Ganesh. C.K : Understand Primary Health Care, Community Health, Communitization and Globalization.
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- Ganesh. C.K : Understand Primary Health Care, Community Health, Communitization and Globalization.
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COMMUNITY HEALTH LEARNING
PROGRAMME REPORT
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2013-2014
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GANESH. CK
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SOSHARA SOPHEA
CONTENTS
• Acknowledgement
• My inner learning’s
• Learning Objectives
• Learning’s from collective sessions
• Learning’s from field
• Research report
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Acknowledgement
The year 2013 July 21, I never forget in my life because it turned out
be a turning point in my life with surge of events that took place in
both my personal as well as professional life. Call it middle age crisis
or mid carrier crisis.........../
It may be clichéd to mention that words are not enough to show my
gratitude to SOCHARA, but it still does not make it false.
I thank Dr. Thelma Narayan, for the wonderful way that the
programme was arranged and for creating an atmosphere conducive
for discussions and learning. In addition to that, she played as a role
of facilitator and has given so much of her valuable time to help me
whenever I needed it. The structure of the programme was very
appropriate for the kind of learning and experience I was hoping for.
SOCHARA as an organization itself is to be thanked, for wherever I
went, I felt confident when I mentioned that I was from SOCHARA. I
felt the importance of being connected with so many organizations to
make movements of successful.
I have not had one uncomfortable moment at SOCHARA as everyone
made the feel like home and family. Even during discussion, sensitive
social issues had been handled with great skill to ensure better
understanding without any motional lobotomy.
The SOCHARA library been of great help to me and I have borrowed
books and kept it for weeks on end with and without Mr. Swamy’s
permission.
I thank Mohammed, Chander SJ, and Kumar, for the sharing their
wonderful experience with us and for always being there to guide us.
I thank office staff of SOCHARA for being with us and for helping Dr.
Thelma,
Yuvraj and Chander, making arrangements for us
throughout the programme.
I thank my field mentors Ameer khan, Naresh (CAH) Dr. Chandra
(DAS-CBR) Thirupattur. Dr. Bhagyalakshmi (SAKHI) and all my
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guiders during my field work for giving me the wonderful opportunity
to spend 6 months with them and to learn from their organization and
their personal experiences. Their dedication, innovativeness, hardworking nature, approach and simplicity were truly inspiring and
encouraging to me. I thank them for the time and comfort they gave
me and will carry with me the wonderful memories and learning’s I
got from there.
SAKHI volunteers have been very kind to accommodate me during
Research in-depth interviews and focus group discussion. They are
also an inspiring group.
I thank the communities of Alijikuppam Kandhili, Venkatasamudram
(Tamilnadu), Mariyammnahalli, Pothanal Nagenahalli (Tamilnadu)
for accommodating me and sharing their experiences with me.
I thank the authors of all the book I have read during the fellowship,
as these are books of great value and have been written for a cause.
I thank my co-fellows – Venkatesan, Suresh, Job k Josef, Nanda,
Sabeena, Banri, Theme, Lekshmy, Samantha, Madhavi, Anusha, for
the wonderful time we’ve had together, teaching me a very valuable
lessons and sharing their journeys with mine. The smile on their faces
and the commitment in their hearts has been one of the driving forces
for me during my fellowship. I wish them all the best and I hope to
keep in touch with them in future too.
I thank my family for being patient with me and supporting me in my
journey. Without their backing, it would have not been possible.
Looking inwards
While looking back at myself, I see many differences that have
happened. My thinking capacity has really improved because now
while going out and seeing people who are suffering, I will not go
without understanding the situation and think and ask with others
what can be done for that. I realize that every issue is related to health
and also I can relate each issue to health.
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My observation skills have improved and I am able to understand the
situation much better. And if I see any problem in the village I will go
to the people and talk with them. If I don’t know anything about the
medicine, I have the confidence that at least I can tell them to go where
they have to; otherwise I will find out about it and pass on the
information. I also visited the PHC and sub-centre I understood about
the health system and the challenges.
My inner learning’s
• In the beginning I was so scared while talking to everyone in
English. Slowly I picked up the language and felt confident.
• My communication skills have improved including my skills in
speaking in public.
• Interacting with the people from different backgrounds was a
good learning experience for me during my field work.
• I learnt about definition of the health and illness.
• Class, cast, and gender session were really good and it made me
to observe the situation what is happening in the world.
• I was able to understand the values and responsibilities of the
community health worker. Dr. Ravi use to tell us ...
“Go to the people
Live among them
Love them
Learn from them
Start from where they are
Build up to what they know”
• Social, Economical, Political, Environment and cultural aspect
and their relationship to the health became more clear. I learnt
how we could relate the issue by telling stories on health.
• The visits to PHC and sub-centre helped me to understand what
facilities should be at the PHC level.
• I also learnt a lot by meeting with mentors and with staff.
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LEARNING OBJECTIVES
• To understand the primary health care
• To understand about community health
• To understand the communitization
• To understand the globalization
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What is community health?
“Community health” as I have understood from the orientation
programme and from the placement is empowering people to have the
power to demand their right and it involves community participation,
community mobilization and community involvement in reaching this
goals as very important components. More to my understanding on
community health its more than just ‘medical’ everything that
comprises the well being of a community is health. Again ‘wellbeing’
health should come to a community through all dimensions of their
daily life. This is what I feel is community health.
Primary health care
Primary health care is traditionally being used to mean first level
contact between patient or communities and organised healthcare. In
this sense it includes the services provided by peripheral health
workers, including general practitioners, nurses and health
auxiliaries.
Primary health care is essential health care made accessible at the cost
of country and community can afford, with methods that are practical,
scientifically sound and socially acceptable. Everyone in the
community should have access to it, and everyone should be involved
in it. Related sectors should also be involved in it in addition to the
health sector. At the very least it should include education of the
community on the health problems prevalent and on methods of
preventing health problems from arising or of controlling them; the
promotion of adequate supplies of food and proper nutrition; sufficient
safe water and basic sanitation; maternal and child health care,
including family planning; the privation and control of locally endemic
diseases; immunization against the main infectious diseases; apriority
treatment of common disease and injuries; and the provision of
essential drugs.
Appropriate Technology
“A technology is appropriate: if it is economically feasible within the
resources available if it is culturally acceptable, not destroying the
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fabric of society which may already be fragile if it’s environmentally
harmless”. (Ex: Prahlad, working with sanitation)
Appropriate technology for health
This has been defined as a wide ranging set of activities, utilization
local skills, knowledge and creativity for inventing, discovering,
testing, improving or adapting, applying or using methodologies and
techniques together with methods of management for solving health
problems.
Examples of appropriate technology
Medical care :
• Herbal, low cost medicines, dipsticks, for lab work, jaipur limb,
low cost dental unit, cycle ambulance, cassette audiometer.
New areas of interest:
• Acupuncture, “fringe medicine” Ayurveda and homeopathy, yoga
and naturopathy.
Gender
Gender is an important role in public health and primary health care,
not to be misunderstood as simply mater of difference between women
and men in society. It is more compels value construct that looks at
roles, status and power relationships between the sexes in the context
of society and access to system and services.
Gender and health
Society prescribed to women and men different roles in different social
contexts. There are also differences in the opportunities and resources
available to women and men, and in their ability to make decision and
exercise their human rights. On including those related to protecting
health and seeking care in case of ill health. Gender roles and unequal
gender relations interact with other social and economic variables,
resulting in different and sometimes inequitable patterns of exposure
to health risk, and in differential access to and utilization of health
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information, care and services. These differences, in turn have clear
impact on health outcomes.
Learning’s from collective sessions
• The collective session began by providing the basic definition of
health, but with the progress of the discussions the multi
dimensional aspect of health, which is beyond just ‘physical
health ‘for the very first time, was introduced to me in such
explicit manner. The sessions gave me a deeper understanding
as how other determinants such as class, caste, gender, language
and other artificial barriers cause a hindrance to good health.
• I usually took the concept of health invariably as a ‘need’ more
than that as a right. The constitution of India has also not
provided ‘health’ as
fundamental
right
but only talked about
in few articles. But
linkage of health as a
fundamental
right
with that of right life
was new learning for
me. The perspective
of seeing health as a
need has changed to
health as a right more so I would prefer the word ‘entitlement’ as
after the brief chat with Dr. Yuvraj I realised the fact that when
we talk about right it comes within the purview of legal battles.
• The monsoon game made me realize, though we say or belief that
fight with situation, come out social barriers ,and bindings, a
simple game taught me how difficult it is to fight out the social
norms, the structure, the power plays, the rules. Poverty,
marginalization does not allow you to question. But game
thought me if one does not question the norms, the norms would
always oppress only a section of society. The role play as one of
the farmer family and the situation, which was the put forward
for the game, was extremely unjust and is very much faced by
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•
•
•
•
•
farmers in real situation also made me realize the daunting
difficulties which the farmers has to overcome.
While understanding the concept of society and social
determinants of health. I understood that the society is
thoroughly stratified in to various strata’s and it is the power
structure dominated by a few, who decides. It is because of the
resources available to this few, which make them the dominant
class. The SEPC analysis gave a better picture on the social
determinants of health.
Health is always been taken into consideration of only being as
just physical but other determinants are also been taken into
consideration. The role play of one group asking consideration
only physical aspect and the other group taking the other
determinants in to consideration showed the differentiation. It is
an extension from medical approach to community approach.
The session discussing the skills and values needed to work with
community made me realize that a community worker in order
to be successful in the work area as to have a variety of skills as
community has various dynamics to it and in order to understand
a community better a worker must be equipped with set of skills
to work towards the betterment of the community. The
documentary on JAN SWASTH SAHYOG was a perfect example
for me to understand the perfect mixture of skills and values
required to work towards community health.
Historical overview of health care system provided me with a
background of understanding as to how the health care system
evolved. The 3 tier concept adopted by government to address the
problems of public health was an area of discovery for me as
mostly diseases occurs at the primary level and the needed for
strengthening of primary health care centres was realized by me.
Introduction to the public health system gave an insight to the
working of public health system. Few concepts about the
structure of public health also came in to light as a new learning
for me. The learning on the manufacturing rights completely own
by drugs control of India under the department of chemicals and
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•
•
•
•
•
fertilizers was a shocker for me as it alone controls every aspect
of drugs from it is quality to quantity.
I realized the need of primary health with the session on
evolution of health system. But the story of RAKU though just
silent picture reinforced the very fact of need of primary health
care. The lack of basic health care results in with the death of
Raku’s child. The story moved me, to understand the intricacy
and problems of marginalized people. I felt how essential it is to
have for primary health care centres in the remote areas.
The session on Alma-Ata discussed how Alma-Ata was evolved.
During the session I learnt that the declaration talks more on
what Bhore committee report had already suggested in 1946. But
even the Alma-Ata declaration is still a dream to be fulfilled
realizing ‘Health For All’ but the people’s health movement is
working towards the goal of achieving the same.
The session on NRHM was a realization as to what might have
been the situation without NRHM as the condition of the public
health care system is still in deplorable condition. It is the call of
the hour and the urgent need of the health care system to be
given a serious thought. NRHM is the blink of lights and with
PHM and other health movements; we will make ‘Health for All’
a reality.
Globalization as I understood has made a huge impact on to the
world out right though making some good but largely making the
world a hollow shell as I learnt it. The concentration of wealth
where poor are getting poorer and rich pocketing the entire
resources is the biggest dividing that globalization is doing in the
world. Its impact is felt at all times and at all levels and health
is one of the crucial areas where impact globalization is much felt
with health being with health being an industry of profit making.
The gender distribution system through the game indeed as how
a woman is over burdened with work and multitasking takes a
serious tool in their health. The superficial ties attached to a
women does hamper their growth in their all round development.
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• Dr. Ravi gave a session national programmes undertaken by
government on various vector born diseases. Its implementation,
success and failure.
• The alternative system of health session by Dr Shirdi Prasad
gave a description the usefulness on alternative medicines and
implications. The session also discussed about how to conduct
training and the requirements of training. This session was very
useful for me as my learning objectives also require training
myself as trainer.
• Interaction with Mr. Prasanna further clarified the session on
globalization and its impact on the health care system, it was
indeed a eye opener as to how the commercialization of drugs has
affected the prices of the drugs and whole of the health care
system.
Key learning’s from sessions
I personally enjoyed every session and there were so many things
to learn from each session. But the once that made maximum
impact were:
• Dr .Ravi Narayan shared with us his experience with the Malur
health cooperative that was setup in Malur. Kolar with the help
of St. John’s medical college in the 70s. This centre was initially
successful and a lot of people were able to access health care at
the cooperative hospital, which succeeded in bridging some of the
societal inequalities also. After a few years, due to certain state
and national level policy changes which were a result of the
‘structural adjust policy’ or SAP by the funding agencies like
world bank, the village eventually turned from being productive
and self sustained to a village plagued with desertification and
debt. The SAP forced the villagers to look at cotton farming and
silk rearing rather than growing food crops. It became clear to
me that no one is in complete control of his/her health. A decision
made elsewhere can lead to the death of a former and his family.
It is important for those working on community health and
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development to keep informed about economic and political
news.
• The important subject of Globalization was introduced us by Mr.
Prasanna One is often not completely clear on the concept of
globalization and its implication. This session was very well laid
out and brought the main positive and negative effects that
globalization has led to. Like most development projects,
globalization may have been started with good intension: it has
now resulted in greater poverty and also to further ignorance
about poverty amongst richer sections of society. This session
showed may tool can be used for right or wrong depending on
how it is used. On one hand the sharing of knowledge across
borders is a boon but the increased exploitation of poor countries
by the west has led to the worsening of the health situation. Now
communities and forests and even countries often stand
defenceless against the might of multinational corporations. Due
to changes that are being forced on import policy, the local
markets which can
provide products at
monetarily cheaper
costs. Local lively
hoods
will
be
destroyed and the
countries
will
be
forced to produce for
the market of richer
nations.
Polluting
industries are being
shifted from the E.U .to South East Asia. It is a lose-lose
situation for the poorer countries.
• Dr. Ravi Narayan and Thelma Narayan have been integral parts
of the people’s health movements from its initiation and hence it
was wonderful to listen to the entire story, from why the
movement was needed and to various communities from various
countries came together for it. The PHM is a response to
globalization. Economic policy changes have lead to many things
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like privatization of health care, stress and medical insurance
and costlier drugs. Also, many local livelihoods are being
destroyed leading to poverty which also adversely affects health.
The movement is actively linked with other development
movements to create an equitable society which is needed if
health for all is to be achieved. Through democracies are
supposed to be ‘for the people, of the and by the people’,
communities have to make a lot of noises to be heard by the
authorities. Such a situation calls for powerful people’s
movements and the PHM is one such example.
• Chander SJ and Kumar shared their personal experience
working
with
communities in the areas
of
health
and
development.
The
sessions mediated by
them were rich with
stories and the wealth of
knowledge they have.
These sessions helped me
a lot in opening up to new
and broader perspectives. The communities of rural India and
also the urban poor face several demons every single day of their
lives. Health apart, they have to worry about where the day’s
meal will come from. In the name of development, several
millions peoples lose their homes, jobs and lives each year. The
term development has lost its meaning.
Field learning’s
My first field placement was Tamilnadu it was good experience for me.
This field work helped me to understand community, community
participation, role of local self government, role of civil society in
community health. And our Chennai team members gave good
orientation about CAH.
What is CAH?
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• CAH stands for Community Action for Health. This is a
continuation of a pilot process known as
Community
Monitoring and Planning (CMP). The CMP pilot process was
implemented as part of the communitization aspects of the
National Rural Health Mission. The process was initiated by the
Advisory Group on Community Action (AGCA). The AGCA
proposed a pilot process in 9 states to actualize the concept of
Community Based Monitoring and Planning that was
conceptualized by the NRHM in its Framework of
Implementation. It was decided to request a number of civil
society organizations to lead the process in the different states in
partnership with the state governments. The pilot phase was
funded by the central government. It was expected that after the
pilot phase the state governments would take over the
ownership, running and funding of the process. In Tamilnadu it
was decided to change the name from Community Monitoring
and Planning to Community Action for health after the Pilot
phase.
• It is important to note that the name of the process was changed
from Community Monitoring and Planning to Community Action
for Health to emphasise that without action the process is
incomplete and that the whole process is driven by a joint
learning approach with openness and spaces for reflection.
The CAH process being implemented in Tamilnadu?
• The process is being implemented in 6 districts of Tamilnadu. In
each of the districts it is being implemented in 1 to 3 blocks. A
total of 14 blocks are presently covered. In each block all the
panchayats are covered and in all 446 panchayats are covered.
The details of the coverage including the number of PHCs, HSCs
and ICDS centers that are covered.
• Districts: Dharmapuri, Kanniyakumari, Perambalur and
Ariyalur, Thiruvallur, Vellore.
Understand the implementing the CAH process in Tamilnadu?
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• In the pilot phase the funding came from the central government.
After the pilot phase there was an external evaluation of the
process. Based on this external evaluation and a series of
meetings with the NRHM state mission director as well as the
Director of Public health and preventive medicine a
dissemination workshop was held to discuss the learning’s of the
pilot phase and plan the broad contours of the next phase of the
project. The Government of Tamilnadu issued a government
order for the project and in principle agreed to support the
process.
• The project is implemented through a state nodal NGO who is
the fund holder for the state and then further through District
and Block nodal NGOs. In Tamilnadu the pilot phase was
implemented by the Tamilnadu Science Forum (TNSF) which
was the state nodal NGO and in the subsequent phases Society
for Community Health Awareness Research and Action
(SOCHARA) took over as state nodal NGO.
• The State Health Society (SHS) and the Director of Public health
and preventive medicine (DPH) were joint signatories on the
MOU with SOCHARA and both the SHS and the DPH have
appointed nodal officers in their respective departments to work
with the process.
• Within SOCHARA the implementing team based in Chennai has
been provided with support and oversight. There have been a
series of reflections and discussions using a SWOT approach
based on a number of presentations made by the implementing
team on various occasions. The executive committee has also
shown keen interest and provided strong oversight for the overall
process. A number of interns who were part of SOCHARA’s
Community Health Learning Program have also spent time
learning from and contributing to the process thus enhancing the
overall organizational ownership as well as learning from the
whole process.
Understand the aim of the CAH process?
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As mentioned earlier the idea of the CAH process is to actualize the
concept of communitization that is introduced in the Framework of
Implementation of the NRHM. The concept of communitization
involves increasing the ownership of the community for the health
system. This increased ownership is seen to increase both utilization
as well as accountability of the system to the people. This combination
of increased ownership, utilization and accountability will contribute
to health system strengthening and the achievement of the goals of the
NRHM. This overarching framework also provides space and
opportunity to take forward the community health approach
predicated on inclusive community involvement.
Understand the steps of the CAH process?
The following are the basic steps of the CAH process:
• Village Health Water and Sanitation Committee (VHWSC)
committee expansion to include wider representation for all
groups and geographical areas of the panchayat. This expansion
was done by holding meetings in all the hamlets of the project
area and explaining the process to the people and getting
volunteers and suggestions from the community for members.
The team also implemented a rejuvenation exercise for the
VHWSC committee after the conduct of the first Panchayat
Planning exercise.
• Orientation and training of the VHWSC committee
representatives was the next major step. The whole committee
was oriented to the process. Subsequently two per panchayat (in
the first phase) and 4 per panchayat (in the second phase) were
intensively trained on the monitoring process.
The next step is the monitoring process where a tool developed
by the state nodal NGO in consultation with the other partner
NGOs, the people and the department is used to collect the
perspectives / assessments of the services available at the village
and PHC by the people. While the first round was done by the
project Animators taking the members along with them, the
subsequent two rounds of the monitoring process were done by
the members themselves.
• After this the information collected is collated into the Panchayat
•
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Health Report Card. Thus one Report card is evolved for each
Panchayat.
• In the next step of the process is the Panchayat Health Planning
Day. In the Village Health Planning day the VHWSC committee
members present the Panchayat Health Report Card to a group
consisting of the representatives of the Public Health
department including the Village Health nurse and the PHC –
MO, the Panchayat president, the anganwadi workers and
members of the community. During this meeting the various
questions / sections receiving a 'red' colour are discussed in detail
with an aim of converting this 'red' score to 'green' in six months.
Thus a Panchayat Health Action Plan is evolved.
• Subsequently this is shared with officials at the PHC, Block and
District level.
• Every month the VHWS committee meet and discuss the issues
arising out of the Panchayat Health Plan and its follow up.
• The whole monitoring and planning cycle is repeated every six
months.
Understand the status of the project in the state of Tamilnadu?
• Formation and strengthening of 446 VHWSCs in 446 panchayats
spread over 14 blocks in 6 districts.
• Support these 446 panchayat committees.
• 3rounds of monitoring of the health system.
• 1 round of fully fledged planning and sharing of the results at the
panchayat and the PHC level.
Have the VHWSC members been able to the use the tools easily?
The tools were built after many rounds of discussions and pilot testing.
In fact there have been minor and a few major changes with each
round of monitoring based on feedback received. Based on an external
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evaluation and the feedback of the people and the government officials
the tool used in the pilot phase was extensively modified to bring it to
its present generic shape.
The major challenge we faced (CAH team) was teaching the members
the logic behind the various health entitlements so that the monitoring
could be linked to action. Apart from this one area of difficulty were
the names of the equipment; however this was overcome by inserting
pictures of the relevant instrument / infrastructure.
Given its piloting and iterative feedback the tool is quite
understandable and usable.
One of the interesting finding is that tool not only helps capture
people's perceptions on health, but in addition by probing a number of
dimensions also spread a lot of awareness and initiated interesting
and in-depth discussions on health.
How much time does it take to fill the tool and complete one cycle of
monitoring and planning?
It has been found that a full set of tools covering all the dimensions of
health services will take 5 days of time. In addition the PHC and HSC
facility survey and exit polling take 1 day. Thus in all the committee
members have to spend 6 days every six months on monitoring
activities. Individual interviews (for the immunization and ANC /
Delivery / PNC) take about 40 minutes to 1 hour per interview. Group
discussions (for school health / adolescent health / village services) take
about 30 to 40 minutes.
In terms of planning about 3 days of preparations are required for
every day of Panchayat Level planning.
Every month there is a VHWSC meeting to follow up the various action
plans.
Understand the staffing pattern of the CAH project?
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The project is implemented through the State nodal NGO at the state
level, district nodal NGOs at the district level and Block nodal NGOs
at the block level.
At the state level there is the Project and Assistant Project Manager,
one accounts manager and a communications officer. Thus the state
team consists of 4 individuals. However due to the felt need for
intensive learning and documentation from the field an additional
Research Assistant was appointed 6 months ago.
At the district level the project has one District Coordinator (full time)
and one consultant (part time) with part time support for the accounts
person.
At the block level there is the Block coordinator (full time).
At the panchayat level there is one animator for every 5 panchayats
generally and for 4 in areas with difficult terrain. In all there are 100
animators in the project.
Understand the governance structure of the project?
The primary group that advises the State nodal NGO is the State
Implementers group consisting of the Implementing NGOs,
representatives of the civil society, representatives of the SHS and the
DPH.
At the district level there is the district mentoring committee which
mentors the process at the district level.
There is a project governing body consisting of eminent academics and
civil society representatives.
SOCHARA has a special sub-committee to provide internal
mentorship and over-sight to the implementing team.
The role of the civil society groups in the process?
The role of the civil society groups in the project are as follows:
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• Capacity building of the VHWSC committees. This is done in
collaboration with the local health staff including the VHNs and
the Health inspectors.
• Facilitating of the work of the VHWSC. This is done through the
interaction with PRI officials and the Public health sector
workers and facilitating their cooperation with the process.
• Sensitization of all involved about the potential impact of the
process.
• Developing systems of sustainability of the process.
Understand the project propose to strengthen the public health
system?
As mentioned in the Framework of implementation of the NRHM the
one of the 5 pillars of the NRHM is Communitization. By increasing
ownership of the public health system by the community the process
not only hopes to increase demand and utilization of the public health
services but also in parallel increase the accountability of the system
to the people.
Apart from this the data generated at each level is unique and these
dimensions are not collected by the routine HMIS. Thus the process
provides valuable information to the health system at different levels.
This information will go a long way in identifying gaps in the system
and enabling the system to fill these. This is through not only the
Panchayat Health Plan but also through the block, district and state
level consolidation and analysis of the data.
Moreover as this designed to initiate community action for health
following the Panchayat Health Plans, it hopes to further strengthen
the system by the process where people get a deeper understanding of
their entitlements as well as the constraints within which the system
works. The process also allows the system a chance to understand the
people's perceptions of the services and thus enable the system to see
the perspective of the people. This two way enhancement of
understanding will contribute to system strengthening.
Systematically / programmatically this approach has led to a deeper
understanding for the need of the perspectives of the health providers
21
to find greater space within the initiative (and indeed overall
governance of the health system). Community Support mechanisms
for the PHC and the HSC can be evolved. Also critically workers’ rights
components and occupational health dimensions of public sector
workers needs greater attention.
Understand the key constraints for the implementation of the
Community Action for Health Project in Tamil Nadu.
Constraints for the implementation of the Community Action for
Health project in Tamil Nadu can be discussed under – social context,
health system related and larger political context.
Social Context
• One of the major constraints that the project has faced has been
the 'indirect' costs faced by the community members who are
expected to voluntarily take part in the various activities of the
VHWSC. These include the following:
• Most of the marginalized communities and especially the women
usually attend the MNREGA work and depend on these for
wages. Thus when meetings and work are expected and it means
give these up obviously it reduces the chances that people living
in such in secure conditions will be able to participate. However
these are the very people who we aim the process at.
• Given the above 'competition' with MNREGA and coupled with
the number of NGOs that give people sitting fees for all trainings
and meetings there is a general tendency to expect money for this
type of work.
• Communities are riddled by caste and gender differences, this
obviously affects the full implementation of the process. Thus in
villages people of different castes refuse to sit together and it is
very difficult to build up community wide ownership of the
process.
• Alcoholism has been reported from a number of districts as
problematic. A number of meetings are disrupted by people who
are drunk. Similarly project staff (especially women) and
VHWSC members who are women are especially insecure.
• The lack of transport is another constraint for the mobility of the
22
members both between villages in a panchayat and between
their village and the PHC and HSC.
• In one of the district’s the presence of a large number of
industries and even a proposed SEZ in the area has led to a
fracturing of the community and an inability of implementing
such programs smoothly.
Health System related
• It has been found on a number of occasions that people are not
very motivated to hold the government system accountable. This
is for the following reasons:
• Most people are unable to access government schemes due to
middlemen or corruption, thus they are not very interested in
spending more energy on these schemes.
• The more educated and wealthy even among the marginalized
communities corner most benefits thus leaving the most
marginalized more frustrated.
• In general the more wealthy and influential capture the benefits.
• In addition the above the government is seen as poor in many
situations and due to rudeness most people prefer going to the
private sector. Thus not wanting to spend too much energy
holding the public sector accountable.
• Frequent transfers of the doctors and officers means that those
in decision making posts even at the local level need to
repeatedly be oriented to the process thus leading to a lack of
continuity.
• The health department views the community either as ignorant
or as not interested in their own health little appreciating the
structural factors leading to this (some as described above). This
attitude of superiority and patronage is not conducive for
processes to develop transparency accountability.
• The peripheral workers are working under severe systemic
constraints and in a very hierarchical system. Unless this is
sorted out these workers will only get more and more frustrated
and will be unable to engage with such processes.
Larger political context
• Regime change leads to an introduction of a whole new set of
schemes and the consequent ignoring or sidelining of older
23
schemes. This leads to a lot of uncertainty and lack of continuity
in schemes like this requiring longer term support.
• Political parties have their presence even at the village level; this
has led to problems in getting people of different political parties
together for health issues.
• Local influential people have a tendency to hold the key to
participation from the community, lot of care needs to be given
to developing a rapport with these people, and else there is a
danger of their making the situation very difficult for the
implementation of the project.
‘SAKHI’ Hospet Bellary
This is a group working on
empowering women. Hospet
is an area that has been
ravaged by the mining
industry and has lead to a lot
of
poverty
and
health
problems. There is also
rampant human trafficking. SAKHI workers on issue women face in
these areas. They also support the education young women. The group
is working on sensitive subjects hence faces constant harassment from
industry and officials. Hats off these women for their courage. They
also showed me a movie they have made on the local mining operations
which was a moving experience. Mining has destroyed the local
environment, roads and glove in the operation. The money that has
come to Hospet through the mining industry has lead to sex trade and
several young girls are falling victims to it.
‘Jagrutha mahila sanghatane’
This is a women group working on empowerment, savings and
livelihoods. The women are from the lowest rung society – Dalith.
Hence they had been the most oppressed lot. Through JMS the women
have become aware of their rights, they publicly protest incidents
where women have been abused, have brought better roads to the
villages and also sanitary toilets. They are also becoming economically
empowered through lively hood initiatives like terracotta jewellery,
herbal medicines and neem seed fertilizers. Living with them for few
24
days was a great opportunity to learn about their lives, the issues the
women face, how JMS has empowered them and how the health care
facilities are functioning in their area
RESEARCH REPORT
INTRODUCTION
Sanitation
“The control of all those factors in man’s environment which exercise or may
exercise a deleterious effect on his physical development, health and survival”
(“WHO expert committee Environmental Sanitation1963-1967”)
Sanitation has been neglected for a long time. This has contributed to high levels
of sickness and death especially among infants and children. More investment is
required in hygiene and sanitation. to Prevent the spread of excreta-related
diseases such as typhoid, cholera, diarrhoea and dysentery.
Only 32% of rural households have their own toilets and that less than half of
Indian households have a toilet at home. There were more households with a
mobile phone than with a toilet. In fact, the last Census data reveals that the
percentage of households having access to television and telephones in rural India
exceeds the percentage of households with access to toilet facilities. Of the
estimated billion people in the world who defecate in the open, more than half
reside in India. Poor sanitation impairs the health leading to high rates of
malnutrition and productivity losses. India’s sanitation deficit leads to losses
worth roughly 6% of its gross domestic product (GDP) according to World Bank
estimates by raising the disease burden in the country.[1]
Open defecation
It is the practice of passing out excreta in open field and indiscriminately. This
excreta often finds its way into sources of drinking water and food and may lead
to disease.
A drop can kill: One gram of excreta can contain;
10,000,000 viruses
1,000,000 bacteria
1,000 parasites cysts 100 parasite eggs
Sanitation differentiate between men and women
25
Women and men have different needs and customs when it comes to sanitation.
Men may be more comfortable than women relieving themselves in public or open
spaces. Women are burdened with a greater share of family work like collecting
and firewood, cooking, and cleaning. They are usually responsible for taking care
of children and their sanitation needs as well. All of these affect their access to
toilets that are safe, clean, comfortable, and private. Addressing women’s needs
often challenges traditional ideas about how decisions are made.
Mental health:
A state of well being in which the individual realize his or her own abilities, can
cope with a normal stresses of life, can work productively and fruitfully, and is
able to make a contribution to his or her community.(source: promoting mental
health as a public health priority)
The number of people with mental illness will increase substantially in the coming
decades. It is seen that there is an increase in the number of young adults with
mental disorders, and 50-75% of mental disorders began during youth. Secondly,
there has been substantial increase in the geriatric population having mental
health problems, as the life expectancy is increasing. Thirdly social factors which
are established risk factors are also causing a change in the rate depression seen
in all age groups. Besides depression anxiety & stress are also affecting children,
the cause being different from adults (source: defending the health of
marginalised, chc1984-2009)
Determinants of mental health:
Poor people with mental illness are not only vulnerable due to their condition, but
also the vulnerability brought poverty which related to their condition. One of the
main reasons that people find it hard to accept people with mental illness as equal
members of their communities is that they do not see them as capable of
contributing to the household or the community. The effect of social determinants
such has poverty, conflict, gender, disadvantage, social exclusion etc. On mental
illnesses are well known. It is also found that, people are not able to access care
due to their social conditions. And due inadequate treatment, people with mental
disorders remain disabled for longer and incur grater health care costs and lesser
ability to work, thus worsening poverty.(source: defending the health of
marginalised,chc1984-2009)
Mental health impact of poor sanitation
For men urinating or defecating at open places are normal and natural. But
women whose anatomy, modesty and susceptibility to attack does not allow them
to discreetly relieve themselves in public – have no choice but to wait until dark,
26
usually early in the morning when there is less risk of being accosted [2]). “Going
to the toilet” for these women often means squatting in a private spot or waking
up before dawn to queue at public toilets. These challenges are greater for disabled
women. They have to depend on others for attending their nature calls to take
them to out of the village, which becomes a burden to the other family members.
Sometimes, these people relieve by the side of their house or within the house
premises, which makes it a nuisance for the neighbours and other family
members. Even the teenage disabled are also using open places for their
defecation, which is objectionable and not accepted among villagers.
About gaps in understanding on mental health impacts of poor sanitation
As open defecation is accepted factor in the villages, but women having no choice
but to go?
There has been three papers presented earlier on open defecations and its
challenges which women faced due to lack of toilet either at home and nearby, one
at Kanpur [3], the second one at Bangalore [4] and a similar study was presented
in a conference at New Delhi [2]. In which it has been mentioned that open
defecation lead to sexual harassment, malnutrition and physical health problems.
But there has not been any research evidence of mental health impacts with open
defecation.
There is also anecdotal evidence on teasing, harassment and stress for women due
to lack of access to toilets, which may impact their mental health. There are no
formal studies to understand the mental health impacts of poor sanitation, and
therefore we proposed to understand this through interacting with women who do
not have toilets in their homes.
Title of the study
“Qualitative study on the mental health impacts of poor access to sanitation
among women in Hospet, Karnataka”
Objectives
•
•
To understand the role of sanitation as a determinant of mental health
among women (including adolescent and disabled women).
To identify the main reasons due to which women are unable to access
sanitation
Study area
The study have conducted in 5 villages and 2 slums this villages located Hospet
taluk, Bellary District, Karnataka
27
Mariyammanahalli
Nagenahalli
Danapura
Byluvaddigeri
Ramasagara
SL chowki & chithwadagi (slums)
METHODOLOGY
Study design
•
Qualitative study
Data collection
•
•
25- In-depth interviews
2 – Focus group discussion
Sampling
“Convenient sampling” method was used in this study
•
•
Women - 21 (Adolescents and middle age women)
Disabled (women) - 04
Two focus group discussion with
•
•
Adolescent girls – 01 (with 12 girls)
Middle aged women – 01 (with 26 women)
Method of analysis: The conversations were sound recorded, and was later
transcribed and translated (Kannada to English). The transcripts were then
thematically analysed based on which the issues emerged.
ANALISYS
The findings have been presented in three parts: The immediate problems faced,
the impact on mental health, and the determinants of poor access to sanitation for
women. The themes that have emerged under each of the sub-headings have been
presented.
28
1) The immediate problems faced by women because of lack of access to toilet
Most of my responders suffer due to lack of a toilet facility in secure place, their
gender identity (women) and family restrictions therefore women fear to go open
place women faced more problems while going open place these follows
1.1 Confrontation with animals (or threat of attack by animals)
Usually in this villages women go
for toilet early morning and late
evening and often it is quite dark
in the village and they face more
problems of street dogs , snake
bites, monkey bites, pig, bears,
and very often this animals
usually move in the dark
therefore women fear to sit one
particular place for defecation.
According to [28year) old women
“One day I went to public toilet which is do not have roof I sat inside five monkeys
suddenly came on top moving on the walls, and screaming in front of me. I got
scared to sit there and even I could not come out because these monkeys were
walking around the walls, that day onwards I am scared to go outside for toilet”.
1.2 Teasing and harassment by young men
Usually in these villages when women go out for defecation, the youth make
comments and look at them in a manner that makes the women uncomfortable.
Sometimes the boys follow them and misbehave with them and play vulgar songs,
or click photos using their mobile phones. This situation they share with their
friends and when these women come back from the field they are called pet name
like ‘Chembu hodugi’( girl who carries a pot) .
According to [22year old] girl
“I was sitting one place for toilet some fellows came where I was seated; they stood
there, played vulgar songs and started to discuss bad issues because they saw me.
When I left that place they them self calling my name indirectly so I feel shame to
go open place”.
According to [29year] women
“We constructed toilet out of the village beside the road one day I sat inside,
outside youth were standing by the side of the toilet and played songs on mobile
29
and threw stones over toilet , I was scared to sit inside after I came out ‘I
questioned why you people are doing like this? then they said this is road, we stand
on the road, why you have constructed toilet by the side of the road, we are not
teasing you, we are talking to each other, you don’t feel like heroine’ like they
teased me”
1.3 Reduction in food intake
Most of the responders are having health related problems because they do not
take sufficient food and drink enough water. It is affecting their health especially
at night because of lack of toilet they prefer not to take any food and thus and
some of responders complain of gastric and body pain but the family do not
consider its relation with to toilet. Sometimes the girls gets their monthly period
while they are out place and since lack of water they have difficult to clean
themselves properly and thus become infectious.
According to (17year) old girl
“One day suddenly I got stomach pain I told my family members, then we
consulted a doctor who said I have gastric problem because I am not taking food
at night and midday due to toilet problem”
1.4 Monthly related issues
women burdening her biological condition specially adolescents in monthly period
time getting stomach pain
therefore need to spend 10to15
minutes in outside because lack of
toilet facility in the time she
getting psychological stress.
According to [28year] old women
“I scared every month end because
of my month period problem in my
house we do not have toilet facility
therefore I am going out of the
village and it is big difficult for me to find discreet place”.
According to [31year] old women: “During my periods I do normally get stomach
pain and thus I need to be longer period in a private place. But it is difficult to find
place outside, thus I face big problems.
1.5) Situations of misunderstandings/suspicion
30
Most of the responder’s family are suspicious of them. Often for women they look
for lonely place for defecation and sometimes they need to go longer way in order
to keep their privacy. Sometimes it takes 15 to 20 minutes to come back and this
questions people at home. Why late? Where did you go and so on? Started to doubt
them. And sometimes over suspicion arise. When they explain to the family their
need, they fail to understand them. When requested to build toilet in order to avoid
these problems the answer is all these years it was the habit that people go to open
defecation, and why all of a sudden you demand of it. Sometimes this suspicion
brings women in to mental stress.
According to 21tear old girl
“Once I went for open defection while I was sitting at one place, nearby honey
hives was there and when I saw it I ran away to the village. Of course I was afraid
and I was not properly dressed. Villagers saw my position and complained to my
mother to mend her properly”.
According to (18year) old girl
“I fear to go open place morning and evening. I told my father to build a toilet but
he told me from last 20 years in our home, women are going to open place. They
never told us that this is a problem; you only tell that this is a problem. Why do
you think this is a problem, why do you look at gents and when you go take
someone else with you? You behave properly and nothing will happen to you”.
1.6) Domestic violence
In my interviews I found due to lack of toilet domestic violence takes place for
middle aged women. Normally it is difficult for them to find a deserted place
outside the village and thus often they come home late. Due to this sometimes the
husbands doubt them and unnecessary questions are being asked and domestic
violence also takes place... Some of my responders faced this problem in families,
misunderstandings take place and sometimes they are beaten up as well. Once
there is also a case of separation
because of this.
(Related to both suspicion and
related to asking for construction
of toilet)
According to [34year] old women
“I am scared to go to open place for
toileting, one day I shared this
problem with my husband but he
31
did not answer me and he went out, I thought he agreed but he didn’t construct.
Again I started to ask him he got angry and he shouted me back and scolded me
by saying ‘all villagers are going outside, you go like them otherwise you go along
with other women so no need to construct toilet’. Next day onwards I started to
cry, he started to beat and shouting. Therefore I returned to my mother house and
now I do not plan to return”
According to [32year] women
“One day I went open defecation I returned after 16 minutes to the house, my
husband questioned me unnecessarily so I was irritated. These issues cannot be
shared in front of family member’s .Therefore I started to ask him to construct
toilet and this became a big issue he beat me shouted at me then next day I
returned to my mother home. He asked me to return to his place but I demanded
for a toilet but he didn’t agree to my problem he asked me for divorce, now he is
married to another women. If he had agreed to construct toilet I gladly would have
returned back but that did not happen”
1.7 Difficulty with hosting guests
Problems faced by an adolescent who has lived in hostel, and friend had a difficult
time at home due to diarrhoeal episode but no access to toilet. Guest decided not
to visit her again.
According to 21year old girl
“One day I was invited one of my friend to my home because of festival event she
yet full mill its new dishes for her, in the night she suffered by stomach pain
motions 18 times we went outside because of no toilet in my home the next day we
went hostel she shared her problem with my other hostel mates ‘in this girl home
they have bike, TV, showcase, but they don’t have toilet they use to go open place
like tribal’s”.
2. Impact on mental health
Women face much more problems
when it comes to toilet issue. While
going for open defecation they face
harassment,
fear,
suspicion,
domestic violence, as well as due to
poverty not taking sufficient food and
water which affects their nutritious
level. Some of them suffer from
gastric problems. Thus they get in to
psychological stress and depression.
32
2.1 Feeling of fear
The most of responders are going for open defecation. Due to lack of toilet women
have no privacy at all. And often it is quite dark; the presence of animals scares
them. Even fear of teasing and harassments. But in the slums the toilets are far
out and in the morning hours it is crowded and in the evening it is dark and far,
impossible to reach. Thus there is a constant fear in these women when even
thinking of toileting.
According to (18year) girl
“One day I went to open defecation I was sitting one place 3 boys were walking
around that place and they played vulgar songs with high volume, because of they
have seen me therefore I fear to go open place”.
According to [34year] Old women
“One day I was sitting at one place a group of pigs came where I was I got scared
then suddenly stood and came back to home, after that I didn’t sit anywhere, like
this each time this animals give more stress to us. It’s difficult to complete our
work and I fear to go open place”.
2.2 Feeling of shame
While women going outside for open defecation they face more problems and feels
shame .Sometimes when it is dark one will not know what is happening next to
you. While defecating one is unable to stand immediately because of shame or fear
of others watching you. One cannot also speak about these issues at home because
one does not feel free to speak of it. Teasing, taking photos, bad comments,
suspicion are the common reasons why a woman feels ashamed of open defecation.
Specially disabled persons depend on others, when they go with family members
or others they feel shame and they not feel comfortable to do toilet in front of them.
Such situation gives guilt feelings to that person
According to (16year) old girl
“I was seated at one open place
and at that moment the land
owner came and clicked my
photo. It became for me a
humiliation as well as mental
stress, I reflect how to show my
face outside and feel shame”.
2.3
33
Feeling of worthless
Women fully depend on men and they do not listen to them at all. When they speak
of toilet, men bring up the idea of tradition and culture. Women are fully ignored
by men in any sort of decision making factors. Most of the families do not give
importance to disabled because usually they depend on others. They cannot
complete their daily activities without others help, therefore in most of the families
women feel that they are a waist, do not give importance in family decision , they
feel they are neglected persons in the family thus they do not get involved in any
sort of activities.
According to 31year old women
“When I asked my husband to construct toilet he didn’t listen fully to my talk and
he didn’t give proper response to my demand. Finally he told me, don’t discuss
unnecessary things and don’t waste my time, then he went out”.
According to 56 year disabled women
“In our home whatever I discuss with them that is useless because nobody doesn’t
give response to my talk, if try to tell anything they use to tell “keep quite you
don’t know anything” like that they always oppressing and avoiding me”.
2.4) Worry
The study picked out most of them do not sleep well at night because often they
are worried of the open defecation, they face problems inside at family and outside
at the community, thus their suffering causes them reduced sleep.
According to 36year old women
“I was anxious of toilet issue because I have 18 year old daughter she suffers due
to lack of toilet facility, she shared with me, I had discussion with my family but
they won’t consider our problem. So this is big psychological problem for me and I
do not sleep well at night”.
2.5) Low self esteem
Most of the respondents are burdened by due to lack of toilet, because women
cannot take decision without family person’s permission. In this situation women
get oppressed mentality and losing self confident in herself and unconditionally
accepting others decision, sometime she confusing to think properly herself
specially disabled they depended others and nobody listen their views nobody
encourage them in the family therefore them self losing their self confident.
According to 33year disabled women
34
“In my family nobody understands my problem, even I go to express any issues
they won’t listen to that, and won’t give positive support in the family. They always
think I am a worthless person in the family therefore I am confused to take any
kind of decision of my life and not confident to do anything.
2.6. Mental stress
Most of my responders get psychological stress because of open defecation, no
privacy, their gender identity, and fear about men and animals. This reason causes
among women stress and depression specially disabled, they go to much stress
when it comes in to the question of open defecation. Because their disability and
very often they feel shy and shame to take each time others help, but have no
option, should take others help. Sometimes at home they hesitate to help them,
but without their help this disabled persons cannot go for open defecation, this
situation give psychological stress and depression.
(Somewhere we should highlight that women are facing repeated insults and that
these are not one time events)
According to 24year old disabled girl
“Sometimes I ask mother to take me out side, she hesitate and shout at me, many
times I cried but I don’t have option. I use to take their help and without their
support I cannot do anything. Totally my life depends on others, so each second of
my life I feel I am useless in my family, in society and this situation brings big
depression on me”.
2.7), Development of suicidal thoughts
Most of responders are especially middle aged women and disabled peoples facing
psychological stress and depression. While going outside for open defecation there
is teasing, fear, no privacy, problems at family suspicion, domestic violence, and
cultural barriers. Because of this women get anxious and having suicidal thoughts.
Disabled face more difficulties, because of their vulnerability. Most of my
responders are truly anxious of their daily activities; they feel shame to take others
help even sometimes hesitate them. They are neglected persons within the family,
this problems push to depression among the disabled; some of responders think to
attempt suicide, to get relief in this problem.
According to 36year old women
“From last 6 months I faced lots of problems due to lack of toilet when I discussed
with my husband, he suspected me and started to beat. Therefore I went my
mother house, after he asked me to return his place but I didn’t agree finally his
get second marriage. Now in my surroundings and village people speak badly of
35
me. I cried several times I can’t get another marriage I can’t leave .in this society
and thus think to die”.
According to 22year old girl
“I cannot complete my daily activities without others help, this is big shame and
stress for me, each time I feel shame to ask them, but I don’t have option sometime
they hesitate me, shout at me, scold me, but all these I took in a positive way, but
some time I feel why should I give trouble to others, better to die, get relief from
this life”.
3. The determinants of poor access to toilets for women
3.1) Economic status
Financial problem is one of the main causes of access to toilet facility Most of the
villagers wage labours their economical status was not much satisfied. in the
responders families women and men daily wage labourers in this context they not
ready spend money to construct toilet they think construction will require huge
money so we not have enough money therefore people not interesting to build
toilet because of poverty. But most of my responders discussed with their family’s
majority responder views were financial problem in this context. In urban
community have public pay toilet basically labours living in the slums from the
morning to evening they need to use 4 to 5 times toilet it will require more money
for toilet therefore people usually going for open defecation.
3.2), Cultural belief system
Each community people have their own culture norms by birth they maintaining
individual norms and they have some kind of restrictions they cannot go beyond
that. Like in sanitation issue they believed toilet construction out of the village
because people believing that is bad human urine& shit bad conception in the
family usually people doing some pooja ,homa . Inside the home and village
Therefore people do not giving importance to construct toilet
3.3), Patriarchal family system
Patriarchal family system which neglects the gender sensitive needs of the women
seems to be an important reason behind the lack of toilet in this community. In
the interviews most of respondents shared that in their families commonly men
were decision makers and the women uncritically accept the decisions made by
the men. Since, open defecation is a gender specific issue that affect women due to
their biological vulnerabilities and stereotyped concept of gender in the
community, men in the family are not aware of the necessity of constructing toilet.
Table no :( 1)
36
Problems caused by poor sanitation (out of 25 responders)
Adolescents
= 10
Middle aged women = 11
Person with disability = 04
Problem
Fear to use open place
Teasing/Harassment
Period Problem
Health related issues
Suspicion
Domestic violence
Age group
Adoloscents
Middle age women
Disabled
Adoloscents
Middle age women
Adolescents
middle age women
Adoloscents
Middle age women
Disabled
Adoloscents
Middle age women
Middle age women
Disabled
Numbers/percentage
10
11
04
10
11
10
06
05
06
04
08
09
08
04
=
=
=
=
=
=
=
=
=
=
=
=
=
=
40%
44%
16%
40%
44%
40%
24%
20%
24%
16%
32%
36%
32%
16%
Table no :( 2)
Mental health impact of poor sanitation (out of 25 respondents)
Problem
Fear
Age group
Adolescents
Middle age women
Disabled
Ashamed and lower self Adolescents
confident
Middle age women
Disabled
Reduced sleep and confused Adolescents
mind
Middle age women
Disabled
Stress and depression
Adolescents
Middle age women
Disabled
Suicidal thought
Adolescents
Middle age women
Disabled
Table no :( 3)
37
Numbers/percentage
10
=
40%
11
=
44%
04
=
16%
10
=
40%
11
=
44%
04
=
16%
09
=
36%
10
=
40%
04
=
16%
10
=
40%
11
=
44%
04
=
16%
07
=
28%
08
=
32%
04
=
16%
Reason for not constructing toilet (out of 25 respondents)
Reason
Poor economic status
Cultural belief system
Patriarchal family
system
Lack of government
support
Age group
Adoloscents
Middle age women
Adolescents
Middle age women
Adoloscents
Middle age women
Middle age women
Numbers/percentage
04
=
16%
07
=
28%
10
=
40%
11
=
44%
03
=
12%
09
=
36%
03
=
12%
Figure. (1) Mental health impact by due to lack of toilet (diagram)
Poor
economic
status
Fear
Feeling
fear
Teasing
/Harass
ment
Feeling
shame
Worry
Cultural
belief
system
Open
Defecation
Period
Proble
Health
related
issues
Patriarchal
family
system
Personal
suspicious
Domestic
violence
DISCUSSION
38
Low self
esteem
Feeling
Worthless
Mental
stress
Suicidal
thoughts
Mental
health
Women faced teasing/harassment, a patriarchal system, absence of privacy,
poverty, cultural traditions, and problems at menstrual periods, suspicion at
home, and humiliation in public which are causing major impact on women’s
psychological problems. They are so deep that the women are unable to share
about them; as a result they suffer in silence from psychological stress. The
findings on the immediate problems faced by the women due to lack of access to
toilets is similar to that reported by earlier studies [2][3][4].
The lack of access to toilets in turn leads to fear, reduced sleep, reduced intake of
food, lower self confidence, distress, confused state of mind and constant worry
about the future. The feelings of being worthless and suicidal tendencies are also
pointed out. From which we can conclude that inaccessibility to toilets is an
important determinant of mental health.
It was also ascertained that lack of access to toilets for women was related to socioeconomic status, cultural belief systems and patriarchal nature of decision
making. Of these, the latter two may be more important, as currently there are
programmer’s available for funding the construction of toilets. There may be a
need to empower the communities to adopt toilets by challenging long held beliefs
and also with information on the benefits of using toilets. It is important to involve
both men and women in this exercise.
Strengths
•
•
•
The researcher has chosen a qualitative study design because to
understand the issue there is a need to conduct in-depth interviews and
direct observations which are categorised under qualitative research and
would be helpful to understand problem scenario.
Researcher divided samples of three age groups (adolescents, middle aged
women, disabled) which helped to identify the range of problems faced by
women from various backgrounds.
Researcher interviewed most of women who lacked toilet either at home or
nearby to know problems affected at present scenario.
Weakness
•
•
•
Absence of men interaction.
Absence of care givers interaction (Person with Disability).
Absence of interaction with local self government.
Recommendations
39
•
•
•
•
Conduct behavioural change training programme for young men to come
the bad assumption about women, and for peoples to come out the cultural
(blind belief) system in toilet issue.
Conduct sanitation awareness and training programmes for both men and
women to the problems by due to lack of toilet.
The study brought out poor economic status one of the major reason to
construct toilet therefore if introduce appropriate technology method for
constructing toilet it will reduce this problem in rural area.
In rural area people not much aware about importance of sanitation and
very only few organizations working this issue therefore to promote
sanitation workers (CBOs, NGOs) to focus this issue and reduce the
problem.
Knowledge Translation
•
•
•
For local community?
Through the hand books (local language) street play, aware them and
conduct awareness programme regarding problems by due to lack of toilet
among women, promote them to solve their problems themselves in rural
areas.
For community health workers and professionals?
Through the research publication (internet media) to aware the women
problems, current situation, problems of access to toilet facility and identify
the alternative solutions for this problems.
For policy makers?
To conduct Presentations, Seminars and discussions, visual documentary
shows regarding women problems by due to lack of toilet in rural areas and
strengthen the current programmes on better way.
Future study
•
•
•
Researcher should consider interacting with men to learn about the
challenges faced by them due to lack of access to toilets, and about the
reasons for not constructing toilets.
Researcher should interact with care givers (Person with Disability) to
understand about the kind of support needed by those with disabilities, and
the challenges faced by the care-givers in this regard during their day to
day activities.
Researcher should interact with local self government and CBOs, NGOs
working with sanitation issue to learn about adoption of toilets locally and
the challenges being faced.
Conclusion
40
Sanitation is a neglected issue at the present situation in the nation especially in
rural and urban (slums) areas where peoples faced more problems by lack of toilet.
Most of them are using open place for defecation, men urinate and defecate in open
place while women faced moral problems in toilet issue, because of their gender
identity. In many slums and rural areas people are practicing open defecation
while women critically accept that situation and face more problems. Going for
open defecation is a problem affecting the psychological conditions of women and
contributing mental health.
Reference
•
The great Indian sanitation crisis live mint and the wall street journal
http://www./livemint.com/opinion/zoKIf2URgrGT22qH6 or o/the -indiansanitation-crisis.html
UN-HABITAT ASIA- Asia pacific ministerial conference on housing and
human settlements.(13-16th December 2006 new Delhi )
• India sanitation portal/absence of toilet expose rural women dangers.
(http://indiasanitationportal.org/18749)
• Sanitation: the hidden gender problem – absence of proper sanitation is
affecting women lives
(http://indiatogether.orgwomen/health/sanitation0702htm/)
• (source: mental health as a public health priority)
•
•
(Defending the health of marginalized, chc1984-2009)Bangalore.
•
Community health and sanitation awareness – 2013 SOCHARA
Bangalore.
•
Lack of water and sanitation hurts women and girls themost,feb042013bylisaschechman. (http://www.trust.org/item/20131004120551omt32/)
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