COMMUNITY HEALTH TN INDIA A -Study Reflection - and a stimulus for further study · Community Health

COMMUNITY HEALTH TN INDIA A -Study Reflection - and a stimulus for further study

Item

Title: COMMUNITY HEALTH TN INDIA A -Study Reflection
- and a stimulus for further study
extracted text: COMMUNITY

HEALTH

TN

ch

INDIA

*

- A -Study Reflection
- and a stimulus for further study

1.

Introduction to Paper

2.

Reflections
I.
Health Care in India - An Historical Overview
Health Care in Post Independent India - An
Overview
III. Health Situation in India (1990)
IV. Community Health in India s Recognising the New
Paradigm
V.
Community Health: the axioms of ’ a new-approach

II.

■*

VI.

»

Is Community Health Growing as a Movement in India?

Methodology of Use
(Alternatives)

1. The paper could be read at one sitting taking all the
reflections together to get an overall understanding.
2. Each reflection could be read by a group and reflected upon.
Identify group consensus on the issues raised. Also ide-.itTfy
areas of differing opinion and newer questions/doubts that
may arise in the group discussion.

3. If access to all the 10 key sources is made possible then
members of the group could read through the original sou; \
and step 2 could be done again so that this paper and its
conclusions would be supplemented by other analysis/
conclusions in the sources, adding to the richness of the
discussion.
\

RAVI NARAYAN

SOCIETY FOR COMMUNITY HEALTH AWARENESS, RESEARCH AND ACTION
(COMMUNITY HEALTH CELL)
326, V MAIN, I BLOCK, KORAMANGALA, BANGALORE

(AUGUST - 1992)

560 034.

ip

1
CCWCTJITY HEALTH IK IKDIA

A Study-Reflection
INTRODUCTION
These notes are part of a background preparation that I made for
a ’reflection’ with the participants of the Community Health Forum,
at Secunderabad in July 1991.

The framework given to me was
i) A recapitulation and consolidation of the health scene
in India.

ii) The evolution of the Community Health Process in India.
iii) Some reflections on the thrusts towards the 1990’s.

After the meeting, in the discussions that followed and later in
correspondence with some of the members I was asked to include
Health Statistics of India; the social model of health, latest
trends in health care systems; NGO's in Community Health in India
in the 1980's; different aspects of community health in India;
new policy by government on health. I realised that putting all
these together in a single article would mean writing a whole book
on the subject.
However since the objective of the exercise is to inform the group
about the key issues and build a framework for further study and
reflection, I have decided to put-together my notes, interspersed
with some reflections from well known sources (books already
available) hoping to stimulate the members of the forum to make a
serious study of the 'reading list' provided and to build on the
evolving reflections of a large number of individuals and groups
who are recognising and building a 'social model* of health.
During this study they should temper the reflections with their
own field experiences and those of other members of'’the forum,
shared during the annual and regional meetings.
'Community Health
in India' is an evolving idea, an emerging process and we all
need a much deeper understanding and linkage if we wish to
facilitate and or participate in Health as a movement.
I present this s_tudy-reflection in the form of short reflections
and -include
extracts
--------- 1 from
a few< of our CHC papers as well as from
the 10 key sources which I recommendI as 'basic reading' material
for the group. These are

Source

1.

Name

Authors & Year

National Health Policy
Statement
Health for All - An
Alternative Strategy

G.O.I.(1982)

3.

Health Care Which Way
to Go

medico friend circle

(1982)

4,.

Health Care in India

George Joseph et al

CSA (1983)

5.

Rakkus Story

Sheila Zurbrigg

2.

ICSSR/ICMR

(1981)

CSA (1984)

2.
Source

Nsce

6.

Health and Family Planning
Services in India

7.

Development with People

8.

Taking Sides : The Choices
Before the Health
.n Worker

9.

Health and Power to the
Pe°ple " the Theory and
Practice of ommunity

Authors & Year
D. Banerji, Lok Paksh (1985)

Walter Fernandes, ISI (1985)

Sathyamala et al
CHAI-CHD

(1986)

(1986)

Health

10.

Community Health in india

Health Action - July 1989

As
”
supplementary

list of 40 titles
the Indian r
experience
which
includes the 10 above is given in on
the
-.j Health Action
(source 10)
-- 1 special issue

All these books and g-groups do not r^
—
necessarily
understand and use
n
terTn‘Community Health
--- ’ 1 in the
J
same
way
- there are diverse
interpretations but tne main point which
I
wish
to stress is that
in all these groups and reflections
some
common
-thread
of assumptions and p
perceptions are emerging. While not :
ignoring
the
differences I feel- the common threads
must
be
identified
and
focussed so that <a broader and deeper
collective
understanding
emerges which will promote linkages and the ('
T"" r“'-“ development of larger
and larger numbers of heal th
health action initiators convinced and
committed to the Community Health
movement in India.

N.B. <

Source

1/2z3z7

Available from
Voluntary Health Association of India
Tong Swasthya Bhavan,
'
£iShitUtii?nal Area' Near Qutab Hotel,
Lew Delhi - 110 016.

Source

4/5

Source

8Z9Z10

Source

6

Source

l,2z10

Available from
centre for Social Action,
Gundappa Block,. 64, Pemme Gowda Road,
Bangalore - 560 006.
Available from
IS?/?11?
A£S°ciation of India,
57/6, Staff Road, Gunrock Enclave,
Secunderabad - 500 003.
Available from
Lok Paksh,
Post Box 10517, New Delhi - 110 067.
Available from
Community Health Cell,
326, V Main, I Block, Koramangala,
Bangalore - 560 034.

I

1

REFLECTION - I/A

HEALTH CARE IN INDIA - AN HISTORICAL OVERVIEW

Vedic Period - to Indian independence
*

BecordS-Of Health writings and health care in India goes back
in History to over 5000 years end is marked by many significant
developments whi h include particularly

i) the concepts and ’technology' of Sanitation in the' Indus
Valley; (3000 B.C.)

ii) the change rrom magico religious medicine to 'aysnore rational
therapeutics in Vedic medicine - representing the development
of Ayurveda, Siddhe & Yoga;

iii) the development of Social Medicine and hospitals for
humans and animals during the Ashoka/Maurya Phase (279 236 B.C.).
*

The growth of Ayurvedic and Siddha medicine is marked by the
development of zamous treatises and writings of great doctors
Charaka, Susruca, Athreya, Jivaka and these traditions were very
integrative.
The strengths even in these traditions
available to this day are the sensitivity and closeness, to local
culture, the stress on healthful living and not disease, and the
close links with home remedies and people's health cultures.

The weaknesses on the other hand are chat these , are based on
empirical logic some of which may have stood the test of time
cut has not been supported by experimental logic; there has been
stagnation due to inadequate professional organisation and some
or the ills of Society be it class or gender inequality have got
internalised without being reviewed from a rational stand point.
It must be also mentioned that due to the factor of colonialism
some of it which continues even today in the form of cultural
colonialism, through the dominance of the western allopathic,
technocentric model (that was transplanted into the developing
heaith system especially during British rule) these traditional
ano indigenous systems have not been adequately studied or
reviewed and have been neglected by the official health system,
A serious_study and research are needed to identify the strengths
o title mdigencus systems and integrate them with the dominant,
system and develop a truly National System of medicine.
A word of caution at this stage is that efforts towards study
anc integration of indigenous systems should be done without
undue romanticism or misplaced nationalism. At the same timq
care must also be taken to differentiate between People's
health culture, local remedies which ere under the autonomous
control of the people and the relatively more organised systems
that have their own practitioners, medicines and training as
well as- care strategies.
*

During the British Colonial phase western allopathic medicine
developed greatly in India. *'While it had already been introduced
by the Jesuits in Goa in 16thi Century it did not spread till
after the advent of British rule* The Health Services during

1—2
the

in the

vJ U. I 1 C. A. y •

Rural areas were neglected in oeneral though there was some
missionary work that took some basic health ccare to many interior
care3 23 Wel1’
PeoPle had to rely primarilyr on traditional health
therS Was an overall neglect of the
yban m health service development (a fact that
of he-l'tb6^
situation today as in the 1850's, the develonment
Sf
services during British rule was affected by the Public

21 iSe IZah

taki?g ?iace in Europe at thatP°SitiVe deVel
i-SSl
°p-

lenl^tS^Sst^e^elLle^!^

- Public health cconcepts
---- '
came into the country in a big way with
organisation of epidemic measures and other forms of prevention
on a large scale.

women and children and by women.
-

ana

responsibility^ for Public Health.
★

9

™ere ™any srna11 and large princely kingdoms in India
°f B^ltlsh rule, these did not always keep
£
newer developments in the British ^residency' s. Local
-ronal systems got patronage and some thrived. However
ysore and Travancore were two kingdoms that evolved'very prooressxve public health and health care policies laying the^ounda”
tions rso’ ^to
' _sPeak for the very different situation in ‘Kerala’
and 'South Kanara
--- 1' in present day India.

track

*

In 1943-46 the Health and Development Committee (also known as
Shore Committee) drew1 up the comprehensive blue print for
Health
Services for India. 1While this was a
pre-independence
committee
set
.Provisional Government, une
the recommendations
recommendations were
very progressive and farreaching. Three significant developments
m 1920's to 1940's definitely inspired this committee,- The
influence of socialism and the health services of the socialist
states the European Public Health movement and the post world
7?heWShe3 ^are^C°eC!?t a\we11 as the growing National movement.
Sokhey report of the Indian National Congress is a fore
runner to a new vision of health/health care).

* The Shore Committee
recommendations included the following :

- Health should be an integral part of socio-economic
development.
- Adequate health care for All
- Free health care for All
- Reach out to vast rural population
- Correct rural-urban imbalance

■

>

•

- Emphasis on prevention, promotion and education

- Key role of self help and active cooperation of people
through representations and committees.
_

= e.

1 5 tv.

II

REFLECTION - H/A

1

HEALTH CARE TN POST-IKDEPEKDENT INDIA

An Overview
-'he Constitution of India adopted in 1950 clearly recognises the

-- -

programmes over the last 40 years.

i------- ------ —-------------- —--- 2____ ________________
Constitutional Pledges

The Suate shall regard the raising of the level of nutri—
tion and the standard of 11
People and the
e„ts ofe Publ le --Heaias
Jh among its primary
duties,
* that the health and r
'
strength
of workers, men and
women, and the tender age of children
------- 1 are not
abused....
■K

that children are given opportunities and facilities
to develop in a healthy manner....

It shall make
j
'
'
provisions
for securing just and human conditi-ons of
worn and
1-1 for
l^r maternity relief....
and

*

-k

cor public assistance in cases of unemployment, old
age, sickness and disablement and in other cases of
unde s erved want.

i

I
- Constitution of India !
These included the

- Development of the Primary Health Centre concept for every one
lakh population.

or.nealth teams including doctors, health inspectors,
dy healu., visitors, auxiliary nurses, midwives, basic health
workers, block extension educators for these health centres.
- The National ’programmes
-for communicable disease’s like Ttiberculosis. Leprosy, Malaria,, Filaria, Plague, Cholera and so
on.
- The Maternal and Child Health, Nutrition and Family welfare
programmes.
- Efforts at re-orienting medical and nursing education.
- Establishment of research and specialist institutions.
- The integration of programmes at PHC level, evolving the multipurpose health workers and health supervisor cadres.

Establisnment of pharmacies and training of pharmacists.
*1

neorlp'-1

II - 2

Taking Stock
In 1972, when we celebraced the Silver Jubilee of our independence,
there began a critical reflection and introspection or the prece
ding twenty five years of development. This was an important
milestone and it became a focus to take stock of the strengths
and 'weaknesses of cur planning and development particularly in
the context of the continuing poor quality of life of a large
majority of Indian citizens.
Lil aspects of national development
came under scrutiny and health policy was no exception.

Assessing achievements/failures

L study group of the Indian Council of Medical Research and the
Indian Council of Social Sciences Research in 1984 listed out the
achievements and failures of the whole health care strategy.

Achievements
- Life expectancy doubled
- Health care services expanded
Manpower training centres increased
- Small-pox was eradicated
- Plague, Cholera and Malaria controlled
- Maternal and Child Health and immunization programmes
increased
- Largest Family Planning Programme in the world

i
1

Failures

not integrated with Development
I - Health
Little
dent on Malnutrition and Environmental Sanitation ,
I -

- Morbidity patterns not materially changed
- Health Education neglected
- TE, Leprosy, Filaria yet to be controlled
Infant and Maternal -crtslity rates still very high
I -- Population
stabilization
a long way to go

I
I

Overall
1. The model of health care was outdated and counter
productive benefitting the rich and well-to-do upper
and middle classes.
I 2.

Health was a low-priority national investment.
Source 2 ICMR/ICSSR

Quantitative Expansion
We had made some rapid strides and a phenomenal quantitative
expansion of health care services. This increase in manpower and
infrastructure development continued into the eighties.

By 2984, we had increased the number of hospitals and dispensaries
three-fold, doctors five-fold, nurses ten-fold and dental colleges
seven-fold — remarkable development indeed it seemed!
Hovrever, when we compare this infrastructural development with the
Shore Committee’s long term goals enunciated in 1946 itself, we
find the situation very different and the so called ’rapid growth’
becomes questionable.
Increasing numbers with goals and base lines can be very misleading!

3

Critical Introspection

In the seventies, the Government of India set up an expert group
on Medical Education and Support Manpower to take stock of the
situation and suggest proposals for reformso

This is what the expert committee (Srivastava Renort, 1975) had
to say s
l.t:A universal and egalitarian programme of efficient
and effective health services cannot be developed
against the background of socio-economic structure
in which the largest masses of people still live
belovj the poverty line. So long as such stark
poverty persists, the creative energies of the
people will not be fully released; the State will
never have adequate resources to finance even min
imum national programmes of education or health; and
benefits of even the meagre investments made in
these services will fail to reach the masses of the
people. There is, therefore, no alternative to
making a direct, sustained and vigorous attack on
the problem of mass poverty and for creation of a
more egalitarian society. A nationwide programme of
health services should be developed side by side as
it will support this major national endeavour and
be supported by it in turn. ii

i

2.,'VJe have adopted tacitly, and rather uncritically the
model of health services from the industrially adva
nced and consumption-oriented societies of the West.
This had its own inherent fallacies; health gets
wrongly defined in terms of consumption of specific
goods and services; the basic values in life which
essentially determine its quality get distorted;
over-professionalization increases costs and reduces
the autonomy of the individual; and ultimately there
is an adverse effect even on the health and happiness
of the people. These weaknesses of the system are
now being increasingly realized in the West and atte
mpts are afoot to remedy them. Even if the system
were faultless, the huge cost of the model and its
emphasis on over-professionalization is obviously
unsuited to the socio-economic conditions of a
developing country like ours.
It is therefore a
i
tragedy that we continue to persist with this model
even- wnen those we borrowed it from have begun to
have serious misgivings about its^.utility and ultimate .
viability. It is, therefore, desirable that we take
a conscious and deliberate decision to abandom this
model and strive to create instead a viable and
l'
economic alternative suited to our own conditions,
needs and aspirations. The new model will have to
place a greater emphasis on human effort (for which
we have a large potential) rather than on monetary
inputs (for which we have severe constraints).”
f
I

3.”In the existing system, the entire programme of
health services has been built up with the metro
politan and capital cities as centres and it tries

1

.. ix-4

4

II

to spread itself out in the rural areas through
intermediate institutions such as Regional, District
or Rural Hospitals and Primary Health Centres and its
sub-centres. Very naturally, the quantum of quality
of the services in this model are ar their best in
the Centre, gradually diminish in intensity as one
moves away from it, and admittedly fail at what is
commonly described as the periphery’. Unfortunately,
the ’periphery’ comprises about 80 percent of the
people of India who should really be the focus of
all the welfare and developmental effort of the State.
It i.s, therefore, urgent that this process is rever
sed and the programme of national health services
is built with the community, itself as the central
focus. This implies the creation of the needed
health services within the community by utilising
all local resources available, iand" then
'
to supplement j
them through a referral service which will gradually
rise to the metropolitan or capital cities for dealing'
with more and more complicated cases.”
)

X

I

4. ’’Throughout the last two hundred years, conflicts have
arisen in almost every important aspect of our life,
I
between our traditional patterns and the corresponding|
systems of the West to which we have been introduced.
In many of these aspects, the conflicts are being
resolved through the evolution of a new national
pattern suited to our own genius and conditions, In
medicine and health services unfortunately, these
conflicts are yet largely unresolved and the old and
new continue to exist side by side, often in functi
onal disharmony. A sustained effort is, therefore
needed to resolve these conflicts and to evolve a
national system of medicine and health services, in
keeping with our life systems, needs and aspirations".
Many other expert committee reports and policy7 statements of the
seventies began to make critical observations about the inadequacies
of the present health care model and exhorted all concerned to
search for more relevant alternatives and aimroaches.

Prof. Banerjee of JNU (Source 6), offers a deeper social analysis
to explain this growing dichotomy. His contention ■ is that the
post-independent leadership had two basic choices in front of them.
Either to expand health services along the pattern set up by the
Britishers choice or to introduce radical changes- to answer needs
of the ordinary masses, while the.latter was the choice in most
!
policy documents the class character of the leadership affected
the realities in practice. The old colonial traditions were
perpetuated -with the focus on urban and curative. The doctors
came from the privileged classes and had internalised the elitist
and modernising ethos. The humanitarian principles and socialist
declarations notwithstanding, the overall focus was on a capitalist
framework. Health policies of the 1950’s $nd 196O’s mainly
answered ideals/aspirations /needs of upper and middle classes and
the health professionals who belonged mainly to these classes, The
focus was mainly on hospitals, medical colleges, and curative
services in cities whilst rural areas got low quality curative care,
some communicable disease control and more family planning services.
..11-5

II

5

This basic dichotomy of needs and aspirations and class character
o_-leadersnip explains the overall consistent lack of political
ltzLL'he- lr-3reasing dichotomy of services for the classes and the
and
urban-rural differential; the over emphasis
heliJn ?nH -rient®b°n ° Family Planning; the promotion of the
1 ea-th mars cry; the increasing corruption in the services and
!biL°f-prtVlte practice’ the neglect of the indigenous
:'2plC1^e' i'ne PopnUst modification of programmes; the
Z-np - ~
y ^amformation; the verticalization of proorammes;
fg
?f pUblic health standards and practice;
ea,H ebucation and awareness building strategies
p orification of technology and the promotion
or privatiZc^ion m health care.
Some of this is echoed in the National Health Policy of 1982 which
is part of rhe cgrowing rethinking on Health Care in India.
‘Community Health Action’ is therefore to be seen in this broader context.
II/B-

additional reading

01. The Post-Independence Model in Chapter I The Historical Background.
(Source 4)
02. Towards a Proper Analysis, Chapter 4
03. The Health Care System, Chapter 3.

(Source

(Source

4)

5)

04. screes Shaping the Health System,
Part III. (Source .5)
05. Health Services Since
Independence, Chapter 3.(Source 6)

06. The DDevelopment of Health Services
in India, Section III
Chapter 1.
(Source 8)

II/C-

QUESTIONS AND TASKS
01. Visit the nearest Primary Health Centre
and .Sub Centres
in rne Taluk/Block in which you are working. From the
PHC^doctor and health centre staff find out’about the
organisation and functions of the centre. What are their
problems and difficulties.
\
02. Talk to (groups of people in your community from.different
socio-economic and
—.cultural
------- - groups and ask them about their
experiences of health care in the government PHC or
sub-centres.
03 o

Fro., these two steps build up your analysis of the
situation of health care in your area - the projected
acr.ievements and. the actual realities.

04. j.ry and identify the factors that operate at the local
level/district level/state level promoting or obstructing
health service development, accessibility and .efficiency."
*

*.■*:.*

★- * *
* *
•st

..II-6

II/D-

II

6

STATEMENT ON NATIONAL HEALTH POLICY, GOVERNMENT OF INDIA, MINISTRY
OF HEALTH & FAMILY WELFARE, NEW DELHI, 1982 (An Extract)

The Existing Picture

In spite of such impressive progress, the demographic and health
picture of the country still constitutes a cause for serious and
urgent concern. The high rate of population growth continues to
have an adverse effect on the health of our people and the quality
of their lives. The mortality rates-for women and children are
still distressingly high; almost one third of rhe total deaths
occur among children below the age of 5 years; infant mortality
is around 129 per thousand live births. Efforts at raising the^
nutritional levels of our people have still to bear fruit and the
extent and severity of malnutrition continues to be exceptionally
high. Communicable and non-communicable diseases have , still to
be brought under effective control and eradicated. Blindness,
Leprosy and T.B. continue to have a high incidence. Only 31% of
the rural population has access to potable water supply and 0.5%
enjoys basic sanitation.

1) High incidence of diarrhoeal diseases and other preventive and
infectious diseases, specially amongst infants and children,
lack of safe drinking water and poor environmental sanitation,
poverty and ignorance are among the major contributory causes
of the high incidence of disease and mortality.
2) The existing situation has been largely engendered by tne almost
wholesale adoption of health manpower development policies and
the establishment of curative centres based on the Western models,
which are inappropriate and irrelevant to the real needs of our
people and the socio-economic conditions obtaining in the country.
The hospital-based disease, and cure-oriented approach towards the
establishment of medical services has provided benefits to the
upper crusts of society specially those residing in the urban
areas. The proliferation of this approach has been at the cost
of providing comprehensive primary health care services to the
entire population, whether residing in the urban or the rural.
areas. Furthermore, the continued high emphasis on the curative
approach has led to the neglect of the preventive, promotive,
The
public health and rehabilitative aspects of the health
existing approach instead of improving awareness and building
up self-reliance, has tended to enhance dependency and weaken the
ccmmuniry’s capacity to cope with its problems. The prevailing
policies in regard to the education and training of medical and
health personnel, at various levels, has resulted in the develop
ment r'f a cultural gap between the people and the personnel
providing care. The various health programmes have, by ana
large, failed to involve the individuals and families in esta
blishing a self-reliant community. Also, over the years,
planning process has become largely oblivious of the iact that
the ultimate goal of achieving a satisfactory health status
for all our people cannot be secured without involving the
community in the identification of their health needs and^
priorities as well as in the implementation and management of
the various health, and related programmes.

REFLBCTICl" -

Ill

tZI/A

HEALTH SITUATION IN INDIA (1990)
•k

aince independence there have been much efforts to imorove the
health status of the i 'commitment to health
qua.^t- or health service for all social groups in the country
has emerged.

?xamin.ation of available information on
on i.^^ll.
mortality
t rate2 <> mo5D1-dltY (illness rates), delivery of health
^Vel°Pment of humanpower and their deployment
a
. e picture of health status in the country is
not as rosy as it seems on the surface'*.
2

Mortality in India

(National in 1988

11,8 Rural

7.5 Urban)

Rural and Urban death rates (CDR) show a continous decline in
the period studied 1971-1988;

- Rural death rates are substantially higher than urban rates
in all the states with the singular exception of Kerala.
- Rural death rates in Bihar, Madhya Pradesh, Rajasthan and
Uttar Pradesh are substantially higher than national averaoe
and the urban-rural differential
----is unacceptably high.

Age and Sex specific death rates
- At newborn male and female weights and heights are similar
_ ar--rning the female child is slightly better off.

- Belov; 10 years of age the death rates in females both in
urban
and rural creds is clearly nigner than in males. The
. jinference therefore is inescapable that the family and social
environment in tne early years is adverse for the female child.
In 10-14 age group the rates rare similar in rural
areas and
female is better than males ina urban areas.

In age 15—34 female death rates are higher than males-,- the
difference being much higher in rural areas and in younger
ages.

- Beyond 35 years female enjoy a lower death rate when
compared
to males.
. Inference ; Child bearing takes a hea^r toll of death ix,
„
in women
MM country especially rural sector and reflects poorlyr on
the n$alth Services.
2

Arj:Ean^ xcrtality Rates (National in 19.88 = 102 Rural, 61 Urban)

t '

Infant, mortality rate is above 100 in Assam (101) Bihar (100),
Q-uj.aret
Gujarat (101), Madhya.
Madhya Pradesh (127)?
(127), Orissa (127)
TT+-A-v.v. -d.
i
t ~
\
_
111)-,
IMy ?r5dei3h (132\
1988 and beloy; IQO- in all theRajasthan(
other
stgt^s.1; -Kerala .is.(the lowest with 30.:
M:’-Mr■
III-2
’•V
::

1 jBBBB; ■ ■ B’.

•B
t

... . r-ttd

; |

... ..

..

: •'
. •

i'-

III

2

- In Punjab, Haryana, Himachal Pradesh and Uttar Pradesh IMR is
higher in females than in males. In Assam, Andhra, Karnataka,
Kerala, Orissa, Jammu & Kashmir and West Bengal, IMR is lower
in females than in males. In all the other states it is more
or less similar.
- Rural IMR's are substantially higher than Urban IMR with
exception of Kerala.

- Neonatal and post neonatal mortality rates show a decline in
all states from 1970 to 1985 except Haryana. Rural rates are
substantially higher than urban rates.

(National in 1987

* Maternal Mortality Rates

= 3.6)

- One percent of all rural deaths are reported to be due to
child birth and pregnancy in India.

- In 1987 the national average ,was calculated at 3.6/1000 live
births. Uttar Pradesh (7.1), Himachal Pradesh (6.5), Bihar (6),
Madhya Pradesh (6.1), Rajasthan (4.5), Orissa (4.3), Haryana(4).
All the other states had lower than National average with Kerala
being the lowest (0.6) and Karnataka a close second (1.0).
- Rural MMR in India is about 15 times more than what it should
be for an Asian country and probably 60 to 80 times more than
that in developed countries of the West.
In a study in Anantpur District (Bhatia, J.C., IIM-Bangalore,
1984-85) MMR was higher in 15-34 age group and nearly half of
all deaths in 20-24 age group was due to maternal death.
43.5% of maternal deaths was on day of delivery and 41.9%of
deaths due to bleeding and infection( 1) .

- 70% of all births in rural India are attended to by untrained
persons.
- An ICMR study on the quality of MCH services in rural India
published in 1989 shows that elementary care of women during
delivery is grossly inadequate in India.
•fc

Causes of Death

- Tuberculosis, Pneumonia, Anemia, Gastro-enteritis, Dysentery
and Typhoid account for 20% of all deaths in India.
- Conun uni cable diseases account for 40% of all deaths in India.

- Diarrhoea is a major cause of illness and death in children
in India.
f

* Nutrition Status

- The National Nutrition: Monitoring bureau monitors nutrition in
the states of, Kerala, Tamilnadu, Karnataka, Andhra, Maharashtra,
Gujarat and Orissa.
- Barring Gujarat and Orissa all other states have shown an
improvement in nutritional status from 1975 to 1989.

- The gicl children/have shown1 greater improvement than the boys!
"'■ ■■

” • •' 4'4< '

.

..m-3

*

Ill

3

■. ........ .............. .........

is high in air theseystate^^->- / '
- Vitamin A deficiericy■/ in

■

Children

ranges from 5-10%.

* gOHtmunicable and Non Communicable Diseases Mortality
Tuberculosis, Leprosy and Malaria are still major problems. ;
Progress in control of TB is disappointing. In Leprosy with'
the introduction of multi drug therapy there seems more hope.
Malaria has shown an increase from 1986 to 1988 (data available)
states of Andhra, Gujarat, Karnataka, Madhya Pradesh,
Maharashtra, Rajasthan and Tamilnadu.

Goitre, Cancer and Blindness are increasingly being recognised
as major problems.
'■
'
. .
.
~

Health infrastructure and hea1th manpower
*

There is growing evidence that 1 the large functional infrastructure
claimed to 'have been created in the country only exists largely on
paper.
- .

*

Official statistics indicate that the objective of having a
subcentre for 5000 people in rural areas'and 3000 for hilly and
tribal areas and a primary health centre for every 30000'population
very nearly achieved. On the other hand, the National’Institute
n a?d FaiT111y Welfare's .National review of Immunization
programme
cnnn
n .shows that only 45% of district have subcentre
5000 population.
. for every
1

*

The ratio of male to female multipurpose worker which should be
1:1 is 1:1.6 which shows a shortage.of male workers.

★

The availability of all types of nurses is inadequate.

*

The practitioners of the indigenous system are about 4 lakhs
(registered) but are yet jto be involved meaningfully by the
health care system.

•Ir\ nummary, it is no exaggeration to say that the health scene
in the country is really grim even.after 40 years of independence.
It is being increasingly realised now that the goal of good health
• °r tl'ie people. of India can only be reached through a process that
is multidimensional, encompassing appropriate universal education,
better environmental management both at home and outside, well
integrated social- services, an u
acceptable minimum living standard
and of course health and medical1 care of acceptable quality!
The message from the1 even the limited data presented in this
paper
is loud and clear, The medical model of health which merely
concentrates on the use <of technological resources in freeing man
from clinically identifiable
disease
---? or disorder is at its best an
inadequate and at its worst an uneconomical and unproductive
approach for the improvement of the health of a people. The medical
..111-4
©

k--

1

teropered ,by^e 'socia! .ode!, of heafth^ichl as

mehtionefeearlief“approaches tHeggoal^f^o^althoughi a
-

ecome
multi-dimensi onal process. ffflealthl<ievelopment ?has to <be
— an
integral:part of the socio-economrc^deyelopmental process. ii

(This section is principally^and^sub'stantially <an edited^and
summarised .version- of - a recerit^pa^er ^'1990) Von 3 Current^Status
of Health in India * presented ..by ^rof
Ramachandra,.^rofessor r
of Epidemiology and Statistics ‘of ^All ifndia ^Institute'Tof Medical
Sciences, New Delhi. The "original paper‘7is'8--pages with 23 pages
of tables as appendix and is available 'ohr,-request fromcCHC;
Bangalore). ' ' ■ V
Vx• -iV -

Ill/B-

ADDITIONAL READING

c :.c x

01. 1 The Current Health Situation b^in . Chapter. 1
Wanted an Alternative -Nationai^Health -Policy;- •
< .(SourCG 2)

02. 11 The Post Independence -Model1 in Chapter 1
The Historical Background?' "(Source■•■■■'4)
..

t

...

.......

;

....

03/’The Present Situation w Chap ter--.3.4 Source- 4)

.........................................cv-: -.'

04. -Many interesting tables in'different chapters
. in Dr. Banerji1 s book, u (Source 6)
■.7<V

-L;.

t

L .

05. The development of Health ;Services in .India.
including health of children?, women, ^adults/:.7
/nutrition. Health Education and Family Planning,
Page 125-235. (Source 8)
‘
III/C-

SCME QUESTIONS AND TASKS
01. From all these source prepare a statistical profile
of the state in which-you are working.
02. Compare your state's situation with the other
states. What does this exercise teach you.

03# Visit the nearest government primary health centre
and or the District Health O.fficer and find out the
latest statistics for your area/region. Reflect on
these in light of some of the issues raised in the
paper.
04. Send these region/district/state profile prepared
by you to other forum members and resource groups
to initiate a reflection on diversity of needs and
local situation.
• .

IV

REFLECTION - TV /A
COMMUNITY HEALTH IN INDIA

1

RECOGNISING THE NEW PARADIGM

?^nCe
mid sixties there has been a growing disenchantment with
the models of development including health care services, which
■
^yitically, from Western industrialised
-nations. .This stemmed from the growing field experience of the
-inadequacies of. these models to meet the needs of the large
majority.of our people and a growing realisation that "development"
is a socio economic-political-cultural process; which must evolve
its own local solutions. These solutions must involve, a critical
ownrar^L^ at<ISbn01?giC31 Packa9es and their adaptation to fit our
own, rather different social realities.
' ' - .

This disenchantment took many forms including the evolution of much
and imaginative writing, innovative field projects,
ideologically based people's movements and protests. ~Besides
ques loning and challenging the assumptions and values of borrowed
fnd rnethods^ there was also a re-examination and reappraisal
welthe experience and thrusts of the post-independence period as
OWn cultural traditions. This quest for .new values,
attitudes, new processes of social change has pervaded all
aspects of development in India and Health care is no exception.
Since.the early seventies a large number of"initiatives and projects
have been established outside the Government system by individuals
and <groups
-keen to adapt health care approaches to our social
realities and this--- > response has grown. Broadly classified as
voluntary
organisations
c NGO
" s, these initiatives were predominantly
- ■
-■
---- ; or
rural to begin with but in
z
—1 recent
years the focus on tribal regions
and urban slum communities has grown. Starting^with .illness care,
most of them moved on to a whole range of activrties and -proarammes
in health and development.
devedoPment, described later. Initially they develcped
independent of each other but, over the years- some networking and^
Pr°9ranin’es emerged inspiring similar‘attempts elsewhere.
As the phenomena evolved community development projects and
®ducation experiments also began: to add dimensions of
J®
* .ah
approaches.
m more recent years further-networking
to share ideas and experiences, .evolve .some common perspectives and
SOrT,e collective action on broader health issues, has taken

thd late 1970s_I believe there were two distinct schools of
thought: on Community Health (refer Source 3)

* The first school of thought hhder-sfood. the . real cause of ill
i.aS 5ei”g roote^ in,the present economic-political system.
It believed chat nothing can-Wdone-.o^ should be\done -unless
the present economic-political system could be changed
This
generated■an:inactive cynicism about'the health of the people.
to this1|chooiaCtlV1StS °f thS left parties Particularly belonged
*

°f thouPht believed that the panacea for all
health.problems had been fountain the 'alternative approach*
u ilizing non-professionals and appropriate technology and
seme micro-lqvel management innovation.i Village Health Workers
and appropriate low cost technology* was felt to be the answer.
This generated an ill founded-euphoria. . The group evolving under
the amorphous^title of voluntary agencies (volags, NGO's)'
belonged to this school.
k
-■j.-rt
■
. I-'
..IV-2

IV

* While the first school did not understand the 'social* meanino
or potential of health the second school did not locate their-'
action m the context of social change. Much more energy was
spent attacking..each other than jointly countering the medical
model of healtn.

In- the latel970's - some integration began to take place through
greater and deeper unaerstanding and the more integrated concept
of'Commumty health emerged as an essentially multidimensionar
process
including socio-political, socio-culturaltechnological
C°mP°nents <See Source 10) . This generated a shift
andl?g °f health frorn its medical technologised
as an em
" Wlth health being seen more and more
an empowering/enabling process rather than a provision of a
package of services.
etworkmg among individuals and groups around issues of health care
began in the early seventies, The medico-friend circle - a pioneering example among these, was a loose-knit network, (of all those
who shared a common conviction and
-^-3 understanding that the present
health services and medical, education
---- ---i system was lopsided in the.
interest of the privileged few <_and must change to serve the
interest- of the large majority -• the poor people of India) that
began in 1974. It saw itself as a thought current upholding human
values and certain new attitudes in health care and 1U
L
medical
education
(see box) and 'offered,a forum for debate and dialooueLto share
experiences and experiments' and 'for taking up issues of common
concern for action ’ .
------ ;-- ------- ---- —
The medico-friend circle —
works towards a pattern of medical care adequately geared
to the predominant rural character of our country.:'
works towards a medical curriculum-, and- training tailored
to the needs of the vast majority of the people in our
country. ...
<

wants to develop methods of medical f ’ ‘
intervention strictly
guided.by the needs of our people and not by.cpmmercial
interests.

stands for popularisation and demystification•of medical
science.
•. •
believes in^a democratically functioning health team and
democratic decentralization- of responsibilities .

^resfe? the primary role pf preventive and-social measures
to solve health problems on? a social, jevel ;and the impor
tance of planning these with'active, participation of the
.community..
wgr*3 towards a kind of medical practice built upon human
values/, concern for .human needs,- equality and against
negative,^unhealthy cultural values and attitudes in society e. g. glorification'of-money and: power, division of
labour intqf manual and intellectual,. domination of men:

..9yer\Vo!°.^P/r-yr^ftj.pyer: rur^l,;; fpreign':‘over Indian.
their proper, place in the modern;^syq|em3of medicalfcare. —•!
:
niedj-9P"“fFiend circle ^ perspective and activities. 1984J

IV - 3
while^the medico-friend-circle-represents a network of individuals
Lne Aix-xndia'Crug . Acuaon Network which emerged in the early eighties
is another pioneering example of networking around a common health
policy issue.
Keen no promote a rational drug policy and more
racional.prescribing practices' in the Indian situation, this
network includes a large number cf health groups and associations,
consumer groups, social activists, trade unions, universitv deoartments ano nospital associations.
This is again a significant ~
since the wealth for All study group had warned in its
5 P°h
eternal viqixence was required to ensure that the
healu. care system does not get medicalised, that the dnr-t-nr~
dOeS nOt exploiT: ths people and that the abundance
.d^gs. Qoeo not beco:..e a vested interest in ill-health1,
—

emerged
7’ie1,PwOteS science movements in Maharashtra and Kerala states
(.Lok Vidnyan Sanghatana and Kerala Sastra Sahitya Parishad) are
°f sclence movements that are beginning to address
1S.SU!S
their campaigns.
The LOCOST experiment in low
cost, quality tested supplies of drugs to voluntary health organi
sations ano small hospitals.in Gujarat is another, more focusled
ut.relevant example.
The inclusion of wider ’health policy’ and
social issues on the agenda- of junior-doctor movements, the-emerleveT dm^hArWC1?i1St Health Collective, the regional or state
level drug-action forums are'more examples.
The establishment of
d®AAS^n Co^unity Health Action network, encompassing much of
A Tk.
ancther example of commitment to similar concerns in
inaindirrisanar-Z¥mf°liSeS>.theafaCt that thiS trend/ being described
in India, is part of a much wider regional trend.
The Asian Community Health Action Network views health as
the physical, mental, social, spiritual, economic and
political wholeness of the individual and the community...

.health Probl?ras-.and-priorities should be
viewed■ in
—• terms
3. : which the community sees them and that
the oommuhity should be actively finvolved in the planning,
implementation, monitoring and evaluation of healthi care-programmes .. .

It seeks to spread a philosophy of community based health
care that envisages a P-c'ocess of self-reliant J^oman
development for the oppressed poor in Asian communities
which will result in; genuine? social change."
An introductory pamphlet of Asian Community
Health Action Network, 1982.
4

heading various aspects of a ‘health for and by the people’
.oIV-4

approach through informal workshops and training oroorammes.
II

What is our new vision of health care?
‘Community Health*. TWe
’ begin with the Community. Our
goal is a healthy community*» We believe in health by
the people.o..

II

’We promote social justice in the provision and distri
bution of health care....

We encourage people to demand health services as a
human right....
Our old health services have been built to favour the
educated, the privileged and the powerful....

We wish all goods and services to be more equally shared ■
with the whole community...„
We assist in making community health a reality for all
I
the people of India, with priority for the less privi
leged millions, with their involvement and participation
through the voluntary health sector."

— Introductory pamphlet
Voluntary Health Association of India.
In the early eighties two other formal coordinating agencies of
hospitals and dispensaries under ’church* sponsorship, the Catholic
Hospital Association of India (around 2000 member hospitals and
dispensaries sponsored by the Catholic Church) and the Christian
Medical Association of India (around 300 protestant institutions
and about 5000 individuals associated with these institutions'
have both begun to reflect this changing trend in policies and
programme directions.
(See boxes). Their policy statements
illustrate their awareness of our ’health care’ realities and
their attempts to respond to these needs through a re—orientation
of their.earlier preoccupations.

"Health is the total well being of individuals, families
and communities as a whole and not merely the’ absence
of sickness. This demands an environment in which thebasic needs are fulfilled, social well-being is ensured
and'psychological as well as spiritual needs are met...

r

The concept of Community Health .. should be understood
as a process of enabling people to exercise collectively
their responsibilities to maintain their health and to
demand health as their right. Thus it is beyond mere
distribution of medicines, prevention of sickness and
income generating programmes.

— Policy statement of Catholic Hospital?
Association of India, 1983..
.1
..IV-5
-

IV

5

-

I

”CMAI emphasises its commitment to Community Health - an
approach that takes into consideration the needs and
problems of the community and begins with a strong
community based primary health care system. Community
Health Care starts with people - the community and is a
process that recognises their right to health care. It
enables or empowers them, to work together to promote
their own health and to demand appropriate health care
services. It encourages people to take responsibilities
for their own health and to influence decisions that
affect their future. It expects health care services
to be relevant, low cost, effective and acceptable to
the people.”
- Policy Statement, 1986; Christian Medical
Association of Indiao

and
A very recent addition to this trend/analysis, though more compre
hensive and scholarly, is the rather voluminous ’Epidemiological,
socio cultural and political analysis’ of the health care situation
in India (Banerji, 1986).

This attempts to formulate the postulates of a new theory, a new
framework within which the ’evolving health care’ ferment could
be placed (refer box).
"Health service development is thus
a) a soci^-cultural process;
b) a political process; and
c) -a technological and managerial process with an
epidemiological and sociological perspective.

There is often a lag between socio-cultur'al aspirations
of the people and their articulation by the political
leadership; the lag is much more between aspirations of
the political leadership and the community health physi
cians who have the responsibility for building the needed
edifice of the health services. The task is to narrow,
if not totally eliminate, lags that may exist within the
three tiers.
Formation of a critical mass of community health physici
ans and other members of the team which can take full
advantage of the scope, offered by the base (i.e.z .the
complex of ecological, epidemiological, cultural, social,
political and economic factors) are needed and require.
a new approach to education of community health physici
ans and other members of the team.”

D. Banerji (1986)
The concept of ’Community Health1 in India must be understood as an
evolving perspective that has diverse interpretations and varied
formulations as the above sources exemplify but there is also an
evolving common thread between these newer analysis, exhortations
and actions.
(adapted from Source 10)
IV/B-

IV/C-

ADDITIONAL RBADTrX;
SQ^S QUESTIONS AND TASKS

Refer end of REFLECTION VX

Refer end of REFLECTION V
,.TV-6

iv-

IV

6

VAJLUES FROM OUR TRADTTTON
For the Alternative Paradigm

There are five jmajor contributions which
our traditions can make to
the development of values
---- j which underline the alternative model of
health care :

of staaes in i
Y
°Ur traditio^ with its ashram concept
life and de tl b
prepare an individual better to accept*
macha^A)
i
! • gr°YL_yp-as-a disciplined -younc man (Brahto
hit h^S 11Fe fully m adulthood (Grihastha) ; adjusts
apa and begins to withdraw from active live (Vana-rastha)•
Y be?Omes totally uninvolved and gets ready
'
sucn outlook becomes, the
hez-lh among the people, because it
will inculcate the right attitudes to pain,
to death.
H
', to growing old, and

Lts t”"—

2> a”p°ro“hv^u?n:

civilization of the industrial^
make health an individual
responsibility_and root it in simplicity and self-discipline,
hc concept of health in the industrial
civilization is that of a commodity. This model has created its
own problems even in the affluent
17“-- - countries and health is becoming
a costlier and rarer commodity all the time
tire. For developing
countries like ours, this model car only be a disaster. a return
to our own tradition in‘this regard is tne only road to good health.
5) In our tradition, healbn
health services
services are essentially an individual
healc°mnlunity responsibility; each community organised its own
Xe StterV1O,e:
th/sta?e had „o han“i„
for h2nt£\j •
borrowed the concept of State support

responlibilitJ'hartt1

i.9 vengeance-

The sense of individual

responsibility has thus begun to be eroded; and we are not

it aione9

a^^SaSra^iS^r^a1?'1

su^ori?

"itb aiscn„lnati„g but suSSSiS^state

4) Yoga can be a powerful’ instrument
■
for physical <and mental health.
It needs to be popularized throughi the educational
and health
systems.
5) Our tradition places a strong emphasis
on simple but effective
things such as naturopathy, the use
of simple medicines, the
practice of growing herbs needed in day-to-day illnesses in
backyards or other places in cevery locality; games and sports
which require little equipmentI or space; and so on. These
valuable ideas should inot' ’be allowed to die out in preference
to the costly life-styles with which
rhHi
"
—
a profit-motivated capitalist
civilization tries
am
---- r to
—> encourage consumer's
consumerism.
(Source s Health For All - An Alternative Strategy, ICSSR and
ICMR, pages 96 and 97)
’=

-

REFLECTION-V

V

1

This COMmrETY HEALTH APPRGACF

In an informal study-reflection
•'
process
the years 1982-86 we discovered that this v/e initiated in India over
term means different
things to different people and there
--- j are a 'very large range of
ideas and dimensions that are included by health
.1 care action
initiators
when they
,, .
-r use this term to describe their action or
Our objective was not to build a single, well
defined, definition acceptable to all concerned but to probe the
depths or the definition and identify the
richness and diversity
P°ss:Lbilities- What we discovered, was a range of dimensions
ar beyond what we generally understand or describe
—? as "primary
healt.t care- or "community medicine". r
We outline these possibilities to.help evolve the component axioms of
a new approach encompassing its philosophical assumptions.
goals and methodologieso
Building on the CHAI vision of "(enabling
' - ’
people, to exercise
collectively their responsibility to their own health and to
demand health as their right, we evolved a
more detailed-, formulation
of the approach.

These were

T_he Community Health" Approach
involves the increasing of the individual
ajatonomy over health
f family and community
and
over the organisations, the means, the copportunities,
-the
knowledge and the supportive structures that
—
make
health
possible.
The -Community Health'1 Approach
includes an r
' ’
• to
•
__ rate health with <’
attempt
integ
development
activities
including
educationV
•
,
------ agricultural extension
— — --—
ano
income generation ---------programmes;
an caYfrnpt

to orient existing medical pr
programmes towards
preventivez, promotive and rehabilitative
.a actions;
a search for and experimentation with low-cost, effective,
appropriate technology in health care/ .'health communications
and recording systems;

a recognition and involvement of local
indigenous
local,, indigen
ous, health
health
resources like traditional birth attendants (dais)7
r traditional
.^^-"eaiclne practitioners, non-aliopathleJ
medicine, herbal medicines and time-tested home remedies;
a training and involvement of vi11age-based health .workers *

a initiation of greater community organisation through farmers.
youth and women's clubs;
.-. .an increasing involvement and participation of the communitv
: through formal and informal organisations and health committees
in decision making for health action including plaS^SKllno
orgonismg and evaluation of health actions;
^-2

V

2

a quest for generating greater coirrnunity support in health action
through cooperatives, health insurance and other schemes as well
as tapping locally available labour, human skills and material
resources;
an organisation of informal and non-formal, demystifying and
conscientizing programmes of education for health.

The Community Health approach
is essentially a democratic, decentralised, participatory, people
building and people empowering activity
and
recognises that this new value system must pervade the interaction
between the community and the “health action" initiators as well
as within the team of "health action" initiators themselves.

To enhance the "community health" approach it is therefore nece
ssary for "health action" initiating teams to evolve a greater
democratic, non-heirarchical, participatory, team building and
'' team empowering" ethos’ in the ir~own relationships as Indiv i du a1s
and members of a team.
The Community Health Approach
recognises that in the present inequitous and stratified social
system there is no ucommunity” in the real sense of the word and
hence community health action will invariably^ mean, the increasing
organisation, involvement and participation of the large sections
of the community, who do not participate adequately in decision
making at present i.e., the poor, the underprivileged, the margi
nalised.
Such attempts will invariably be opposed by "status quo" forces
and all those who draw greater advantage from the present situation.
A "community health approach"' will recognise the presence of these
conflicts of interests and the inevitable social tensions conse
quent to community health action but being committed to a
"community empowering" process it will support actions and
struggles as they go beyond "health" issues.

The Community Health Approach
recognises that-, the large majority, the poor and the disadvantaged
are not themselves "one community" even though they are linked
by their poverty and social situation, since they have interna
lised various social, cultural, religious and political diffe
rences that divide society at large.
It therefore accepts-that\in terms of process, efforts-to imbibe
the concept and the spirit of community, to improve group dynamics
and group inter-relationships are preliminary to evolving commu
nity actions of any sort. Hence through all its component
programmes and activities, the community building process will be
promoted and enhanced.
The Community Health Approach
recognises that the present over-medicalised health care system
is characterised by certain, features viz., heirarchical team
functioning and non-participatory decision making;
water-tight division of responsibilities with over-emphasis.on
the role of doctors;
V-3

V

3

quest for specialization and compartmentalization of professional
activities;

a preoccupation with the understanding of human illness in terms
of an organ-centredness and at intracellular, molecular levels,
forgetting the whole "being" in the proces'sr
a clear distinction between "providers” of the service and the
"users” of the service;

an overemphasis of the "physical" dimension of health and a
disregard for the psychological, social, cultural, spiritual.
ecological and political dimensions;

over-professionalization, which controls the spread of technical
knowledge and skills to members of the health team and to the
people at large-;
“providing” orientation of services and action., rather than the
“enabling” orientation;
an over-emphasis on drugs and technology leading to a complete
dis-regard for non-drug therapy and skills;
a preoccupation with the -allopathic system of medicine ignoring
the existence or utilization of the culture and practices of the
other systems of medicine and healing. .

Community health action initiators even though ^they most often
emerge from these medicalised environments, do not see themselves
as just -extensions of this medicalised system. They constantly
confront these issues in their approach and actions and try to
evolve new attitudes, new skills and new approaches that are
people and community oriented and place medicine, professional
skills and technology in their right and limited context.

The Community Heal th Approach
evolves action from.the community, outwards, and upwards confronting
the various components of the existing superstructure of health
services which includes
the primary health centres, dispensaries, hospitals, teaching
and research institutions the medical, nursing, paramedical
and public health teams and professional training centres and
associations;

the health programmes and health institutions under government
or non-government voluntary agency auspices.

It confronts the superstructure to become
a) more "people” orientated
is sensitive to the realities of the life of the large
majority of people - the poor and the underprivileged.

b) more “community" oriented
i.e., understanding health in the context of the problems of
the whole community and all its sections and not just as
individual problems.
. . V-4

V

4 • ,

c) more " socio-epidemiologically" oriented

i.e., recognising the biological, socio-economic, psycholo
gical, cultural, spiritual, political and ecological
dimensions of health.
d) more "democratic”
i.e.z participatory in its growth, planning and decision
making processes.
e) more 11 accountable"
i.e., increasing the subservience of medicine, technology,
structures and professional actions, to the needs and hopes
of the people, the patients, the consumers, the "benefi
ciaries" and the community which they seek to serve.

The Community Health approach
is therefore not just a speciality, a new professional
discipline, a new "technology fix" or a new package of actions.

It is predominantly a new vision of "health" and "health care"
a new attitude of mind, a new "value orientation" in health
action and a new perspective for the future linked to a new
vision of society.
It must therefore pervade existing health care systems, insti
tutions , research efforts, training programmes, professional
ethics and health planning exercises.
Community Health action
is closely interwined with efforts to build an alternative
socio-political-economic-cultural system in which health can
become a reality for all people.

The "community health approach"
therefore recognises that the components of actions are means
and not ends and will therefore be flexible enough to reorient
reprioritise, disband or change towards more relevant actions
and directions as they evolve in* the interactions at the
community level.

(Source : Community Health s The search for an alternative
process s

Report of a Study reflection action experiment
by CHC Bangalore, Jan. 84 - June 86.)
REFLECTIONS IV & V

SOME QUESTIONS AND TASKS

01. Community Health in India ,i_3 an evolving concept and all the
above sources explain their understanding of it. Reflect on
these and evolve a working definition for your own group action.
02. Start with the statement on Community Health in the earlier
minute of the CH Forum and build on it adding points and
issues from the CHC reflections and other sources mentioned.
03. Identify through reflections on Ti
own field experiences,
your
the factors that promote community health and those that are
obstacles to it. Identify and evolve the components through
practical action-reflection.

VI o 1

REFLECTION. - VI/A
IS

'COMMUNITY HEALTH*

GROVHNG AS A MOVEMENT IN INDIA

Arc there signs of suer, e movement evolving in the country? The
tren^ is not conscious bur. implicit in many developments in recent
years which art possmy creating the righr social milieu for such
an evolution. The delay has been due uo^a
double failure - a
no
failure of community nealuh projects to
to see themselves
_______ . _ _ _as
_ part
___ __of
largersocio-political change process in society and the failure
of political
activists,
~~ '
------ - - i--- organisations and people's movement to
recognise the value and true meaning of health. Yet probably a
beginning is being made.
I

—> V*

Z—* z—

_

“1

•

I

•

“»

The pre-requisites for the developmen-c of a Community Health
movement are many:

i) Firstly there is a need for a clearer understanding among all
concerned about Health as a ‘social justice' and 'civic right'
issue.

ii) secondly more and more groups should recognise that community
Health action need not always be a providing/distributing
process but can aiso be a enablinc/empowering process.
i ii)Finally this understending and dialogue must be actively
initiated at the grass roots level with the people at the
community level recognising the significance of collective
health
action. in their daily life struggles.
Health action,
Today there eare positive
’ ' ’
trends supporting this possibility and
negative trends which will
stall such a development. ‘ What are
-------these?

Positive trends

Firstly there is a growing army of villagers and lay 'workers who
have been trained as nealth workers both by governmental and nongovernmental
voluntary. .
. - agencies,
- Whatever the quality or orientation
in the overall, a phenomenal process of de-mystiof training, taken m
ncauion of health problems has already been initiated.
Secondly there is a growing number of individuals — development or
political activists - who are beginning to recognise the non-medical
dimensions of health and are including it in their action programme,
Thirdly there is a <growing body of hearth knowledge which has become
pare of the syllabi of adult education
and
non-formal education
education in
in
- — — — —■ —313
c>. non-formal
the country. Science education experiments have also introduced
health aspects into the innovative curricula developed by them.
Fourthly people-oriented science movements like the Kerala Sastra
Eahitya Parishad, the Lok Vigyan Sanghatana (Maharashtra) and many
Ocher smaller forums are actively taking uu health issues in their
awareness building programmes, in their Jathas and their exhibitions.

ifthly there are a series of evolving people's movements around
1S^UeSz environmental issues, other social, issues which have
health of people' as an intrinsic component though not always well
recognised. Sixthly there is an evolving interest in the trade
union movement, the women's movement and other mass movements about
e importance of health issues and the need to include them as
components of the wider struggles.. Seventhly, even within‘the
• 57T

?

VI. 2

me real and nursing professional and institutional networks there
2~OWing sensitivity to the needs of linking health activities
with tne broaoer issues of social change and not to see them as a
narrow technical or professional enterprise.
Finally even expert documents on health in the country are beoinninq
to echo tms challenge. The ICSSR-ICMR (1981S94) report clearly
suatt-s that the conditions essential for success of the ’health for
all goal is "to reduce poverty,; inequality and to spread educationy^nisc tne poor and the underprivileged groups so that they are
able to assert themselves;; to^ -move away from
2
the counter-productive,
consumerist western model of
health
_f l.ZLlLh care and to replace it by the
alternative based in the community"o
Negative factors

However, there is no cause
rfor unbounded optimism. The trends
favouring the evolution of the community health movement. are
definitely there but the trends opposing and most often :
the gains made are equally there and probably stronger. neutralising

^^^lisation, professionalisation, and the consumerist orientation
of heaith care is increasing and is symptomatic of the overall
situation m the country. Many so-called health projects are
mushrooming all over the place goaded by foreign funding agencies
vying with e.ach other to invest in the alternative; or by industrial
houses as part of the rural development oriented income tax benefitsor by professionals interested in involvement for prestige, status
and power and for many other objectives counter to the spirit of
community health. This band wagon nature of the growth of
alternative health care’ out of context of social analysis
understanding of peoples needs and insensitive to social chance
process is going to be rather counter-productive.
A lack of adequate networking ramong the committed community health
catalysts to share perspectives,
~, support each other, evolve a
common understanding of a highly complex situation is a serious
lacuna.
Finally the ability of the existing exploitative socio-political
socio-political
system, the bureaucracy, the health planners end the decision
makers to internalise the ideas and experiments in jargon and
rhetoric but defeating the spirit of the process is phenomenal-and
rather confusing.
.
To sum up then in the early 1990's - community health movement is
far from becoming a reality. There is a potential for such an
evolution but there is much more ground work to be done. The first
is to recognise partners in the movement and establish linkages and
interactionsthat go beyond ideological debates, individual eoos
and mstitutional/project frameworks. The second is to have a
deeper study reflection on the nature of the paradigm shift that
has to actively take place in the understanding of community health
andcommunity health action -from a 'medical model' to a 'dynamic
social model'. Thirdly is to support existing struggles and or
initiate new ones all over the country, around issues related to
health - be it towards a :rational
’ ‘
’
drug policy;
towards supports to
peoples health culture and traditions; against corruption., medical

•-VI.3

VI. 3
malpraxis and unethical practices or towards communities demanding
components of primary health care as their right.
It is by this three pronged strategy that a movement can
c- be
generated, and all committed Community Health activists
_j have to
seriously
face up to this challenge in the years ahead.

REFLECTZOKS IV TO VI

ADDITIONAL READING
01. The Alternative Model : General Principles and Organisation,
Chapter 6 & 7 (Source 2)

02. Medico friend circle
Page 219 (Source 3)

Which Way to Go?

a debate

03. Possibilities of Relevant Action - Chapter 6 (Source

04. The New Vision of CHAI — Appendix IL
05. Some Alternative Programmes

Chapter 27

06. Epilogue Postulates of a Theory

4)

(Source 4)
(Source 6)

Chapter 30 (Source 6)

07. Community Health, the
'
quest for an alternative.
Chapter 4.
(Source 7)

08. Widening the Scope of health work. Chapter 5

09. Health and Power to the People

(Source 8)

(Source 9)

SOME QUESTIONS AND TASKS (F0R VI)

01. Identify in your region of the country all the individual
groups/projects/processes who are potential partners in a
Community Health movement of the future. Visit them. Interact
with them. Get to know their plans and perspectives. Evolve
linkages and some common action for the area however limited.
02. Identify the; problems that come in the way of such a 'linking
process'. Are these problems ideological, psychological,
sociological or any other issue-related. Discuss in your
regional and national forum meetings how to get beyond them.

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