TOWARDS A PARADIGM SHIFT A Viewpoint from COMMUNITY HEALTH CELL. Bangalore

Item

Title
TOWARDS A PARADIGM SHIFT A Viewpoint from COMMUNITY
HEALTH CELL. Bangalore
extracted text
SOURCE:

LINK Newsletter - Vol.7, No.2, August-September 1988

TOWARDS A PARADIGM
SHIFT
— A Viewpoint from COMMUNITY
HEALTH CELL. Bangalore
Dr. Run Nuravan
(These reflections <’n ’hr thrmc
of the worksht’p draw
ipon a
study-reflectlon-iction experi­
ment with a large numocr of
community health action initia­
tors in India, particularly
in
the state of Karnataka. since
1984.
Its
perspectives are
rooted in "grassroots" involve­
ment in India, which may or may
not always be relevant to the
situation in other countries of
Asia or other parts of
the
world.
However,
its "inspira­
tion" is derived from a growing
an
conviction that there is
urgent need for a paradigm shift
from • med ic ine as a "providing
as
an
process
tr
_
Heal
__ th
Its basic
"enabling process",
plea is that the real issue
facing us today is not Primary
versus Secondary/Tertiary Health
Care; Vertical versus Horizontal
Programs; Selective versus Comp­
rehensive Health Care;
but
Medical model versus a Socia?
model of Health, be it indivi-

lua1.
commonity
not 1ona I .)

of

inter-

INTRODUCTION
’’Primary Health Care is essent ia 1 health care made universal ly accessible to individuals
and acceptable to them,
through
their full participation and at
a cost the community and country
can afford."
- Alma Ata Declaration,

1978

Primary
Health Care
(PHC)
emerged in the Alma Ata Declara­
tion as an alternative view of
health and health care, which
included locating health in the
wider context of socio-economic
development
and
exploring
actions beyond orthodox medical
care, that would be pre-requi­
sites and/or supportive of the
health of communities. The four
principles
stressed
in
the
Declaration were:

_____ j______________

I

i
1)
2)
3)
4)

Equitable distribution
Community participation
Multisectoral approach
Appropriate technology

Apart from a scries of techno­
logical and managerial innova­
tions that were considered in
the view of Health Action that
emerged at Alma Ata, probably
the most significant development
was
the
recognition
of
a
"social-process"
dimension in
health care including community
organisation, community partici­
pation,
and
a move towards
equity.
Health service provi­
ders would be willing now to
appreciate social stratification
in society, conflicts of inte­
rests among different strata and
to explore conflict management.
These
were
not
explicitly
delineated but were inherent to
the issues raised in the Decla­
ration.
An equally important
fact wan that these perspectives
emerged
from the
pioneering
experience of a large number of
voluntary
agencies and
some
health ministers
ministerfl committed to
the development of a more just
and
equitable
health
care
system.

DISTORTIONS IN I’HC:
In recent years, however,
however, we
have been gradually witnessing,
the world over, a shift of empbasis
from the compr2hrnnive
community oriented exhortat ions
of Alma Ata, to a narrowing down
of
the scope and focus
of
primary health care.
Some of
the distinct trends noticed are:

a)
Primary health care is
becoming a top-down, communityimposed program not a bottom-up
community derived program that
it was meant to be.
b)
Primary health care is
becoming a selective
se
package of
services
not a comprehensive
program
of
locally
evolved
activities.

c)
Primary health care is
getting over-technologised.overmanaged and over-professionalised at the cost of the social
process
dimension
including
community
empowerment
and
demystification.
d)
Primary health care is
being protpoted as a monotonously
similar "model" rather than as a
locally created process appre­
ciative of local diversity.

e)
Primary health care is
being "socially marketed"
by
Health Ministries, coerced by
international
health
and
resource
agencies
and
not
socially promoted or proposed by
community
involvement
a
in
participatory management.

Primary health care conf)
cepts have a growing re levance
for
secondary
and
tertiary
levels of health care as well,
However, they are still being
strictly focussed on
primary
levels.
g)
Primary health care i.a
getting medicalised, and industrially
produced al ternat ives
that can be sold or distributed
are being promoted, at the cost
of educational, organisat ionaI ,
awareness-building and empowering approaches.

h)
Primary health care conceptw
and
principles
(even
words) are being coopted by the
t’xiflting medical system which
han a veacrd interest in illhealth.
The deeper meanings of
the principles are lost in this
procesfl.

i)
Primary health care
car<? has
been hi jacked by teaching
coaching and
research institutions and inter­
national NCOs in-thc drveloprd
world who arc now promoting "PHC
courses" and "PHC research" as
stepping stones co
to a lucrative
career in International Public
Health and not as a cha 1 lenging
commitment towards a movement
for social justice in health
This distortion and pro­
care.
motion of myopia also stems from
the fact that most staff of such
institutions have little or only
peripheral, remote and secondhand
experience of community
based health care in the develo­
ping-world situation.
In addi­
tion, their own personal expe­
rience of the* high-technology,
institutionalised and professio­
nally m.lanaged health services of
their own countries is of little
relevance to the task.
j) .Primary health care has
not continued to learn from the
creative experience of voluntary
agencies and health ministries
committedI to social justice! in
health
<
care,
which was its
initial inspiration.
It now
draws sustenance more and imore
from top-down, "management: by
oriented
health
objectives "
projects thrust
on
research

health ministries of developing
countries by international NCOs.
These stress targets, quanti­
fiable indicators and measurable
objectives, overlooking process
indicators which may be qualita­
tive,
and all the
emerging
participatory management, trai­
ning and research skills.
k)
Ln short. Primary Health
Care in 1988 is fast becoming a
caricature of its original philosophy, a captive of an over­
medical ised health care system,
a rhetorical slogan coopted by
an inequitous social and economic order, both at the national
and international levels.

For.ty years after the cotnprehensive definition of health by
WHO and ten years after Alma
Ata, is our understanding; of
ive or
health care - compr
otherwise - still where it was
before?

COMMUNITY HEALTH
Is there an Emerging
Alternative?
I.
Cownunity oriented health
action haw been an important
dimension of Indian health plan­
ning ninee independence.
The
Primary Health Centre concept,
the national programs, the con­
cept of the multipurpose health
worker and community health wor­
all were in principle
kers,
and
geared to the planners*
professionaIs * percephealth
need s.
of
community
t ions
However, all the tinkering and
attempted reforms were hampered
by the fact that we had uncriti:ally
adopted a
technology­
intensive, institutional model
of
health care from western
industrialised nations, that was
proving to be more and more
inadequate to meet the social
realities
of- a predominantly
rural and agricultural popula­
tion.
By 1975, the group on
Medical Education and Support
Manpower, a high-powered commit­
tee set up by the Government of
India was constrained to record:
"It is desirable that we take
a
conscious
and
deliberate
decision to abandon this model
and strive to create instead a
viable and economic alternative
suited to our conditions, needs
and aspirations"

- Shrivastava Report 1975
2.

In the meanwhile since the

23

■

X'

late sixties, a large number of
initiatives and projects outside
the Government system were esta­
blished
by
individuals
and
groups keen to adapt health care
to our social realities. Broadly
classified as voluntary agen­
cies, (now NGOs
NGOs),
), all of them
started with illness care, but
moved on to a whole range of
activities in health and develo­
pment.
Soon, ongoing community
development projects and commu­
nity education experiments also
began to add health dimensions
to their actions. As the number
increased, networking and trai­
ning efforts were also
ini­
tiated. Soon health issues began
to feature on the agenda of
people-based movements - be they
environmental or around women's,
dalit's or trade union issues.
This upsurge was a spontaneous
development and not an organised
pre-planned movement.
3.
From 1984, a team of us
have been studying this process
through participatory
reflec­
tions and presently a much more
detailed report is in circula­
tion among health action initia­
tors in India for participatory
and collective comment.
From
these reflections, liowwer, we
have begun t«> ♦ivoIvh a svrius <>t
principle* and issues th.it arc
emerging from the successes and
failures, strength* and weaknvssen
of dll these
community
health action initiators, and we
list some of them out here:

The broad definition that
4».
has emerged of community heal th
itself, initially, is
process of enabling people
to exercise collectively their
to their
responsibility
own
health and to demand health as
their right, and involves the
increasing of the individual,
family and community autonomy
over health and over organisa­
tions,
means,
opportunities,
knowledge, skills and supportive
structures
that make
health
possible**

5. The next set of issues are
components of community health
action wh'ich are very similar to
those outlined in the Alma Ata
declaration.
These
being
attempts to:
i

Integrate Health with develop*
me nt programs,
Integrate curative with preve-

I
■!

24

Experiment with low-cost ,ef fective, appropriate technology,

v) Recognising that community
health needs community-building
efforts through group work, pro­
moting cooperative efforts and
celebrating collectively;

indigenous
Involve
local,
health knowledge, resources and
personne1,

vi)
Confronting the super­
structure of medicalised health
delivery system to become

health

more poor people oriented,
more connnunity oriented,
more soc io-epidemiologicaIJy
oriented
more democratic,
more accountable

ntive;
promotive
rehabilitative activities,

Train village-based
workers,

and

Initiate,
support community
organisations like youth clubs,
farmers clubs and mothers clubs,

Increase community participa­
tion in all aspects of health
planning and management,
Generate community support by
mobilising financial,
labour,
skills and manpower resources.

These abov<? dimensions could
broadly be described as technological and managerial innova­
tiona, which, in principle could
also become part of top-down
vertical programs, though they
reach their full potential in
♦*vol ved
community
based and
programs.
Ilov<’vt,r. in our rvt Ivc.inothrr
we discovered
set ui is such and actions
could b<» broadly c lass I-*
tied as "social process dimens ion®'* which w«*re beginning Co
a
be seriously taken up by
programs.
growing
number of
These were:

6.
t ions
whole
which

Organisat ion of noni)
forma I , informal, 'demyst i fying
consclent is ing 'educat ion
and
for health’ programs;

ii)
Initiating a democratic,
decentralised, participatory and
non-hierarchica 1 value-system in
the
interactions within
the
health team and in the health
team-consuunity interactions;
iii) Recognising conflicts of
interests and social tensions in
the existing inequitous society
and initiating action to orga­
nise,involve all those who do
at
not/cannot
participate
present;

iv)
Questioning
overQuest ioning the
medicalised
value system
of
health care and training insti­
tutions and challenging these
within the health tenia',- learning
new health oriented values;

Recognising the cross­
vii)
cultural conflicts inherent . in
transplanting a Western Medical
model on a non-western culture
and hence exploring integration
with other medical cultures and
systems in a spirit of dialogue.

Recognising that comviii)
munity health efforts withi the
above principles and philosophy
cannot be just
a spec iality;
a professional discipline;
a technology fix;
of actions;
a package
,
a project of mvaaurnbl* activi­
ties;
but han to transform itself to
a new vision of health care;
a new v.ilue-orientat ion in
action and learning;
a movement, not a project;
a means, nut an end

Are these
alternat ive?

the

axioms

of an

THE PARADIGM SHIFT
We have suggested a 'paradigm
shift' from a Medical model of
health to a social mode 1 of
health as the basic plea of this
paper. From all the perceptions
that have evolved in the action­
reflections in these past years,
we see this as the crucial and
probably
the key
perceptual
change that has begun to take
place in our own perceptions,
values, definitions, indicators,
methodologies
and
plans
of
action.

In table I we propose a short
list of the differences between
these
two models.

«
7

Recently we received a letter of
concern from David Werner and
his colleagues at the Hesperian
They were distresFoundat ion.
sed at the top-down approach
being used to promote ORT as
They were keen to
part of PHC.
help evolve a more integrated,
decentra 1ised, effective peopleoriented approach to ORT. David
sent a chart comparing the two
strategies to us.
It was a
the
further
indication
of
growing awareness of the two
of
approaches to health care,
the tendency of technology to be
equally people-debilitating as
it can be people-empowering.

TABLEI
PARADIGM SHIFT
HEALTH
Medical Model
Ind ividua1
Patient
Disease
Providing
Drugs & Technology

to
to
to
to
to
to

Predominantly physical &
mental
Professional control over
skills and knowledge
Intracellular research
Patient as beneficiary and
consumer
Mystifying knowledge

to

to
to
to
to

Social Model
Community
Persons/people
Positive living
Enab 1ing/empowering
Knowledge & social
processes
Physical/Mental/Soc ia1
Ecological/Political
Transfer of skills &
knowledge to lay people
Social Research
Patient as participant
in process
Demystifying knowledge
and promoting autonomy

the
same
We
believe
that
d ichotomy/divergence exists in
Approaches to training, manage­
ment and research in emerging
health care.

I
1

TWO STRATEGIES FOR ORT PROGRAMS

AN APPROACH TO
DIALOGUE

Siritfqy of nta I! a UmiTl
Iftler1i0A4i
V."

training, evaluaManagement,
t ion and research approaches 1 n
they
our health care system aa
exist
today reflect moat
often
the dominant. orthodox, me d 1 C a I
Thia medical orirnviewpoint,
their
cation
io built
into
aaaumptions.
incurpret at ion o(
facts,
under it and ing of comm.ini t y rea | 11 im ,
priority 4«»d
methodologies.

4
ic«MAtea
4t p4,t Of
itltC

measure

enabling

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1 •-•orewo 3u4i'’y of

and

Do we
empowerment dimensions,
have an understanding of such
indicators yet?
These will be some of the issues
that are going to emerge in any
discussion thjit seeks to explore
the issue "vertical
interven­
tions vs CBHC".

, .A.^e ma
tMqif or ifriii
• ■f.iTnMli 4440t»4 11) lOCH

/•IQurret.

• •IOC 14 I 'Mritl1*1
■ .|0<l|l mom I I/4< l QA '70U’"9
POHUCU"* 4"0 <»i«oritiei 10
profit It )

To
do justice to the new
ve
community health approach
would have to explore process
indicators which may be qualita­
to

■Ateqrjlrd into <OAQfeArAt1.f ;
u«X tne X-<,.4
IIA 1

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N1IA f«XUl 4*4 IA.«H«WA<
■ >9* prnclvc t 1 , l«4Auf4Ctv’4 4"4
4 11 < r I SwlUni

rf
How justified would we be
orthodox
indicators such
as
mortality and morbidity were the
only ones used as the criteria
CBHC
evaluation
of
for
are
when
we
especia I ly
increasingly recognising it as
a social process at base.

tive,

il *<4

arq.,’

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. . p 4 < » « < I “f <l»* 14 Hl |JlM<0t4
04l«4I
• •*<4A44r4l l»4 f'>r*.l4

in
How justified would wr b**
imposing
thewe approaches
to
study/learn/undi’ratand the new
alternative
‘social model' o I
health car" that
11 emerging
today out of the experience of
numerous community based health
care programs m Asia.

I

nf

1 na Din

Fol 1:1 cal Strategy:
tueoort
uSin? -m.-,;.-,
lirrn;-.A4-n 4*0 fp’.tll’f
r-nner 1
jnc T4t» p*o©i« :<•>.*.!«-<? XI
art. »•■?*»* U0»5'->»n- • ... -

References:
I. The Alma Ata Declaration
2. Cccrnunity Health: The Search

| "■n rooulf y,ccort j j
•.nil
tr0 f co*#' XfOp.e.
"♦•P’nc tn«-» tp see 4W
eu
cepenoent. -o** te
-*• • .-t

for
an
Alternative
Process
(Report of the Study-ReflectionAction Experiment of Cooraunity
Health Cell, Bangalore.

25
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