsibilities we study in college - & then we’ll be in a set up
where we will actually fulfil these roles & functions…!!!
Wow how calculative… How thoughtful of humans to stay together!
-+-+-+-+-+-+-+-+-+-+-+-++-+-+-+-+-+-+-+-+-+-+-+-◊
◊
The first key to wisdom is constant questioning. By doubting we
are led to enquiry, and by enquiry we discern the truth. – Peter Aberlard
3
I have finished my college…
Now I’ll sit in some hospital, on doctor’s chair and treat patients…
Which hospital? Who are the people I will work with? What are their value systems – have
they grown up the way I have? Do they see human life, human misery the way I do?
Who will see that I do justice to my profession? Who will ensure I keep up on my skills
and learning – that I don’t resort to cheating, neglect or unethical practices… I am a
human…! Who will catch me when I make a mistake?
Who will pay me for my work? Treating people is a responsibility I have towards the
society or the person who comes to me to get relief from distress?
Is there a need to think about all this when work for community is involved… everyone
works in and for "their own communities"? …or people just live the life their way… and
communities come and go…
Ha… why are these questions bothering me?
Why don’t I simply practice medicine like other friends of mine…, within the structures
that have been established for ages? Everyone says - in practice I am the best, so I should
do MD medicine… simply!
Can’t I be a good clinician without bothering about the larger structure of the system where
I shall practice ‘medicine’? Can a clinician do justice to her profession that ways?
Who are the people who built these institutional structures, have they done complete justice
with their roles and responsibilities??? …O working at that level must definitely be more
fascinating and fulfilling, it’s a more creative… and then that is the requirement of the day!
Come on let me go ahead and learn those skills from the people who look after
institutions and organizations – from people who are more socially conscious and
community sensitive!!
‘If a man will begin with certainties, he will end in doubt,
but if he will be content to begin with doubt, he shall end
in certainties.’ – Francis Bacon
4
As a clinician who wants to study Public Health, and want to learn what goes into ensuring
effective functioning of institutions that give health care to the communities – who wants to
know why does government spend so much on our education and lets us do private practice
in isolation… with no control on our professional practice and skill development. As a
clinician who has not known the world outside school and hospital… this is going to be a
daunting job…
{- Am I thinking of bringing about a professional revolution?!?!!}
Studying the art of social sciences, understanding communities is not an easy task…
Unlike medical sciences, which do have a theoretical base – studying society (which ever
society) needs a practical base… on which you propound theories – which takes ages, or
might simply never be stated as principles.
For this purpose my learning should have following components –
- what the established structures can teach, (formal education in practice of PH)
[To gain the established body of knowledge]
- some personal learning (experiential learning)
[To gain practical knowledge & make it an enriching experience]
- An ongoing process of skills development to be able to creatively impact upon the
improvement in the practice of ones profession (medicine and PH for me)…
[To professionally establish myself, to be able to appropriately apply
◊
my knowledge]
Formal education is available in various universities/ colleges – Generic subjects
taught for the practice of PH are: Preventive and Social Medicine, and Public Health
Administration or Health Management. Composite course works on Public Health tries to
combine both these disciplines.
Public health administration, Social medicine and Medicine (Internal medicine &
Preventive medicine) – all disciplines are concerned with the functioning and practices
within the health sector; but not only practically, also academically they are they appear delicked.
Where the links exist, if they do, and how to strengthen or establish such linkages are my
major professional & intellectual quests. Medical training strategies should lie at the heart
of this quest, because it is from here that these links should have best established for them
to be applicable during professional role definition.
Where and how does one connect all these learnings into practice…
How will they impact on the system in such a way that doctors stay satisfied professional &
give high quality to their professional practice, besides being ethical, sensitive and
responsive humans…
◊
He who never made a mistake, never made a discovery – Samuel
Smiles
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…study how systems are established and maintained right up to the grass-root levels – how
are organizational issues dealt and planned at higher administrative levels.
Experiential learning comes through working in the field i.e. by practicing ones
discipline and applying it in the work areas.
My first experiential learning in these aspects, as mentioned earlier was as a clinician,
which inspired me to go a head and learn more about Public Health, social medicine &
community health – that led me into a Social Science institute, the CSMCH department of
JNU (Delhi), and the SOCHARA (CHC), at Bangalore.
The CH fellowship programme of CHC & SRTT offered me this unique
opportunity to gather the ‘ground-level field- experience’. The speciality of the programme
was that it was also designed to identify the (learning) needs of people who want to
establish themselves for improving the PH situation in the country, so it gave me yet more
space and flexibility for reflection and exploration; and I have been stubborn enough to
utilize this flexibility to its maximum! With due apologies, I express countless thanks to my
mentors for their patience and gratefulness for letting me take enough time to explore – …to
think and absorb.
This report ‘should/ might’ thus reflects my attempts to put together my formal education
from CSMCH with my experiential learning, as a clinician or medical intern and then as a
community-health intern; and how I can relate them all with my basic education in health
sciences:This report is not at all exhaustive of the activities and teachings that happened during the
fellowship programme, which consisted of classroom teachings, group activities,
discussions, presentations, seminars, role plays, field visits, visits to some organizations &
guest lectures as well… I have limited the contents of this report to documentation of my
personal experiences, encounters and reflections, and moreover the questions that arose
during this exploration phase; than activities we fellows did for ‘formal experiential
learning’ of the subject. Somehow, I feel that the orientation of this report is more toward
personal reflections and questions, because this is what we were motivated to do more
during the fellowship. This is a special skill only some people have, and I admire my
mentors for this, and for taking in all the scraps that comes in our mind with so much
emphasis being given to our (reflecting) hearts and (questioning) minds.
Also my field experiences, observations and learning might not be completely documented,
– because experiences are better experienced & felt than expressed… at least so for me, as
of now… I am just a beginner in the field of PH to be able to grasp and word all the
relevant experiences in one shot…!!! Or, putting it simply – for me it is not easy to put
everything decently into a comprehensible form for the reader, which should not irk the
reader… (?!?) Hope with time I am gradually able to pick up on that skill too.
That is what experiential learning is all about…!!!
6
Men sail a boundless and bottomless sea, there is neither harbour for shelter,
nor floor for anchorage, neither starting place nor destination. The enterprise
is to keep afloat on an even keel; the sea is both friend and enemy; and the
seamanship consists in using the resources of a traditional manner of
behaviour in order to make a friend of every hostile occasion.
- Michael Oakeshett
CHAPTER I
INTRODUCTION
I had decided to make a sudden switch from clinical practice to the Public Health
field, without much knowledge about its teaching or functional status in the country. I
wanted to practice Public Health because in my clinical practice I realized that my training
had not prepared me to work in the actual real life situation. I felt that urge to put my
creative energies into bringing about this link, instead of fending for myself in improving
my clinical skills in a system which was so non-conducive for a fresher. I wanted to gain
qualification that would provide me with the skills and authority to work with the higher
level planning structures of the health system. Little educated that I was about the subject
of Public Health, I felt that having a PH degree that was recognised by govt. of India shall
give me the necessary skills and position for my dream to come true…
But, mistakenly I did not realise that where medical education was a bit not in line
with the system, same could be the case with the PH institutes. If there are institutes to
teach PH, there is no clear cut system for them to practice and implement what they have
learnt. Those who get the authority, are unable to apply the principles of PH…?? What is
all this confusion? How do things work when they are not at all planned to be streamlined?
What is the work of ‘Public Health’ practitioners, and how do they exactly do it? I
know how a physician works in a clinic; I have known how the knowledge of medical
sciences gives an insight into the various aspects of disease and healthy living… but how
the factors that operate outside the clinic controlled for providing and maintaining a healthy
environment and healthy lifestyle…? I mean where are these links that broaden the
functional areas for the operationalization of this vast knowledge of health sciences… It
appears more worth while, more exciting and innovative to find out such possibilities and
work in those areas to be able to create a greater impact on the health status of the people –
for which our profession is meant to operate. Limiting our knowledge within the four walls
of the clinic appears to be restricting; constricting when above all this there is the problem
of poor systems management… right up from the level of policy formulation.
But…, all this gets too over-whelming and so broad – I should be able to go out and
explore all these kinds of probabilities and develop a framework of this broad picture, for
my better understanding… within which I can identify the roles functions of various
professionals…, …, …etc etc. to be better informed about my position in the larger system,
- when the next time I start my practice within this system.
…These were the vague; confused thoughts that brought me to CHC, where my
confused state was appreciated… the more I got confused, the more I got conformed to the
nature of committed community health fellows. But frankly, I don’t understand what else
7
can confuse you more than the thought of being appreciated for staying in a confused state
of mind… rather than being appreciated for asking the right question to arrive at the right
answer. It is such a torture to be in a confused state …and not knowing where to look for
the answers.
Anyways, something, and somebody convinced me that this fellowship could be a right
beginning if I am too ignorant of the ways of the world and just want to go out and see the
world… So I joined the fellowship with an open mind, keeping the faith on mentors; and
my luck, wherever they lead me… So …So shall be my learning…!
With so much of confusion in my head, so vast was my ignorance that I wanted to know
everything and so had real trouble trying to figure out what exactly should be my Learning
Objectives. Somehow, without bothering to find a focus - I managed to decide on my field
placements… Though, I am still unsure how my mentors allowed this for me (!), but it
happened and I got to see a lot of …as they say… ‘Both the worlds’…!!! Hopefully this
has provided me with enough experience to get an idea about the practice of PH, before I
actually start working in the field – a dilemma that I had faced in my clinics…
But again, the development of a framework for putting these learning together… was a
difficult feat – not even complete …but somehow I was able to make some sense of things
& experiences… which did take a lot of time though, and so was the time taken in
completing this report. I owe my special gratitude to Thelma and Sundar, who patiently
listened to me even months after my fellowship and (tried to) explain a lot of things and
events to me… even my feelings… may be that is the reason I am compelled to write a
long prologue – to contextualize my experiences for the readers – who even give a thought
to go through the report!
Objectives for the fellowship
As my interests lay around the development of an understanding about public health
systems, I decided to do my placement at SHRC, an organization that works closely with
the state government as its technical advisory body. Knowing that this would give me an
exposure to high profile policy level work, I also wanted to do my placement at some
community based organization. For this I chose Prayas. I had met Dr. Narendra, the
director, earlier and from what he explained about his organization I gathered that it might
suit my purpose.
Thus, the broad objective for my fellowship was just to go out and see what work is going
on in an organization, and get involved with their activities – I should be able to find a
focus at least at the end of the fellowship about the place I would like to start working for
…in the PH system.
The report thus gives a detailed narration of what I …tried to learn at SHRC; what I did
learn and saw at Prayas; with a short chapter on work of another organization Samavesh
that sort of made me feel a bit too emotional– about the cult of the ‘non-governmental’
organizations.
Other lessons:
One outstanding experience I gained during the fellowship programme was the experience,
or rather an opportunity to get exposed to the “Right to Health” campaign that was going
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on in parallel… I call it outstanding, because where I did feel the need to improve my skills
and knowledge for better health status of the people – I tried to look for answers around the
development of my profession, so that the system functions properly i.e. where I was
holding a narrow thinking about how ‘I’, as a member of this vast community can play its
role in bringing about the development of this same community – ‘advocacy’ was an
unfamiliar tool or skill for me… I had not identified the need for such kind of strategy
beforehand.
The experience was overwhelmingly enlightening and thought provoking - This was the
first time I was a part of any campaign for the ‘rights’…at least it was the first time that I
was led into thinking seriously about the strategy and its effects.
Though witnessing the spirit of the campaign mode and the zeal and zest for human rights
was very enthusing, yet I cannot avoid critically analysing and questioning the direction
where these efforts and enthusiasm will lead us… Like a technical person I was more
concerned with the methodology of the campaign, more than the ideology and the fervour
for human rights.
…I wrote a mail full of questions, to the leaders of this campaign… and I did not get a
reply.
In contrast to this - while I was in Bhopal, for the ‘public hearing’ event of the ‘Right to
Health’ campaign I made a short visit to this organization ‘Samavesh’. This too was a very
timely and a telling experience that sort of explained / gives answers on how one can try
and overcome the limited governance capacities of the government, or provide a supporting
hand to the people -not the government- for that matter – a strategy that stood in complete
contrast with the ‘tool’ of advocacy; and more important than anything else during this visit
was the fact that – The leaders could answer: why they chose to work like the way they
do… they have a whole history of evolution; and the reason for this evolution was
‘education’ – the basis of evolution. They not only talked about their guiding principles and
concepts of working with the ‘communities’ (which was a term not so often used, they said
- people), but also about the working principles for their team that works for the betterment
of the people. They felt disgusted if they were confused – they ask questions and have a
clear strategy on how to proceed with answers – there is no formula to get the answer, but a
formula for the methods to get to the answer… ‘Ask the Right Question.’
The history of Eklavya (ref. chapter 5) and the evolution of Samavesh – led me to think on
varied topics; as in - …Has all this to do something with just the ideologies and politics of
the country? What about educational status? How can one ignore the importance of
education – even for the role it plays in the development of ones own ideologies and
understanding of politics…
Further, at SHRC, I heard something about the campaign on ‘Right to Education’… and
today we see the results of the campaign… and we see its memories in the eyes of the
teachers at Eklavya. What shall be the fate of the so-called similar ‘Right to health’
campaign? Who will be remembering it in the same way as the teachers and students of
Eklavya do?
I need not go any further on this.
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…but, hey that leads me into thinking – how many politicians have actually studied
political science; and how many students of political sciences are in the political and
governing field… well before that – what proportion of students want or feel the need to
study, and then practice such kinds of subjects. Why have these subjects lost their
importance? Where exactly do the greater proportions of students from institute of
humanities go?
“It is time for a major investment of effort into the development, refinement
and standardization of various kinds of scales and other measures, needed
to carry forward the programme of documentation and analysis of various
dimensions of the human experience.”
– Angus Campbell.
______________________________________________________________________
All that shines is not always gold; everyone who travels around is
not always lost.
CHAPTER II
Placement at State Health Resource Center (SHRC)
I had known Dr. Sundar for quite some time now and heard about his Mitanin Scheme
that I was told to be a government initiative. I was not sure about the type of work Dr.
Sundar was doing in Chhattisgarh, apart from the Mitanin training, but his personality and
background attracted me. I wanted to learn about public health system from him and work
with him. So I suggested doing my placement there.
It was only then that I came to know that Dr. Sundar is the backbone to the
Government of Chhattisgarh for their initiative of improving / strengthening their Public
Health System.
…He was the Director of the State Health Resource Centre of a newly established
state, Chhattisgarh! So, I need to go through the publications of SHRC before I face the
Director, so that I am able to make full use of my time there with him… because he must
be very busy and preoccupied with his work – in a separate cabin of his own (!).
I flicked through the report of the study done by SHRC for the purpose of
strengthening of the Public Health System… wow(!) the title of that report was itself
fascinating for me…
I went through the report, not interested in the exact figures and data it provided, but
in the study design and various components identified as necessary determinants and
indicators of Public Health System’s effective structure and functioning… All these
learning objectives were provided for by the report – so, mistakenly I did not discuss it in
detail with Dr. Sundar. Though I was also not sure how and from where all these factors
and indicators were identified.
10
What I did at SHRC was to just look at the various activities that took place in the
office then. How things moved in an office, I was not sure of… so in trying to be a
participant I remained as an observer.
The Director was not at all unapproachable, without a separate cabin for himself. I
saw an excellent leader in him. He knows how to work with so many different types of
people. He knows who can do what and how you can make them do that. He has built a
completely non-hierarchical environment and takes care of almost all the activities of the
institute… handling all the political pressure and constraints for all the health initiatives. To
me he appeared to be the only brain behind all the initiatives…
Indian democratic politics is too much for a technical brain to handle – but not too difficult
for him to comprehend and play with!!
11
After being clear with the role of SHRC in the Public Health system and after
familiarizing myself (a bit) with the activities that take place at the State Health Resource
Centre, I formulated a set of learning objectives for myself…
My Learning Objectives:
Keeping in mind my motivation for working in the field of PH, during the Fellowship
programme I would like to get a broad understanding of:
How do we study and analyze the Health System; its structure and functioning.
How can the final conclusions / recommendations so drawn from such a study be
implemented – right from the central to state and local peripheral levels, with
legislative and administrative changes visible at all levels.
How exactly are these changes brought about – i.e. a broad understanding about
law formation and politics in the system. (!?!)
…Something about Policy Formulation and Implementation.
Develop some of the basic skills thus required; or at least be able to recognize
what skills are required and then develop on them…
Observing the functioning of SHRC and how it was established, besides knowing its
visions and objectives – gave an insight into how institutions are conceptualized,
established and maintained… the manpower, technology, politics, leadership and (may be
sometimes) the philosophies (or ideologies) that go into it.
Taking part in some of the activities there - …was not a very fulfilling experience
because as a beginner it was difficult to get fully involved in any specific activity, and
complete it with quality in just 2 months time. Dr. Sundar had cautioned me on that, but
said that as I was just in the exploration mood, there is no problem with just hanging
around… that is what I got at the end of two months – a hang on the ‘health-related’ work
outside the hospital set-up.
Following is my attempt to document an understanding about the strategies for
Strengthening of the Public Health System, as adopted by SHRC of course, and explained
by Dr. Sundar and his working philosophies and work style.
12
The PUBLIC HEALTH SYSTEM: Its components
Characteristics of a strengthened Public Health System and various links
important to bring about this improvement in the present system –
•
Infrastructure– i.e. having desirable number of Health Centres with enough
staff and facilities to be able to cover whole of the population of the state. And
also with a good and efficient referral system for such decentralized health
services, so that people know where to go for solutions of their problems.
New strategies making use of the private sector and civil societies will have to
be examined for this.
While planning for expansion of health services it is necessary to keep in
mind the rights of the disadvantaged classes. It has been seen that the poor are
unable to take advantage of the government schemes meant for them. This
must be ensured during the planning process itself, so that the scheme goes to
the target groups.
•
Capacity building of the staff to be able to deliver community centered health
services, accordingly provide infrastructural or functional feedbacks to higher
level administrators or policy planners (this also includes capacity building of
administrators and sensitivity of planners on the relevant ground level realities
and issues).
Training of voluntary workers, and people working in social sectors will have
to be organized for this. This should be done on a large scale, and seen to it
that effort of voluntary workers are integrated with the government efforts.
•
The Panchayati Raj institutions and the Urban Local Bodies have been given
the full responsibility of public health by law. For decentralization of Health
Services full assistance of local government institutions should be taken.
It is necessary to train these institutions so that they are able to carry out their
public health responsibilities to its maximum capacity and make their full use
in the health sector.
Training of people working in the government system will have to be
necessary so that they are able to work in partnership with local government
institutions, non-governmental organizations and the private sector.
•
Integration of ISM and other alternative systems with the Public Health
System, with administrative unification at the district level and programmatic
synergy at programme design level.
Many people have faith in these systems of medicine and also practitioners of
these systems of medicine have been able to reach the communities
individually – may be more easily where the mainstream public health system
has not reached. It is thus necessary to plan for their maximum development
and mainstreaming them to make their maximum use in public health.
13
•
A system to collect and maintain health statistics (MIS) that would provide a
database for various purposes from monitoring the health status of the people
and disease surveillance, to monitoring of the health system functioning.
•
Empower the communities in Public Health – provide them with adequate
health education and knowledge of the available facilities and schemes for
themselves; plus empower them to be able to demand for and avail these
facilities.
For this it is important to establish an understanding of Public Health among
the social workers, and communities, so that they are able to solve ordinary
health problems (or those related to the determinants of health or preventive
aspects of a disease) at local level.
•
A good Information, Education and Communication machinery is important in
the state, which would maintain a database and provide community education
to ensure community participation in health.
•
Policy, politics and state level issues of administration ???
This is a difficult field to address, and then policy issue comes only after the
entire situation has been studied and ground level needs assessed, i.e. after the
policy issues have been completely identified, so that the policies don’t follow
a piece meal approach.
Besides, politics and who possess the administrative powers are the critical
factors in operation!
Following is what SHRC, Chhattisgarh, had to say in this context:
“The formation of a new state provides new opportunities.
Though it inherits from it’s predecessor a policy
framework, it is open and willing to re-examine this
inheritance and reformulate its own policy, drawing upon
lessons from all the states.”
“The Government of the state of Chhattisgarh is now
engaged in the process of assessing the public health
care system to arrive at policy options for developing
and harnessing the available human resources to make
greater impact on the health status of the people.”
“Any attempt to explore policy options for human power
development must be based on an empirical understanding
of the conditions under which the present system
functions and how it responds to the challenges that
arise from within or outside the health care system. Our
understanding of the prevailing conditions and search of
policy options should also be guided by an appreciation
of the capacity of the system to respond to immediate
challenges as well as those that are likely to occur in
future.”
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Work of the state planning machinery for strengthening the public health
system–
-
Baseline studies or surveys to know the health status of the people and
their health care needs. Also study the present health system structure
and functioning to recognize the changes necessary for strengthening
the system, and the constraints…
-
Making recommendations based on the conclusions drawn and
constraints recognized – thus deciding on the Strategy and Action plan
to strengthen the public health system, its structure and functioning.
This includes planning and management for infrastructure and
manpower development. And establishments of institutes like, the state
institute of health and family welfare etc. not only for research and
resource purposes but also well linked with the administrative
machinery - with some powers to check the administration for
rendering good, up-to-date services.
-
Strategy (and action plan) for developing a health information
system, and for health education to bring about community
participation* in health care provisioning and help in community
orientation of service provisions.
-
Thus provide for policy review and policy options for developing and
harnessing the available human resources to make greater impact on
the health status of the people
It must be noted here that when we say Public Health Services, it should refer not
only to those facilities and services that provide just preventive, curative and rehabilitative
‘medical’ health care from primary to tertiary level.
Primary Health Care is an integral part of communities’ overall economic and social
development, for which it has to coordinate on the national basis with country’s total
development strategy.
It thus “involves in addition to health sector, all related sectors and aspects of
national and community development, in particular agriculture, animal husbandry, food,
industry, education, housing, public works, communication, and other sectors.”
An ideal structure of Public Health Services at the grassroots must include a primary
care team accepting a district or neighbourhood responsibility not only for local
epidemiology and health education but also for environmental control – these are
responsibilities usually vested in the public-health services – not just health care services.
This would require the effective linking up of the Basic Health Services with the
municipality, the pollution control board, and public works department. But, in the present
situation, this could only be possible if first the medical setup is completed and has been
made fully and efficiently functional. Ones this has been made possible, then the goal of
providing the Primary Health Care to all would be possible, with a few more inter-sectoral
linkages for better nutrition, education and vocation.
15
To achieve this total review of the administrative system may be required, for
reallocation of resources and introduction of suitable legislation to ensure that
coordination takes place.
Baseline studies to know about the health care needs of the state and health system
functioning.
Numbers of studies were recognized to be necessary for developing an overall
understanding of situation of the public health system functioning, possibilities for the
rationalization of health services, human power development and workforce management
that would result in better utilization, outreach and quality of health care services.
The studies should be able to address the following three questions –
How adequate are the existing human and material resources at various
levels of care (sub-centre to district hospital); and how optimally have they
been deployed? This is an assessment of their outreach and performance.
It examines the availability and utilization of existing facilities. This
involves mapping of facilities, personnel in place and vacancies, health
care financing and cost of health care, type of services available
including the extent of extension services provided, etc.
What factors contribute to or hinder the performance of the personnel in
position at various levels of care?
This looks into the workload of health functionaries at various levels in the
state, the organizational and motivational factors that affect their
performance, and the current training strategies.
What structural features of the health care system, as it has evolved, affects
its utilization and effectiveness?
This examines the current policies and their implementation with respect to
budgetary allocation, drugs and equipment procurement; personnel
recruitment and postings, transfer and career planning.
This also requires mapping of private sector recognition of factors that
would help develop a policy framework to facilitate and regulate the
private sector in health.
Apart from this situational analysis of the existing health system organization, there
is also a need to examine the peoples’ perception of health functionaries and
facilities. Assessment of the burden of various diseases in the communities and
review the specific health programmes should also be done; and a system
established to be able to gather and maintain such data on a regular basis.
16
17
Together these studies will help the state planning machinery in the following ways –
•
Lay down norms for various facilities and services and identify constraints on the
access to the optimal utilization of basic facilities (geographic, personnel and
systemic).
•
Project additional requirements for health human power. As part of this component,
this study will also identify competencies and social skills for various functionaries.
•
Identify organizational issues and policy processes to address motivational factors
that affect performance of health sector personnel.
•
Suggesting organizational policies including appropriate recruitment, transfer and
career planning.
•
Identify potential for partnership with the private and voluntary sector and suggest
ways to go about this.
•
Identify components and processes to effect decentralization.
Initial activities to strengthen Public Health System’s structure and
functioning:
o Infrastructures development –
-
Mapping of facilities’ requirements (according to the norms)
-
Action plan for funding and infrastructure building
-
Establishment of institutes like the state institute of health & family welfare
o Manpower development and capacity building
-
Recruitment of staff and development of their skills
-
Development of a cadre policy for health personnel
-
Medical education and health workers training – it’s reorientation or
required improvement
For community empowerment, health information and education
o Networking with various stakeholders and civil societies (or other institutions)
o A system for collection, maintenance and dissemination of relevant information on
health status and health issues.
o Establishment of the state resource centre for training and health education
The idea of community empowerment, it seems has always romanticized the
concept of Community Health Worker – but no one is sure which CHW programme
has really been able to provide this ‘empowerment’.
18
Chhattisgarh
Chhattisgarh is a new state formed out of Madhya Pradesh, in November 2000. It is
relatively backward and a poor state with a population of little above 2 crores; with HDI of
39 (for India it is 45).
There are approximately 34% Scheduled Tribes, 12% Scheduled Caste population,
with more than 50% other Backward Classes. The people here are relatively poor but state
is rich in natural resources. Large reserves of coal, iron ore, limestone and bauxite are
present. Almost 40% of the state is covered with forests.
Literacy levels of Chhattisgarh are relatively good (65.18% as against a national
figure of 65.38%; with female literacy rates of 52.4%) but health status is relatively poor.
According to SRS 2003 Crude Death Rate is 8.8 (India – 8.4) and Infant Mortality Rate is
76 (India – 66). Total Fertility Rate in 1997 was 3.6 when Indian figures were 3.3; and
Crude Birth Rate in SRS 2003 was 26.3 when national figure was 25.4.
Chhattisgarh also has a relatively poor infrastructure for health services. The Health
System is completely hospital based and treatment of disease has got precedence over
prevention of disease. Still the state has only two Medical Colleges and even the hospitals
attached with them are not fully equipped. There are 16 districts in the state, but only 9
District Hospitals. Out of 146 blocks only 114 have Community Health Centres. Many
posts of health personnel lay vacant; and many remote tribal areas remain un-served.
Further, to make matters complicated the uneducated quacks are taking advantage of the
public in such areas.
Being a new state it also lacks laboratory facilities. There is no lab for drug quality
testing, or for food adulteration. There is also no Training Institute for health workers or for
collection of health statistics. A good Information, Education and Communication
machinery is lacking in the state that would maintain a database and provide community
education to ensure community participation in health.
Apart from this, whatever Public Health System has been established, that itself is
distant from the people who are supposed to use it. Present policies have instead of
empowering the people have made them more dependent on the government machinery.
Underlying this is the increasing complexity of the Health System itself. Doctors are
educated in towns and in a hospital setting. They are not interested to stay and work in a
rural area, where all the public facilities are very poor; if they do agree, they are not well
able to relate to the rural life of their patients. On one hand the Health Department feels
that people do not take advantage of the health services offered, on the other hand people
feel that Government is not able to provide for even the basic health care amenities.
Thus, there is a gap both on the supply side as well as the demand side that needs to
be looked into. To be able to bridge this gap the general health services need to be made
more community based and the people empowered for their own health. All the policies
should be made keeping communities in as the focus.
19
Problems identified in the Government health system functioning…
The Government sees itself as investing in this vast network of health facilities and
being faced with the problem of gross under utilization of these services.
Reasons that under-lie this under utilization are identified to lie in –
• Weak systems management within the health department and poor accountability
at all levels,
• And in problems of outreach and poor health education and awareness.
Government constructs a CHW programme to improve utilization by working on
outreach and health education. It also stimulates pressures to improve it’s own systems and
accountability…
This led to the launch of a massive community health programme called Indira
Swasthya Mitanin Programme, as one of the components of Rajiv Jeevan Rekha
Programme. This programme was given high priority on the government agenda and
showed great political commitment to people’s health.
The programme was large, with the aim of training a woman in each single hamlet 54,000 in all – and it was difficult with the limited government resources. For funds a
policy decision was made to utilize the funds of Sector Investment Programme, supported
by the European Commission, for this purpose. For manpower, involvement of civil
societies was recognized to be important.
In a joint consultation of GoC with representatives of EC, the state officials, NGOs
from across Chhattisgarh and health activists from other parts of the country as well, it was
realized that Mitanin Programme was unlikely to succeed unless wide ranging
structural reforms were undertaken in the Health Administration. Various areas of
the health services that required such structural and practical changes in existing
laws, policies, programmes and institutions of health care delivery were identified.
There was a need to make a transition from the existing state of health
services to a community based health provisioning. The focus remained on
strengthening community health system, primary and district level health delivery
systems, health surveillance and epidemic control.
20
The State Health Resource Center
The State Health Resource Center was established in March 2002 under the MoU
signed between the State Health Society (then the RCH Society) of the Government of
Chhattisgarh and Action Aid India.
This happened in parallel with the formation of State Advisory Committee with
representatives from the directorate of health services, all donor agencies and seven NGO
representatives who were involved in the health sector reform process. These NGOs had
played a lead role in formulating the priorities for health sector reforms in the state and
helped in conceptualizing the basic tenets of the Mitanin Programme.
SHRC, though institutionally autonomous, values and utilizes SAC for social audits and
rigorous interrogation. All programmes that SHRC heads, or contributes to, are
implemented by the programme committees where officials of health services are present,
and often play the leading role (as in EQUIP).
The SHRC started functioning with one programme coordinator and assistance of
Action Aid staff, till October of the same year, when Dr. T. Sundararaman was appointed
as the Director of SHRC, on deputation from the central government; and a full
complement of staff was built up.
The state office has currently three programme coordinators and three support staff.
There are about 27 field coordinators (assisting the 146 blocks) under the Mitanin
Programme. Each field coordinator monitors 5 to 7 blocks and provides training and
planning support to the district RCH society.
Action Aid functions as an internal finance section and coordinates with the State
Advisory Committee for informal periodic social audits of the programme.
Goal of the Organisation
“Is to contribute and strengthen all efforts directed towards attaining
health for all primarily through ensuring universal access to the basic
goods and facility services and working and living conditions that are
necessary for the attainment of highest level of physical, mental and
social health of all.”
Such a goal is interlinked with all efforts towards social development
policies, which are equitable, sustainable and democratic. Such efforts
shun all forms of discriminations and most necessarily reach out to the
weaker and more marginalized sections of society and empower them
so that they are equal participants in their own development and
destiny.”
21
The Objectives
SHRC was conceived as a functionally autonomous body fully supported by the state
government, which would act as an “additional technical capacity to the State Department
of Health & Family Welfare”.
It was initiated “for the implementation of the Community Heath Worker
Programme (Mitanin) and carrying forward the pro-poor reforms proposed under the
Sector Investment Programme.” SHRC would further help in designing the health sector
reform agenda and in developing operational guidelines for implementation of reform
programme; plus arrange for or provide on-going technical support to District Health
Administration and other programme managers in implementing this reform programme.
SHRC was thus envisaged as having a core team of full time experts and support staff who
would:
-
Produce quick situational analysis on various aspects of health sector,
-
Prepare policy change proposals for the consideration of GoC, based on the
situational analysis and/or specific studies undertaken by it or through
individual experts or institutions.
-
Draw up the ToRs for any consultancy contracts and/or for engaging
individuals or institutions for short term or long term assignments as may
be needed from time to time
-
Conduct workshop or meetings as may be necessary, on behalf of GoC, for
effective operationalization of reform process.
-
Undertake or facilitate operational research and epidemiological inquiry into
disease prevalence and determinants
-
Assist in programmes to build capabilities of various different levels of
health department cadre.
-
Perform such other tasks as may be assigned from time to time.
It was further stated that these tasks would be consistent with the following objectives, laid
down in the MoU of partnership:
“Make structural changes in state policy, and practice, to make health services
more accessible to the people who need them the most. These include the very
poor and marginalized groups, tribal people inhabiting remote hamlets, women
and other people at risk.
This would be done mainly by strengthening
community health systems, primary and district level health delivery systems,
health surveillance, epidemic control and comprehensive reforms in policies,
laws, programmes and institutions for realizing the vision of ‘Health for All’.”
22
Studies undertaken
To begin with, SHRC organized a study on Workforce Management and
Rationalization of services and Human Resource Management in Public Health Services.
The study was organized into three overlapping but distinct sets of:
Facility Survey
Organizational Culture and Motivational Factors
Workload Assessment
Apart from analysis of secondary data, the primary data for the study was gathered by
sample survey. The components of which were:
-
A questionnaire based survey of facilities
-
A questionnaire based survey of organizational and motivational
aspects of health system
-
Number of field visits, focused group discussions, interviews with
senior officials and self-administered questionnaire of senior officials.
The study report provides the baseline data on current situation of health services in
the state and documents number of organizational practices and various lacunae in them. It
thus evolved into a set of pragmatic recommendations towards a policy on workforce
management, with emphasis on organizational, motivational and capacity building aspects.
The recommendations were finalized only after a serious discussion with various
stakeholders in a three-day workshop. The employees and their associations; the officers of
national, state and district levels, the medical profession and the professional bodies, and
the civil societies in health were recognized as the stakeholders for such a discussion.
The recommendations were formulated in terms of how the existing resources of
manpower and materials can be optimally utilized and critical gaps identified, and
addressed. It further looks into how the facilities at different levels can be structured and
reorganized.
Besides these technical aspects on how the study was conducted and
recommendations given, other conditions considered to be important for the same purpose
was pointed out in the report, and stated there was as follows: “ It was decided to not to outsource the study. This was so decided because to come
up with useful and implementable outcomes a high degree of participation and even
ownership of the study outcomes by the states health department is essential.”
“This study approach recognizes that the leadership of the state health department is
seized with the major problems and has developed an understanding of its solutions. When
we propose reforms, one has to necessarily start from there and build on it, with them –
rather than position oneself as an external critic and make largely gratuitous
recommendations. Moreover by doing the study with the local team, assisted by national
consultants with appropriate expertise, capabilities in such a vital area could be built up
inside the state.”
23
Other areas that were considered important for the follow up studies, were –
⇒ Financing of health care and the cost of health care
⇒ People’s perception of health care facilities and their satisfaction with
them
⇒ Assessments of burden of disease and review of specific programmes
⇒ Mapping of the private sector and development of a policy framework to
facilitate regulation and growth of private sector.
Some aspects of public-private partnership, as an important component of
facility survey, were however addressed.
During my stay at SHRC, some of these studies were initiated. :
A questionnaire for the assessment of cost of health care, at a family level was prepared
and field-tested. The cost of medical care was assessed against the family’s income and
household expenditures. It was called as The Study of Household Expenditure in Health
Care. Thus, it could also, to a certain extent indicate towards people’s satisfaction and
perception of health care and medical services.
A planning was on for analysis of financing available for health care and it’s allocation
under the various heads, plus its utilization.
Analysis of medical prescriptions written by various public and private doctors of
allopathic medicine was also being done, to assess their skills and prescription habits.
A study was initiated on the diet pattern and food habits of the tribal population, plus
the practice of tribal medicine. This was done to prepare a database of nutritional value
of their food and study the locally available medicine plus their healing practices and
health culture.
Based on the results of the study, various conclusions drawn and recommendations
given, following activities and major programmes that are ongoing o The Mitanin Programme
o The Sector Investment Programme
o EQUIP Programme
o Capability Building in State Health Sector i.e. Training of MPWs, ANMs,
TBAs, Medical officers
o Draft Training Policy for the state department of health and family
welfare
o Draft Drug Policy for Rational use of Drugs
o Preparation of Standard Treatment Guidelines
24
o Malaria Control Strategy
o Building a strategy for Public-Private Partnership for the RCH services
The Mitanin Programme
The Approach to Community Health Action
‘Mitanin’ in Chhattisgarh means a friend. According to an age-old tradition in the
villages of Chhattisgarh, customarily girls become Mitanin of their close girl friends.
Similarly there are ‘Mitans’ for boys. This relationship, like marriage is also established
ceremoniously and continues after marriage, establishing a bond between families.
It is this tradition which this programme seeks to revive, where Mitanin is not only a
voluntary worker but also a friend, philosopher and guide to all the people of the
habitation. So the community should have full faith and confidence in the ‘Mitanin’. They
should have friendly relationship with a sentimental element towards her, and be rewarding
for her work.
With this position in the community, the Mitanin has to perform following work in the field
of Public Health, for better Community Health: •
She will give Health Education to the community
•
She will take up the leader-ship role in all the Public Health activities of the village, and
will encourage community work.
In this she will coordinate with the ANM or other health staff of the village and the
PRI.
•
She will provide first aid, and over the counter drugs for minor ailments; and refers
other cases for proper treatment.
For this she is provided with not only the required knowledge base on common health
problems, their care and means of prevention, but also skilled to gradually take up
responsibilities for treating these illnesses in the village.
Further she is also given knowledge how to refer cases beyond her competence to a
proper health facility. The most important thing in this is that, whether she will treat a
disease or not is dependent on her the confidence she has on herself, or the sector team
on her.
For this she requires a continuos support, continued training and supervision. This is
presently provided by the SHRC team and should be provided by the ANM, Panchayat
and other health staff, in future.
•
The Mitanins will gradually take on such other responsibilities, and perform such other
functions as the Panchayat and the district administration may decide.
She will be trained for performing these duties, and duly compensated for by the
concerned department.
The Mitanin thus becomes the main link between government and the people in the
habitation. For this it must be stated here, that to derive full benefits of the scheme the
25
actual functions of the Mitanin, which she does for the health department, must be
planned and coordinated at the village level only. Thus, powers must be delegated to
the PRI for this, and capacity building of the PRI becomes more important.
The programme design thus, also has an in-built withdrawal strategy for SHRC.
26
Objectives of the Mitanin Programme
Main objectives of the programme are to –
1.
2.
3.
4.
Improve health awareness and health education of the communities.
Promote community initiatives for communicable disease control
Improve utilization of existing public health care services.
Provision of first contact curative care at the hamlet level. This not only provides
immediate relief from the common health problems but also avoids needless, often
hazardous care.
5. Organize community, especially women and weaker sections on health care issues.
6. Sensitize Panchayats and build up its capabilities.
Four critical components for achieving these objectives –
1.
2.
3.
4.
Mitanin selection
Mitanin training
Support to the Mitanins in her tasks
Making health system improvements that enable the system to respond to the
demand for services that her work brings about.
Operational objectives set for the programme –
-
-
Select, train and deploy a Mitanin in every habitation of the state.
Ensure effectiveness of the Mitanin by supporting her internally in the
habitation by women’s health committee, village health committee and the
elected Panchayat; and externally by a cadre of trainers and the local
government employees.
Ensure skills and effectiveness of the Mitanin by providing her with at least
20 days of camp-based and 30 days of on-the-job village level training.
The Mitanin
Mitanin is a hamlet based unpaid community health worker or health activist. She is
drawn from among the women of the hamlets who volunteers herself and is also agreed
on by the villagers. She is recognized to possess leadership potential and is provided
adequate and regular training and supervision in her work.
She is preferably a married woman supported by her family in her Community Work.
Her educational level is not important but good level of literacy is highly desirable.
She is not paid for her work, so the most important principle is that her livelihood
should not be compromised. This is like a part time job she is doing voluntarily. Three
hours daily for 4 days a week would be sufficient for her hamlet based activities. Once in
two weeks she is required to go out of the village for training or meetings with other
Mitanins and their trainers. In between she has to go for residential training, at a training
centre for 3-4 days at a time. She is provided with compensation on these days for loss of
livelihood.
Mitanin also helps create and sustain a local village health committee that provides
her a continuos support. Besides, the village Panchayat, the ANM, local PHC and the
27
AWW are also expected to work and liaison with her for effective support and
coordination.
Programme Structure and Operational Guidelines
MITANIN TRAINING
For any programme to be a success, the leader should meet the workers regularly,
troubleshoot their problems, constantly update their knowledge and keep their
motivation high – providing timely retraining and replacements, wherever gaps
occur.
Training - Training builds up specific competencies by imparting knowledge and
developing various skills to use this knowledge, and bring about attitude change within
them, where required, and in the communities.
Mitanin training strategy envisages 20 days of camp based training and 30 days of on-thejob training. There are seven manuals provided to them, which she can always refer back to
for guidance and are to be used regularly in meetings for revision. These manuals or
training modules are written in their local village language, in the style of a conversation.
Titles of these can be listed as follows –
1.
2.
3.
4.
5.
Introductory book on health and Mitanin Programme.
Introduction to public health services and facilities.
Basics of child health action.
Basics of women health action.
(A) Local planning for malaria and gastero-enteritis control.
(B) Manual on Tuberculosis and Leprosy.
6. An introduction to first contact curative care.
7. ‘Kahat hai Mitanin’ – a pictorial book with key messages for Mitanin that she can
use for local communication.
Training camps are staggered over a year, with training sessions extending at stretch
to a maximum of 4 or 5 days, usually 2 to 3 days. The training contents for these camps
are –
•
•
•
•
•
First Round of Training – three day residential training with the first three training
manuals. This training ends after a field trip.
Second Round of Training – two day training, preferably residential. This training
reinforces child health training and all the issues of first round.
Third Round of Training – with training manual No. 4.
Fourth Round of Training – may be a two or three day non-residential training
using training manuals 5A and 5B. This round may be repeated to cover more
communicable diseases if they are a local priority.
Fifth Round of Training – should be at least of four days and residential. This
training introduces the Mitanins to the village medical kit and first contact
curative care.
28
•
•
Sixth Round of Training – three day training with training manual 6, that reinforces
the curative care aspects.
Seventh and the final Round – at least four days residential. In this training, they
would be taught how to assess the local health status and draw up a local
health plan. Further means of continuing the Mitanin work and for sustaining
the programme would be discussed.
The in-service training would constitute one or two days in a month. In this the
trainer makes a visit to the village and works with the Mitanins. Occasionally, the
trainer can gather all the Mitanins of the village in one place to provide training and
discuss issues in a group, rather than individually. This provides quality peer learning
and helps boost up their morale.
This in-service training is most essential part of Mitanins training, her work, her motivation
and her support system.
Knowledge is imparted gradually as per the schedule and the training modules, and
simultaneously, skills are developed; as in –
-
skills for establishing rapport with the family
Learning Dos and don’ts of how to approach and address family on various
topics at the doorstep.
- How to counsel family on different themes, like newborn care, child
nutrition, malnutrition, women’s health, etc. In this they are taught to avoid
victim blaming for the sufferings, and she also has to promote the use of
Public Health system, through this counseling.
- Identifying anaemia, jaundice, dehydration, case of high-risk pregnancy,
grades of malnutrition, signs of pneumonia, estimating fever, respiratory
rate, spleen size, and so on…
- And accordingly what action to take and what advice to be given in such
situations.
- How to construct local inquires on availability of health services and how to
increase public awareness and utilization of these services.
- Conducting a village level meeting of women and children, and of all
maintaining a basic health and health services register.
- How to make a blood smear for malaria, how to do tepid sponging for fever,
how to make mosquito repellant oil, how to map places of mosquito
breeding and draw up a local plan for its control.
- How to identify lesions of leprosy and to test for sensation loss.
- How to disinfect water in pots, wells or other water storage devices.
- How to identify medicines in her kit and use them appropriately.
Given the low literacy level and lack of experience for such work it is unrealistic to
expect most Mitanins to grasp adequately from camp based teaching. Unless the
trainer goes to her village and makes house-to-house visits with her, and helps her
29
with meetings etc. once or twice a month – they would find it very difficult to pick
up the knowledge and skills.
Working with them on-the-job would really make them capable, the camp having
provided them with the motivation and introduction. Learning is better in concrete
situation.
Also, Mitanin needs continuos support and that she is regular visited; and needs to
collect feedback from her about service delivery.
For these types of activities and relationships, it is preferable to have women trainers. The
trainers are motivated and educated women suitable for such work, facilitators often
identify these trainers. They are also identified according to proper geographical
distribution – one per cluster of gram-Panchayats. Often, a trainer has about 20-25 Mitanins
under her to train in-service.
TRAINING STRATEGY
Mitanin Selection The health department or the local administration could have been given this responsibility
of CHW selection. But here, the health department employee would go in for a person who
can be persuaded to take up the tasks and in case of PRI, where there is no tradition of
consultation but rather of patronage – Sarpanch’s family member or someone he is obliged
to would be selected.
Or a local NGO can take up the responsibility of identifying a CHW in their area. Their
prolonged contact and familiarity with the local people may help they identify easily the
person who is sensitive to the local issues and have empathy for the poor and marginalized.
But such NGOs can cover a very small area of the state. These were the areas chosen for
the pilot phase of the programme.
Also, Mitanin is seen as a part of a social process for empowerment – for social and
economic justice. She is thus a person owned by the community, acting on its
behalf – not at the behest of the government, and much less as a philanthropist or a
funding agency. (Health is seen as a right, attained for justice – not as charity.)
So, the critical factor in Mitanin selection is that the village should make the choice.
To combat the problems of wrong selection and for providing ownership of selection to
village people, three major innovations were made –
A team of facilitator for Mitanin selection is trained and is chosen after one or
two months process by a small district group constituted for the purpose. They
are given the task of informing all the villagers about the programme and role of
Mitanin. He also meets all the sections of the village separately so that needs and
views of the weaker sections are also articulated adequately and different point
of views are adequately negotiated for healthy partnership.
The selection is done in a general village meeting with good attendance, and
special emphasis is on involving the Panchayat and its health committee in this
process.
30
-
Selection of Mitanin is done at hamlet level, which ensures greater penetration
of health messages and participation of almost all the people in the village, as a
hamlet tends to inhabit people of similar groups. This also ensures lesser number
of families for Mitanin to cover – usually around 50 which makes the work
feasible on voluntary basis.
The selection process involves a number of women and tries to build in
enthusiasm for a collective will to action, and to instill a feeling of ownership
among people. These women who participate, though not selected in as Mitanin
get involved in women’s committee that provide continuos support to the
Mitanin and discusses various issues of health in the village.
This is Social Mobilization. This campaign is centered on kalajathas (troupe of
artists), built in the selection phase.
Training of trainers The trainers are trained by the State training team and the District resource team (three
persons per block). District resource team consists of government as well as nongovernmental people, three in each block, making a total of about 210 district trainers are
trained for this purpose.
Thereafter the state level training the district resource team would train 25 trainers per
block. These block level trainers receive initial training of four days and then on monthly
intervals as per schedule.
These 25 trainers would then split into groups of 5 each and each team trains two groups of
about 40 Mitanins, as per their schedule. Thus, in a block, there have been almost 10
training camps for 400 Mitanins, held in 5 parallel camps in the first round followed by
another five camps the next week. This was to be repeated for all the consecutive training
rounds.
Mitanin trainers work in a group, so that if there is some redundancy, still there will be 2-3
good trainers in a camp, and working together they can manage better.
After the first training camp each pair of trainers commit for the next month to visit eight
villages twice, so as to help the Mitanin get started and provide some in-service training.
This makes 27 days for trainer’s work in the first month – 4 days in getting trained, 6 days
in training, one day in post training review, and 16 days in village visits. That is what the
minimum quality training would take.
In the next month the trainers are retrained over three days and they give two days of
training in two batches, and another 16 days for village visits. This makes 23 days in a
month, and most likely it would remain the same for the next 18 months, for a really good
Mitanin Programme.
After about eight months of training and activities at village levels, then the curative
aspects of heath care are introduced, and given a drug kit for this.
Before introducing Mitanins to medicines and cure of disease, an understanding of
health and disease has been made. This is to fight the prevailing culture of seeing
health as analogous to taking tablets and medicines. Also, this would prevent the
public from demanding medicines before listening to all the health advice and
education.
31
She is also involved with numerous preventive and promotive activities in the village,
which are much more important, so for that to not to get overshadowed by the curative
aspect of her work, this strategy is important – first things first. Her work also involves
explaining to the people that use of injections is a waste and how much of their expenditure
in drugs is a waste. And this must be done before starting to give medicines herself.
Three strategies are identified to prevent “transmission loss” in this training pyramid.
a) Good quality training at the top most level where maximum transmission loss occurs. It
is seen that very little is lost between the trainer and the Mitanin.
b) Better to go for an approach where training material can be read out and then discussed
and explained by the trainer. Apart from these presentations of the readings must be
made, with group activities, role-play etc. The training material is made keeping these
training needs in mind.
c) Training Evaluation - at the end of training, a set of questions is circulated separately
that help in revision and also evaluation. The consciousness that their work is going to
be evaluated also gives some seriousness to the training process and prevents its
degeneration into strings of speeches.
The evaluation is done according to a base-line set for the necessary knowledge level.
In the training strategy it has been made sure that there is much space to redo everything
and allow one round of turn over at every level before the final team settles. There is
further space to provide training to the Mitanins selected late in the programme and for
those who missed their training rounds.
Support to Mitanin in all her tasks
The nature of support envisaged comes from two levels –
A) Support within the village comes from –
- The Women’s Health Committee providing support of local people for
whom Mitanin works at the hamlet level. After each training that Mitanin
attends she shares her learning in the committee and the committee
members’ share all the tasks designated to the Mitanin.
This is in the sense that Mitanin is seen more as a convenor here, rather than
a solitary worker.
- Panchayat: this is the most critical part for the sustenance and maintenance
of the programme at the local level. To involve them and maintain their
interest, block level meetings of Panchayat leaders, attended by the
collector, with specific requests should be periodically organized.
These requests could be like – for ensuring coordination between AWW,
ANM and Mitanin, planning for malaria control, or for TB and leprosy etc.
But this can only be done after some effects of the outcome are visible at
around 18 months of the programme.
32
-
Other Mitanins: the Mitanin trainer also helps in this, and to make them
realize the organized strength they have - as people are moved for the
change.
B) Support from outside the village –
- Trainers, who regularly visit them, at least twice every month.
- ANM/ AWW/ MPW/ LHV: as they make their regular field visit to the area.
But here it is important to maintain a democratic and not a top-down
relationship. They need to be explained they have to work in cooperation
and not by delegation of responsibilities.
- Medical Officers: provide referral services, making occasional visit to the
village on Mitanins request and so providing them with encouragement.
- District Administration: they provide encouragement and support for what
the village and the Mitanin demands, and also by consulting them whenever
a village level programme occurs.
Improvements in the health system…
…To make it responsive to people’s needs and demands.
The State Advisory Committee (the state-civil society partnership that has set down the
parameters for the Mitanin Programme) has identified a set of systemic changes for reform
that would go along with the Mitanin Programme. They are as below: 1. Community basing of health services
2. Delegation and Decentralization
3. Strengthening health intelligence, surveillance, epidemiology and planning machinery
4. Control of Epidemics
5. Dealing with Health problems of the poor
6. Capacity Building
7. Policy for Rational use of Drugs
8. Improving internal systems of the Department of Public Health
9. Workforce Management and Transfer Policy
10. Drug Distribution and Logistics
11. Clinical protocols for Uniform Treatment across the state
12. Management Information System
13. Decentralized Laboratory Service
14. Mainstreaming the Local Indian System of Medicine
15. Dealing with the problem of Drug Resistance in Malaria.
33
Work on many of the above areas is proceeding in parallel to the Mitanin Programme.
Some work that brings systemic improvement in complete synergy with the programme
are –
- TBA training programme
- Coordination with ANMs, through village and block level meetings
organized, during the training sessions and during their regular village visits.
- Improved designs with village level programmes
- Strengthening referral services up to CHC, with feedback mechanisms to
Mitanins for identified categories of health problems.
- Linking data inputs from the community through Mitanin Register with the
MIS and Disease Surveillance system.
- Streamlining drug procurement and distribution mechanism
- Eventually formation of a village health plan with the district health system,
with in-built feedback from disease surveillance and MIS to enable
decentralized planning of health services.
34
SOME MORE READINGSAccess to health services, in the country has been ‘a part of wider struggle for access to
fruits of the overall socio-economic development of the country. The roles of specific
health interventions to raise the health status of the masses have been limited as compared
to the socio-economic improvements.’
Since independence, India has planned and created number new categories of health
personnel like malaria workers, FP workers & MPWs. But many manpower schemes have
turned counter productive and wasteful. CHW schemes were started, based on the success
of bare-foot doctors of China; but it did not succeed as expected. Though CHWs are
considered as agents of social change and meant to bring about community participation,
but ‘their functioning is hampered by the political and economic context within which they
work.’ These also result in problems with election of CHWs. This is mostly seen to happen
due to lack of understanding on the part of planners about the context and setting within
which they have planned the CHW scheme, leading to wastage of precious health care
resources.
Anyhow, it is the lack of community participation and centralized, arm-chair planning,
without needs assessment are the major problems for an effective formulation and
implementation of health policies in the country.
Broad guidelines for establishing a primary health care programme:
- it should start with an overall understanding of the life styles and cultures of the
community
- there is need to understand other basic services rendered in the community, so that
health care delivery can be better coordinated with other services in agriculture, clean
water supply and sanitation services, school health programmes etc which have close
links with the health of the communities.
- PHC should be viewed as a process where people participate actively, not only to
solve their health problems but also strive to promote their health continuously.
- This calls for keen sensitivity to people’s needs and the development of managerial
and social skills.
35
Some Reflections
Mitanins – Their potential and …their future.
Potential for the Health department –
In the present organization of the health system following is the stated functional structure of
health services at the grass root level --
The local health unit closest to the people serves the first line of responsibility for
community health. The health officer serves as the administrative head of this unit,
who besides providing for the medical care facilities at the PHC or CHC, also
collaborates with the local self-government, and may perform any or all of the following
functions:
-
coordinate health planning
investigate communicable diseases
maintain free clinics for early diagnosis and treatment of communicable disease
provide laboratory services
conduct immunization clinics
maintain public health nursing services
collect vital statistics
supervise water supply and sewage disposal
supervise for the quality of food, milk and meat available in the markets
investigate and supervise general sanitary conditions in public places
conduct health education programmes
provide preventive and rehabilitative services in chronic disease control
promulgate rules and regulations
provide mental health services
provide medical care to the indigent
provide maternal and child health care
provide for Family Planning Services
Under the ‘Rural Health Scheme’, which started in 1977, a three tier system of
health care delivery was established, based on the principle of “placing people’s health in
people’s hands”, as recommended by the Shrivastava Committee.
Under this scheme there are two functionaries at the village level – The Village
Health Guide and a Trained Birth Attendant. They are selected from the local population
itself and provided training with a manual and a kit to carry out their functions. They
receive technical support and continuing education from multi-purpose workers posted at
the sub-centre. The village health committee or the Panchayat should ideally provide
other administrative support and supervision.
The VHG besides providing for the first contact primary health care, MCH and FP
services and health education is also supposed to look after sanitation of the village. He is
supposed to help bridge the cultural and communication gap between rural people and the
organized health sector.
36
There are ‘Anganwadi’ Workers also at the village level, provided for under the
ICDS Programme. She undergoes a 4 months training on health, especially on nutrition
and child development. Her services include health check-ups, immunization, health
education and supplementary nutrition to children less than six years of age and to
pregnant and lactating women.
Sub-centres are the most peripheral outposts of the existing health care delivery
system, supposed to be manned by one male and one female health worker. Both are
responsible for the work assigned to them by the medical officer of the PHC for
implementation of various national health programmes, and cater to the health needs of
the community and refer patients to the health clinics.
The female health worker’s (ANM or LHV) duties mostly emphasize on MCH, FP
and immunization, whereas male health workers (MPW) are mainly utilized for
maintaining sanitation and control of communicable diseases.
This is the formally proposed organization of the health system, but due to number
of reasons it has failed to function at the grass roots the way it was supposed to.
Training of health workers came as government projects or scheme, which had no
long-term strategy. It came in the form of Jan Swasthya Rakshak in Madhya Pradesh (and
old Chhattisgarh) and as Jan Mangal Joda in Rajasthan.
These Training programmes also never came at regular intervals and have never
been monitored or evaluated. There has never been any consistency in their training
schedule nor has there been any regular support to the scheme or to these CHWs. So the
reasons of their failure have rarely been documented, and whenever the scheme has been
evaluated and feedback provided, no proper strategy for corrective measures have been
possible.
Against this backdrop now if we see the Mitanin Programme, we will see that they
are given all the tasks visualized for the CHW proposed under the Shrivastava
Committee, and most of their functions complement the community activities for the
peripheral outposts of the public health system. The Mitanin Programme is also
conceptualizes and operationalized on the theme of – ‘placing people’s health in people’s
hands.
The experiences of other failing government CHW programmes, against the success
stories of the Mitanin Programme, provide an excellent learning to the health department.
The training structure of the Mitanin Programme can now be considered as a model
for training other CHWs. The structure provides enough flexibility and space for local
adaptation, in fact that is how it was meant to be. Here it must also be noted that
functioning abilities and operational capacities cannot be seen as components different
from the structural components of the programme.
Potential for the Public Administration, or the Government –
CHW should be seen as a major carrier of health education – and only till the time general
education has been universalized and has attained a quality. This is when the health
education will be completed during their 10-12 years of schooling and people would
37
become literate enough to acquire further knowledge according to needs, and would know
where and how to access this knowledge.
There are so many activities listed for the ANM and other health workers that it would
be inappropriate to expect them to carry out all these activities with minimal assistance
and limited skills and knowledge background. Natural and social geography of the state,
with poor transportation and problems of lack of security services pose a further
constraint to the problem of outreach for these workers.
So, Mitanins cannot be seen as another partially skilled health worker assistant, but as an
empowered citizen of the community… with adequate knowledge base on health and
health care, plus a unique link between community and service providers. Here a thought
needs to be given to the fact that till when one Mitanin in a hamlet will need to be replaced
with another when the government is unable to replace and develop the more qualified and
more needed staff faculties… But, definitely, it needs to go on till the community has not
been able to understand the concepts of health education and is not using the pubic-health
services provided through the government… And till the community has not acquired
other means of continued quality health education for its people and children, or does not
have health services close to their houses or at an easily approachable distance from there.
That is to say - till the time government’s negligence done till now, has not been fully
compensated.
If simultaneously, intensive efforts to improve the basic health-care services are not made
to improve the outreach of the existing the public health system, all the efforts going on in
the Mitanin Programme will become a waste… rather it may ruin the whole system to an
irretrievable state. It would become too difficult to get this opportunity again, and then to
be able to utilize it.
(The need for better infrastructure, training, management and organizational development
for efficient functioning and community orientation of the health department can no
longer be neglected, or postponed. That is to say, all the funds that were for the SIP,
should now be permitted to go in for the actual SIP activities… as it was visualized then
by the EC.)
Mitanins can be seen as community’s social health activists, who support and take
care of the health of the local people and represent them or lead them in the quest for
better health and development. They are now the enlightened and most sensitive people
of the communities who have a high degree of acceptance in the community, and (to an
extent) in the political front also. They represent the great human power of democracy,
only it needs to be ensured that they don’t become the tools of politics in the hands of
those who have acquired more prestige in this democracy.
Non-payment of Mitanins for their work has proved to be one of the major strength in
this aspect; which has always been critiqued by everyone, everywhere – except of course
the enthused Mitanins themselves. Another important link is that the Panchayat has always
been involved in their selection or in the endorsement of their functioning.
And then, the money for village development, which often goes unutilized at village
levels, can now be utilized where the Mitanins can provide local leadership. In these
development programmes, where community participation is non-negotiable element of
38
the planning process, the cadre of Mitanins thus formed cannot be neglected – for the time
being till whole of the hamlet’s families are empowered through this process of
development.
And then, in the long run the communities can become self-reliant and intelligent enough
to realize their needs, their rights and their leaders. They can demand for, and can act in
order to fulfill their social and democratic needs - their rights and duties.
The Mitanin Programme, when it started was the major agenda on government’s list –
the question of “why?” provides a doubtful answer. It might have been considered
important for people’s development, or may be for the political party’s development –
who knows…!?
But, SHRC really made a great stride and snatched the Mitanins from the political game. It
tried to educate them on matters of health and governance, without letting education and
status become a barrier for them. It equipped them with leadership for their own hamlet,
without them being a representative for any political party.
Congress, who came with the idea of Mitanin, also must not have realized that it would
work that ways. Now Congress is no more in power, despite having given such a
wonderful scheme for rural health, and BJP can’t withdraw the support to this programme.
It has gained a lot of momentum, which is now spilling over to force the government to
invest in ‘health sector!’ and frame their policies accordingly… and this is creating real
upheaval in the government, with so much funds being asked for in the welfare sector.
With my personal interactions with the Mitanins, I can say that Politics is now almost
sidelined at the grass roots, and Mitanins are “in” that may help link the government
health centres with the people.
For them, governance is more important…
Governance has now become more important, though the Mitanins have yet many political
and socio-economic challenges to face, to be able to reach to its full potential. This may be
one of the factors (besides having gained recognition and good-will among the villagers)
for them wanting to contest the Panchayat elections.
A mid-term process evaluation of the Mitanin programme has been done. This
evaluation was based upon various indicators to assess their skills and programme
implementation process…
The knowledge level of Mitanins remained around 50-60%, those who made adequate
house visits and regularly filled their registers were never more than 30% and hardly 10%
could effectively coordinate with the Panchayats, government officials or health
personnel.
The knowledge levels are by no means poor for those women who have never before
studied so seriously! – In the training programmes there is a lot of stress on reading of
training modules, and there are lot of these modules to be studied, still the Mitanins
39
‘though complained of inadequate training modules, no one complained of too much.’ It
shows that the programme is giving them, what they want and need.
So what, if almost 50% of the Mitanins were not able to work as efficiently as the rest of
them… they at least aspire for it and definetly bear the potential for lot more if adequate
support is provided by the…‘superiors’ (!)
Their function to be able to effectively relate and coordinate with the Panchayats and
health personnel is their true potential and most important aspect of their functioning. But
it can only be achieved after much of confidence has been instilled into them and these
officials also respond adequately to their demands, which is anyway most important aspect
of good governance. So, again the programme cannot be a success in itself until the
government system is also not built up strong enough from within to respond to people’s
demands and deliver what they truly need. And, Mitanins cannot be considered as an
extension to the government health staff…
Mitanin is the voice of those women who would never have been heard in such a
backward state as Chhattisgarh even in the next 10 years from now. They have created a
wave in the health department, and have a potential for lot more, which no one can avoid
or deny.
It is strange that though I was never involved with programme implementation, still now,
as I write the pages of this report I can feel that force that has been created in Chhattisgarh
by this programme, and can feel the energy that has made it a possibility. Though still there is still lot to accomplish and lot of challenges to face …if it has to continue in the
same direction.
There is thus a major need to search ways for building capabilities and systems
that would help in exercising these roles of community representatives and local
leaders; as a major component in bringing about overall development of village
societies and Government systems. Be it CHW scheme or Panchayati Raj or any other
Public Service Department.
…So that a democratic system does not just work for preventing
concentration of power in a few hands, but also that it gives adequate powers
to each and every individual …and the freedom to be able to use them
adequately.
!!!!!!!!!!!!!!
Here there is an important issue of recognizing and accepting women as the
best person for local leadership in health initiatives and so… overall
development!
40
Need of CHW in the PH system
– Is it the best or a cheaper or quicker alternative to a strengthened PH system?
Community Health Programmes became well known in the seventies. Many organizations
carried out different forms of community health work across the globe, and India too has a
rich experience of such programmes.
The central motive for these organizations to start a Community Health Worker
programme has mostly been one of the following1. Some doctors, often doctor couple wants to put their skills to the service of poor.
2. Institutions trying to make a scientific demonstration of the validity of the approach
and development of tools or models to replicate this approach.
3. Organizations whose prime motive was to give cost-effective quality care.
When these programmes have run as small projects under voluntary leadership, they have
shown to do well. But, when they are large programmes integrated with the main system,
as those run by the government, they tend to perform poorly.
One aspect that has been established, by the pioneers of community health action was that
improvements in health status could be brought about by a team of well-trained and guided
community health workers despite their low literacy skills and educational levels.
Further, there seems to be residua of absolute non-negotiables involved in the success of
these programmes –
1. Referral linkages for higher level of illnesses that can’t be handled at village level.
Usually, at least in the form of a 10-30 bedded rural hospital.
2. High quality leadership providing active support and training throughout the
programme.
3. Programme duration of atleast 5-10 years for substantial effect on the health status
to be visible.
4. Usually women as health care providers at the community level.
When the government tries to replicate the programme on a gigantic scale, as in the
Mitanin Programme, at least these four lessons provided by the CHW programmes that run
for a miniscule part of a population can not be compromised with.
Government constructs a CHW programme to improve utilization of health services,
by working on outreach and health education. It also stimulates pressures to improve it’s
own systems and accountability… CHW of a government scheme cannot be an extension
of semiskilled professional in an inefficiently functioning health care system… but as an
strength to provide for the elimination of some the flaws in the system.
These CHW, apart from improving outreach and health education, generates pressure to
increase accountability. This pressure is perceived within the government as being
desirable and related to the larger issues of health sector reforms. But of course these
‘pressures’ and ‘reforms’ need to be properly coordinated and timely reciprocated, for
maximum benefits and right direction.
NGOs look at the need of CHW as an alternative against the failing public health system.
41
With this perspective, if we try to answer the question as to why often the NGO’s CHW
schemes succeed and government schemes fail. – To this we can add the question as to
why these schemes keep coming back in the government policies… and have not yet
been realized as very important factor – We Can Add the following points to the
discussion.
-
NGOs look at the need of CHW as an alternative to provide for ‘easy’ health
care against the failing public health system. They provide ‘easy’ medical care
with little assistance from a private doctor and are usually accompanied by
other developmental activities done in the same area earlier, by the same
NGO.
-
NGOs have their own laws and principles different from a government set up.
With this it is possible for them to provide those services, and to an extent
which the public sector has not been able to provide.
-
The area covered by the NGO is quite small and their organization itself is not
very vast. …The staffing pattern and organizational structure of an NGO is
very different and not feasible in a government sector.
-
Government schemes till date have also given the role of extended health
professional to the CHW, and have not recognized their role as community
representatives. This could have been due to the general politics that prevails
and more so, due to the pressure for more health care services.
(And now since when Mitanins have been given the role of drug depot holders,
they also appear to be facing a similar sort of a problem in their functioning. Drug
delivery becomes the ‘visible’ service delivery of the Mitanin and it overshadows
their role of sensitive community representatives. The development of the
Mitanins role has been in a phased manner, and so has been able to provide the
general impression about their capabilities and ‘various’ social roles.)
-
The Government cannot look upon CHW schemes as a developmental
alternative in rural areas. It can also not be seen as an alternative for the
absence of doctors and effective public health care services– which means that
lesser skilled professional and cheaper facilities for the villagers when more
skilled professional and better facilities are available in urban areas with better
accountability and accessibility.
-
Having not been able to realize their local leadership potential they have not
been able to build up adequate pressure and if whenever it was able to, the
government could not provide an adequate and timely response to it.
-
There has been limited success in efforts of the government to be able to link
these CHWs with the Panchayats (local elected representatives) as an effector
mechanism for Panchayats in the area of health. This is in addition to the
problem of inefficiency of the Panchayats in health related activities – d/t
various problems of the system itself… a separate issue in itself.
-
The government has not yet mastered the skill of decentralization, which is
most important for CHW schemes, and for Panchayati Raj also. This just
42
cannot be neglected and is necessary, right up to the village and at least the
district level.
And to achieve this, civil societies must be seen as an institution besides the
government set up not as an answer to or as an alternative to government
structure at the grass root peripheries.
(Size is the uniqueness of the Mitanin programme, as that for Godzilla, “size does
matter”, for good governance. To make this size manageable, its local adaptation
was important, and that was the compulsion for the Mitanin Programme to
collaborate with the civil societies.)
There is thus a major need to search ways for building capabilities and systems that
would help in exercising these roles of community representatives and local leaders; as
a major component in bringing about overall development of village societies and
Government systems. Be it CHW scheme or Panchayati Raj or any other Public Service
Department.
It can thus be said: that the CHW programme can (If it has not)
bring about ‘Empowerment’
of the weakest section of the society - to bring about
health awareness and community development.
As a government initiative, it can be an excellent tool or strategy for
‘Community Participation’.
…The only challenge is that it be properly utilized to its full potential and
protected from the prevalent style of government system’s functioning, that ispassive-functioning and corruption.
One important issue to be considered here is that such programmes should not be
confused as an alternative health care system for the remote rural areas.
But, it must be considered only and only as a supplement of the system to
increase its outreach and to ensure proper utilization, as and when required by
the communities, through their full participation.
Thus, a strong and a well functioning Public Health System with highly skilled efficient
staff is the most important component.
CHW programme is just a beginning - in starting to build an effective system;
43
- In a way that the communities be involved from the very beginning, in its planning
and formation process.
CHAPTER III
Placement at Prayas
The organization Prayas, as I had known from my prior meetings with Dr.Narendra
Gupta; seemed to focus on all the various parameters of Human Rights and socio-economic
development of the communities. They had also worked with government health officials
and village communities for better health status of people and better health care system.
Seeing the wide variety of work they are involved with, and also knowing that they
are working to improve (or find out ways to improve) the public health system and its
access to the communities, I had got interested to do my placement there.
I thought that not only I will get a chance to learn about the health system and how
we can work to bring about a change in its present state of functioning, I will also see
‘communities’ closely and learn how to work with them or study them. This will enable me
to understand the functioning of the health system and its workers in relation to the local
environment and needs of the people and also how they can be more responsive to the
communities’ perspectives and attitudes.
And then, having had no previous exposure to community-based organization or civil
societies I also saw it as a great opportunity to know about them – as a part of the larger
system. Prayas, being a very powerful and a renowned NGO of Rajasthan, proved to be a
great experience in these lines.
Accordingly, I formulated my learning objectives for this 2½ months of placement, or
rather prepared a framework to put my observations into a learning process…
Learning Objectives
Having done my first placement with the resource center at state level, where the
kind of work done was of coordinating and instructing the district level institutions or
voluntary bodies and supplying resource materials and guidence to them; now the next step
in my socialization process is to see how actually are these works done by local or district
level bodies.
My learning here would include the following• How district level bodies involve the communities in planning and
implementation of their programme and to what extent they are able to do it
• How they support and coordinate with other neighbouring organizations; and,
inversely what is provided to them by these or state level organizations /
institutions – how much of it is relevant in the local context and how and when
can they manipulate or bargain to suit their local needs
• The relevance of projects, and their approaches at the field or grass-root level
• How do the communities look up to these activities and how they respond to
these initiatives
• A little more exposure to experience with the “communities”
44
•
See the interface /intervening structures between the government services and
the communities…
Also, taking up some work responsibility would be a skill developing exercise for
me. Then of coarse further learning and liking depends on the specific work environment I
get here.
Learning from the roles Prayas play as a civil society, besides as a communitybased non-government institution that helps government implement some community
based programmes- is more or less subtle but I am sure it shall be an important part of
my socialization and search process.
Working with Prayas happened after seeing the work of Samavesh and a few
other service providing NGOs in Karnataka - these gave me a broad understanding
about the roles, ‘functions’ and ‘functioning’ of civil societies, NGOs and their
interactions with the local governing bodies; and the communities – all this is most
important to know the ground level situation of the country! …more so for me, as I
mentioned – I have never had such exposure previously.
And at SHRC I got an insight - to an extent, about the politics of governance…
or wait a minute – may be that was the process of governance I tried to learn there and
here at Chittorgarh I learned about the politics!!? I am sorry, had I been an arts student,
I might have been able to explain it and taken a stand… but, as of now – it’s just an
experience for me! And definitely, its got to be a mix of both, it is difficult to draw a
line between the processes (technical aspects) of governance and politics of
government.
Prayas – a profile
Prayas (Endeavour) is a voluntary organization working for social, political
and economic development.
The organization has a vision to build a society free from social, cultural, economic,
religious, geographical and gender-based discrimination.
Its mission objective is that only revitalization of the self-esteem of poor can bring about
improvement in the quality of life.
Primary objectives of Prayas are:
•
To enable poor to have opportunities for their social, economic, physical and
cultural growth.
•
To create alternative knowledge and mechanisms for community development.
45
•
To lobby to secure social, economic, political and cultural rights of all
•
To respond to contemporary poverty related community needs
•
To campaign for gender sensitive conduct and equity.
Substantive Area of Work Focus:
Focus
Prayas focuses its work on aidivasis (tribal community) dalits and gender issues.
Main activities include:
Universalization of quality education
Women’s social and economic empowerment
Community based protection and promotion of natural resources
Advocacy for plugging the process of land alienation through invoking of protective
legislation.
• Development of off-farm income opportunities
• Campaign for the marginalized, the dalits and for women’s rights.
Geographical area of Operation: Chittorgarh Dt. of Southern Rajasthan and some parts of
Udaipur and Madhya Pradesh.
•
•
•
•
Source of Funds:
Foreign Funding Agencies:
Indian Funding Agencies:
a) n(O)vib, Oxfam, the Netherlands.
a) Sir Ratan Tata Trust, Mumbai.
b) Action Aid India, Bangalore
b) Integrated Population Development,
Govt. of India.
c) SDC (Swiss Agency for Development
Corporation) New Delhi
d) SPWD (Society for Promotion
Wasteland Development) New Delhi
of
e) Plan India
f) Winrock International Institute for
Agricultural Development, Arkansas,
Morrilton.
c) Population Foundation of India, New
Delhi.
d) CRY (Child Relief and You) New
Delhi.
e) Aravali, Jaipur
Prayas has been a registered NGO since 1979, I visited it in its Silver Jubilee year. It
has had its long and prosperous history, which is very inspiring, but I think I should restrict
myself to its present functioning. What all activities I got to see and know about, and got
the chance to be a part of…
In short, Dr. Narendra Gupta, founder member of this NGO had started with his
clinical practice in the village area of Devgarh, but he gradually realised that only medical
care is not what the people seek for their better health. He got involved with other
important and more compelling matters of people’s health… and working on them, he
finally started this organization called “Prayas” (Endeavour); and got it registered in 1979.
Fighting for people’s rights with the government and creating awareness for health
among the people, made the government to ask him / or invite him to run a local PHC
46
because none of the medical staff stayed there for long. He worked there for quite some
time, but many government doctors did not like this idea and some conflicts arose due to
which charge of that PHC was taken from him. Since then the organization did not work
directly on matters of health; apart from taking up some projects of Government of India,
or some other organizations like WHO, CRY, Action Aid etc.
Recently, that is, just one year back they started their own programme on
empowerment of rural poor for better health; which they called as the “Jan Swasthya
Sashaktikaran Abhyan” The project is funded by n(O)vib (Netherlands)and runs in two
blocks of Chittorgarh District, Choti Sadari and Badi Sadari that are old field areas of
Prayas.
During my stay of 2 ½ months there, two more projects on health were finalized. One
project was from OXFAM on HIV/AIDS in Chittorgarh itself. Another one was with
UNICEF on similar but more detailed lines, as the n(O)vib project. This project was not for
Chittorgarh but Dhoulpur, a seperate district in Rajasthan. I got a chance to visit this place
also.
Despite these projects on Health and Health systems, most of the time I was not
working with these projects, as it was not feasible to get totally involved with their
activities during this short period I was to spend in the organization; and also may be,
because I wanted to study the over all functioning of civil society. Such activities may not
be directly related with health services or health sector but had some relations with them, as
they do impact on ones health status. So also because I might not get this chance later!!
Also, apart from their projects on health, for selected districts of Rajasthan, Prayas
was one of the key NGO involved with the implementation of the IPD project of
Government of India.
List of some of the ongoing Projects
•
•
•
•
•
•
•
•
•
•
•
•
•
•
“Jan Swasthya Sashaktikaran Abhyan” (People’s Initiative for Health Security Project)
“Swasthya Suraksha hetu Jan Pahal” (People’s initiative for Health promotion).
Primary schools of alternative education
A project of CRY
Protests and campaigning on the issue of Land alienation*
Campaigning for social and human rights of Kanjar community
A project on electricity connections, to reduce transmission loss
Formulation of a Rural housing scheme
A project on Joint forest management
Usual routine functioning of SHGs and Kala Jathas
IPD project – planning for Gender Sensitisation training for health personnel,
setting up of FCC and selection of Counsellors for the same.
Finalising of a project proposal for HIV/AIDS and planning meetings for its
implementation
Various ‘Melas’ (camps) for children, women health, and for the disabled and
handicapped
Various workshops, conferences and campaigns, with other networking NGOs**
47
The list above is not exhaustive for all the activities that happened as a part of
organizational functions. There were other ongoing activities taken up, from time to time,
that were not a part of any project work. These were like - a visit to Baran, for
investigation of Hunger Deaths that happened in a specific tribal community of that area.
It was investigated as a case for deprivation of Human Rights, followed by a dialogue
with the commissioner for corrective strategies, with a newspaper release about the
activity.
Land rights of the tribal – Issue of land alienation
According to law, the Government of India allots each tribal family a land for
their social and economic development; and they are not supposed to sell off this land
to anyone nor is anyone supposed buy this land. If such a transaction does takes place
then a criminal case is filed against the one who buys this land from a tribal, and the
person who sells off this land may not get back his land because then they are
considered as ‘unworthy’ for the land. In such a situation, the land might just stay
with the person who bought it…
Often due to economic constraints tribals have sold off their lands at very cheap
prices, because they were unable to cultivate the land due to lack of resources… this
often makes them homeless. And, if and when caught for selling off their land against
the law – they don’t get the land back. Thus, the purpose of the law itself is defied.
Prayas identified many such cases and tried to get such people together to claim
their land back and to advocate for a change in law so that the tribals don’t loose upon
the benefits given to them by this law.
They organized a workshop for tribal farmers where they told them about their
legislative rights and how according to rules they can get their land back. The
attendance in the meeting was not very good, may be because of the distance and
work. It was decided to have a village level meeting for those who had lost their
lands. They were asked to come with all the relevant documents of their land etc. and
together they will try to negotiate with the person who has bought off that land… or
file their cases in the court with a plea to change the law.
At a later date I got to hear from the Prayas staff, and also read in the newspapers
that where people refused to give back the land, the villagers and Prayas activists
together forcibly took over the land. The police also could not interfere!
The above issue very well showed the role of civil societies can play in
influencing the implementation and formulation (mostly amendments) of government
policies and in ensuring that such public services are known to the marginalized
people, and they adequately avail these services. Civil societies can similarly try to
address other serious problems with determinants of health - the socio-economic
48
underdevelopment, ineffective agricultural development, inequities, migration of
populations, poverty and landlessness… …weaknesses of health systems and poor
environmental health issues.
But…
49
…‘health-care’ policies don’t seem to so straight forward nor so well understood by
all, nor peoples attitudes toward it are studied or analysed so that any civil society
would actually know how to influence the government or the people for its adequate
utilization… this sounds a bit difficult feat to me – I would know only the technical
and professional (“bio-medical”-??) functions of the policy aspects. …Lets see how
Prayas does it… it is renowned to have done so in the past.
Health Committee
Prayas recently got the government orders to formulate a ‘Health Committee’ at
Pratapgarh CHC to ensure its effective functioning; to help monitor and co-ordinate
its services to be more community oriented i.e. Prayas shall voice the concerns of the
community to the health officials, and where need be take the dialogue forward to the
government authorities for the necessary policy modifications. I attended the first
meeting of this committee, which was chaired by the chief medical officer of the
CHC, attended by the medical officers, some nurses and health workers under his
jurisdiction, and a few village women; besides the members of Prayas.
Health Committees are seen in principle as an important feature for community
participation in primary health care provisioning. They are supposed to oversee and
promote health activities, are brokers between the communities and the health
authorities; they are elected by the communities, but where available, the local
resident physician or nurse, are the ex-officio members. The by-laws are supposed to
be drawn by the ministry of health; but here as committees are not a regular feature,
may be on an experimental basis, Prayas seems to have been given quite an authority
to direct the functioning of the committee.
Before the outcomes of such committees become visible, which is definitely going to
take some time; one needs to see its functioning quite closely to know its impact on
hospital’s functioning through such 'de-professionalized’ monitoring structure, which
is supposed to have community representation, and thus an ‘explicit’ (?) community
participation. It thus becomes important to understand the new dynamics created
within the decision making and functional authorities of the hospital.
50
Integrated Population & Development Programme
The Reproductive and Child Health Programme (RCH), the way it had started,
lacked community orientation, which was tried out in RCH II.
The UNFPA funds the IPD project to strengthen this community orientation of
RCH programme; with stress on women empowerment and on reducing gender
discrimination. The evaluation of this project is done by result based ‘monitoring’;
unlike earlier when it was done on the basis of inputs made in the programme.
Objectives of the RCH Programme
1) to add quality to Health Care provisioning
2) infrastructure development for better health care services
3) bring in a rights based approach in Reproductive Health Care services and
Family Planning Programme
Activities for community orientation of the RCH Programme
•
Population development – policies for the same and social
sensitization of the policy implementers; also for decreasing
gender discrimination, gender based violence and declining child
sex ratio.
•
Advocacy work
•
Reproductive Health Care and health education.
Country programme 5 of programme 6 in its Phase II
This is the formal name of the IPD project that started in 1996 - as the programme
administrators refer (!)
The areas of work under it are –
I) Reproductive Health Care services and their Management
II) Women empowerment and community initiatives
III) Adolescent Reproductive and Sexual Health (ARSH)
These are the ‘Hard’ core activities, for accomplishment of which many soft activities
are planned. These soft activities are like organising workshops and training sessions for
the government officials and the participating civil societies; infrastructure development for
facility up-gradation and service provisioning.
For the monitoring and evaluation of activities performed under this programme, seven
indicators have been formulated. Various activities to be performed, as a part of this
project, are referred to by their output indicators for which they are being performed…
{This denotes the importance attached to the indicator for assessment of outcomes of the
programme. The programme appears to be indicator driven – making it look mechanical
and overshadowing the need for assessment of other unprecedented effects or overall
impact.}
51
Output indicators under Activity (I) of IPD Programme
•
Output 1 – decrease unmet needs of couples for contraception to 70%
•
Output 2 – provide facilities for Emergency Obstetric Care
•
Output 3 – decrease the incidence of high-risk sex behaviour in reproductive
age group i.e. 15-49 yrs.
•
Output 4 – is related to management of quality assurance in health system
Output indicators under Activity (II) of the IPD Programme
•
Output 5 – people (both males and females) are enabled to demand for quality
reproductive health services within a rights framework, through
supportive environment in the community and health system
•
Output 6 – institutional and community mechanism enabled to address Gender
Based Violence.
Output indicators under Activity (III) of the IPD Programme
•
Output 7 – improvement in the knowledge about adolescent reproductive and
sexual health and life skills of adolescents, in-school and out-ofschool.
Prayas is one of the key NGOs that are implementing this programme with the
UNFPA and Govt. of Rajasthan. This information about the IPD Programme was given
during various meetings and workshops I attended as a representative of Prayas, or on its
behalf.
One was the review meeting at the DM’s office, for the activities that were done
under the IPD project in the district of Chittorgarh. UNFPA’s District Programme
Management Unit (DPMU) organised it and was attended by the DM and CM&HO of
Chittorgarh, DPMU staff and representatives of the local NGOs and civil societies and key
institutions concerned with this project.
Another was an orientation workshop at State Resource Centre, Jaipur with the
government officials, civil society representatives and DPMUs of the IPD Project on the
issue of Gender Based Violence and for the establishment of Family Counselling Centre in
their area. I represented Prayas, who not only had the responsibility of setting up a Family
Counselling Centre at Pratapgarh CHC, but also works as a civil society monitoring body
for this hospital. I also attended a monthly meeting organised at the FCC established in the
main police station of Chittorgarh, which is run by another local NGO working on
women’s rights.
I also got a chance to attend a life-skills training workshop for the village animators.
The workshop, was meant for ‘output 7’ of the IPD programme, and was organized by
another NGO working in Chittorgarh. The participants showed great zeal and involvement,
performing skilfully in all group activities and role plays. It was a real pleasure to see their
enthusiastic tutors - how they instilled spirits in them to keep up the motivations and
remove inhibitions from the village women who had always stayed behind their veils. But
52
the tutor confessed – “I am not sure if what we are doing is really worth it. We, ourselves
had real problems understanding this life-skill education and had a tough time practicing
for these classes. Don’t know how much these women will grasp - to replicate it in front of
the other village women. Even if they do – what about its application… …!? …”
…There are no means of assessment, to provide a feedback about the direct community
level impact of these activities.
Where no one can deny the importance of having a life-skills education, at the same time it
becomes difficult to comprehend its operational-ability, in such disjointed ways through a
national programme, which works through a targeted approach. Can’t the Education
Department be reinvigorated and be involved in a big way for such activities… …?
Being a witness to this district level implementation machinery of the RCH
programme, some questions come to my mind regarding the RCH and family planning
programmes – after population control policies took the shape of family welfare how did
the health department and the administrative machinery got together on these maternal
and child care initiatives; and how is the health department playing its role in the process
of population development.
The history of evolution of family planning programmes will reveal this process of
integration of services for development and health - but it just gets overwhelming to think
about the dynamics that must be operating between these two public systems – the public
administration and the health administration. I wonder how much the ‘health
administrators’ are aware of the operative principles of public administration and ditto for
the public administrators about the (unseen) realities of health care system and its
management. I feel that this must be an important determinant in the type of dialogue that
takes place between these two departments – who gives suggestions, who takes the
decision, who evaluates and assesses the operation of the programme and its overall
impact vis-à-vis the relevance of the operational plan and problems faced in its
implementation. And then, besides these two departments, there are the special-interest
groups, the NGOs and the civil societies; who have their powers, positions and ideologies
impacting on the decision making and implementation process… does enough harmony;
and understanding of the subject exist among all these stakeholders to make the ultimate
decision for the ultimate wager – the communities.
…am I being too idealistic? – but I feel, I am trying to look for loopholes that might lead
to wrong planning or policy implementation… this doesn’t give a vision of what a perfect
system requires, or how it should be like, or what ‘sins’ (?) people commit to make the
system as bad as it is, but it seems to be leading me to an understanding of how a vicious
cycle is created that destroys good intentions and so, a good system.
…am I sounding lost? I hope this exercise provides some clarity… … at least show the
right approach for breaking such cycles. Such an understanding might just help in
reducing the risk of making mistakes - …something which is very evident as we trace the
history of Indian Public Health System, its structure and function; vis-à-vis the health
status versus the economic growth of the country.
53
If you are not a part of the solution, you are a part of the
problem.
54
Declining child sex ratio
Disturbed child sex-ratio is a glaring problem in most part of the country and more so
in Rajasthan and Punjab, that are relatively more developed among the states in the north.
National figures are – 927 for the year 2001; which was 953 in 1991, 962 in 1981; and
972 in 1961. These figures indicate sex selective abortion with increasing discrimination
against girl child; which would lead to numerous negative social consequences.
UNFPA also funds a project for controlling the declining child sex ratio in 5 districts
of Rajasthan. They are Jhunjhunu, Rajsamund, Dhoulpur, Chittorgarh. Prayas here plays
the role of a resource NGO and assists other local NGOs in organization of workshops
for this project. I got to participate in four such workshops: one at Rajsamund, which was
organized for the local NGOs; two workshops at Dhoulpur for local NGOs and for health
personnel; one at Chittorgarh for the media.
Of all these the workshop organized at Rajsamund, was my favourite as it was most
informative and enlightening, besides it had the best follow-up with substantial results.
Detailed minutes of the workshop are given below, and explain well the importance of
sex-ratio, cause, significance and implications of declining child-sex ration.
Workshop on declining child sex ratio
At Rajsamund with local NGOs
17th September’04
Introduction
The partner organizations of Prayas in Rajsamand district are Jatan Sansthan and Mahila
Manch in whose collaboration district level activities are carried out.
The workshop with the representatives of the NGOs was organized by Jatan Sansthan; and
was attended by representatives of various NGOs from across the district.
The workshop began with a round of introduction of all those present. Representatives
from various NGOs gave a brief introduction of themselves and their organization. They
also stated their expectations from the workshop and how they can contribute in this
programme
Sh.Mukesh from Jatan Sansthan welcomed all the participants and briefed them about the
project and the objectives of the workshop.
55
Objectives of the workshop –
•
To discuss the issue of declining child sex ratio with the local NGOs with
it’s causes and consequences.
•
Thus, work out a strategy of activities to be carried out for stopping this
trend and making the PCPNDT Act rigorously implemented.
Briefing on the issue –
Pallavi, as a resource person from Prayas briefed the delegates with the census data on
sex ratio at national, state, district and block levels…
She said that if we look back in history and demography of developing countries, we see
that females live longer and have always out numbered men. Also according to science
female fetuses are inherently stronger and so have better chances of survival, still we see
that about 100 females are missing in the district for 1000 male children?
She also informed the participants about the PCPNDT Act and its provisions.
Possible reasons of the missing girls and it’s consequences –
The group discussed the issue, sharing their own experiences and social learnings.
They said that the basic reason for less girls being born is that they are killed
before they are born as they are considered the weaker sex that is a burden and great
responsibility on the family. Instead males are preferred because they stay with their
parents and carry their lineage forward. Preference for a male child has been a part of our
patriarchal society since time immemorial… you can be a proud father of a son but never
of a girl.
Earlier the girl child was killed as soon as they were born, but now due to
availability of diagnostic USG they are able to know the sex before the child is born so
they get the abortion done. Still killing of girl child was not so common as feticide today;
so the decline in sex ratio is the problem of technology and development.
In today’s world it is not fair to think this way as women have now proved that
they are in no way less than men, and are also more concerned and caring for their old
parents. There are families who do not consider girls as a problem, but now they want a
small family so they go for sex detection in early pregnancy so as to ensure that they have
at least one son. They would abort their second girl child for a boy but would never abort
a second male fetus.
The baffling question was that why do women themselves let this happen to their
girl child and to their own body… the reason for this is definitely the age old patriarchy
which even women have accepted. Knowingly or unknowingly they support it and are
unable to fight themselves out of it for the sake of their husband/ son/ brother/ or farther.
And for the same reason they become enemies of their own sex…
So there is need of empowering women with enough freedom and economic
security so that they are able to decide for themselves what they want and not become
suppressed by this patriarchy at least if they don’t want a matriarchal society!
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Despite so much of women’s liberation, and now when many don’t believe that
girl’s are a burden, still the sex ratio is not in favour of girls. This is due to many old
illiterate and un-liberated women who are aware of this technology… many women
agreed that it would continue until the older generation of women die off.
BUT by then it would be too late. By that time girls will become a precious
commodity and will need to be kept in parda or prevented from going to college and
married off early… some even jokingly said it may also bring back the custom of
swayamwar. While other’s pointed out that it’s a serious matter and may be Dropadi
pratha will also start. …which is seen in some communities where bride price is also
paid.
The problem of female feticide is so well evident that there are villages known
where a baraat had come after 150-200 years. There are instances of bride price being
paid instead of dowry and inter-caste marriages in families where it was strictly
prohibited, due to lack of girls in the same caste.
Issues of concern in deciding for the strategy
Where population and population growth rate is the major problem, couples are
expected to plan for their family size and increase the use of contraceptive methods. In
doing so, where pregnancies have to be planned, how do we ensure a sex balance?
Where population control is the major focus, another more serious issue is the type
of care provided for family planning, e.g. the quality of services for MTP, for sterilization
operations, the advice given to the eligible couples on family planning and their freedom
to choose between options…
Thus, there are further deep issues to women's health, pregnancy risk, and risks due
to abortions; and their rights which are linked with the issue of declining sex ratio, which
are of a much greater concern and needs to be handled for a just society.
So where everyone was convinced that control in family size is important, they
were not sure whether population control will lead to the country’s development. They
thought that due to large population there is scarcity of resources to bring about
development.
But since independence where population has grown twice it’s size, economic resources
have grown five times.
So, though not at the national level, yet at the family level people need to realize the
benefits of small families, in terms of available resources.
People do not consider children as liabilities but as an asset, which do not ask for
investment but are earning hands for the family. These people need to realize their
responsibility towards their children and get familiar with alternative healthy life style
possible with small family size.
57
One of the delegates pointed out that where family planning is very
important, population growth is studied ‘and popularised’ region and
religion wise, neglecting the more serious issues of increasing feticide and
declining female population. This gives us a very sad picture of our social structure
and mind construct of our people.
The group thus concluded that decreasing sex ratio is a problem of
advancing technology and development; and increasing population was
considered a problem of low education and poverty, rather than ignorance
or religion and caste!!
Strategy and Action Plan!!
After such a deep discussion on these issues, with much active participation and
enriching inputs from the group members; they finally had to decide on a workable
strategy within the given conditions. And keeping the discussion in mind, need to
implement the plan and materialize our vision/efforts.
A work plan was discussed and responsibilities divided amongst the various local
groups. While Jatan Sansthan had tried to get the information regarding the committees to
be formed as per the PNDT Act but they could not get the complete information. So it
was decided that a group of people would collectively ask for the information. The
participants said that most of the people from the district go to Gujarat for medical
services as they do not have confidence in the services within the district. Thus sex
determination and abortions are also done largely in Gujarat, which is not our work area
(?!?). Yet some members wanted to go to the clinics as dummy clients and ask for sex
determination to find out whether such tests are being conducted.
Next meeting of the group was planned after a fortnight to share the information
collected till then.
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“Jan Swasthya Sashaktikaran Abhiyan”.
(People’s Initiative for Health Security Project)
This health project planned and proposed by Prayas is funded by a funding agency
from Netherlands called n(O)vib. A project of Government of India and WHO (1999),
which Prayas had implemented in its area, inspired this project proposal.
To begin with, the project was started in two blocks of Chittorgarh district – Choti Sadri
and Bari Sadri, and has been running for quite some time now. It seems to have sort of
got stabilised as one of the routine activities of the organization, and its field staff.
The work I was asked to do for this project was to prepare a questionnaire for
investigation (verbal autopsy) of maternal and infant deaths; and to prepare a proposal of
the health insurance scheme for the beneficiaries of the project, in consultation with
them.
Verbal autopsy has lately been considered as an important tool for ascertaining
the causes of deaths in developing countries, where most of them go unreported and
uncared for due to lack of proper health care services.
Such an exercise helps gather data for insight into the problem - its frequency and its
cause – which is otherwise unavailable for analysis and health-care planning.
Hopefully, it was a part of this project for similar reasons, but here it is likely to be used
for advocacy purposes. By the time filled in forms come in, I won’t be here for analysis
or its utilization… so I tried to leave a number of foot notes for future users of the form,
and tried to explained things to the permanent staff.
It was necessary to field test the form in front of the field workers; and then ask them to
fill the forms in front of me. In accordance to how much they were able to understand
about the utility and interpretations of the questions and the responses, for their
convenience I made the necessary modifications in the form; also to identify or remove
the observer’s bias and minimize the wrong interpretation in analyzing the forms - as
the forms were supposed to be filled in by the field workers who are the local villagers
and would be interpreted by a more qualified, technical staff of Prayas.
As an important component of health care security, Health Insurance had to be
an important part of this n(O)vib project …a buzz word in health sector!
So, a health insurance scheme had to be formulated ‘to meet the local needs’… (!?!)
…for the area where the legitimate health facilities available were the (poor)
government health care center and 4 private registered medical practitioners, who have
clinics in the village but not their residences. [This means that emergency care and care
of the critically ill was a major problem, in terms of health care provisioning.]
59
We had a meeting with the Health Team of Prayas at the Choti-sadri office, to discuss
on the issues around the various components of an insurance policy.
The focus of discussion remained around the… recognizing and listing of the common
disease conditions seen locally where health insurance or financial coverage was
required the most – on the basis of recognized need of the people and expenses incurred
on such illnesses, people’s paying capacity and their willingness to pay for such an
Insurance Policy. And also to recognized groups for whom this policy would (or could)
be made; and who could be targeted or convinced (!) to accept this policy.
Major points that came up in discussion with the village people were –
• Major chunk of expenditure in seeking health care goes to ‘OPD-type’ of
illnesses. For which people neglect treatment most of the times, either due to
money constraints or they don’t give it much importance and don’t recognize its
seriousness. But, the basic reason was that they mostly went to the non-registered
doctors nearby or faith healers. It was said that they avoided government facility
in the initial stages of their illness due to the uncertainty of finding a doctor or
medicines… and may be because they will anyways have to spend the same
amount of money in commuting, and buying medicines etc. besides the time
spent.
• Once these common or early stages of illnesses are neglected, they get
complicated leading to very heavy expenses at a later date… So, the major
expenses come in treatment of complications of an illnesses arising due to
neglect, or unavailability of treatment or due to wrong therapy.
Thus, OPD coverage was recognized as the major link in Insurance
policy, or a necessity in health assurance.
• For the people the problem was not only the lack of money for health care
facilities, but the unavailability or inaccessibility of the health services itself.
• Then there were issues as to which health facility to be recognized as one
providing legitimate treatment to the policy holders… in this the health seeking
behavior and the type of health facility available were the constrains.
• Because government facility was anyways the only reliable service available, so
people can be explained and motivated to not to go to the untrained doctors. Also
then, there was no need to provide coverage for diseases covered under the
national programmes.
This would also build pressure on the government officials to provide the
facilities available, as now the people would know what is provided in a
government facility and demand for the same. The other problem that now arose
was… that those who were not insured may then be devoid of these medicines.
Anyhow, Insurance policy was still identified as a strength and necessity in such a
situation, as the policy can be used as a means to be able to mould the health
seeking behavior of the people, and may be able to force the health facilities to be
more responsive and quality conscious.
60
Government facility was thus ‘accredited’ for the insurance policy. In
case of distance from the house of the policy holder, nearby
registered private hospitals or clinics will have to be identified by
the insurance agency, which were anyways not many in the area.
• And then we had to identify important inclusions and exclusions for the policy.
• Conditions that were considered important for Inclusions in the insurance coverage
were - snake bites, cases of RTI / STDs, obstetrics care and skin diseases. It is
important to note here, that these conditions are hardly covered in health
insurance policy. Maternity benefits, also unlike other policies, should not be
limited to first two deliveries.
• For exclusions everyone wanted to keep the list to the minimum, so according to
what the company already excludes in their policy, we decided on –
-- Common cold, jaundice, acidity, nutritional deficiencies, services covered by
the national health programmes; Neurotic illnesses, psychosis (?), asthma, chronic
illnesses like COPD, hypertension, coronary heart disease, diabetes
But, if any of these illnesses gets severe and presents as an
emergency requiring surgery or necessary hospitalization, then the
financial risks should be covered.
• Some minor and common ailments which may at times get severe or require
expensive treatment, the minimum cost of illness to be reimbursed could be
limited. The health team suggested that if any illness costs more than Rs.100/then it should be covered. But, that would come out to be very difficult, so
arbitrarily, and as a guesstimate everyone preferred to having something like –
-- Reimbursement is made when the total expenditure exceeds
Rs.75 per day, and / or a treatment is required for more than
10 days.
• Then, what do we define as a family. Usually in a family insurance plan, it is
defined as 2+2, but this sounded highly inappropriate. The policy should
cover all the children at no extra premium. It can limit the number of
episodes of illness or the maximum sum insured for the children, instead of
specifying children or their number. Or, can have two cut offs – for a family of 5
and a family of 6-8.
• An extra premium can be taken in case the policy holder or her spouse requires
coverage for their parents. This extra premium on which people would agree upon
could be Rs.75/- per annum per parent, when the premium for the family is
Rs.250/- per year.
61
Thus, we see that though there was a well recognized need for health insurance, i.e.
financial assistance for health care services, the terms and conditions of the policy
did not at all suit the people.
Despite having all these points on board – ‘without adding any confusion’ to the
smooth running of the project, I was asked to draft Insurance policy, which would suit
our needs and also be easy for us to negotiate with the HDFC. ‘Parivar Suraksha Bima’
is the Health Insurance Policy which HDFC already has. We made arbitrary changes
within the policy, without doing any calculations on the basis of overall impression of
the paying capacity of the people, their health needs and services available in the area.
In this draft we also tried to explain to the HDFC people why we want these
changes… they can get their calculations done by their underwriter! The company
ignored all our concerns – which is anyhow very much understandable. The health
workers were able to convince considerable number of villagers for the utility of the
insurance policy and HDFC insurance was given to them…
Here, anyone would ask that:
Leaving aside the local context for the utility of health insurance policies that are
available - as we see in this case, it is a well known ‘Law of Medical Money’ that
medical costs rise to equal the sum of all private insurance and government subsidy – and
this is being done in a village which is already poor and has no access to ‘decent’ level of
health care – not even a proper health education. Where is all the cost i.e. the premium
going? What is the need for people who can’t control the hygiene of their immediate
environment – for them to put aside money for ‘unexpected’ kind of health risk?
Even leaving aside a simplistic question for complicated technicalities We can still say:
It was so strange - if no policy actually was able to meet the needs of the people, why
the idea of having an insurance coverage for the villagers couldn’t be dumped…? Are the
donors so strict about the protocols mentioned in the project proposal…? But before that,
I couldn’t even understand the need of introducing such a thing in such a project that is
titled as ‘People’s Initiative for Health Security Project’ – who are the people who have
has taken the initiative of health security, and above all what kind of this security is
provided… there have been numerous examples of ‘initiatives’ at village levels but
getting a private business firm to get involved with this – that too not as a part of their
social responsibility – is a feat beyond my comprehension.
It is a well known fact that health insurance is a tool for risk-sharing, in case of an
'unexpected' health event – paying a premium for it is more like a luxury for the one who
has extra bucks in his pocket; and is also at quite an experimental stage to state its utility
with much authenticity. It is well known, that by an informed choice - it is only the
middle and the upper class who takes up any health policy, if they want to – and here the
poor villagers were ‘educated’ or may be, ‘informed’ (if that is the term to be used) for it
to be one of the better option to ‘ensure good health’. Aren’t there ethical issues involved
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in introducing such a policy by an NGO without research attached with this approach,
without having used or tested other tools or even before assuring better preventive,
promotive and curative services in that area. Why one should feel so compulsive for the
‘propagated’ technologies and tools, which are recognised not to have much utility in the
local situation? …I mean to question this to be able to understand and comprehend the
purpose, roles and functions of a ‘civil society’, not just “any” society or ‘community’.
I don’t need answers for the questions I have just posed. No one will want to look for
such answers – BUT the prime concern remains: What we, as Community Health
Fellows, have to offer to the field of ‘community health’ in such situations?
My activity calendar
calendar at Prayas
th
· 16 Sept. – Reached Chittorgarh
· 17th Sept. – attended a workshop at Rajsamund on declining child sex ratio.
· 19th Sept. – “Bal Mela” at Bhadesar
· 20th Sept. – Co-ordination Meeting of senior staff members at their head office in Devgarh
· 22nd Sept. – Health Camp at Mongana
· 24th Sept. –a meeting of “Mahila Suraksha aivam Salah Kendra” (women protection &
counselling center) & networking NGOs. With the SP at Chittorgarh Collectrate.
· 27th Sept. – visit to villages of Baran district where Hunger Death had been reported.
· 29th Sept. – workshop at Dhoulpur, with the local NGOs on declining child sex ratio
· 30th Sept. – a similar workshop with health professionals, doctors and government
officials
th
· 9 Oct. – People’s Tribunal on population control policies and family welfare programmes, ISI
Delhi.
th
th
· 11 , 12 Oct. – monitoring of Pulse Polio Programme; as a State Monitor
· 16th Oct. – “Mahila Swasthya Mela” at Manpura village, block Choti Sadri, dist.
Chittorgarh
th
· 30 Oct. – an orientation workshop at State Resource Centre, Jaipur with the government
officials, civil society representatives and DPMUs of the IPD Project for the
establishment of Family Counselling Centre in their area.
·
– Review meeting of the activities done under the IPD project in Chittorgarh
District, at the DM’s office
nd
· 2 Nov. – review meeting at Mongana office of Prayas. There work on health had started
few months back and this initiative is named as “Swasthya Suraksha hetu Jan
Pahal” (People’s initiative for Health promotion).
th
· 5 Nov. – review meeting at Choti Sadari office of the activities done under the n(O)vib
project i.e. “Jan Swasthya Sashaktikaran Abhyan” (People’s Initiative for Health
Security Project)
Also attended a session of life skill education training being given to the
village animators under IPD project
63
· 6-7th Nov. – field testing of Verbal Autopsy form for infant mortality; and meeting with the
Adolescent girls group in Mongana village
·
- Camp for People with Disability: they were told about various government
schemes for them, and various certificates and concession forms were
provided. Medical check-ups were also performed and crutches, hearing aids,
cycles etc. were also distributed to some.
· 29th Nov. - workshop at Patapgarh, with bank officials to prepare a model for financing a
Rural Housing Project for Devgarh village
A Planning meeting at Pratapgarh office of Prayas for starting the HIV/AIDS
project
th
· 30 Nov. – on field work in Choti Sadri for the ongoing external evaluation of the n(O)vib
project.
th
· 4 December – left Chittorgarh.
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CHAPTER IV
The organization - Samavesh
The NGO "Samavesh", which I visited for three days, is an offshoot of a renowned
non-profit, voluntary organization "Eklavya", registered in 1982. The group is well known
for its work in the field of children's education.
They basically started work with improving the teaching methodology of
Science and Social Science subjects in schools of west Madhya Pradesh. For this purpose
they also had a fellowship scheme for school and college teachers, approved by the UGC
and funded by the Ratan Tata Trust. Their experiences in field testing of innovative
curricula – stimulating learning materials, activities and training programmes, and
implementing systems in the mainstream was found useful by number of governmental
and non-governmental institutions across the country. They have thus worked as resource
agency in education for such institutes or organizations, across the country. Such intensive
collaborations demanded from them to provide support in developing all the elements of an
education programme. They have thus also contributed greatly by working on women’s
health issues.
If we track down the history of Eklavya – it is interesting and very enlightening to
see how gradually they evolved and expanded their work area through their own
experiences and learning; Starting from Education programmes to Rural Development and
now heading towards the Health programme in
We Believe…..
the same field area.
They started with Hoshangabad Science
Teaching Programme for middle schools, (in
1972) to promote scientific temper in children,
making the child a confident life long learner and
creator of knowledge. To make comprehensive
impact on quality of elementary education, they
took up Social Science subjects also. For these
purposes they developed resource materials for
teachers as well as students, conducted
workshops, exhibitions, teachers training and
student evaluation programmes. They conducted
studies to document classroom transaction
processes, which the new teachers can cross-refer
and will help them to further innovate the
curriculum package.
Working with the middle schools, they
noticed that students had not developed the
linguistic abilities required for these classes. So,
they started a Primary Education Programme
"Prashika", which focused on cognitive and
affective skills that could ensure overall
• That education can be a means for
motivating people to change the
conditions in which they live
• That science and technology are not
esoteric spheres of thought and action.
They need to be approached with wisdom
and a concern for social equity and
justice.
• That development must, necessarily, be
sustainable and in consonance with
environmental imperatives. Such
development must be based upon the
participation of local communities.
• That education cannot be looked in
isolation from the society and
environment in which they are located.
• That education should first be centered
around the needs and thought processes
of the child.
• That education should help to develop
problem solving skills, the spirit of
enquiry and scientific temper.
• That…
Source- Eklavya: a profile
65
development of child at this stage of schooling. For this they conducted workshops,
developed toys and workbooks called "Khushi Khushi" for the primary sections. They
conducted teacher's orientation programmes and focused on planning and strategy to
identify and deal with different levels in one classroom that a teacher has to address. They
provided support to schools for implementing the programme. They developed a system of
peer follow-up by Cluster Academic Coordinators. They also mobilized the parents and
community to help children in education agenda outside the school – to overcome the
alienation.
They talked about children's inquisitive minds, their understanding and the role of
education plus the relationship between the two. They worked to find out the relationship
between schools and society programmes, thus, working towards social change through
education!!
Eklavya's main areas of work are:
- Innovations in school education,
- Publication of educational literature,
- Children's libraries, activity centers,
- Popularization of science and society issues,
- Involving the community in planning and development,
- Developing alternatives in rural technology
In their mission to increase or improve the educational status of the people they
realized that development of the society has to be a parallel process if they are expected to
make the best use of the knowledge gathered so far. They did this through conducting the
Rural Technology Projects under which they focused on Natural Resource Management
and Water Management. They conducted workshops on organic farming, carpentry,
fishery, cheap building constructions and leather making. They also participated in the
literacy movements and soon realized the need to work with those sections of the people
who don't access schools on a firm basis.
As a result of all this they finally decided to initiate programme to work with
Panchayats and in related areas of community mobilization. They thus started the umbrella
programme called "Participatory Planning for Rural Development" (PPRD) which
included:
-
-
Orientation and training of Panchayats
formation of community groups like children clubs "Chukmuk", groups to develop
local leadership "Jan Pahal" and "Sakhi Pahal" Women's SHGs and Seed Banks for
small and marginal farmers.
Natural Resource Management with support from local Communities and Panchayats
Community involvement in Health and Education
66
With increased social organization, disadvantaged groups are in a better position
to take up suitable economic activities and related marketing efforts. These activities
require increased public awareness through open debates about nature of participatory
processes and their role in development.
These activities are concerned with community mobilization, which require to be
followed up by increased responsibilities in social sector like health and education, as well
as increased availability and improved quality of natural resources.
Organizational Chart of Eklavya became thus:EKLAVYA
|
GOVERNING BODY
|
ACADEMIC COUNCIL
(Senior full time members of the organization)
_________________________________________________________________________
__
|
|
|
|
|
|
Programme Coordinators
Director
Field Center-in-charge
|
School Education &
Planning
&
Development
Publication Sub-Committee
Sub-Committee
Thereafter the Planning and Development sub-committee formed a separate group
"Samavesh" in June 2004. This was so because the working style and the type of inputs
required by this sub-committee were very different from the committee working on
children's education.
PPRD is thus the major work area of "Samavesh".
The overall objective of PPRD, and Samavesh for that matter, is to evolve a model
of community based development, integrating various activities under the guidance of
elected representatives and local community leaders.
Their strategy is to identify practical steps that would help panchayats and village
communities to develop their capacities and know-how required to do their own planning
and implement these plans effectively. PPRD began in the year 1998 and work has been
done in all the planned areas, except health. This delay in starting the health programme is
not only due to lack of person-power but also because it was not the well recognized
demand of the community.
The reason for this was clearly visible in my field visit. The people there are
generally very poor and their real concern is food and income. Hygienic environment and
67
sanitation even are not on their priority list. Malnourished people and sick child is a
common site – they feel that the capability required to avert this is not in their hands. For
this, and otherwise also, they need money which is anyhow their major quest and struggle.
Nothing else apart from their daily livelihood bothers them – they don’t care what the
panchayat or the government is doing for them. Good enough if they do, if they don’t there
are many more things for them to be concerned with.
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EPILOGUE
Public health or Community health, for that matter, is a multi disciplinary field.
It is strange that all its allied subjects, though quite well developed in themselves
and the need for their application are well recognized, still they have had less opportunities
for its practical application. One probable reason I can think of as a medical person is that medical professionals, the hard core health professionals, are weakly exposed or hardly
ever trained to deal with such aspects. They are taught only about the biological sciences
for dealing with ‘disease’ conditions, and the wide array of socio-economic, cultural and
political issues that affect ‘health’ stay away from their domain. This has lead to the
beauracratization of the health system - as the medical professionals are unable to respond
to or influence the policy level issues. Health always remains as a major political agenda…
and many professionals feel that this is something they need to stay away from or cannot
interfere with it. Then there are market forces also that influence policies – and would
rather actively try to persuade it to suit their interests.
Whatever the factors that have led to the establishment of such a Public Health System, as
it is today – they have been very complex; but what is more important is to establish and
maintain a ‘System’ that is required for the present times and hopefully responsive for the
future situations.
•
Millions wish to change the world into a better place,
while a few show the way, how to!
•
Many men have the light enough to be a visionary, but
only he who clearly sees, can behold the vision.
Nonetheless –
•
When young men have vision, dreams of older men come
true.
So then, for all Community Health fellows:
Dream this with the joy that I may aid in its coming to those
who shall live after us.
- Rosenau
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