Comniiiiiily lleallh: The Quest tor an Allernalive

Item

Title: Comniiiiiily lleallh: The Quest tor
an Allernalive
extracted text: I

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DI’VI•I.OPMI NT WITH I’TOPI I’

would soon fuse into ;a-----mass---------movement covering the whole country. Development will only take eflect, when it becomes
--------- » a mass
movement.
After having written at such length about the importance
and the need of a non-formal education approach for critical
awareness budding, the temptation is rather strong to elaborate
upon the process of this awareness building. But fortunately,
this is done very clearly in the various ease studies (hat follow.
The methodology techniques and media they use arc good
models that portray (he blending and assimilation of personal
experience and reflection with orientations from abroad. A lot
of practical lessons and orientations can be derived from a close
study of these experiments.
What is common in all successful programmes is very signifi
cantly expressed in the Pauta Community Development pro
gramme. The group of three who started the work left their
life-long environment and its amenities and went and lived with
the people. I think that basically this is the real need of today
that (hose who arc working to bring about a critical awareness
among our people, should live with them and have a full involve
ment with their lives at the village level. For (his is where the
problems arc, and it is here that we can empathise totally with
(he people. It is this identification that we consider a primary
quality of the development worker. We hesitate to use the word
‘identification’ because it has not got the full meaning of what
we would hketo express. This full meaning is expressed by the
word ‘incarnation!’

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Comniiiiiily lleallh: The Quest tor
an Allernalive
Ravi Narayan

I

The health worker must decide
whether to join the labourer and
peasant in common struggle for
radical social change. Or whether,
in the charitable and therefore “safe”
posture, to stand above them, distributing
the largesse of health services,
“alternative” or otherwise. (Zurbigg 1984: 190)
III health in the ultimate analysis is a direct product of an unjust
socio-political system which results in poverty and inequality of
resources and opportunity. An assault on ill health must, there
fore, inevitably become part of a development and social change
process which seeks solutions for the issues of social injustice;
of which illness or disease is but a symptom. This seldom takes
place in practice, for many reasons, not the least of which is the
confusing of health’ with ‘medicine’ and the emphasis on health
care being a 'providing process’ rather than an ‘enabling process’.
This emphasis has its historical roots in the ‘mcdicalisation’ of
health that we have witnessed over the last many decades. If
health has to mean what the World Health Organisation defined
it, i.c. ‘as a state of complete physical, mental and social well
being and not merely the absence of disease or disability’ then
activities and services with health as their goal must be much

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DEVELOPMENT WITH PEOPLE

more than the prescribing of medicines; much more than the
diagnosis of illness using sophisticated technology in order to
prescribe more medicines. Health activities must include preven
tive, promotivc and rehabilitative activities, health education and
dc-mystification of medicine, popularisation of health producing
activities and attitudes, programmes to strengthen the people's
traditions of self care, attempts to increase the individual’s auton
omy over his own body and finally awareness building and an
organisation of people and communities to get the means, the
opportunities and the supportive structures that make health
possible.

IMcdicalisation of health

What wc sec around us today, however, leaves little doubt that
health has come to be used as synonymous with medicine and
health care as synonymous with doctors, drugs and hospitals.
This attitude is fostered by the established conspiracy between
the medical profession, the pharmaceutical industry and (he
growing medical technology industry which converts‘health’ into
a commodity and promotes, advertises and sells it in the pursuit
of a profit motive. The signs of this growing conspiracy arc seen
by the following trends in our society:
—the phenomenal increase in hospitals and dispensaries;
—the increasing commercialisation of practice and the recent
entry of the corporate sector into what was traditionally
the cottage industry of private practice;
—the unbridled growth of the pharmaceutical industry (wc
produce over 30,000 formulations in this country when the
I lathi Committee recommends that 116 drugs is all that
we need to run our health services).
—the mushrooming of capitation-fccs-taking medical colleges;
—the well established doctor-drug producer axis which
exploits people through the production of an abundance of
drugs;
- the continuing political rhetoric of more doctors, more
hospitals, more medical colleges and more specialists
means more health (an oft-rcpcatcd slogan heard at the

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foundation stone laying ceremonies of our medical insti
tutions and at the inaugural and valedictory functions of
professional medical conferences);
the increasing evidence of excessive and unnecessary labo
ratory investigation and equally unnecessary surgery; and
so on. All this unashamedly in the name of the people’s
health.

All nnti-hcallli value system
/
Through these trends not only does health become mistaken
with medicine but institutions and (cams internalise a value
system which becomes counter-productive to health itself,
luiough has been written on the characteristics of this value
system which include among others a dependency creation, a
compartmcntalisation and an organ-ccntrcdncss, a hierarchical
decision-making, a mystification and professionnlisation, an
encouragement of consumerism iatrogenesis both clinical and
social and ultimately a dehumanisation, all of which arc patently
anti-health. Medicine rather than generating health begins to
generate ill health and the ultimate vicious circle is established
ill health-medicines more ill health—more medicines. No
wonder the ICSSR-ICMR report (1981: 179) warns that

There is always a dangerous turning point at which the over
production of drugs and doctors creates a vested interest in
the continuance or expansion of ill health. It is not generally
recognised that wc arc dangerously close to this explosive
point.
Notwithstanding the establishment of a vast network of in
stitutions (service, educational and research), the reduction in
mortality rates, the increase in life expectancy at birth, the control
of small-pox, cholera, plague and malaria and the gigantic expan
sion of the maternal and child health services especially family
planning (probably our only achievement), the disparities and
weaknesses of our health system arc even greater. The ICSSKIC'MR report (ibid: 81-84) lists these out as:

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DliVliLOPMl NT WITH PEOPLE

—a health care system which has no roots in the culture and
traditions of the people and relies almost exclusively on the
imported western model;
— a service based on a curative approach in urban hospitals,
a bias which has not changed in spite of the establishment
of Primary Health Centres (PHC) and rural dispensaries;
— a service which benefits mainly the upper and middle
classes and fails to reach the bulk of the poor, especially
rural poor;
—a health delivery system devoid of any participatory
element and hence increasing the dependency of the people;
—a service whose costs arc exorbitant;
—the failure to integrate health with overall development;
—little dent made on the massive problems of malnutrition
and environmental sanitation;
—woefully high rates of mortality among women and
children;
—no programme of health education worth the name;
— health itself having a very low priority in the planning
process and getting an investment about half that of edu
cation which itself is given a step-motherly treatment.

All this led the ICMR/ICSSR expert committee (ibid: 84) to
categorically state that
A linear expansion of this model and the consequent pump
ing of more funds into the system will merely add to the
existing waste and make the ultimate solution of our health
problems more difficult. We arc also convinced that mere
tinkering with the system, through well meant but misguided
efforts as better training, better organisation or better ad
ministration, will also not yield satisfactory results. This is
precisely what has been done during the last thirty years; and
the meagre results obtained, is a strong pointer to the futility
and wastefulness of continuing the same policies.

The quest for alternatives
Though this assessment of the situation is slowly becoming
accepted in some of the higher decision and planning levels in

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the country today, the social disparities and the health needs of
the masses have all along challenged and stimulated individuals—
doctors, nurses and others- to search for alternatives which not
only arc more suited to the lives and needs of the large majority
of the people but which arc also more committed to health
promoting activities and attitudes. Starting hiostly from the
early seventies a growing number of health care projects have
developed in the country which may loosely be grouped under
(he title of alternative health care projects or community health
care projects. Most if not all were rural based projects concen
trating on illness care initially, but moving on gradually to activ
ities and programmes much beyond illness care. For most of
the decade, these experiments nearly always developed indepen
dently of each other though in the eighties they have inspired
similar attempts elsewhere. There has also been a growing net
working through which perspectives gained, lessons learnt and
new ideas evolved arc shared. The focus of study of each of
these has often been to see them as innovative models, created
by highly motivated charismatic ‘health’ leaders and consisting
of good ideas worthy of emulation. On the contrary, it would
be more realistic to see them as a generic response of socially
sensitive individuals reacting creatively to local realities. The
‘project’ mentality has also often overshadowed the recognition
of ‘process’ in these efforts.

The component of ‘alternatives’

Much has been written on many of them and hence giving a
detailed list of sources would suffice (see 1CMR 1976; Naik 1977;
FCMR-ICSSR 1981). What is more important, however, is to
identify the broad components of health care emerging in these
alternatives.

/. An at tempt to integrate health with development
activities

Recognising ill health as the product of poor nutrition, poor

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DF.VELOPMLNT WITH PEOPLE

income, poor housing and poor environment, many health proj
ects have gradually got involved with agricultural extension
programmes, water supply and irrigation programmes, housing
and sanitation schemes, income generation schemes and basic
education including non-formal and adult education program
mes. Similarly many rural development projects which had some
of (he above components have added a health dimension to their
activities.

2. Preventive and promotive orientation
Many of these health projects have moved beyond the mcdicaliscd concepts of health symbolised by the distribution of drugs
to activities individual and groups that prevent illnesses and
promote health. Immunisation programmes, maternal and child
health care, environmental sanitation, nutritional supplementa
tion and nutrition education and school health programmes arc
the commonest among them. A strong component of health
education is a characteristic of most of them. This education has
in many cases been dc-mystifying and dc-profcssionalising thus
increasing both the individual’s and the communities’ autonomy
over health activities.

3. Search for an appropriate technology
Many projectshave evolved medical care and health technologies
that arc more appropriate to the health needs of the very poor
(ICMR 1981: 85-86). The emphasis is not only on it being low
cost but also on it being more culturally acceptable, dc-mystifying and more within the operational capabilities of local people
and health workers. The range of appropriate technology varies
from dai kits to nutrition mixes produced from locally available
foods, an indigenous MCM calender, a locally manufactured
lower limb prosthesis, bangles and tapes to measure nutritional
status of children, low cost sanitation options, home based oral
re-hydration solutions, herbal medicines and home remedies
from the background or kitchen. Many of these have been adapta
tions of ideas developed outside the country and many have

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been recognition of the usefulness of ideas that are already part
of the local culture. Two additional areas of technological
appropriateness which have been experimented within many of
these projects arc:
(a) Communication'. Attempts have been made to use low
cost media alternatives like flash cards and flip charts and also
to adapt and involve local folk media and traditional cultural
forms of communication like puppetry, ballads, kathas, street
theatre and song and dance (nachnd) particularly in tribal areas.

(/>) Recordinglcvaluation iechniqucs’. Many projects have
evolved simple methods of recording, quantifying and keeping
track of health activities or resources utilised by the health
workers. These arc geared to the capacities of the local people
(if they arc patient retained) or to the capacities of local health
workers. Many arc geared to get over the constraint of illiteracy.

4. Promotion and utilisation of local resources
Local health rcsouices include local family based traditions of
health and self-care as well as traditional systems of medicine.
Many health projects have created positive relationship with
local dais oi birth attendants, traditional healers, folk medicine
practitioners, and practitioners of the indigenous or traditional
systems of medicine. This relationship has very often gone
beyond a mere association to a sharing of knowledge and skills
and an adaptation or acceptance of some of the medical and
health practices by the projects themselves. Promotion of herbal
medicines and home remedies is an important aspect of many of
these projects.

5. Training of village based health cadres
Training of local representatives of the village in basic health
care activities, minor ailment treatment, recognition of illnesses
needing higher levels of care, nutrition, environmental sanita
tion, communicable disease control, mental health and so on has

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DF.VI-LOPMP.NT WITH PFOPI.H

been probably the most characteristic feature of most of these
projects. The selection methodology, the training methodology,
the expected skillsand scope of training have varied from proj
ect to project but the most important result of such a trend has
been the conscious dc-mystilication of health issues and the
creation of better informed village based individuals who arc
available to help (lie people in their times of crisis. Depending
on (he orientation of the trainers themselves such village based
health workers* need not necessarily be ‘lackeys of the existing
health services' but can well be and have often become ‘vibrators
of their people’ (Werner 1980). In many projects once health
workers have been trained to understand, plan and decide on
health matters, certain leadership qualities arc generated so that
gradually issues wider than health arc tackled as well. Only
recently I heard about a group of women health workers in a
fishing community who organised the people to protest against
the local bus system which refused to allow women to carry
their baskets of fish in the bus to the market. In some planta
tions women health workers called link workers have recently
emerged as local union leaders. Such situations are not at all
unusual.

6. Increasing community participation

In addition to training village level health workers, many of these
projects have attempted to involve villagers in (he planning and
decision-making processes through the organisation of local
village health committees consisting of formal and informal
leaders. Many have involved local youth groups, mahila mandats,
teachers, religious leaders and farmers’ associations and co-opera
tives in health work. This is a very important trend but has often
become an expression of rhetoric rather than real participation.
Two pre-requisites arc essential if (his ‘community participation’
has to be a genuine process of enabling people to take responsi
bilities for their own health services.
(i) Firstly the involvement of all sections of the community.
In the stratified set-up of the village with certain groups
always dominating and exploiting certain other groups

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75

this must often mean a more purposeful and even exclu
sive involvement of the more disadvantaged and oppressed
sections of the village.
(ii) Secondly (he openness of the team to learn from the
people and their own experience of life. This means a
dialogue on more equal terms where the people arc in
volved in all aspects of planning and decision-making
and not just expected to participate in programmes
organised by the ‘health team'.

7. Initialing community organisation

The qualitative dilTcrcnce from No. 6 above is only one of
emphasis. Many projects have themselves initiated or catalysed
the development of youth clubs, mahila mandals, farmers’ asso
ciations and co-operatives recognising the need for local organ
isations to participate and sustain health activities. Il is, therefore,
not just involving (he existing organisation in the community if
there are already some, but seeing this step as a pre-requisite and
hence being involved in their initiation and their growth.

8. A quest for financial self-sufficiency

Many projects have concentrated on the dimension of the finan
cial participation of the community. These projects have concen
trated on generating local finances to run and support some or
all of the health activities The experiments have included health
insurance schemes, adding health functions to dairy and other
cooperatives, graded payment of services according to family
income and so on. 1 xpcricnce has, however, cautioned (hat an
exclusive pursuit of this objective can often result in the exclusion
of the very section of the community which needs the health
services the most (Bang 1981).

9. Education for health
Many projects have introduced health issues in their ongoing

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bl VI I.OI’MINI Wl ! II PIOI’I I

adult education and non-formal education programmes. This
process docs not only help to further dc-mystify the health issue
but has often served as the starting point for individual or group
action. As people discover the causes of the illnesses they experi
ence, and identify the roots of it within their own social situation,
they arc then prepared to do something. School health program
mes where teachers and high school students arc oriented to do
something about their own health, that of their families and
their community, share the same vision.

/(). Conscienii.salion and political action
There arc some projects where the health teams based on their
own experiences have begun to show a deeper understanding of
issues for conscicntisation and recognise the need to support
political action especially those of people’s movements and mass
organisations. 'This support may be through the organisation of
health activities particularly for the members of such movements
or (he addition of health issues on the agenda of people’s strug
gles. In the South, especially the demand for a provision of a
water supply point, has often become a rallying point.

Community health is not community medicine
To summarise then, the state of the art of alternatives in health
care in the country includes health integrated with development
activity; a preventive and promotive orientation; a search for
appropriate technology; promotion and utilisation of local health
resources including herbal medicines and traditional systems of
medicine; training of village based health cadres; promoting com
munity participation and community organisation; a quest for
economic self-sunicicncy; and a commitment to conscicntisation
and socio-political change processes.
Docs (his constitute COMM UNITY JlliALTII? A personal
quest to discover an answer to this question took my wife and
me around parts of the country in 1982, visiting many commu
nity health and development projects. We spoke to doctors, health

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77

workers, developmental activists and others about field level
realities, about (he successes and failures of micro-level projects,
about the strengths, weaknesses, opportunities and threats of
grassroot health action, about the problems of team work, about
personal motivation ideological, religious or otherwise about the
emerging networks and about the future.
One of the most important insights we got from this rich
feedback was the difference between ‘community health’ and
‘community medicine’ and this was more (han a matter of seman
tics. We understood for the first time that all these alternative
health trend setters, (hough often labelled as ‘community health
projects’ were not all ‘community health oriented*. Most often
they were extensions of the hospital system in organisation,
method of functioning, team work and hence should rightly be
labelled a community ‘medicine’ project. 'True to their medical
roots, many of these projects for instance continued to distribute
not only drugs but vitamins, vaccines and food with the same
dependence creating mentality. Their teams were hierarchical and
in the absence of participatory decision-making even within the
teams, the claims of community participation seemed hollow.
The water tight division of responsibilities, the compartmcntalisation of health, development and educational activities, the
profcssionalisation, the clear distinction between the ‘providers’
and the ‘users', the quest for efficiency and cost-cffcctivcncss,
the preoccupation with targets- all belied their overall coni mi tment to health as a community building process. Consciously or
unconsciously they had internalised the value system of the
hospital and even though on a superficial overview they appeared
to be different from hospital medicine, a deeper evaluation of the
projects showed that they were just community-based extension
of a mcdicaliscd form of health. Was this because most if not all
the project initiators had a professional medical or nursing back
ground and, therefore, this ingrained professionalism, superiority,
sense of inborn leadership and ‘know all’ attitude was difficult
to discard?
Due to this orientation, therefore, many projects we saw had
built up highly organised systems of health care delivery cut
oil from the lives of the poor people in their own communities.
They were bureaucratic, project oriented, and at best no better

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than government health projects except that they were more
efficient, more organised and probably more cost effective, but
no less irrelevant.

Towards a new value system
On the other hand, there was a small but growing number of
projects of interventions that had teams committed to the process
of socio-pohtjcal change, identifying their health activities as
collaborative eflorts in the overall process. They were identifiable
y their commitment to a real democratic, decentralised involve
ment of people in decision-making, a commitment to dc-mystification and awareness building through non-formal group
methodologies, a commitment to work through and support
people’s own organisations, a concentration on the human element
o the effort not on the structural or material, a clear understand
ing of their role as catalysts not ‘service providers’, or project
organisers; a commitment to process not projects and a commit
ment to trying to internalise most of these attitudes and value
system, within their own team’s functioning.
An equally important development raising some cause for
optimism was that even in the so-called community medicine pro
jects mentioned earlier, this change of value system was beginning
to take place encouraged by frank (cam evaluation and openness
to feedback from the people.

VVImt llicn is community licahli?
Based on this overview, therefore, it would not be out of place
to attempt a definition of what community health should be
Community health has been defined as “a process of enabling
people to exercise collectively their responsibilities to maintain
their health and to demand health as their right” (CHAI 1983)
This definition could be extended further by adding that the com
munity health process would involve increasing the people and
community’s own autonomy over their own health and over the
organisations that can prevent ill health and promote health. The
process would include the concepts of present day Primary Health

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79

Care minor ailment treatment, village level workers’ training,
appropriate health technology, promotion of herbal medicine
and home remedies, nutrition and environmental sanitation,
community participation and organisation--but would essentially
be a democratic participatory community building process.
I his would invariably increase local tensions since any pro
cess aimed at increasing the participation and the organisation
of the under-privileged and poor (which has to be part of any
movement toward greater social justice) will be opposed by the
staitis-quo factors and exploiting sections of the community.
Rooted in the people and committed to a process of health build
ing through the people's own actions and struggles, all those
committed to community health would support and participate in
the process even as it goes beyond health issues. Projects, struc
tures, health activities would then be means to an end —not the
end itself. Such projects would then be willing to even disband
programmes if they become counter-productive to the wider
struggle or abandon them in favour of more relevant approaches.

Is community heallli possible?

Arc there signs of such an alternative evolving in the country?
The trend is not conscious but implicit in many developments in
recent years which are possibly creating the right social milieu
for such an evolution. The delay has been due to a double
failure a failure of community health projects to see themselves
as part of a larger socio-political change process in society and
the failure of political activists, mass organisations and people’s
movement to recognise the value and true meaning of health.
Yet probably a beginning is being made.
Bang and Patel (1981) have described this as a conflict
between two schools of thought.

One school feels confidently that the panacea for the health
problems of the people has been found. It is the alternative
approach of health care delivery usually meaning utilisation
of non-professionals and appropriate technology in health
care. Another school is equally confident that the only real
cause of ill health problems of the people is the present

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1)1 VI-I.OPMF N I WITH PFOPI.FCOMMUNITY III AI.TII

economic system and nothing can be and should be done to
solve these health problems unless the present economicpolitical system changes by revolution. The first leads to illfounded euphoria . . . (the second) to inactive cynicism
towards the burning health problems of the people.

Positive trends

Firstly there is a growing army of villagers and lay workers who
have been trained as health workers both by governmental and
non-governmental voluntary agencies. Whatever the quality or
orientation of training, taken in the overall, a phenomenal pro
cess of dc-mystilication of health problems has alcady been
initiated.
Secondly (here is a growing number of individuals develop
ment or political activists—who arc beginning to recognise the
non-medieal dimensions of health and arc including it in their
action programme. Thirdly there is a growing body of health
knowledge which has become part of the syllabi of adult educa
tion and non-formal education in the country. Science education
experiments have also introduced health aspects into the innova
tive curricula developed by them. Fourthly people-oriented
science movements like the Kerala Sastra Sahitya Parishad. the
Lok Vif^yan Sanghatana (Maharashtra) and many other smaller
forums arc actively taking up health issues in (heir awareness
building programmes, in their Jathas and their exhibitions.
l ifthly there arc a series of evolving people's movements
around forest issues, environmental issues, other social issues
which have ‘health of people’ as an intrinsic component though
not always well recognised. Sixthly (here is an evolving interest
in the trade union movement, the women's movement and other
mass movements about the importance of health issues and the
need to include them as components of (he wider struggles.
Seventhly, even within the medical and nursing professional and
institutional networks there is a growing sensitivity to the needs
of linking health activities with the broader issues of social
change and not to see them ns a narrow technical or professional
enterprise.
Finally even expert documents on health in the country are

81

beginning to echo this challenge. The 1CSSR-ICMR (1981:94)
report clearly states that the conditions essential for success
of the ‘health for all' goal Is “to reduce poverty, inequality and
to spread education; to organise the poor and the underprivileged
groups so that they are able to assert themselves; to move away
from the counter-productive, consumerist western model of
health care and to replace it by the alternative based in the
community."

Negative factors

However, there is no cause for unbounded optimism. The trends
favouring the evolution of the community health alternative arc
definitely there but (he (rends opposing and most often
neutralising the gains made arc equally there and probably
stronger.
Mcdicalisation, profcssionalisation, and the consumerist
orientation of health care is increasing and is symptomatic of the
overall situation in the country. Many so-called health projects
are mushrooming all over the place goaded by foreign funding
agencies vying with each other to invest in the alternative; or by
industrial houses as part of (he rural development oriented
income lax benefits; or by professionals interested in involve
ment for prestige, status and power and for many other objec
tives 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 insensi
tive to social change process is going to be rather counter
productive.
A lack of adequate networking among the committed com
munity 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
system, the bureaucracy, the health planners and (he decision
makers to internalise the ideas and experiments in jargon and
rhetoric but defeating the spirit of the process is phenomenal
and rather confusing.

&

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DI-VI I.OPMENT WITH PIOJ’IJ!

To sum up then the evolving Communiy Health approach is
an attempt to bridge the ‘ill-founded euphoria of the alternative
health care deliverers’ and the inactive cynicism of socio-polit
ical activists about the role of health care and to bring the two
groups together if possible in a common endeavour. All com
mitted community health activists have to seriously face up to
this challenge. Are there efforts bringing this about?

5

Social Housing as a Tool for
People’s Development
L.M. Menezes

The theme of social housing has been bandied about a great
deal: as a means to an end, as an end in itself, as an entry point
to a host of things. Inevitably, when the subject is discussed in
a seminar, proceedings get stuck on definitions and semantics.
What is social? What is housing? Is social housing necessarily
private effort? In that ease can government programmes for
housing the poor be called social housing? If there is no direct
participation of the people in the construction itself, then is
housing no longer social? These doubts arise mainly because of
the diverse levels of participation, representing a wide crosssection of experience and understanding of the subject. I bis is
quite natural since the field is so vast, so general, so non
specialised in a way, and the problem is so colossal in India that
everyone has a finger in it.
This being the ease, the slogan really should be, ‘Get on
with it’ rather than debate definitions and concepts endlessly. No
doubt, not all housing efforts would stand the discriminating
scrutiny of the subject’s philosophers and fundamentalists not
enough people’s participation, not affordable, not cost-effective,
not indigenous etc. But then a few more houses would have
been added to the meagre housing stock of the country anyway.

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