PUBLIC HEALTH FOR COMMUNITY-CARE

Item

Title
PUBLIC HEALTH FOR COMMUNITY-CARE
extracted text
In this Issue

swasth hmd

Public health for community care
■Kum. Saroj Khaparde

Pa8e
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Health in India : Forty years’ achievements
Phalguna-Vaisakha

March-April 1988
Vol. XXXII, Nos. 3 & 4

Saka 1909-1910

■ since Independence
Dr. Harcharan Singh and Dr. A. K.Kundu

gg

Building a healthy life: Maternal and child
health

World Health Day—1988
The seventh of April each year is celebrated as
World Health Day, because it marks the date in
1948 when the Constitution of the World Health
Organization came into force.
Ever since 1950, a theme related to international
public health has been chosen for World Health
Day, with ah appropriate slogan.

This year's World Health Day, 7 April, is also
birthday. It is also the 40th year of
India’s Independence. India like the who is in a mood
to derive the lessons for the future from the achieve­
ments—and setbacks—of the past. A year that will
also mark the 10th anniversary of the historic
Declaration of Alma-Ata offers a golden opportunity
to highlight the need for equity and justice in heal-:
th, to restate the aims embodied in the goal of
Health for all by the year 2000 agreed by all who’s
member countries, and to emphasise cnee more that
Health for all will be attained not by high-tech hos­
pitals but by primary health care and the community’s
involvement in its own health.
who’s 40th

This is why Swasth Hind devotes this issue to
the slogan chosen for World Health Day 1988—
Health for all—all for health.

73

Christiane Viedrna
Insects, communicable diseases and health—
Role of government, society and individual
Dr. P. K. Rajagopalan

7g

India : Health progress at a glance
Dr. (Smt.) D. Lahiri.

$2

Health for all—All for Health—A Primary Health
Care Approach
84
Dr (Smt) V. K. Bhasin
Community participation in the control of
vector borne diseases—a national experience •
8g
N. L. Kalra and Dr.M.V.V.L. Narasimham
The challenges we face
92
C. R. Krishnamurthy

Leadership development for achieving health
for all by 2000 A.D.
Prof. Somnath Roy

94

Whither health education !
Dr. K. S. Sanjivi and Dr. K. Venkateswara Rao

9g

Behavioural Sciences for public health and
medical care
Dr. K. R. Sastry

1qq

Voluntary associations in health care

102

Alok Mukhopadhyay
All for health—a must for health for all- -an
experience
Dr. Sanjiv Kumar and Dr. G. V.S. Murthy

104

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EDITOR

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Sr. SUB-EDITOR

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COVER DESIGN

B. S. Nagi

The contents of this Journal are freely reproducible. Due
acknowledgement is requested.

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for publication

A^—

PUBLIC HEALTH FOR
COMMUNITY CARE
Kumari Saroj Khaparde

Primary health care relies heavily on community involvement and participation in
the planning, implementation and evaluation of services in the first place; and in
the establishment, support and maintenance of services, to enable people to be­
come both the major activists in and the main beneficiaries of primary health care.
urative medicine is only a part of medicine and

not the whole of it. So is preventive medicine
with all that goes with it—sanitation, hygiene, pre­
vention, nutrition, genetics and behaviour. Neither
of these two branches of medicine nor the variety of
sub-specialities within each of them can stand alone.
It is only when they arc joined together and by en­
suring the developments in one proceed synchronously
with those of the other, can wc ever hope to bring a
degree of social, economic, educational and political
advancement.

In India, the Joseph Bhore Health Survey and
Development Committee in 1946 made a heroic effort
to bring together curative and preventive medicine,
and to provide comprehensive health care to people.
Giving a pride of place to preventive work at com­
munity level, the Committee proposed a health system
linking primary health care at community levels to
secondary, district, provincial and Central levels of
the health system, ensuring the availability of increa­
singly sophisticated preventive and curative services.
The Committee went to the extent of proposing that
the future doctor should be a “social physician” and
that hezshould place prevention of disease in the
forefront of his programme and should so continue
“remedial and preventive” measures as to confer the
maximum benefit on the community. Their recom­
mendations laid the foundation for the beginning of
the modern health planning including public health in
India.

The efforts at the international scene continued to
provide a package of health services to the people
although these moves were motivated by economic
rather than ideological compulsions. .

March-April 1988

The most recent effort however, was the Inter­
national Conference on Primary Health Care held in
Alma-Ata in 1978. The Conference recognised that
health care, as delivered, was fragmented and was
inadequate to meet the health of the people, especial­
ly of the large majority lying in the rural areas and
of the urban slums, who have little or no access to
any form of health care, and this is despite the un­
precedented advances of the West. The conference
recommended to bring to the people a package of
services consisting of at least the eight essential ele­
ments of primary health care. The package of ser­
vices would include education concerning prevailing
health problems and the methods of preventing and
controlling them; prevention and control of locally
endemic diseases and immunization against major in­
fectious diseases, promotion of food safety and pro­
per nutrition: adequate supply of safe water and basic
sanitation, maternal and child health care, including
family planning; and appropriate treatment of com­
mon diseases and injuries and essential drugs.
Primary health care relies heavily on community
involvement and participation in the planning, imple­
mentation and evaluation of services in the first place;
in the establishment, support and maintenance of ser­
vices, to enable people to become both the major
activists in and the main beneficiaries of primary
health care.

Primary health care represents in its radical depar­
ture from conventional health care, an enormous
challenge to medical schools for training health pro­
fessionals. Indeed, whether or not primary health
care will succeed depends largely on how well train­
ing institutions will face up to the challenge.
Contd. On Page 97

65

HEALTH IN INDIA

Forty Years' Achievements
since Independence
Dr Harcharan Singh
and

Dr A. K. Kundu
The successive increase in the Plan allocations in every subsequent Five Year Plan indi­
cates strong political will to improve health of our people.
These efforts, since Inde­
pendence have led to an improved health status of the population in general.
became Independent in
1947 and adopted the new con­
cept of ‘Welfare State’ with the
cherished goal of improvement of
the quality of life of its people.
Without the development of health
of the people, this dream shall re­
main unfulfilled.
ndia

I

Health situation

The health situation in India at
the time of Independence may be
described under the following pro­
files:
(i)’ Demographic profile —India
was confronted with a population of
around 346 million with crude birth
rate of 39.9 per 1000 population and
annual population growth rate of
1.25 %. Large proportion of popula­
tion was ‘Young’ under 15 years and
low proportion of people living
beyond middle age.

66

(ii) Mortality profile—Crude death
rate was 27.4 and infant mortality
fate around 146 per 1000 livebirths
and life • expectancy at birth was
around 32 years. Infective and para­
sitic diseases accounted for more
than 25% of deaths in India.

diseases—Ischaemic heart disease,
hypertension, diabetes, mental dise­
ases, accidents, drug addiction, some
occupational diseases and environ­
mental pollution were also posing
problem in some social groups.

(iv) Health facilities—Doctor po­
(iii) Morbidity profile—(a) Infec­ pulation ratio after Independence
tive and Parasitic diseases like was around 1:6000. Similarly, there
malaria, kala-azar, smallpox, mea­ were shortage of paramedical wor­
sles, poliomyelitis,
enteric-fever, kers.
Health care delivery was
diarrhoea, dysentery, cholera, tuber­
curative oriented and though more
culosis etc. were responsible for
than 80% of the population, was liv­
60% of hospital admissions, (b)
ing in villages, more than 80%
Malnutrition—Protein energy mal­
health care facilities were distribut­
nutrition among under-fives, nutri­
ed in urban areas only.
tional anaemia among women of
As soon as the country became
reproductive age-group and pre­
school children, Vitamin ‘A* defici­ Independent in 1947, Ministries of
ency, endemic goitre were some of Health were established at the Centre
the major public health problems in and in the States. The post of
this field, (c) Non-oommunicable Director General, Indian Medical

Swasth Hind

Services and of Public Health Com­
missioner were integrated in the
post of Director General of Health
Services at the Central level: the
same practice was followed at the
State levels also.

The Government was immediate­
ly confronted with the burden of
improving health of the people. The
‘Health Survey and Development
Committee’ popularly known as the
Bhore Committee had earlier been
appointed by the British Govern­
ment in India in 1943 to survey the
then existing position regarding the
health conditions and health organi­
zation in the country and to make
recommendations for the future deve­
lopment. The Committee submitted
in 1946 the famous report which
runs into four volumes and this be­
came the basis for most of the plan­
ning and measures adopted by the
National Government.

The concept of the delivery of
curative and preventive health care
services to rural population through
the primary health centres and
major changes in medical education
including three-month training in
preventive and social medicine were
ushered in from the Bhore Com­
mittee recommendationsIn the meantime in 1948, India
joined WHO as a member State and
Employees State Insurance (ESI)
Act was passed. The Constituent
Assembly adopted the Constitution
of India on 26 November, 1949.
Article 246 of the Constitution co­
vers all health subjects. These have
been enumerated in the Seventh
Schedule under three lists—Union
list, Concurrent list and the State list
and thus the Constitution defined
clearly the role of central and the
state Governments in the field of
medical and health care delivery to
the people of India.

March-April 1988

In 1947, India had limited medical colleges. Today, there are 106 medical colleges
with a few premier institutions where facilities for super-specialities also exist.

To encourage research and deve­
lopment, the Indian Research Fund
Association was reconstituted as the
Indian Council of Medical Research.
In 1950, as soon as the Constitu­
tion of India came into force, the
Planning Commission was set up
which started drafting, country's
First Five Year Plan wherein Health
Planning was an integral part of
overall socio-economic developmen­
tal planning for . the whole country.

Control of
diseases;

non-communicable

Development of
the Indian
Systems of
Medicine and
Homoeopathy.
1.

Control of Communicable
Diseases

(i) Malaria—In 1950, this was
India’s number one public health
problem. According to the esti­
mates in 1952-53, about 200 million
people were living in endemic areas,
75 million cases were occurring
The broad objectives of the health
annually with eight lakh deaths
programmes during the successive
directly due to Malaria. In 1953,
Five Year Plans have been: —
the National Malaria Control Pro­
•
Control/eradication of major gramme was launched and by 1958,
communicable diseases;
the incidence came down to two
• Strengthening of the basic health million cases. The National Malaria
services through establishment
of health infrastructure in rural Eradication Programme was started
areas with supportive and refer­ from 1958 but due to various admi­
ral services in the urban areas; nistrative, operational and technical
• Population control:
reasons, resurgence took place in
•
Development of health man­ mid-sixties. As a result, modified
power resources;
plan of operation for effective con­
•
Reorientation of medical edu­ trol of malaria was introduced in
cation and research;
1977. The incidence of the disease

67

came down from 6.4 million cases
in 1976 to 1.7 million cases (P /a/ciparuni cases 0-6 million) in 1986
with 232* deaths. At present, it
is a Centrally-sponsored Scheme
with 50 : 50 sharing basis between
the Central and State Governments.
An independent expert committee
had made an in-depth evaluation of
this programme and submitted its
report to the Government in Octo­
ber, 1985 and the Government is
working on the remedies of the pro­
blems identified.
(ii) Leprosy—It was estimated
that there are about four million
leprosy cases in the country; of
which 20% are infectious, 25%
have some sort of deformity and
20% of the total cases are children.
The National Leprosy Control Pro­
gramme was launched in 1954-55
as a Centrally-aided scheme; now
it is a 100% Centrally-sponsored
Scheme and known as the National
Leprosy Eradication Programme.
So far, the Programme has already
identified 3.3 million cases and 3.04
million cases were brought under
treatment.
Seventy-six districts
with a case-load of 10 and above
per 1000 population are targetted to
be brought under multi-drug treat­
ment including development of in­
frastructure and massive health edu­
cation activities to create awareness
among people during the Seventh
Plan period. The programme has
been recently evaluated and the re­
port is under study of the Govern­
ment.

Thanksjto the Universal] Programme of Immunization, the maternal and infant
mortality rates have been brought down considerably.

Presently, it is a Centrally-spon­
sored Scheme with 50 : 50 sharing
basis and operated in urban areas
only. Three pilot projects are in
progress to develop a suitable stra­
tegy for control of filaria in the rural
areas.

(iv) Blindness—It was estimated
that about 45 million people are
suffering from visual impairment and
over nine million are completely
blind which include about five mil­
lion who can be cured by surgery.
Starting from initiation of Trachoma
Control Pilot Project in 1956, the
Government has launched a 100%
Centrally-sponsored scheme of the
National Programme for Control of
Blindness in 1976 with the objective
(iii) Filaria—It is estimated that of reducing blindness in the country
about 236 million people are living from 1.4% to 0.3% by 2000 A-D.
in endemic areas and 18 million To achieve this aim, the programme
people are harbouring parasites in is providing immediate relief to the
their blood and 14 million are hav­ needy by camp approach and by
ing disease manifestations? The establishing permanent eye care faci­
National
Filaria
Control Pro- lities with graded expertise at diffe­
•gramme was launched during 1955. rent levels coupled with health edu­

68

cation measures. Besides providing
eye care facility at every level start­
ing from the PHCs, every year more
than one million cataract operations
are being performed throughout the
country.'
(v) Tuberculosis—It is estimated
that there are about 9 to 10 million
cases of Pulmonary Tuberculosis in
India; of which 2 to 2.5 million are
bacillary cases at any point of time.
The National Tuberculosis Control
Programme is a Centrally-sponsored
Scheme on 50 : 50 sharing basis in
respect of equipments including Xray machines and TB drugs. The
programme strategy is to detect ac­
tive TB cases in early stage by spu­
tum examination in the peripheral
health centres and their treatment
through an organised district TB
Control programme evolved in 1962.
Every year,
through this pro<
gramme, 1-3 million to 1.4 million
cases are being diagnosed. The
programme has recently introduced
short course Chemotherapy Drug

Swasth Hind

Regimen to reduce the duration of
treatment from 12/18 months to
about 6/8 months.

Table—I
Achievements under Minimum Needs Programme

Name of

No. as on

(vi) Smallpox—Fight against this infra­
1-4-1985
structure
killer disease started as the National
Smallpox Eradication Programme in
2
1
1962. Later, WHO began a cam­
paign in 1967 to bring down the in­ Sub-centres
84588
cidence to zero and finally the di­ Primary Health 10796
Centres
sease was eradicated from India in
Community
. 725
April, 1977.
Health Centres

7th plan
Target
(Add!.)

Target

3

4

5

6

7

8

9

54883
12390

6122
1455

7891
1770

8766
1554

8670
1651

101149
14217

9233
2274

1553

298

233

278

272

1230

257

1985—86

1986—87

No. as

Achi­ Target Achii evements
cvements

1987—-88
Targets

(vii) Plague—This was another duced in the Fifth Five Year Plan
gery, Paediatrics, Gynaecology and
dreaded disease with 23,191 deaths were directed towards the objective
Obstetrics—for every one lakh po­
only during 1948 just after Indepen­ of providing minimum health care
pulation. The Table 1 shows tar­
dence. However, since 1968 not a facilities integrated with family plan­
gets and achievements under the
single case of human plague was ning services and nutritional im­
Minimum Needs Programme till torecorded in the country.
provements besides attempting to date.
(viii) Other Communicable Dise­ correct the prevailing regional im­
It is expected that 100% sub­
ases—Guineaworm which was ende­ balances. To achieve these basic centres and Primary Health Centres
mic in Karnataka, Gujarat, Madhya objectives, the concept of Minimum and 50% Community Health Cen­
Pradesh, Maharashtra, Andhra Pra­ Needs Programme was evolved, tres required in the country will be
desh, Rajasthan and Tamil Nadu, is under which efforts are being made ready by 1990.
expected to be eradicated by 1990. to strengthen and augment health
Though more attention has been
care infrastructural facilities in rural
For control of sexually transmit­
given
for development of rural
areas including hilly and tribal ter­
ted diseases and diarrhoeal diseases
health
infrastructure but in recent
rains through adoption of adequate
including cholera efforts are gradual­
population norms.
Further re­ years the urban population has been
ly being strengthened. As compared
structuring and re-orientation of growing at a very high rate creat­
to early fifties the morbidity and
these programmes was aimed at in ing serious health problems. The
mortality have greatly reduced to­
the Seventh Five Year Plan in the existing urban health services are
day.
context of the nation’s accepted under pressure, services in the slum
Recently, the world is threaten­ long-term goal of “Health For All areas being most vulnerable and
ed with another dreaded disease call­ by 2000 AD”. During the Seventh inadequate. There are multiple
ed AIDS (Acquired Immuno Defi­ Plan more emphasis has been given agencies providing health services
ciency Syndrome). Keeping in view for qualitative improvement of the in urban areas, but poor co-ordina­
the recent problems associated with infrastructure created alongwith the tion among them results in duplica­
this disease, adequate measures are training of various categories of tion and inefficiency of services.
manpower needed for staffing these During the Seventh Plan in conso­
being taken to prevent the spread
units- As per existing population nance with the guidelines provided
of this infection in the country.
norm there will be a sub-centre for in the National Health Policy, the
2. Strengthening of Health Services
every 5000 population (3000 popu­ following measures are to be
in Rural and Urban areas
lation for tribal and difficult terrain taken: —
High priority has been assigned
for promotion of health care services
in the rural areas right from the
inception of planning process in the
country though during the initial
period it was a little urban-orientcd
The policies and programmes intro-

March-April 1988

areas), a Primary Health Centre,
with two observation beds for every
30,000 population (20,000 popula­
tion for tribal and difficult terrain
areas) and a Community Health
Centre with 30 Indoor beds and four
basic specialities of Medicine—Sur­

(i) Taking into account the bed
position in hospitals run by various
agencies in urban areas further
strengthening will be done keeping
in view the objective of one bed for
1000 pouplation. Hospital beds are
to be distributed rationally so as

69

Post-Graduate Medical Sciences at
Lucknow. Indira Gandhi Institute of
Medical Sciences at Patna, etc.
These institutions are equipped with
sophisticated equipments and highly
trained staff so as to support to the
organised referral system in the
health care delivery system.
3.

Maternal and child health services ensure that women
may carry their pregnancy to full term without risk.

to provide adequate support to pri­
mary health care services. Further
besides providing primary health
care to urban population the urban
health service organisation has also
to provide back-up support to rural
health organisations through referral
system and
specialist
services.
Therefore, the district hospitals are
to be provided with facilities of im­
portant specialities for this purpose.

d

have to be made to certify the re­
gional imbalances through streng­
thening of specialised institutions
and super-specialities in areas where
serious deficiencies exist.
Premier institutions

After Independence, many pre­
mier institutions like the All India
Institute of Medical Sciences, New
Delhi: Post-Graduate Institute of
Medical Education and Research.
(ii) Considering that the facilities Chandigarh; Christian Medical Col­
for specialised services in the coun­ lege, Vellore; etc. have been deve­
try are limited and not available in loped and many more are coming
all regions in equal measures, efforts up like Sanjay Gandhi. Institute of

70

Population Control

The most crucial problem facing
the nation today is the galloping
population which doubled during
the last 30 years and is expected to
double once again over the next 40
years if birth rates do not decline
rapidly. Just after Independence,
the Government of India realised
this and adopted family planning
programme in 1952.
The pro­
gramme has gone through several
stages in its evolution and received
greater emphasis in successive FiveYear 'Plans which is evident from
the fact that Plan outlay of Rs. 0.1
crore in First Five-Year Plan has
been raised to Rs- 3256 crores dur­
ing the Seventh Five Year Plan. The
very rapid decline in birth rate is
possible only if substantially more
and more couples can be made to
restrict family size by using one or
the other method of family plan­
ning. Experiences all over show that
acceptance of family planning me­
thods is closely associated with the
level of infant mortality, socio­
economic standards and status of
women.
Strengthening maternal
and child health services and mea­
sures to improve status of women
would greatly help the reduction in
the rate of population growth. MCH
services have been included in the
Family Planning Programme which
has been renamed as the Family
Welfare Programme and included in
the 20-Point programme of the Go­
vernment of India and made essen-

Swasth Hind

tially an integral part of the over­
all socio-economic development pro­
grammes in the country. It is now
being delivered to the people as
package of Family Welfare Pro­
gramme integrated with nutrition
and general health care services.
This is also keeping close coordina­
tion with other developmental pro­
grammes like education, poverty
alleviation programmes, housing,
water supply and sanitation pro­
grammes etc.
Impact of the Programme

(i) Couples Protected—The per­
centage of couples effectively protec­
ted increased to 37.4% as on 1
April, 1987 from 22-2% in 1979-80.

(ii) Births averted—Since the in­
ception of the programme up to the
end of 1984-85 about 68.21 million
(estimated) births have been averted
and further it is estimated that a
total of 115.01 million births will be
eventually averted up to 2011-12
AD by which time the goal of Net
Reproduction
Rate of Unity is
targetted.

Tuberculosis eats into vitals of a nation. The National Tuberculosis Control Pro­
gramme is a Centrally-sponsored .Scheme on 50 • 50 sharing basis regarding equip­
ments includingJ[X-ray=niachines-and T. B. drugs. ’

The National Leprosy Eradication Programme has]-identified 3.3 [million cases
and has brought 3.04 million cases under treatment. -

(iii) Fertility levels—The birth
rate has declined from 41.2 in 196171 to 32.7 in 1985.

(iv) Growth rate—In spite of
steep fall in crude death rate from
27.4 in 1941-51 to 11.7 in 1985
the decadal growth rate which had
steadily increased from 13.31% in
1941-51 to 24.80% in 1961-71, has
been steadied around 21%.
(v) Infant mortality rateThis is
a sensitive index of the impact of Fa­
mily Welfare Programme which has
been’brought down’from 146 during
early fifties to 95 in 1985 and this
was possible due to improved MCH
care including immunization pro­
gramme to mothers and children
particularly infants through Univer­
sal Immunization Programme.

March-Apri 1 1988

71

4.

Health Manpower Development

In 1947, when the country achiev­
ed Independence, the Government
of India was confronted with the
problem of shortage of both medical
and paramedical workers. Gradual­
ly, through successive five year plans
emphasis has been given on training
work and providing more medical
and paramedical personnel to meet
the country’s needs.
Today we
have—

In the field of medical research,
though Indian Research Fund As­
sociation was established in 1911,
there was very limited scope of
medical research. After Indepen­
dence, this institution was re-named
as the Indian Council of Medical
Research (ICMR) and besides some
other Central and State institutions
the major part of the health and me­
dical including family planning re­
search activities are being carried
out by ICMR through its various
permanent institutions spread all
over the country and through various
medical colleges/organizations.

gramme, Cancer Control Pro­
gramme, programmes dealing with
prevention and treatment of acci­
dents, blood banking and also pilot
projects for developing strategies for
control of rheumatic heart disease,
diabetes, mental and dental health.

and to some extent in the field of
non-communicable diseases. The
concept of domiciliary treatment
with biweekly regimen in tubercu­
losis control programme, multi-drug

The Table 2 shows the allo­
cations in Health and Family
Welfare Programmes starting from
the First Five Year Plan to the
Seventh Five year Plan:

(1) Doctors (Allopathic) 2,97,228 (1984)
(2) Nurses
•
■ 1,70,880(1984)
(3) Dental Surgeons •
9,598 (1985)
(4) Health Visitors
•
11,455
(5) Pharmacists
64,494 (1984)
(6) ANMS/I Icalth Wor­
Today, the major thrust of re­
kers (F)
95,615 (1986)
search
is directed to the area of de­
(7) Health Workers (M) 84,122 (1986)
livery
of
primary health care, com­
(8) Health Guides
• 3,95,572 (1987 March)
municable
diseases control, contra­
(9) Trained Birth Atten­
dants
•
• 5,15,691 (1986)
ceptive technology/fertility control

During the Seventh Plan more
emphasis has been given in deve­
lopment of health manpower.
5. Re-orientation of Medical Edu­
cation and Research
In 1947, the country had limited
number of medical colleges and
today it has reached to 106 medical

colleges with quite a few premier
institutions.
In order to bring about a change
in curative oriented time-old me­
dical education, re-orientation of
medical education, a Centrallysponsored scheme was introduced
in the Sixth Five Year Plan with
the objectives
of (i) introducing
community bias in the training of
under-graduate medical students
with emphasis on . preventive and
promotive services; (ii) orientation
of the role of medical colleges, so
that they become an integral part
of the health care system and do
not continue to function in isola­
tion; (iii) orientation of all faculty
members to ensure that hospital­
based and disease-oriented training
is progressively replaced by com­
munity-based and
health-oriented
training for providing comprehen­
sive primary health care; and (iv)
the development of effective referral
linkages between PHCs, District
Hospitals and Medical Colleges.

72

7. Indian. System of Medicine
Homoeopathy

and

In British India, Indian System of
Medicine and Homoeopathy were
not given any recognition but from
the Fifth Five Year Plan onwards
popularization and development of
Ayurveda, Unani, Siddha, Yoga,
Naturopathy as well as Homoeo­
pathy is continuing and emphasis is
given on undergraduate and post­
graduate training in the subjects,
standardization of drugs and re­
search.

Table 2
Outlays/Expcnditurc from First Five-Year Plan to Seventh Five Year Plan

(Rj. in crores}
Period

1st Five Year Plan (1951-56) Actuals
llnd Five Year Plan (1956-61) Actuals .....
Illrd Five Year Plan (1961-66) Actuals.........................................
IVth Five Year Plan (1969-74) Actuals .....
Vth Five Year Plan (1974-79) Actuals .....
Vlth Five Year Plan (1980-85) Outlays.........................................
Vllth Five Year Plan (1985-90) Outlays
.
.
.
.

Health

Family
Welfare

65-2
140-8
225-9
335-5
760-8
1821-1
3392-89

01
2-2
24-9
278-0
491-8
1010-0
3256-26

treatment in leprosy eradication pro­
gramme, phage-typing of cholera
vibrio,
environmental control and
genetic control of mosquitoes and
concept of integrated approach of
malaria control in NMEP, are some
of the important outcome of bio­
medical research in our country.

The successive increase in the
Plan allocations in every subsequent
Five Year Plan indicates strong
political will to improve health of
our people. These efforts, since In­
dependence, have led to an improv­
ed health status of the population in
general as revealed by indicators
like improvement in life expectancy
6. Control
of Non-communicable
at birth from 41.2 years in 1951 to
Diseases
54.4 in 1980, and decline in infant
After Independence, the country mortality rate from 146 per thou­
was confronted with problems of sand livebirths in 1951-61 to 95 in
major communicable diseases; hence
1985 and crude death rate from 27.4
no attention was paid to non-com­ per 1000 population to 11.7 in 1985
municable diseases control.
and the country is progressing to­
Today, the country has launched wards achieving the goal of “Health
the National Goitre "Control Pro­
For All by 2000 AD”.
<

Swasth Hind

BUILDING A HEALTHY LIFE

Maternal and Child Health
Christiane Viedma

Global progress has been achieved on all fronts of family health: there has been a decline in in­
fant mortality, a reduction in the percentage of low birthweight babies, an extension of immuniza­
tion coverage, an increase in family planning programmes, and an improvement in the nutritional
status of children, not least through the use of oral rehydration. There is one black spot: the
health of mothers. Besides WHO and the Govt, of India, women themselves are in the forefront
of the great movement to help the human race towards Health for All.

he health of mothers is inex­
tricably bound up with the health
of their children which, to a large
extent, underlies the development
of society as a whole. From the
moment it was established in 1948,
WHO has devoted an important
part of its efforts to maternal
and child health. These efforts have
borne fruit, for mortality in children
under five has fallen from a world­
wide rate of 271 deaths per thousand
live births in 1950 to 109 in 1986.

T

Abundant research, both in sci­
entific fields and in the delivery of
health services, has proved that
primary health care based on the
involvement of the people and the
community, and on intersectoral
activities, provides an ideal setting

March-April 1988

for maternal and child health care.
In Costa Rica, for example, 46%
of the drop in infant mortality not­
ed between 1972 and 1980 can be
attributed to primary health care
technology and programmes, and es­
pecially to family planning; yet the
overall cost has been no more than
17% of the national budget for
health. In many other instances,
primary health care has led to mark­
ed improvements in the health of
women and children even though
there has been no change in the
economic situation.
At the instigation of WHO, family
planning is increasingly seen as a
powerful means of protecting health,
and indeed it has achieved spectacu­
lar advances in the last 20 years.

While only a few countries in the
world had programmes under way in
the early 1960s, 120 governments are
today giving their direct or indirect
support to such programmes.
Member States are increasingly
tending to base their health policies
on the risk approach, that is, identi­
fication of the most vulnerable
groups, which are given absolute
priority in programmes — as ad­
vocated by WHO. Appropriate tech­
nology is welcomed, and countries
are also seeking to ensure that more
specialized interventions, such as
essential obstetrical care-—caesarian
sections and blood transfusions —
which may be heeded at the local
level, are included in primary health
care.
-

73

Nutrition

NATIONAL IMMUNIZATION SCHEDULE

More than 9 million children die
Based on the recommendations of the National Coordination Com­
every year in the Third World be­
mittee on Immunization, the Government of India has revised the minimum
fore reaching their first birthday.
age for DPT, OPV and BCG vaccinations in the national immunization
They are caught in a vicious circle,
schedule. The revised schedule is given below for ready reference:
in which malnutrition and infectious
diseases combine to erode their
health.

THE SCHEDULE

'WHO advocates a number of
measures', especially growth moni­
toring based on the use of a growth Beneficiaries
chart, which can be incorporated
into primary health care and which
Infants
make it possible to detect malnutri­
tion well before the first clinical
signs appear.

Age

•

Vaccine

No. of Route of
Doses Administration

6 weeks to (“DPT
9 months / Polio
LBCG

3
3
!•

Intra-muscular
Oral
Intra-dermal

Measles

1

Subcutaneous

9 to 12
months

With the decline of breast-feed­
♦For institutional deliveries. BCG should be given al Birth.
ing. the only complete form of nutri­
tion for infants up-to four to six Children
16 to 24
f DPT
1**
Intra-muscular
months
months. WHO has launched an im­
\ Polio
!♦♦ ,
Oral
portant promotion campaign, one
♦♦Booster
dose.
.. aspect of which is the “International
Intra-muscular
fDT
it
Code of Marketing of Breast-milk
5 to 6 ycars^
2
Subcutaneous
(_ Typhoid
Substitutes”, adopted by the World
Health Assembly in 1981. Breast­
f Tetanus toxoid
Intra-muscular
10 yrs.
feeding has been increasing in the
^Typhoid
Subcutaneous
It
industrialized countries since the
f Tetanus toxoid
Intra-muscular
It
• 1970s, and WHO is trying to en­
16 yrs.
\
Typhoid
Subcutaneous
courage this trend, especially in the
It
burgeoning cities of the developing Pregnant Women
16 to 36
Tetanus toxoid
Intra-muscular
It
countries.
f2 doses, if not vaccinated previously.

Weaning, through the introduction
•of foods prepared from ingredients
of the family diet, which should be
reasonably priced, highly nutritional,
and both clean and easy to eat, has
a considerable influence on the
child's health and on its nutritional
development. Here again, WHO
is encouraging research and educa­
tional campaigns.

This nutritional policy is part and
parcel of the health measures which
encompass primary health care, im­
munization and the control of diar-

74

NOTE : —Interval between 2 doses should not be less than one month.
Minor coughs, colds and mild fever are not a contra-indication to.vaccination.

rhoeal diseases, and have led to a
regression in. the most serious forms
of malnutrition — particularly pro­
tein-calorie malnutrition (wasting) —
in the last 15 years. Today these
serious forms persist only in a few
countries of Africa and Asia.

But another danger, hitherto es­
sentially observed in the developed

countries, is now beginning to ap­
pear in the developing countries as
well : this is the malnutrition of ex­
cess that comes from overeating and
results in obesity and cardiovascu­
lar diseases. WHO is carrying out a
programme of research into this
aspect of malnutrition through its
Regional Office for Europe.

Swasth Hind

“All the indications are that
WHO's global programme to control
diarrhoeal diseases is well on its
way to achieving the goals that have
been set for 1989’’
This is the prediction of the pro­
gramme’s Director, Dr Michael Mor­
son. Set up in 1978 to combat the
high level of mortality among
children under five caused by the
high incidence^ of serious diarrhoeal
diseases, this programme is based
on oral rehydration using a mixture
of different salts coupled with con­
tinued normal feeding during acute
attacks of diarrhoea. More than 100
countries, which together account for
about 95% of the children under
five in the developing countries, have
now launched national programmes
in the framework of their primary
health care. Overall mortality has
regressed by 40-50% in Egypt, Hon­
duras, the Philiopines and Thailand.

In 1985, about 270 million pac­
kets of oral rehydration salts were’
prepared by different manufac­
turers — twice as many as in 1983
and five times as many as in 1982.
Although UNICEF — an important
partner with WHO in the control
of diarrhoeal diseases — remains
the principal external supplier, more
than 40 countries had begun their
own production by the end of 1985,
and today more than half the pac­
kets that are distributed have been
produced in the developing coun­
tries.
The objectives of the WHO Glo­
bal Programme for 1989:

— 80% of children with diarrhoea
will have access to oral rehyd­
ration:
r— 50% of children will receive
effective treatment;

March-April 1988

Breast milk best for infants. It is the complete form
of nutrition for infants up to 4 to 6 months.

— 1 million to 1.5 million child
deaths from diarrhoea will be
avoided every year.
Speeding up immunization

Measles kills one child every 15
seconds. Diphtheria is fatal in 1015% of cases. Tetanus kills 800 000
newborn babies a yean Every year
50 million children develop whoop­

(CHEB Photo)

ing cough and 600 000 die. There
are 275 000 cases a year of polio*
myelitis, the leading cause of disa-'
blement in the developing countries.
Tuberculosis claims up to 10 mil­
lion victims.

To counter the menace of these
six diseases, which not only take
a heavy toll of human lives but

75

also seriously undermine the already
precarious nutritional status of
J children in the Third World, WHO
^established an expanded programme
on immunization in 1974, with the
■ultimate aim of making immuniza­
tion available to all the world’s chil­
dren by 1990.

i* Last August, the Director-General
of; WHO, Dr Halfdan Mahler, said
that more than 50% of children have
received; three doses of DPT or
' polio immunization and can now
be considered to be protected
against diphtheria, tetanus, and
-whooping cough or poliomyelitis, as
. compared with only 5% ten years
ago. Two-thirds of all infants have
/•received at least one dose of these
vaccines.

Progress is such that it is esti­
mated that the programme is now
preventing more than one million
'deaths from measles, neonatal te­
tanus and whooping cough
and
saving more than 175,000 victims
..’from contracting polio in the deve­
loping world every year.

/Dr Ralph Henderson, Director
of the Expanded Programme on Im­
munization, warns: “We must not
rest on our laurels, for we are
pnly half-way to our goal.” Pro. grammes must therefore be accele­
rated during the coming three years
through social motivation and im­
proved management of immuniza­
tion services.
Healthy youth: our best resource

Young people between the ages
of. 10 and 24 — they make up 30%
of the world’s population — are not
so much exposed to disease as to
health problems which are the re­
sult, of behaviour characteristic of
this age group. It is therefore es­
sential that they should be informed

*

76

of the health risks they may be
running, and that health services
should be adapted to meet their par­
ticular needs.

WHO has included the health of
adolescents in its Eighth General
Programme of Work (1990-1995) and
is conducting a number of activities
in collaboration with governments.
with professional groupings, and
with nongovernmental organizations
which include the young among their
members, in the framework of its
family health programme. These
activities include the prevention of
psychosocial disorders, such as drug
addiction, alcoholism, tobacco de­
pendence and accidents, and there
is special emphasis on reproductive
health.

Both in the developing countries
and in the big cities of the industria­
lized countries, repeated pregnancies
at short intervals and a very early
age are not uncommon and pose a
threat to the health of young
mothers and their children. They
very often mean an end to the
women’s education and a setback
to their social development. The
young must be able to plan their
families in the light of their future
careers; consequently they must
have access to information and ser­
vices which meet their needs.
The elderly

By the end of this century, there
will be 580 million people aged 60
and over, as compared with 370
million in the 1970s. Those over
75 run a high risk of disease and
severely disabling conditions, which
often become chronic. Most of the
elderly also suffer from loneliness.
These problems inevitably increase
the demands placed on the medical

and social services and often mean
that institutional care is needed.
At the World Assembly on Aging
organized by the United Nations in
1982, it emerged clearly that the
health of the elderly was part of the
mandate of WHO. An international
programme of research into the
health of the elderly has therefore
been established within the Organi­
zation and is being conducted under
the responsibility of the WHO Re­
gional Office for Europe.
Objectives

This programme is built on the
principle that it is possible to re­
main healthy even at an advanced
age, and has the following objec­
tives :

— understanding the process
aging:

of

— control of disorders related to.
aging;
— promoting the active integration
of the elderly in society;
— providing guidance for research
so that optimum use is made of
resources and the results of re­
search are harnessed to the
real needs of the elderly.
Towards safe motherhood

She was 30 and had never heard
of family planning clinics. Preg­
nant for the sixth time, she hardly
dared to tell her husband, who work­
ed hard to support his family of
seven. And so she went to an abor-'
tionist.
She haemorrhaged for three days,
and then had terrible abdominal
pains. Her husband took her to
hospital, where they diagnosed an
incomplete abortion*, two days
later, she was back home. She began

Swasth Hind

to have pains again, hut said noth­
ing because she was afraid of losing
her job. Then came fever and vomit­
ing, and she had to be admitted to
intensive care. But it was too late.
Five days later she was dead.

There may be 200,000 women
who die like this every year in deve­
loping countries as a result of illegal
abortion, one of the five major cau­
ses of maternal mortality. Some
500,000 women die each year from
causes relating to pregnancy or
childbirth, but only 6000 of these
deaths occur in the industrialized
countries. In many parts of Africa,
women have one in 14 chance of
dying from pregnancy or childbirth.
The risk is one in 18 in southern
Asia, but only one in 4000 or even
one in 10,000 in the industrialized
countries.
WHO has identified four major
areas of health care to ensure that
women may carry their pregnancy to
full term without risk:

— good nutrition and health care
for girls and women;
— family planning as part of pri­
mary health care;
— prenatal care and skilled assis­
tance in childbirth;

— access to essential obstetric care
in emergencies.

But women's health cannot really
be expected; to improve until there
is collaboration from other sectors
so that women have the opportunity
to make a free and informed choice.
For every dollar spent on health
care, 10 cents spent on biomedical re­
search and 10 cents spent on opera­
tional research, a further dollar
needs to be spent on information
and education, and yet another on
the creation of employment to gene­
rate incomes—Courtesy: WHO.

March-April 1988

WORLD HEALTH DAY, 1988
Dr H. Mahler
Director-General of the World Health Organization
Forty years have elapsed since men and women of goodwill and fore­
sight laid the foundations of the World Health Organization.
For the first time in history there would be a truly global cooperative
enterprise to protect and promote human health. Health which is rightly
defined in the WHO Constitution as not merely the absence of disease or
infirmity but as a state of complete physical, mental and social well-being.
Remarkable progress had been made in science, technology and medi­
cine. This was consolidated in the course of the first 30 years of WHO's
existence. Sufficient know-how and expertise became available to ensure
health care for all the inhabitants of our planet.
There is however a wide gulf between the health “haves’' and the health
“have nots’’. We unfortunately are still not equals in health on our space­
ship earth. For instance:
Nearly 1,000 million people are trapped in the vicious circle of poverty,
malnutrition, disease and despair that saps their energy, reduces their work
capacity and limits their ability to plan for the future.
Average life expectancy fluctuates between over 70 in some countries
to barely 50 in others.
In most developing countries, from nearly 100 to more than 200 out of
1,000 infants born alive die during their first year, although industrialized
countries have succeeded in bringing this rate down to between 10 and 20;
and even less.
Women in most poor countries have a 200 limes greater risk of dying
during pregnancy and delivery than women in a rich country.
It became a matter of equity and social justice to make health progress
available to all people through new approaches, new strategies and better
management of available resources.
Within WHO, 166 Member States are now unanimously committed to
Health for All: a strategy firmly anchored on four basic pillars:
*
Technology — not necessarily sophisticated but APPROPRIATE
technology and by appropriate I mean not only scientifically sound
but socially acceptable and economically affordable.
*
Political will to improve health so as to enable people to lead
economically productive and socially rewarding lives.
*
Health sector cooperation with other key devlopment areas such as
education, agriculture, industry and information.
*
Last, but by no means least, community and) individual participa­
tion in the quest for better health: All for Health by the Year
2000.
The Almai-Ata Declaration on primary health care, now 10 years old,
clearly mapped the road we are firmly engaged in. It is along this road
that we should go forward, all of us, men and women everywhere who are
not only the objects of development but are in fact Ute very subjects of
that development and quite particularly of health development.
Men and women active in education, agriculture, industry, information
and so many other different walks of life recognizing the mutually bene­
ficial effects of development, in harmony with the protection and promotion
of good health.
People everywhere, including top level political and spiritual leaders,
from north and south, east and west, recognizing beyond all their differences
that health is good for all people and essential for human progress. That
there is both economic value and social justice in health. Surely we must
all recognise that health is not everything, but that there is nothing with­
out health. In the interest of the human race there must be Health for
All and All for Health.

77

INSECTS, COMMUNICABLE
DISEASES AND HEALTH
Role of Government, Society
and individual
Dr P. K- Rajagopalan

There is all-out war against
such creatures as serve, un­
wittingly, as vectors of dis­
ease. Mostly these are in­
sects: the mosquitoes that
transmit malaria, filaria and
Japanese Encephalitis; the
housefly that spreads gastro­
intestinal infections like dy­
senteries,infantile diarrhoea,
typhoid and many other pa­
rasitic diseases.
Signal advances have been
made in finding ever newer
chemicals to fight both in­
sects and parasites, and to
overcome
the resistance
which such creatures invaria­
bly
develop.
Continued
efforts both governmental
and people’s participation
can safeguard human commu­
nities from the scourge of
vectorborne diseases.

78

nsects belong to Phylum arthropoda (with three pairs of
segmented legs) and as a group
pose great challenge to health and
wellbeing of mankind. They com­
pete with man for food and shelter
and in this process cause consider­
able loss not only by damaging
ci ops and property but also by
transmitting many diseases. Though
an accurate estimate of the damage
is rather difficult it can be con­
clusively stated that the impact of
insect on human health is colossal.
Insects causing annoyance, blood
loss, allergy, injury or destroying
property are commonly termed as
“Pests”. Insects which transmit
pathogens (disease causing organ­
ism) from one host to another in­
cluding man and in which a part
of life cycle of the pathogen may
be completed are termed “Vectors”.
Some of the pests and vectors im­
portant from, the health point of
view are listed in Table.

I

rectly
through an
intermediate
host (American Public Health As­
sociation 1960). The mechanisms
bv which an infectious agent* is
transported from reservoir to sus­
ceptible host arc (a) by direct or
indirect contact (b) through food
and water (c) through air and
(d) through a vector. The num­
ber of communicable diseases and
the insects causing health problem
are so large that it is not possible to
deal with all of them in this paper.
Mosquitoes and Houseflies

Amongst the long list of insects
posing threat to human health,
mosquitoes and houseflies attract
the major attention because of the
striking mortality and morbidity
caused by the diseases associated
with them. Mosquitoes in India are
directly responsible for transmitting
diseases like malaria, filaria, Japa­
nese encephalitis, dengue fever, chikungunya fever, West Nile fever, etc.
Communicable diseases are the In addition, Citlex mosquitoes are
illnesses caused by specific infec­ also found capable of transmitting
tious agents arising through trans­ other pathogens like leprosy bacilli
mission of that agent from a reser­ and hepatitis virus under experi­
voir to a susceptible host, either di­ mental conditions. It was estimated
rectly from infected person or indi­ that 304 million people are exposed

Swasth Hind

to risk of infection of filariasis and creased in recent time. They breed
38 million people are actually in close association with the man
suffering from the disease (Sharma in human and animal waste. They
et al. 1983). Similarly, incidence of are the potential vectors of several
malaria (only reported and confir­ enteric infections such as dysenteries,
med cases) in recent years shows infantile diarrhoea, typhoid, food
a plateau around two million poisoning, cholera, worm infection,
cases. In addition periodic out­ poliomyelitis and certain skin di­
breaks of Dengue, Chikungunya seases. They constantly come in
and Japanese encephalitis cause contact with the filth and food
mortality and morbidity for another thereby carry the pathogens from
million. Thus all told approximate­ one place to other. Thus their sur­
ly at least 40 million people suffer vival and capabilities of transmit­
in India due to mosquito-borne di­ ting diseases are directly linked
seases. Houseflies, on the other with solid waste disposal.
hand, help in causing many gastro­
Mosquitoes, on the other hand,
intestinal infections by mechanical­ are the most important single group
ly transmitting the disease organisms of insects in terms of public health
and millions of people particularly importance. Their survival depends
children die due to gastrointestinal on water availability and waste
infections every year in India. water disposal. The mosquito resThus the mosquito and housefly posible for transmitting bancrofcarried diseases
alone constitute tian filariasis—Culex quinquefasciabulk of the communicable diseases tus—breeds in stagnant and pollu­
thereby posing greatest challenge to ted water bodies in urban areas.
human health and comfort. These Highly polluted water rich in orga­
insects proliferate mainly due to nic matter is the ideal environment
the gross
environmental changes for this species. In urban areas they
bi ought about by man and the in­ were found breeding profusely in
vasion by these insects have been cesspits,, soakagepits, open septic
so extensive that they have be­ tanks, stagnant drains, etc. In ur­
come a part of everyday human ban areas, malaria transmitting
life. The common factor responsible mosquito Anopheles stephensi bre­
for their enormous increase is eds in clean water. The main breed­
breakdown of sanitary services ing habitats are man-made and they
due to negligence of the govern­ are cisterns, overhead tanks and
ment, civic bodies and of the peo­ wells.
ple. The reproductive potential of
Similarly, mosquitoes respon­
these insects in general is so high sible for Dengue fever (Aedes
that earlier attempts to control these aegypti) also prefer to breed in
insects without considering the eco­ clean water. The main breeding
logy and behaviour had ended in habitats are artificial water collec­
failure. The initial success achieved tions such as discarded containrs,
after the introduction of DDT was flower vases, cement tanks, tyre
dampened by the enormity of the dumps, coconut shells, ornamental
problem created by the mismanage­ tanks, etc. On the other hand in some
semi-urban areas, Anopheles culiciment of the environment.
facies and Cluex tritaeniorhynchus
The common housefly has been transmitting malaria and Japanese
a nuisance to man since time im­ encephalitis respectively breed in
memorial though their number in­ rain water pools.

March-April 1988

Role of Government in Insect
Control

Thus it is evident that the chan­
ges in the environment brought
about by man have facilitated the
proliferation of mosquitoes and
houseflies. The process of develop­
ment and industrialisation which
was supposed to improve the liv­
ing conditions of human beings are
grossly defeated by the uniscctorial planning and improper imple­
mentation of the projects. Such
unplanned and uncoordinated acti­
vity had resulted in innumerable
slums and the breakdown of sani­
tary services. The waste and wa­
ter disposal system were neither
planned nor implemented and the’
towns and cities have now become
ideal breeding grounds for mosqui-:
toes and houseflies. The agencies
mainly responsible for prolifera­
tion of these insects are Municipa­
lities, Public Works Department
and Town and Country Planning
Department. While negligence on
the part of these departments have
resulted in insanitary conditions,
no attempt was made to reverse this
trend because the major responsi­
bility for mosquito control is under
two programmes, the National Ma­
laria
Eradication
Programme
(NMEP) and the National Filaria­
sis Control Programme (NFCP).
The scientists of the Indian Coun­
cil of Medical Research had clear­
ly demonstrated in
Pondicherry,
Kheda, Haridwar etc. by Integra­
ted Vector Control technology that
mosquitoes can be controlled in a
cost-effective manner and with mi­
nimal use of insecticides. The tech­
nology aims at prevention of mos­
quito breeding through environ­
mental improvement. However, any
new technology/innovation given by
research institutions is not readily
accepted because of the reluctance

79

standing water, move it
on the part of bureaucrats and tech­ if it is
(drain
or
fill);
if it is moving water,
nocrats to change any established/
routine procedures. The personnel compress it (reduce surface area); if
of large organizations jealously it is hidden water, expose it (make
guard their traditional perquisites it accessible to control and inspec­
and privileges; except in exchange tion)” Knipe (1953). Instead of tak­
for something as good or better. ing preventive measures new plans
They rationalize their positions by with huge capital outlays are prepar­
assuring themselves that what is ed to tackle the situation and the
good for them is best for the or­ enthusiasm of the public as well
ganization. The personnel of bu­ as Government wanes after some
reaucracies are not simply carriers time. Mosquito control does not
of their organizational culture; they need any sophisticated technology
are also psychological entities nor any new department. If the
needing ego-gratification. They do sanitation is perfect, i.e., proper
not want to recognize that mos­ disposal of solid and liquid waste
quito control is basically a sanita­ neither the mosquito nor the house­
tion and water management pro­ fly would proliferate. Sanitation is
blem, the responsibility for which the responsibility of the local
lies with civic bodies, Public Works bodies and should ideally be car­
Departments and Town and Coun­ ried out by the Public Health En­
try Planning Department- The inte­ gineers. Whereas in our country,
rests of the departments responsi­ this function is being done by the
ble for construction work are sustain­ physicians. The real problem is
ed till construction is over. They masked by all sort of imaginary
are least bothered about the after­ problems. A famous malariologist
effect of such construction. In urban Dr. T. Ramachandra Rao who was
for introduction of
areas, drains are constructed by responsible
spending huge amount of money DDT in India after a life-time ex­
where water hardly flows and perience in vector control stated
mosquitoes continue to occur. One “There docs not appear to be any
cannot justify such wastage of technical or economic problem in
money and no one in the govern­ achieving a good degree of control.
ment system can be held responsi­ Urban areas are most suited for
ble. The statement made by Le- environmental improvement. What
Prince (1916) is apt to describe was lacking was the will to under­
the government’s contribution to take the programme and a certain
mosquito-breeding and we quote amount of spoon-feeding of the
“For the most’ part, man-made foci local administrations by the cen­
of mosquito breeding can be attri­ tral and state governments had
buted to the negligence and care­ taken away the initiative of the
lessness of construction engineers”. local bodies.” This is the right
Therefore if one wants to control time for handing over the respon­
mosquito, one have to control the sibility and authority of sanitation
engineers first. However, how to and mosquito control to local
control the engineers will depend bodies which also include the peo­
on the degree of political will. The ples’ representatives. Since the peo­
methodology of control is simple ple pay tax to local bodies some
and can be summarised “If it is amount of accountability can be
water, clean it (remove obstruction); ensured. Unless this is done peo­

80

ple will continue to suffer from the
vector-borne diseases while the
different departments will be shift­
ing the responsibility from one to
other.
Role of People

The pepole in India are equally
responsible for the insanitary con­
ditions creating mosquito and
housefly breeding. The indiscrimi­
nate dumping of garbage into drains
has
caused
the proliferation
of
filariasis
vector.
While
the sense of personal hygiene is ex­
cellent in average Indian his civic
sense is intolerable specially in
urban areas. People in the urban
areas are accustomed to get every­
thing done by the governmental
agency and not prepared to do
anything beneficial for the commu­
nity. This is because people in the
urban areas are heterogenous hav­
ing migrated from various places
and their social interaction is
limited. Since they migrated from
different places a sense of belong­
ing to a particular place and the
concern for the particular -place is
also missing.

However, lack of people’s parti­
cipation is mainly due to the fact
that the programme does not take
into consideration people’s priority
at the time of designing of pro­
gramme. Having designed the pro­
gramme various departments ex­
pect that the people should tow
their line which can by no means
be called "people’s participation’.
What is expected from the indivi­
duals of the community to lessen
the mosquito and housefly menace
are:
1. Refrain from throwing solid
waste into the drainage sys­
tem which would block the
drain and create mosquitogenic
condition.

Swasth Hind

TABLE

Some important insects and the diseases they transmit
Insect

Disease '

Causative agent

Housefly
(Musca domestical

Typhoid
Cholera
Dysentery
Dysentery
Amoebic Dysentery
Leprosy
Tuberculosis

Salmonella typhosa
Vibrio cholarae
Shigella dysentriae
Escherichia coli
Entamoeba histolytica
Mycobacterium leprae
Mycobacterium tiiberculae

Lice

Louse borne typhus
Relapsing fever

Rickettsia prowazekii
Spirochete

Bancroftian Filariasis
West Nile fever
Japanese encephalitis

Wuchereria bancrofti
West Nile fever virus
Virus

Mosquitoes
Cukx

Manson ia

Brugian Filariasis

Brugia malayaii

Anopheles

Malaria

Plasmodium

Acdes

Dengue fever
Chikungunya

Virus
Virus

Sand flics

Kala-azar
Sand fly fever
Bartonellosis or Oraya fever

Leishmania
Virus
Bartonella bacilliformis

Culicoides

Filariasis

Mansonella

Mango flics (Chrysops)

Loaiasis

Loa loa

Flea

Plague
Murine typhus

Yersinia pestis
Rickettsia typhi

2. People keeping cattle should
not dispose of solid waste
material into drain but dispose
of as per civil regulations.

3. Construction of any kind of
structure over the drain which
will hamper cleaning and
maintenance of drain should
be avoided.

•

7. Seek advise from the local
bodies regarding
drainage
outlets prior to construction
of house, and should strictly
follow the regulation.
8. If they own a low-lying plot
accumulating water, it should
be filled up to a level so
that water accumulation does
not occur.

4. Screening/hermetical sealing of
septic tanks and unused wells
should be done
by house­
owner.

0. Cooperate
with the
local
bodies and extend all help to
serve people.

5. Individuals should check for
container
breeding in and
around the house and empty
them at least once a week.

10. If there is any water body
or any other breeding habi­
tat
creating health hazard,
the local authorities should be
informed.

6. They should not dig any pit
which may form permanent
breeding source for mosqui­
toes. .

Our experience in Pondicherry
clearly shows that given proper edu­
cation
people's
participation is
not difficult to attain. However.

March-April 1988

if the local bodies fail to recipro­
cate the people may get frustrated
and cease to participate. For exam­
ple if people complain about some
unhygienic condition
government
should take it up in the right spirit
and rectify the deficiencies as early
as possible, but if the government
fails to do so people would stop
complaining. Similarly, if garbage
is not removed daily from pub­
lic dustbins people would revert
back to the old practice of dump­
ing them here and there. The local
bodies are apathetic generally to
such demands from public and
there is no accountability. Thus the
first and foremost thing to be done
is- to reduce the number of orga­
nizations responsible ’for mosquito
control to a single authority at the
local level so that there can be
some accountability.
<

81

INDIA : HEALTH PROGRESS AT A GLANCE
Dr (Smt) D. Lahiri
I^eing a signatory to the Alma-Ata declaration of providing health for all by 2000 A.D., the Government of
India has launched a number of programmes to attain this goal of health for all and a net reproduction rate of
unity by 2000 A.D. Emphasis has been on providing comprehensive primary health care services and family welfare
services to the masses specially those who are living in the rural areas. Preventive and Pro motive aspects of health
services are being continuously augmented. Special emphasis has been on maternal and child health care in general
and for reducing infant mortality in particular by providing immunization against the six common childhood
diseases - -Diphtheria, Tetanus, Poliomyelitis, Tuberculosis, Measles and Whooping Cough--all preventable
diseases. The Universal Immunization Programme has been launched in a number of districts with the aim to cover
all the districts in the country by 1989-90. The programme is expected to further reduce infant mortality which
is 96 per thousand livebirths at present. National programmes to further reduce incidence of malaria,
goitre, T.B., prevention of blindness etc. have been in progress. Special inputs have been provided to improve the
health care and family welfare services. Population norms have been relaxed fcr providing sub-centre and
primary health centre for a tribal population. Similarly, to benefit the scheduled castes attempts are being made
to locate health and family welfare units in or the areas adjacent to the locality inhabited by scheduled castes.

The expectation of life at birth is more than 58 years (in 1986) and death rate has declined te’l1 • 1 per thousand
as a consequence of better health services now available to the community. Facilities for earlier diagnosis and
treatmeat of the killer diseases like cancer are also being provided throughout the country. The figures given below
indicate the progress made towards better health during 40 years of Independence.
1951

1961

1971

1981

1985

1986

361-09

439-24

548-16

685-19

752-01

776-34

39-9

41-7

36-9

33-9

32-7

•32-4f

27-4

22-8

14-9

12-5

11-8

11-lf

(c) Life Expectancy at Birth (in years) •
(i) Male ..................................................
(ii) Female ••••••

32-45
31-66

41-89
40-55

46-40
44-70

54-1*
54-7*

N.A.
N.A.

58-1
59-1

(d) Infant Mortality Rate (per 1000 live births)

146

146

129

110

97

96f

61840
1-7(5)
2694
6515

80084
l-8@
3094
9406

151129
2-7(51
3858
9087

268712
3’9(5)
6804
16751

306966
4-1(6)
7474
255S4

7748
25870

3-2

5-7

6-5

8-3

8-7

8-8

725

4631

5112

5740

7284

12269**

28489

51405

82946

90317

10-4

22-8

32-1

34-9

89-5
51-7

80-6
85-3

72-3
90-3

57-9
123-8
90-53
86-10

108-1
93-9
81-81
III -8

78/6
6/- 8
75-8
85-4

I. Population
(i) Population in millions

.

.

.

.

(a) Birth rate (per 1000 population)

(b) Death rate (per 1000 population)

•

IL Health and F.W.
(i) Registered Medical Practitioners (Numbers) •
(ii) No. of Hospitals
.
.
.
.
.
(iii) No. of Dispensaries •
•
(iv) Beds (all types) i.e., Hospitals, Dispensaries,
PHCs, Clinics etc. per 10,000 population

IM. Primary Health Centres
IV* Sub-Centres

•

.....

..................................................

V. Effective Couple Protection (percentage)

VI. Immunizations Status
(% achievement of targets fixed)
T.T. (for pregnant women)
....
T.T. (for school children)
10 years .......
J 6 years
.......
D.P.T. (Children below 3 years) •
Polio (Infants) •
|•
•B.C.G. (Infants)
•
•
DT (new school entrants 5—6 years)

•
•

•

•
1

NOTE-; 1980, ♦♦Includes PHC’s and si bsidiaries centres, @per, 10,000 population. fProvisional
Population figures for 1985 and 1986 are projected figures. The IMR was 146 between 1951 and 1961
Source : Hand Book of Health Information of India—1987 (in press).

82

Swasth Hind

HEALTH FOR ALL-ALL FOR HEALTH
A Primary Health Care Approach
,

Dr (Smt) V. K. Bhasin

Health for All by 2000 A.D. is a lofty goal and a challenge. It is possible to reach this goal by
re-ordering priorities and full utilization of present and potential resources. The challenge is in
creating health consciousness through health education among people and make them understand
that health is more a result of personal efforts than any other factor. And that is individual parti­
cipation by each and every person.
Health
means giving people a positive
sense of health so that they can
make full use of their physical,
mental, and emotional capacities.
This is well understood in India
-by the planners, administrators and
programme
implementers.
The
theme highlights the goal of
‘Health for All by the Year 2000’
on the one hand and emphasises
the fact that we all have indivi­
dual and collective responsibilities
for maintaining health
through
healthy lifestyle, personal hygi­
ene and maintenance of healthy
ealth for All—All for

H

84

clean environment and the judici­
ous use of appropriate health tech­
nologies locally available-

India is celebrating the 40
years of its Independence. And
Health for All by the year 2000
is the goal to which we are fully
committed. The theme for the
Day is significant for us to inform
and educate people about their roles
and responsibilities in the achieve­
ment of this goal.
There are about
13 years to
achieve the goal of Health
for
All by 2000 AD. India being a

signatory to the Alma Ata declara­
tion is committed to achieve the
goal by that time. The country
witnessed significant progress in
health and family welfare work
since Independence in its march
towards the goal of health for all.
Healthy life style

Almost everyone who is born
comes into this world endowed
with nature’s most generous gifts
for survival, growth and adaptibility.

Healthy jiving begins at home.
What does the family eat and

Swasth Hind

drink? What rules of hygiene do
they observe?. What do they do in­
times of illness? How safe is the
home? These must form the con­
cerns of every family and no efforts
must be spared to make the home
a healthier and safer place to live
in..

personal hygiene, (2) environmental
sanitation, (3) safe drinking water,
(4) healthy habits for safety, (5)
balanced diet,
(6) immunization,
(7) small family, (8) maternal and
child health, (9) healthy youth and
their’ role.

The health of an individual, a
family, a community and a nation
depends for the most part on fac-'
tors within the purview of the in­
dividuals and the community. Per­
sonal responsibility covers a wide
area in the promotion of healthy
life style. Individually, one can
take steps to improve his/her
health by taking balanced food;
using safe drinking water and pro­
tecting it from contamination; re­
gular exercise; practising personal
hygiene and keep the house, sur­
roundings and place of work clean.

Maternal and child health

Community on its part can create
facilities for better upbringing of
.children and youth; take steps to
prevent and control communicable
diseases; arrange for facilities for
holding sports events and regular
exercise; encourage the use of lo­
cally available inexpensive nutrious
foods; change the social norms of
■smoking and drinking, and thus
promote healthy living. Commu­
nity can also organise health ser­
vices and can ensure full utilization
of the available health services.
The role of the Government will
become much more pointed for the
development of health of the peo­
ple, if the people themselves are
conscious and alive to their res­
ponsibilities for maintaining and
promoting health, and prevention
of communicable diseases. The
active participation of the people
individually and as a community
in health programmes is a must for
ensuring healthful living.

Some of the basic points
for
promoting healthy living- are: (1)

March-April 1988

In spite of expansion of the
health infrastracture and educa­
tional programmes in the country,
the knowledge about health and
nutrition education and child rear­
ing practices continues to be quite
low; particularly in rural areas.
Mothers and children together
form a very vulnerable group in
society. Though pregnancy and
child birth are physiological pheno­
menon, women have to undergo
stress and strain and as such need
special care. Chidhood is the
growing period and hence, chil­
dren need special care. The mater­
nal and child health services are
provided as a part of total health
care to the community through the
existing infrastructure in rural and
urban areas. The health infrastruc­
ture is gradually being expanded to
reach the population as close to
their doorsteps as possible. As
child-survival is a key factor con­
tributing to promotion of Planned
Parenthood. Ministry of Health
and Family Welfare, Government
of India have sponsored in a big
way ’ the immunization schemes
against nutritional anaemia among
mothers and children and prophy­
laxis against blindness due to Vita­
min ‘A’ deficiency.

• The immunization services are
provided, through existing health
care delivery system and there is
no separate cadre of field workers.
The services are available in hospi­
tals, dispensaries and MCH Clinics
in the urban areas and the Primary

Health Centres (PHCs) and Sub­
Centres in the rural areas.
The
health workers also organize out­
reach sessions in the sub-centres
and villages which are not within
easy reach of the health centres.
The immunization services are be­
ing intensified more, rapidly to
meet the
objective of universal
coverage of all eligible infants and
pregnant mothers. In the 7th plan
period, it is planned to cover 82
million infants with 3 doses each
of DPT and Polio vaccines and
one dose each of BCG and
measles. Measles vaccine has been
introduced in the programme in
1985-86. It is planned to immuni­
ze over 50
million infants with
measles immunization by
1990.
More than 93
million expectant *
mothers are likely to receive pro­
tection against tetanus by TT vac­
cination services as part of the
ante-natal care.
The universal immunization pro­
gramme launched in
November,
1985, is operating in 92 districts.
Additional 90 districts have been
taken up in 1987-88. Our aim is
to cover all the districts in the
country by 1988-90. The universal
immunization
programme is ex­
pected to further
reduce infant
mortality which is 95 per thousand
live births at present.
Primary health care approach

We have adopted the primary
health care approach that seeks
to provide universal, comprehensive
health care services relevant to the
actual needs and priorities of the
community. The health and family
welfare services are being provided
to the people through the length and
breadth of the community via 12,314
primary health centres; 89,815 sub­
centres; 1.85 lakh
multi-purpose
workers of which about one lakh
are females; 3.9 lakh trained health
guides and 5.45 lakh trained dais.

85

Healthy youth our best resource

WHO’s fortieth anniversary selected as
the World’s first ‘NO-TOBACCO DAY’

Young people between the ages
of 10 and 24 are not so much ex­
posed to disease as to health pro­
blems which are the result of beha­
viour characteristic of this age group.
Wednesday, 7 April, 1988, the day marking the fortieth anniversary
They constitute a substantial and of the World Health Organization, will also be celebrated as the world’s
growing proportion of our popula­
first no-tobacco day.
tion. Despite the over-all progress
in various fields, the majority of
This follows a resolution adopted in May 1987 by' the Fortieth
young people lack access to educa­
World Health Assembly aimed at curbing tobacco*related disease, the most
tion, employment opportunities and
preventable cause of death and suffering world*wide. The resolution, des­
health care.
cribed by one of the delegates who sponsored it as a “moral appeal”, is
Young people is our best resource addressed to the mass media, manufacturers and vendors of tobacco as
to promote healthly living and can well as to governments. “There is nothing in the text of regulatory nature”.
contribute significantly to improve the delegate emphasized.
the quality of life of our people. Their
participation in matters of develop­ To mark WHO’s anniversary:
ment of personality, health, creative
— The world’s print and electronic media are asked to “voluntarily’’ refuse
activities, social services and other
advertisements, if not indefinitely, then at least for one day.
developmental and welfare activities
— Manufacturers of tobacco, and advertisers, are asked to “refrain volun­
is of utmost importance.
Schemes
tarily from all publicity in all countries, especially in developing coun­
like National Services Scheme (NSS)
tries
”.
and Nehru Yuvak Kendras are
— Vendors are asked to “refrain voluntarily from selling all tobacco that
aimed at building up our young
people towards voluntarly dedicat­
day”.
ing to the cause of social and econo­
— Governments are asked to “encourage the population, by all appropriate
mic development of the country.
means, to desist from smoking and using tobacco in all other forms”—a
reference to the growing addiction to smokeless tobacco.
Healthy mind, healthy body
These countries sponsored the resolution: Algeria, Australia, Belgium,
If health is more than the mere
Canada,
Iraq, Jordan, Kuwait, Lebanon, Oman, Qatar, Sudan, Sweden and
absence of disease, then mental
the
United
States of America.
health is more than simply the ab­
sence of mental disease. Mental
and physical health are inexorably
linked—sickness and disability can
upset the delicate balance of the
mind just as mental illness can lization in the country has given rise
Many health problems have their
affect physical health.
It follows, to mental and emotional problems
roots
in various aspects of commu­
therefore, that if we can improve our especially among our young people.
nity
life
and cannot be influenced by
bodies through health care and They are likely to suffer from drug
medical
or
health intervention alone.
healthy behaviour, this will have a addiction, alcoholism, neurosis delin­
Safe
and
potable
water is not avai­
salutary effect on our minds.
If quency and other behavioural pro­
lable
to
the
majority
of our popula­
we learn to cultivate a more positive blems.
tion.
Many
of
the
water borne
approach to the stress and crises of
diseases
are
preventable
but the im­
To
tackle
these
problems
there
is
daily life, this in turn will protect
portance
of
the
use
of
pure
and safe
a
need
to
improve
mental
health
and enhance our physical health
water
as
well
as
personal
hygiene
education
of
our
people
and
also
to
and our bodies.
strengthen the facilities for the treat­ are not properly appreciated. En­
Distortion and disruption of our ment of mental and other health vironmental sanitation is very poor,
traditional social system in the wake problems, rehabilitation centres and. particularly in rural areas and in
urban slums.
of rapid urbanization and industria­ counselling services.

86

Swasth Hind

About 80 per cent of al! diseases
in the developing world are linked
to unsafe water.
These diseases
include cholera, typhoid, dysentery,
diarrhoea, guincaworm, infective
hepatitis, etc.
People themselves
should take the responsibility for the
supply of safe drinking water to the
community by protecting the water
supply to the area.
The best
method to make water potable is to
boil it or purify by using chemical
disinfectants like bleaching powder.
The community should be educated
about the importance of proper
maintenance of water resources,
simple means of purification of water
and the use of safe water.
Obser­
vation of personal hygiene should
be emphasised.

Sanitary latrines and uninals are
of high priority for healthy living.
Diseases like diarrhoea, dysentery,
typhoid, cholera, polio, jaundice
(infective hepatitis) and worm in­
festation can be controlled if our
surroundings are healthy and clean.
This can only be achieved if we all
get interested in healthy living and
take a lead in improving our own
lot.
Safety against accidents

Accidents at home arc due to a
variety of causes.
The most fre­
quent causes are burns and accidents
involving children.
Accidents in
homes, factories and farms as well as
road accidents each year are respon­
sible for much morbidity and mor­
tality.
These can be prevented
with a little extra care on the pari
of adults in the family. Persons in
old age are also more prone to acci­
dents.
Falls are very frequent in
old age due to failing eyesight and
poor mobility on account of pain in
the joints. Women, while prepar­

March-April 1988

ing the food, and young children
unaware of the danger, arc especial­
ly at risk. It is, therefore, essential
to keep the children away fron. the
kitchen.
All objects which can
harm children should be kept out
of reach. Some measures are also
necessary to prevent falls, burns,
fractures, etc.
Good food and proper nutrition

Nutritional deficiency stares of
varying degrees in regard to proteincalore malnutrition, Vitamin A and
iodine deficiency
and nutritional
anaemia are prevalent in a wide sec­
tion of population.
Nutritional
deficiency states are particularly
noticeable among pregnant and
nursing mothers, and in infants and
children.

The underlying causes of all these
forms of malnutrition are closely
linked to home and family beha­
viour, though an ever present milieu
of social, cultural and economic fac­
tors frequently make it very difficult
to change nutrition-related home be­
haviours including faulty feeding
practices.
Healthy people are less likely to
become victims of disease than those
already weakened by malnutrition.
Therefore, first key to good health
is better nutrition.
Governmental efforts

Our Government is committed to
achieve the goal of health for all
by 2000 A.D.
In this context,
the primary health care approach
has been given priority in the pre­
sent health policy.
The emphasis
is control and prevention of com­
municable diseases, nutritional pro­
blems, treatment of common ail­
ments and injuries and supply of

essential drugs.
ft also lays stress
on environmental sanitation, provi­
sion of safe water, maternal and
child health including family plan­
ning. ‘ immunization programmes.
and supply of essential drugs.
The importance of preventive
measures and health education has
been recognised bv our Government.
These are being promoted through
all ongoing health programmes. A
wide range of media are being utili­
zed to disseminate useful health
knowledge and information. Radio
which reaches 80 per cent of our
population is being utilized for edu­
cation programmes. All local com­
munication channels, leaders, exten­
sion workers and teachers are also
involved in promotional aspects of
different programmes.

Our objective is to see that the
vast masses of the people, including
those in far-flung areas understand
the concept of better health, and
know the importance of safe water
and of maintenance of clean environ­
ment and of their own health.
Health messages have, therefore, to
percolate down to every segment of
people through all media channels
available so that people change their
way of living and keeping health
becomes a habit.

Health for All by 2000 A.D. is
a lofty goal and a challenge. It is
possible to reach this goal by re­
ordering priorities and full utiliza­
tion of present and potential resour­
ces.
The challenge is in creating
. health consciousness, through health
education among people and make
them understand that health is more
a result of personal efforts than any
other factor. And that is individual
participation by each and every
person.
<

87

Community participation in the
control of vector borne diseases
—A national experience
N. L. Kalra
AND

Dr M. V. V. L. Narasimham

Vector-borne diseases continue to take a heavy toll of human life and health despite many
disease control programmes. But no disease control programme can succeed unless commu­
nity accepts these programmes as their own programmes and not that of the government only.
ector borne diseases continue to

V

take a heavy toll of human life
and health in spite of many disease
control programmes. The AlmaAta Conference in 1978 look stock
of failures and inequalities in health
care and the costly and sometimes
inappropriate services provided un­
der the different control strategies
for vector borne diseases. Very often
these strategies also ignored the so­
cial and economic origins of ill hea­
lth- The deliberations brought out
that Government’s effort alone in
future will no longer be sufficient
unless communities involved them­
selves actively for their own protec­
tion. To meet these challenges, the
Conference recommended Primary
Health Care approach which would
place more value on equity and jus­
tice in the use of existing resources
and self-reliance in individual and
community participation.

To develop greater community and
individual participation in the control
of vector-borne diseases the WHO
Expert Committee (Seventh report of
the WHO Expert Committee on

88

vector biology and Control,—WHO
Technical Report Series, 688, 1983.)
envisaged community participation
as “a process whereby individuals,
families and communities are involv­
ed from the beginning in planning
and implementation of the vector
control programme as well as of local
vector-control activities so as to en­
sure that the programme and its
activities meet the local needs and
priorities become shaped around
people’s life styles and patterns and
promote community self reliance
with respect to development”.
In this article an attempt' has been
made to highlight the magnitude of
vector borne diseases in India and
the degree of success achieved for
their control through Primary health
care approach with community parti­
cipation.
Magnitude of vector borne diseases
in India
The important vector borne dis­
eases in India are malaria, filariasis,
dengue/dengue haemorrhagic fever
(D/DHF), leishmaniasis (Kala-azar),
Japanese Encephalitis (JE) and gui­
nea worm.

Malaria.—Malaria has been recog­
nised as a major public health pro­
blem. The annual incidence of mal­
aria at the time of independence was
estimated at 75 million cases with
0.8 million deaths. In other words,
every fifth person used to get mala­
ria during the course of year and
mortality rate was one per cent of
the total cases. During the epidemic
year, the mortality and morbidity
were nearly double. Presently, 93
per cent of the population (of 776
million) is at risk of malaria as per
1987 data.
Filariasis.—As per current esti­
mate, nearly 342 million people are
exposed to the risk of Bancroftian
filariasis; of these 251 million people
live in rural areas and 91 million
in urban areas. About 24 million
people are estimated to be harbour­
ing microfilaria and 18 million people
suffer from different clinical mani­
festations of the disease.

Dengue I Dengue Haemorrhagic Fe­
ver.—-India is endemic for classical
dengue* The vector species is main­
ly confined to large towns/cities

Swasth Hind

and is widespread in Indo-Gangetic
plains, north-western plains, eastern
coastal areas and river valleys. India
recorded a series of outbreaks be­
ginning in 1956 and the latest occu­
rred in Maharashtra in 1986.
Japanese Encephalitis.—Prior to
1970, cases of Japanese encephali­
tis (JE) were recorded from ‘South
India’, however, since 1973, large
scale outbreaks of JE began to occur
in northern and north-eastern part
of the country and 3000 to 4000 cas­
es were annually reported in 1986.
During 1986, three districts in Uttar
Pradesh were affected recording 1773
cases with 616 deaths.

Guineaworm.—Guineaworm
is
endemic in six States in India. An­
nually about 30,000 cases are report­
ed yearly and a population of about
6 million is at risk of infection.
Current Vector Borne Diseases
Control Programme (VBDC)

There are three national disease
control programmes in India, name­
ly National Malaria Eradication
Programme, National Filaria Con­
trol Programme and Guineaworm
Control Programme- For other vec­
tor-borne diseases, there are no na­
tional programmes but the Dte. of
NMEP is given the responsibility
for monitoring of these diseases and
advise control measures to the State
Governments and local bodies.
1. National Malaria Eradication
Programme
(a) Rural malaria: In India,
NMEP was implemented through a
unipurpose organisation in 1958 and
by 1965 a total of 0.1 million
cases were recorded with no deaths.
Thereafter the country experienced
a resurgence of malaria, with a re­
cord cases of 6.4 million in 1976.
Since 1977, the Modified Plan of
Operation was launched through
Primary Health Care as per natio­
nal directive to undertake compre­
hensive health care services includ-

March-April 1988

(CHEB Photo)
Presently
,\93
per
cent
of
the population
Malaria is a major public health problem.
(of 776 million) is at risk of malaria as per 1987 data. Photo shows a blood slide
being taken from a fever case.

ing disease control activities. The
important operational component of
the new strategy included—
(i) Decentralisation of epidemio­
logical surveillance activities at
PHC along with laboratory
services under Multipurpose
Scheme (MPW).

(ii) Spraying of insecticides in
areas with 2 API and above,
with provision of limited sp­
ray in areas with API less
than 2. (API = Number of
confirmed Malaria cases in
1000 Population in an year).

population on nominal hono­
rarium basis. It was envisaged
to provide both preventive
and curative services for
minor ailments and for pro­
moting public participation
in health programmes.

(iv) Health Education material is
displayed at prominent places
in villages, dispensaries, post
offices/ schools and other pub­
lic places. Health Education
efforts are being promoted
through television, radio, postal
stationery, wall posters, photo­
graphs, cinema slides and
feature films.

(iii) Active community participa­
tion through Drug Distribu­
(b) Urban Malaria: Urban mala­
tion Centres (DDCs) and Fever ria scheme was launched in 1971. It
Treatment Depots (FTDs)
is now operative in 127 towns
managed by school teachers/ spread over 17 States
and two
village heads, health workers. Union territories.
Main thrust
farmers on voluntary basis. for malaria control in urban areas
It was further augmented by included—
appointment of Village Health
■ (i) Recurring antilarval measures
Guides drawn from within the
on weekly basis and
communities for every 1000

89

(ii) Seeking community participa­
tion in proper management of
water storage practices in do­
mestic / peridomestic situation
to prevent breeding of vector
mosquitoes.
As a result of implementation of
Modified Plan of Operation, mala­
ria positive cases declined from
6,467,215 in 1976 to 1,733,855 in
1986 and the total P. falciparum
(Pf) cases for the same period from
153,713 to 600,228 indicating a re­
duction of 73*2 per cent in total
cases and 20.4 per cent in P.f cases.

(ii) Active case search twice a year
and management of cases with
drugs/dressing of ulcers.
(iii) Vector control with temephos
and
(iv) Community Health Education*
The programme brought down
cases of guineaworm from 39,782 in
1984 to 23,070 in 1986.
Community Response to V.B.D.C.
Programmes
Despite the fact the VBDC Pro­

grammes have been meticulously
planned and executed but the re­
sults are not forthcoming to the tar­
geted levels. Number of committees
In urban areas 72 towns (65.4 per appointed by the Government have
cent) showed decline but metropoli­ reviewed the situation and have re­
tan cities showed increased incid­ peatedly found that while part of
ence.
the failure could be attributed to
technical, financial and administrat­
2. National Filaria Control Pro­ ive constraints, but the major obst­
gramme
acle has been the lack of “commu­
National Filaria Control Progra­ nity participation”.
It has been the frustrating experie­
mme was launched in 1955. At pre­
nce
of the disease control organi­
sent 40 million population is being
protected through 199 control units* zations that the tasks which require
The anti-filarial measures include— domiciliary visits, or treatment of
houses with insecticidal spray or
(i) Recurrent antilarval measures checking of breeding containers
on weekly basis.
indoors have to face high refusal
(ii) Anti-parasitic measures using rate at the hands of the commun­
ity. These refusals may be due to
DEC through night clinics.
many reasons, i*e., fear of theft,
(iii) Seeking community participa­ orthodox attitudes towards killing
tion with, emphasis on build-up of mosquitoes, inconvenient timings
of healthy environment by of visits by field staff for example
proper disposal of domestic in tribal areas, spoiling of furniture
sullage.
and other articles due to residual
spray, fear of harm to some cottage
These measures where in opera­
industries, vfe., silkworm, loosing
tion over five years, have resulted faith in the efficiency of DDT in
in marked reduction in microfilaria control of pests as evinced by incr­
rates.
eased population of bed bugs and
3. Guineaworm Eradication Pro­ scores of other reasons. In urban
setting, where most of the breeding
gramme
potential is man-made is largely
contributed
due to lack of intersec­
A country wide Guineaworm Era­
toral
coordination
between various
dication Programme was launched
developmental
agencies,
and casual
in 1982. Strategy adopted included—
attitude of communities particularly
(i) Provision of safe drinking those belonging to lower socio-eco­
nomic groups towards health and
water supply.

90

its environments. Sometimes prob­
lems are allowed to persist
(e.g.1
grass farms, sullage lakes, etc.) for
some personal monetary benefits*
Under these conditions Government
efforts for control of diseases cannot
succeed unless the individuals, fami­
lies and the community at large be­
come active partners rather than
passive spectators on sustained
basis.
“People’s Health in People's hand”—
measures for enhancing community
participation

It has increasingly become clear
that no disease control programme
can succeed, unless the community
accepted these programmes as their
own programme and not that of the
Government only. Therefore, it is
not only essential for'the control
organization to understand the needs,
attitudes, convictions and response
of the communities but should also
offer simple, culturally appropriate
and economically feasible strate­
gies for vector control. To achieve
the above objectives the following
suggestions could profitably be
pursued:

(1) Health Education
Health Education in the present
context amounts to throwing the
idea to the public through the media
of T.V., radio, film shows, exhibi­
tions, wall posters, cinema slides and
by publishing do’s and don’ts thro­
ugh newspapers, like annual rituals,
during the transmission season/mos­
quito abundance. This may lead to
the acceptance of the idea but not
necessarily their participation. The
community participation requires
highly skilful approach.
Health
educators must first learn culturally
regulated behaviour of the commu­
nity, their beliefs, and traditional ap­
proach to the health problems* New
health packages technologies offered
should be simple, should fit into
their culture, cost effective, have so­
cial and psychological support and

Swasth Hind

should be equally satisfying and
must not conflict with the old re­
medies. Such an approach will go
a long way in removing the suspi­
cions of the community on the one
hand and help in knowing the needs
of the community on the other, so
-that programme’s efforts can be
tailored in such a manner where
the community can take active inte­
rest and fully participate*
(2) Inter-sectoral Coordination
“Source reduction” which is the
simple important method of vector
control, stipulate cooperation and
coordination of various developmen­
tal agencies. For achieving cohe­
sive inter-sectoral co-ordination,
there is a need for forming functio­
nal administrative and technical co­
mmittees. The task of such com­
mittees is not only to find remedial
or corrective actions of the existing
problems (short term actions) but
also to draw development plans in
such a manner that these do not ge­
nerate mosquitogenic conditions or
modify the environment to the ad­
vantage of the community. This
calls for continuous monitoring of
the existing problem as well as new
projects by the joint technical com­
mittee comprising of engineers and
public health experts and members
of community for whom the projects
are being formulated.

to secure entry into the houses for
insecticidal spray. In metropolitan
cities there exist additional measures
under Municipal Corporation Act
for the control of breeding of mos­
quitoes of malaria and filaria.

(4) Health fairs
Face-to-face education is much
superior to television and media
appeals. The above approach has
been successfully tested in Singapore
where the Health Ministry’s training
and health education department or­
ganised health fairs. Fair features
included tests of height and weight,
blood pressure, blood sugar, carbon
monoxide and lung capacity tests
for smoker and breast self-examina­
tion teaching for women. Such fairs
can be organised by the department
of health and family welfare in con­
sultation with community leaders
and supported by welfare organiza­

tions. This results in increased he­
alth consciousness and greater know­
ledge about what makes a healthy
way of life.

Public sector/multinational com­
panies engaged in manufacture of
insecticides for use under public
health programmes can take active
part in such health fairs. These com­
panies spend huge sums on sales
promotion programme. Instead of
spending money on sales promotion
these companies
should suitably
draw health education programme
with active support of social scien­
tists for the rural masses to accept
insecticidal spray as advocated by
the programme managers. The im­
proved insecticidal coverage of the
houses will not only help in achiev­
ing the desired targets of disease
control programme, but will also
generate more demand for their
products.
<

STATEMENT ABOUT OWNERSHIP AND OTHER PARTICULARS ABOUT
NEWSPAPER SWASTH HIND TO BE PUBLISHED IN THE FIRST ISSUE
EVERY YEAR AFTER LAST DAY OF FEBRUARY
FORM IV

1. Place of Publication
2. Periodicity of its publication
3. Printer’s Name
Nationality
Address

(See Rule 8)

New Delhi
Monthly
Manager
Indian
Government of India press, Coimbatore
(Tamil Nadu)

(3) Legislation
For the success of any public he­
Dr. (Smt) V.K. Bhasin
4. Publisher’s Name
Nationality
alth programme, health education
Indian
Address
has limitations in overcoming pub­
Director,
Central Health Education Bureau,
lic apathy and ignorance and to elicit
Directorate General of Health Services,
public cooperation, legislative mea­
Kot la Marg,New Delhi-110002
5. Editor’s Name
sures, therefore, achieve significance
Nationality
Shri N.O. Srivastava
in implementation of the programme
Address
Indian
not only during emergencies but also
Central Health' Education Bureau,.
the punitive clauses create the much
Directorate General of Health Services
Kot la Marg, New Delhi-110002
desired fear psychosis to keep the
6. Name and address of individuals
who
own
the
newspaper
and
partners
environment neat and clean to desir­
Nil
or shareholders holding more than
able limits. There exist legislative
one per cent of the total capital
provisions under the Epidemic Dis­
I, Dr. (SmO V.K. Bhasin, hereby declare that tho particulars given above are true to
eases Act, dealing with elimination the best of my knowledge and belief.
of potential breeding places within
New Delhi
23 Feb. 1988
Dr. (Smt) V.K. Bhasin, Director.
specified time and manner and also

March-April 1988

91

THE CHALLENGES WE FACE
C. R. Krishnamurthy
The challenges in public health are both qualitative and quantitative.
Quantitatively,
we must in the next 13 years create, organise, and set in motion health services that will
double the coverage of what has been reached today. The qualitative challenge is even more
daunting and reflects the changes in social and economic terms; in terms of ecology,
and patterns of morbidity and mortality.
We have to search for new approaches.
HE mission and purpose of change. Leadership is
the link
social philosophy is not to between thought and action. It is
explain the world but to . trans­ a catalyst. The function of leader­
form it. The world consists cf ship is to steadily increase the
nature and society. Man is a so­ awareness of the people and to
cial being with independence and enlist their unexhaustible energy
creativity.
Independence means and creativity to the maximum in
that man extricates himself from the implementation of a social phi­
the shackles of the world and do­ losophy.
minates it. Creativity means that
The challenges in public health
man transforms the world with full are both qualitative and quantita­
aim and proposes and creates new tive
Quantitatively we must in
things.
Independence and creati­ the next 13 years create, organize
vity for transforming nature and so­ and set in motion health services
ciety are the essential features of that will literally double the cover­
man’s existence and activity. In­ age of what we have been able to
dependent consciousness and crea­ reach today. The qualitative chal­
tive ability belong only to man. lenge is even more daunting and
They are social products. Man is is a reflection of the changes in
not born with them but acquires social and economic terms; in terms
them in social relations through of ecology and in terms of the
the practical struggle of transform­ patterns of morbidity and morta­
ing nature and society. As inde­ lity. The health system must deal
pendent consciousness and creative with a population which is geo­
ability developed by the preced­ graphically and eventually becom­
ing generations are transferred to ing more urbanized and in which
new generations through educa­ the ratio of the elderly is increas­
tion, we call them social products. ing. We have, necessarily, to search
As an independent being is a so­ for new approaches.
We must
cial product, it cannot be won initiate a process of profound
individually. It is only when peo­ change in the health system and
ple fight with concerted efforts col­ its relation with the social, politi­
lectively can they defend their in­ cal and economic environment. The
dividual independence which can current approaches and trends are
be preserved through the struggle sure guarantees for disaster with in­
for public interests, not for indi­ calculable repercussions.
vidual interests.
It is unavoidable that health
The objective is to change the system be organised in accordance
world. People are the instruments with the principles and values for
and motive force to achieve the Health for All and Primary Health

T

92

Care (PHC), equity, social justice,
universal coverage, participation
and efficiency.
Extreme poverty
and disparties in access to - health
care services among different so­
cial groups must be reduced.
Health services must be oriented
to permit each individual to live a
socially and economically produc­
tivity life. The need for community
participation extends to involve­
ment of the community in decision
making and control of activities.
Efficiency demands that we halt the
waste in health systems—estimated
at rough 50-60 per cent. This
waste involves uncoordinated and
duplicate services offered by diffe­
rent institutions and systems, orga­
nisational deficiencies, use of inap­
propriate technologies,, idleness of
costly equipment etc. There is also
inefficiency in recruitment and ma­
nagement and personnel with ab­
solute feudal attitudes which gene­
rate underground resistance or
open confrontation.
There must
be revision of the way health is
integrated in social—economic de­
velopment and health must change
its image of a ‘non-productive
sector’.
Thus, this qualitative and quan­
titative challenge we face requires
mobilization of political will. It re­
quires the search for the opportu­
nities and ways to deliver a dean,
precise message in a spirit of col­
laboration, to all political and so­

Swasth. Hind

cial sectors.
The message is that
health is the concern of everyone
for everyone; that health is not
the last wagon but in fact the lo­
comotive for human energy which
drives on the tract' of development.
Challenge before leaders
The challenge of redefining and
modernizing health system cannot
be met without leaders at all levels
who will promote and . cultivate
the search for social and human
excellence. The efficacy and effi­
ciency of socio-economic policies,
particularly those pertaining to
health are determined by the ca­
pabilities of those charged with the
conception and execution of those
policies. Leadership has many fa­
cets. It includes the patient and
persistent struggle to form coali­
tions
within and among institu­
tions and sectors. It includes the
challenge of orchestrating personal
agendas and interests in search of
a different vision and of the com­
mon good.
It encompasses the
need to express,
define and re­
iterate new concepts and values
ana to revive others that have
been forgotten. It requires cou­
rage to stand firm against obsolete
views and obscure practices.
It
requires understanding of the in­
ter-disciplinary character of health
and of the political processes and
their repercussions for health. Lea­
dership goes beyond accepting a
mandate and beginning to carry it
out. It is the indispensable basis
for the search for excellence. And
without this continuing search for
excellence the perspectives for the
health sector are discussed.
More important than all these

is the need for leadership to bring
about social coherence and solida­
rity. We might become aware of
different and better avenues, be
willing to change direction, achieve
new heights of personal and instutional efficiency and produce the
best local,
national and interna­
tional leadership; but if we fail to
act together in a spirit of social
coherence and solidarity., we will
have made little headway beyond
manipulating resources in a hit-ormiss fashion or on a case-by-case
basis.
The human race unleashes ever
more spectacular scientific and tech­
nological pyrotechnics, almost on a
daily basis. Meanwhile, humanity’s
ethical evolution, of which solidarity
forms a part, leaves much to be
desired. The lack of solidarity takes
many forms.
Humanistic Values
Rejection of humanistic values
and lack of unity bring about con­
flicts and impede human advance­
ment. Nonetheless, the broad con­
sensus that physical and mental
health is beneficial and the right
of every human being—together
with the widely accepted fact
that illncss/disease knows no front­
ier, race or ideology, shows that
health can increasingly ‘become the
catalyst* for the solidarity among
people, which we all seek.
Consider three different vignettes
or scenes. In a village, a man digs
a hole for burying an infant—one
of more than 2,00,000 infants who
die annually from completely pre­
ventable causes.
This sad, grim
scene provides a searing commen­
tary on poverty and ignorance and
is a tragedy that offers a profound
challenge. In another scene health

workers hold a dharna seeking
higher salaries and fringe benefits.
This is a glimpse of the conse­
quences of economic and financial
crisis and of the failures in health
systems operation and leadership.
In the third scene we find health
professionals in the private sector
in urban setting virtually rushing
from one job Co another rarely car­
rying out any of these functions
with the degree of professionalism
their patients deserve and which
their self-respect demands. They
are in a constant struggle to main­
tain a modicum of dignity in an ur­
ban environment super-saturated
with health professionals and spe­
cialities that neither the population
nor the institutions can ever afford.
What can be done about this poor
use and unequal distribution of
valuable resources. This is another
challenge which the health field
must face in the years and decades
to come.
These familiar vignettes remind
us of the challenge we face daily:
how to avoid the tendency to (intellectualize) and distance ourselves
from what is a day-in and day-out
better fight for life for health, and
for social justice. If we do not ad­
dress the practical goal of chang­
ing and improving the better reali­
ties that many of our people live,
then we are part of the problem,
not of the solution.—Based on the
observations of the author during
the workshop on Leadership De­
velopment for achieving Health for
All by 2000 AD at the National
Institute of Health and Family
Welfare in New Delhi and Dr Car­
lyle Guerra de Macedo's article
'The Challenges Ahead" published
in ‘‘World Health", October, 1987.

FIRST WORLD DAY ON AIDS
The first ‘World Day on AIDS’ will be 1 December, 1988, said Dr Halfdan Mahler, Director-General of W.H.O. The WHO is to
organise the first World Day on AIDS to promote information and education in the global straggle against AIDS. The ‘World Day*
reflects the endorsement by Ministers of Health from 114 nations and hundreds of top public health experts at a World AIDS Summit of a
‘London Declaration’ making 1988 a Year of Communication and Cooperation about AIDS. The Summit of 26-28 January 1988 was
jointly organized by the Government of U. K. and the W.H.O. Global programme on AIDS.

March-April 1988

93

Leadership Development for Achieving
Health For All By 2000 A.D.
Prof. Somnath Roy
1977, a momentous decision
was taken at the World Health
Assembly for achieving a social
health target for attainment by all
the people of the world by the year
2000 A.D. of a level of health
that will permit them to lead a so*
daily and economically
produc*
tive life. In September, 1978, in
the International Conference on
Primary Health Care, jointly orga­
nised by the WHO and UNICEF
at Alma-Ata, USSR, the World
Health Assembly decision was fully
endorsed and the following declara­
tion was made:
n

£

“Health, which is a state of
complete physical, mental and so­
cial well-being, and not merely
the absence of disease or infirmity,
is a fundamental human right and
that the attainment of highest pos­
sible level of health is a most im­
portant social goal whose realisa­
tion requires the action of many
other social and economic sectors
in addition to health sector”.
The primary health (P.H.) care has
been defined as “essential health
care based on practical, scientifi­
cally sound and socially acceptable
methods and technology made uni­
versally accessible to
individuals
and families in the community
through their full participation and
at a cost that the community and
country can afford to maintain at
every stage of their development
ip the spirit of self-reliance and
self-determination”. The essential
components of P.H. Care are:

94

1. Education of the people
about prevailing health prob­
lems and methods of prevent­
ing and controlling them.
2. Promotion of food supply and
proper nutrition.
3. Adequate supply of safe wa­
ter and basic sanitation.
4. Maternal and child health
care and family planning.
5. Immunization against major
infectious diseases.
6. Prevention and control of lo­
cally endemic diseases.
7. Appropriate treatment of com­
mon diseases and injuries.
8. Provision of essential drugs.

people to manage the*r own health,
and to enhance the ability of the
people to achieve their own goals.
HFA Leadership Development Ini­
tiative of WHO

Following the Alma-Ata decla­
ration in 1978, almost all the
countries have framed policies, for­
mulated strategies and initiated
actions for achieving the
HFA
goals. However, there has been
a growing realisation that great
gaps exist, between
the policy
laid down and strategies drawn
out, and the actions required to
implement these. Recognizing theneed to narrow the existing gap,
a new initiative called
“Health
for All Leadership Development”
has been launched by the DirectorGeneral of WHO in January, 1985.

For successful
implementation
of the various components of P.H.
Care the following supportive acti­
vities are to be organised:
1. Community involvement and Aim and Concern of the Initiative
participation.
The main aim of this initiative
2. Intra- and inter-sectoral co-or­ is to develop a critical mass of
people throughout the world who
dination.
3. Development of effective re­ should be able to assume leader­
ship in HFA/2000 A.D. movement
ferral support.
4. Development and mobiliza­ within their own countries and
internationally.
tion of resources.
5. Involvement of managerial
The initiative is concerned with
processes.
triggering and sustaining actions
6. Medical and health services for:
research including innovative
(a) More rapid progress towards
approaches.
HFA goals.
7. Development and application
(b) The leaders to fully under­
of apropriate technology.
stand the processes involved;
8. Health manpower develop­
(c) The leaders to pursue the
ment.
value of the process and to
The ultimate goal of the HFA
develop qualities and abili­
movement is to better stimulate the
ties to lead the process.

Swasth Hind

(cl) Narrowing
the policy
tion.

the gap between
and implementa­

Objectives

The principal
initiative are:

objectives of the

(a) to improve the understanding
of those who influence health
development about the con­
cepts of HFA policy and
strategy;
(b) to enhance their ability to
influence and develop the
policies and strategies;
(c) to strengthen their
capacity
to identify, analyse and re­
solve critical issues for imple­
mentation of HFA strategies;
(d) to enhance their ability to
direct and guide actions for
facilitating implementation;
(e) to enhance WHO’s capacity
to support development and
implementation of HFA stra­
tegy at all levels.
Scope and key Issues
It is well to remember that the
ultimate goal of HFA is to stimulate
the people to manage their own
health and to enhance their ability
to achieve their own goals. The
scope of the initiative would be:

(a) to promote awareness and to
develop interest in critical questions
and. issues concerning HFA goals;
(b) to develop approaches or seeking
answers; (c) to stimulate commit­
ment and to convert intellectual com­
mitment to emotional commitment
and
to
translate commitment
into actions for achieving the HFA
goals.
The emphasis should be
on development of commitment of
leaders rather than their self-image.

(d) Promoting
inter-sectoral co­ be able to recognise health impli­
cations of policies and program­
operation
mes of other sectors and be able to
(e) Mobilising commitment
argue and convince the need for
It has further suggested several
promoting intersectoral collabora­
ways of stimulating the leadership
for discussion on key issues, and tion and coordination.
these approaches for learning are:
(a) Open discussions
(b) Simulation exercises
(c) Case studies
(d) Role plays
(e) Problem solving exercises
(f) Using trigger films.
Focus of the Initiative
While the first urgent step will
be to influence and strengthen the
existing leadership, there is a need
to encourage and support prepara­
tion of future generation of health

(iii) Using information for deci­
sion making and creating change—
One should be able to use infor­
mation to create a climate for
change, and to help decision
making concerning priority issues.

(iv) Mobilising commitment—One
should be able to motivate others
and help them to convert the intel­
lectual commitment to emotional
commitment, and to sustain such
commitment and
translate this
into action.

leaders.
The principal target
groups for HFA leadership are:

(v) Initiate the leadership deve­
lopment—One should be able to
(a) national policy/decision makers set in motion development of leader­
and senior managers from ship and thereby orienting natio­
health and health related sec­ nal health efforts towards health
and development by mobilising the
tors;
(b) potential leaders in the coun­ critical mass of leader* at all levels,
tries including political leaders; committed to the values inherent
in HFA movement.
(c) members of health professions;
2. Identifying individuals and ins­
(d) the WHO staff especially
titutions that would be able
WHO. programme coordi­
to provide support :
nator and representatives and
senior programme managers.
(a) Such institutions will include:

Approaches

1. Identifying critical issues in
the Implementation of national
HFA strategies.
The following five priority areas
may serve as entry points for ini­
tiating discussions and development
of HFA leadership :

(i) those concerned with HFA
leadership development; (ii) those which train key people
such as national and central
training institutes, administra­
tive staff colleges, etc.
(iii) those who run courses in
development studies, commu­
nity health and administra­
tion.

(i) Developing and maintaining
health policy and strategy based on
HFA principles—One needs to
(b) Individuals who may provide
The WHO Task Force has identi­ understand health as an important support include:
fied five key issues for HFA deve­ component of overall development
(i) those who provide examples
and be able to recognise the gaps
lopment and these are:
of appropriate leadership for
or weaknesses in national HFA
HFA;
(a) Initiating leadership
(ii) those skilled in the process of
(b) Clear understanding of the policy or strategy and be able to
react in filling these gaps.
mobilising the people to work
policy and strategy
together and in drawing out
(ii) Promoting intersectoral di­
(c) Using information in decision
their inner resources;
making
mensions of health—One should

March-April 1988

95

7. Networking and follow-up
A number of activities are being
(iii) such people as are important
supports:
components of critical mass organised by the governments and
are being supported by the WHO
of HFA leadership.
(a) In order to support initial acti­
and
other
agencies
for
promoting
vities,
it will be necessary to develop
Selected institutions might con­
leadership
development
and
which
a
network
of three types of people:
duct training programmes as a
are likely to lessen the gaps between
back-up by these country level
(i) enlightened and skilled people
HFA policy, strategy and imple­
activities. These leaders, potential
providing guidance and sup­
mentation.
It will be important
leaders and other resource persons
port in Ministries of Health
to identify the ways in which these
work together for implementing
and other sectors;
and many other activities may be
HFA strategy.
They
develop
(ii)
people in institutions compe­
supported and encouraged for pro­
leadership skill by doing.
tent to provide support;
moting HFA values and primary
(iii) selected WHO personnel who
3. Starting with the people who health care approach.
already function as enablers
are presently working in leader­
5. Preparing potential leaders:
and facilitators.
ship positions.
(a) It will be important to iden­
(b) People from each of these
(a) The Task Force will be tify methods of supporting young
groups
are facilitating the HFA
concerned directly with stimulating professionals who show leadership
processes
within their own setting.
and supporting activities to enable potential.
The
initial
members of support net­
the current health leaders to exer­
(b) Strengthening existing insti­ work are to be carefully selected
cise leadership and to promote
tutions which aie reorienting their on the basis of their ability to moti­
leadership at other levels in their
programmes towards HFA and thus vate others and to guide their natio­
own countries.
encouraging the development of a nal health processes towards HFA.
(b) The apptoach will be people new breed of public health profes­ They should be supported by a
oriented and will encourage deve­ sionals whose perspective should be Core Group of resource people who
lopment of skills in critical mass of broad and multi-disciplinary and are skilled in the processes of human
people, and the strategically placed oriented towards health and deve­ resources development.
leaders will be mobilised.
lopment.
Expected Outcome of Leadership
(c) New generation of HFA lea­
6. Developing resource materials: Development Initiative
ders would bo identified and their
(a) Appropriate resource and in­
Such initiative will help in the
leadership potentials are to be
formation material should be pre­ following manner:
developed.
pared with the object of stimulating
(a) It will further clarify the con­
(d) Enlightened and skilled people not only discussion but also action
cept
and processes enshrining the
in the Ministry of Health and other and thus.promoting leadership deve­
HFA
policy and strategy to the
sectors are providing inspiration lopment.
Such material* will
existing
and aspiring health leaders.
and guidance, and such people faci­ emphasise active experience and
(b) It will help to the fullest pos­
litate HFA processes within their problem-solving.
sible
development in the potentials
own setting.
They may act
(b) The approaches and methods
as models of primary health care should consistently emphasise active of these leaders in converting ideas
approach.
learning related to actual problem, into actions and converting obsta- •
(i) such people may be brought and should focus on participants res­ cles into opportunities.
together exchanging ideas and ponsibility for their cwn learning.
(c) It would encourage and sti­
discussing their experiences
(c) Resource packages should mulate them to take actions for
and difficulties. This process
be so designed that they could be closing the gaps between what is
will help in deepening their
modified and adapted for use in a said about HFA and what is done.
understanding of HFA.
variety of HFA leadership develop­
(d) It will enable the existing
(ii) such meetings and proper ment activities.
national leaders learn from others
follow-up activities will help
(d) Guidelines are to be deve­ and support each other.
in turning the participants
(e) The short-term outcomes of
loped to help • the
organisers
themselves into facilitators.
such
initiative will be:
to conduct programmes which in­
4. Linking with existing and volve full participation and lead to
(i) preparation of a set of re­
planned activities which lead to development of self-reliance and
packages and guidelines for
commitment.
HFA leadership development:
triggering dialogue, stimulat-

96

Swasth Hind

mulating progress towards HFA
Evaluation and Follow-up
1. The follow-up activities after by nurturing people’s actual and
the initial steps will provide some potential capacities for leadership
and bringing
together different
indications of their effectiveness.
individuals
and
groups around a
2. After learning from initial
(ii) it will support network of experiences, it will be important to common theme.
individuals and institutions at rapidly disseminate information for
These people wili work together,
country level together with the appropriate adoption and application
encourage and support a more rapid
members of the WHO.
at different levels.
translation of ideas into action and
3. There should be an appropriate each of these individuals has many
(iii) it will help in establishing
linkages with a variety of mechanism for consultation involv­ links and avenues for action.
existing activities and pro­ ing existing leaders, people from
grammes working towards appropriate institutions and selected
This initiative will complement
WHO personnel who will enable and where possible enhance and sup­
HFA goals.
adoption of an approach of 'Learn­ port these many activities
and
(iv) to develop a plan of action to ing by doing’
which reflects the programmes and a concerted drive
ensure mobilisation of sup­ principles of primary health care.
to maximise efforts from all quarters
port for nurturing and sus­ Perspective
and close the gaps between what is
taining the process of leader­
The HFA
leadership initiative said about HFA and what is done
ship development.
has the aim of facilitating and sti­ for achieving its goals.
®

iflg actions and promoting
leadership development at all
levels; these may be tested out
and modified appropriately.

(Cotltd. From Page 65)

In the first instance, primary health care places the
individual at the centre of the health scene. While
he is the main beneficiary, he is also the major acti­
vist deciding what form of health care is appropriate
to him and his community, planning and helping to
instal services, supporting and maintaining them, and
finally, using them judiciously.
Secondly, health
care is only a part of the individual's needs, though
an important part of it. He must, in addition, take
such measures as to ensure his social, economic, edu­
cational and cultural advancement. In this much
larger context, the health worker must now play an ex­
panded role, often as a resource to the individual who
is the major activist.
The Government of India, after a detailed study of
the recommendations of the various committees for­
mulated the National Health Policy in 1983.
The
National Health Policy echoes the views of the AlmaAta Declaration regarding primary health care.
The health worker in the context of primary health
care without abandoning his technical role has to
play a much larger role in people's social and eco­
nomic wellbeing; show them the way, generate the
will and the capacity to work and participate, and
sustain their morale.
The health worker must ac­
quire different attitudes and skills, skills of the social
worker,'educator, friend, guide and philosopher.

This poses a challenge unparallel to the schools of
public health when we consider that health workers
of all disciplines must acquire some, if not all of
these new skills, here and now. Right from the grass­
root level workers like the community health workers

March-April 1988

to the top functionaries who are more technically
skilled, highly qualified, specialist and senior health
system administrators need training to perform their
roles effectively under rhe primary health care system.
Just as preventive health personnel require cura­
tive skills to perform primary health care functions,
so do curative health personnel require preventive and
promotive care skills; without such training they can­
not be expected to assume primary health care leader­
ship roles.

But, the training of health teams cannot begin with­
out the training of teachers.
Fundamental here is
the recognition that (he role of the teachers is not
so much of a fount of knowledge, but more impor­
tantly, of a facilitator of learning: for the student is
the one that learns and the teacher can only facilitate
the learning process- Besides, the teacher needs to
recognise that his role and\that of his institution are
to educate health teams for health systems. For this
purpose, it is important to be aware of the national
strategy for health for all under the National Health
Policy and the role and function that the students
will perform after his training.

The new training programmes to provide thaining
for primary health care must be based on appropriate
research.
While such research should direct pro­
grammes, research itself must have been done in rea­
listic field situations drawn from an understanding of
community needs/demands^ including present and
prospective roles of health personnel.—From an ad­
dress on the celebration of the Foundation Day of the
All-lndia Institute of Hygiene and Public Health,
Calcutta, on 30 December, 1987.
#

97

Whither Health Education !
Dr K- S. Sanjivi
Dr K. Venkateswara Rao
L_T ealth education encompasses
a: 1 the matters the citizen should
know in order to maintain his own
and his neighbours health.
The
objective of the endeavour should
be to obtain the co-operation and
participation of every
individual
man, woman or child.
Health
Education is essentially a process
that enables people to find out their
health needs and match them with
suitable behaviour. Health Educa­
tion should aim at the attainment of
positive health through all the five
levels of prevention, viz. Health
promotion, specific protection, early
diagnosis and prompt treatment.
disability limitation and rehabilita­
tion.
A good communication compo­
nent is essential for successful health
education.
Such a communication
should be a two-way process.

In almost all cases where health
education is in practice there is no
systematic follow up tp ascertain
the effect of the health education.
Health education should not become
a theoretical, vertical and target ori­
ented programme.
It must deve­
lop side by side as an integral com­
ponent of on-going health activi­
ties. ft should be the key and
essence of primary health care acti­
vities.
Education on health should really
be integrated with general education
and projects on total rural develop­
ment. The latter will include topics
like kitchen gardens, animal husban­

98

dry, poultry keeping, cottage indus­
tries etc. The suggestion has been
made that the health agency should
itself undertake education on all
these matters.
In fact, it has
been done in a few centres.
We
do not agree with this. Nou-formal
education or functional literacy to
remove ignorance should be the
only project undertaken by the
health agency.

Ji is our conviction that nonformal education should be a compo­
nent if not a predecessor of health
education.
We have undertaken
this task in several villages.
A
monograph has been prepared for
this purpose.
About 800 words in
Tamil have been listed in alphabeti­
cal order.
About half of these
are well understood even by the
most illiterate person.
However
a few' of these words may still re­
quire elaborate explanations.
For
example ‘Amina’ (mother).
Al­
though the word itself is most uni­
versal in meaning, the functions of
the mother as the most dependable
para-medical worker are spelt out.
The other words, with which the
average illiterate citizen is not fami­
liar, are explained in detail. Par­
ticular attention is given to words
on which ideas for health mainte­
nance can be pegged.
The Need

Who is in need of health educa­
tion and who should give it? Taking
the second question first we insist
that every educated person who

knows should consider it his duly
io impart the knowledge to his less
fortunate neighbours.
No country
in the world, least of all a country
with a large population and small
resources can afford to employ ins­
titutionally trained health educators/social workers.
While such
graduates or diplomates in these
subjects should certainly be availa­
ble to provide tlic necessary guid­
ance and leadership, maximum
work must come through the ordi­
nary literate citizen.

Schools and colleges dealing with
health education and schools of
social work should not think that
health education is only their do­
main.
Certainly they have a role
to play in developing the an and
science of health education. They
should concentrate on imparting
the necessary skills to the different
programme personnel.
They can
also provide suitable training modu­
les for training different categories
of health workers. They can also
conduct research into the health
behaviour in a time dimension and
assess the efficacy of the various on­
going communication programmes.

Throughout their work doctors,
nurses, health workers in different
programmes have to deal with peo­
ple. They should get into the habit
of providing health information and
utilise every opportunity for health
education without any special or
deliberate overt effort.
By and
large people in medical profession
are in the habit of not communicat­
ing properly. They will give health
instructions but not with a touch
and intimacy and involvement.
We have insisted elsewhere that
it is totally wrong to offer incen­
tives to people for taking action for
their own welfare, such as accept­

Swasth Hind

ing contraceptive procedures or
donating blood.
It is wrong to
offer incentives and disincentives to
adult parents for acting in their own
interests.
Social workers, in our
broad definition, must find a few
minutes needed to talk to the people.

The students in the higher secon­
dary classes and in colleges should
receive basic information on health
matters and convey the same to the
masses.
Using the National Ser­
vice Scheme volunteers to build
roads is not the proper use of intelli­
gent, educated manpower.
It is
not the road to health.

Nov/ who is in need of health edu­
cation?
Every one from the
senior-most functionary to the threeyea r old child in the most remote
village; only the content of health
education will vary.
Health Education is required for
all ages, both sexes, all classes of
people (rich or poor), literate or
illiterate and in all parts of the
world. Even in advanced countries
health education becomes impor­
tant in changing conditions, of life as
new vistas of knowledge are be­
coming available every day. Health
Education is a continuous process.
People having the responsibility
to govern the country, politicians
and bureaucrats, must know enough
about the health needs of the coun­
try in order to spend the health
rupee properly.
Even doctors
require education on health apart
from the clinical knowledge they
acquire in the medical colleges.

Now we should go further and
ask when, where and how youth
should be told the facts. The ans­
wer is simple. The warning should
be continuous, clear, constant and
through every media, including
individual contact.

March-April 1988

Crime and violence depicted as
part of a feature programme on the
TV have been reported upon several
times in medical literature as having
an adverse effect on children prone
to violence. While films also have
a similar effect it is impossible to
keep children away from sitting in
front of the 'idiot box’.

It is essential part of health edu­
cation to let the people know basic
points with regard to serious disea­
ses. Taking again the symptom of
cough for a case study, the lay per­
son should know that he cannot ig­
nore a persistent cough of more
than two weeks duration especially
if accompanied by fever, blood in
the sputum etc.

Informal method

The informal, person to person
method of health education has
been found to be very successful in
our Project Area.
In our project
the Lay First Aiders functioning for
every 1000 population are having a
good rapport with the community
being local residents.
They are
able to harness their personal con­
tact for providing not only valuable
health information to the Higher
category health workers but also
provide the much needed informal
health education on matters of breast
feeding, growth monitoring, im­
munization, nutrition supplementa­
tion and oral rehydration.
These
category of workers receive only
four weeks training in the basics of
health care and health ^education.

Regarding taking personal prophy­
la tic measures, by the community
no elaboration is required as every
literate person must be aware of
these. ’As regards immunization
the field staff of the public health
departments are today highly in­
efficient and casual in that they do
not take the necessary steps of deli­
vering all the doses that are requir­
ed to confer immunity.
Official
returns should report on children
protected rather than injections
given. Most of the parents do not
know why a particular injection or
a drop in the mouth is being admi­
nistered. There are several instan­
ces where children received more
than double the normally required
doses.

In a disease like tuberculosis or
leprosy where the drugs have to be
taken for several months this failure
to educate the patient often results
in the patient becoming a “defaul­
ter”.
Defaulting results not only
in failure to effect a cure in the
patient but also in considerable risk
to the patient’s contacts.
How­
ever the patient is not always to
blame. The Government/the Insti­
tution providing the treatment run­
ning out of supply of drugs pro­
duces a loss of credibility in the
patient who fails to turn up for’sub­
sequent attendance.
x

Finally health education will en­
tail letting the citizens know all that
they should to preserve their own
individual and their community’s
health. Community health includes
general literacy as already men­
tioned. the other points discussed
earlier and a number of other to­
pics. These will be food producall ages, housing, accidents, vio­
lence and even war; the organi­
sation of health maintenance sys­
tem.
Many seminars and conferences,
workshops and symposia have been
held all over India to highlight the
role of health education.
These
meetings are not followed by con­
crete actions.
It is high time that
we get up to some practical work
and stop talking rhetoric.
©

99

Behavioural Sciences for
Public Health and Medical Care
, Dr K- R- Sastry
Many socio-cultural
vaccine is in­ to poverty.
effective unless people are im­ factors influence the type of food
munized.
Cancer detection is im­ people eat and practices of cooking
and sharing of food which influence
possible unless people cooperate.
Leprosy and Tuberculosis can be the nutritional levels of the popu­
Women and children, in
successfully treated but for the pro­ lation.
particular,
are adversely influenced
blem of drop-outs. AIDS can be
by
social
customs
related to food.
prevented only if we can change
the sexual behaviour patterns of Margaret Clark (1959) has report­
people. These and other such state­ ed that among certain Mexican
ments clearly demonstrate the role Americans diseases are classified by
of behavioural sciences in the field perceived causation: diseases of
of public health and medical care. “hot and cold” imbalances, disea­
Sociology., psychology and anthro­ ses of dislocation of internal organs.
pology, which directly deal with diseases of magical origin and disea­
Diet res­
human behaviour have contributed ses of emotional origin.
trictions
during
pregnancy
and
post­
a great deal to public health and
partum
phase
is
a
common
practice.
medical care in exploring the social
origins of the disease., in promoting Parallel examples can be given from
appropriate educational service.deli­ our own society. Therefore, efforts
very systems and in obtaining maxi­ to curb malnutrition cannot suc­
mum participation of the commu­ ceed unless these socio-cultural
nity for resolving
the problems. factors are tackled.
Behavioural research is of great rele­
Iswaran (1968) has found .in his
vance to health care, in all the three study of a South Indian village that
vital aspects, namely, cause, treat­ the whole community responds to
ment and prevention.
the person who is sick, defines the
nature
of his illness and prescribes
The causal factors
appropriate mode of treatment.
Social epidemiology is emerg­
The village medical culture defines
ing as field of great promise
diseases as multi-causal.
Some
in understanding disease patterns
diseases are considered divinely
and their distribution in populations.
ordered’ but in a mild form, others
For example, cancer of the cervix
‘divinely ordered’ but in a severe
is found to be more frequent in
form.
Some diseases are attribut­
populations where early marriage
ed to immediate physical causes,
and child-bearing is a social norm.
others to magic and sorcery and
This practice is also related to high
some are classified as epidemics.
infant, child and maternal morta­
The nature of treatment varies ac­
lity and high birth rate.
Anthro­
cordingly.
For smallpox which
pological studies have documented
was considered to be due to the
that female infanticide is practised
wrath of a goddess, the prescribed
in many communities where a strin­
treatment was to propitiate the
gent ‘dowry system’ is prevalent.
goddess Dyamavva. offer, rituals
Malnutrition is not entirely due and gifts of oil and ghee.
For
oliomyelitis

P

100

measles the prescribed treatment is
to smear the patient with red earth,
expose him to hot sun and give him
a bath in the evening. For leprosy
three courses of treatment are pres­
cribed : worship a snake, get bitten
by a cobra or worship the Sun God.
Mathews (1979) reports from
his study of some villages in Tamil
Nadu that
traditional healers
(Chembadawars) specialising in the
treatment of child diseases are even
preferred by villagers. They use a
combination of Ayurvedic, Unani
and Siddha medicines together with
spiritual methods of healing. Jswaran (1968) reports that treatments
prescribed by the community vary
with the nature of the disease,
usually displaying a fusion of moral,
religious and physical approaches.
At the same time, all the three levels
of treatment are pursued.
Physi­
cal symptoms are noted, but they
are considered inadequate for diag­
nosis.
When physical symptoms
denote cholera, smallpox etc, the
villagers attribute them to gods and
immediately take the precaution of
propitiating them.
They consult
the astrologer, and then seek the
services of a local native specialist
and later, approach native specia­
lists outside the village.
This is
followed by visit to local registered
practitioners. Visit to the hospital
in the nearby urban centres is the
last resort. Of course, when all
else fail, they turn their faith to
where they began—the gods.
These are only a few excerpts
from studies to show the importance
of understanding the socio-cultural
factors in promoting health
pro­
grammes.

Swasth Hind

bing revealed that this was due to
guidelines for immunizing people
several socio-cultural and domestic
against bad rumours.
All these
serve many social goals and there­ factors relating to decision-making examples explain the role and im­
portance of behavioural research in
fore they cannot be easily changed. and delayed action.
In an experiment of ‘depot hol­ health promotion. Further, new
Hassan (1967) reports from his
study of some villages in Uttar der’ systems for distribution of found diseases like AIDS also call
for a good amount of behavioural
Pradesh that open air defecation in­ condom in rural areas conducted
research.
cidentally meets some social needs. by the same institution in the six­
He says that women go to fields ties, it was found that residents Prevention
Finally prevention of illness is
for defecation mostly in groups. of a village went to a far-off village
more
a mattei of changing the
to
collect
their
requirements
of
con
­
Going in groups serves many pur­
habits
and
customs of individuals
doms,
avoiding
the
depot
holders
poses like saving the fear of attack.
affording time off from the routine in their own village. This interest­ than controlling environmental con­
domestic work and freedom to con­ ing phenomenon when investiga­ ditions or immunizing populations.
verse in the absence of elders, etc. ted, revealed that the villagers did The emphasis of public health
Especially for younger daughters- so ras they did not want their friends rather than legislation is giving
in-law this gives an opportunity to to know about the frequency of way to greater reliance on volun­
Consequen­
share their problems of living with their sexual activity. This indica­ tary participation.
tly,
ways
and
means
of
obtaining
tes
that
non-personal
...channels
of
their mothers-in-law. Often issues
wider community
participation
left incomplete are continued the distribution are preferred.
have to be found.
This requires
next day.
These important social Treatment
goals encourage the habit of open
In the treatment of leprosy and adequate knowledge of behavioural
Also, the initial empha­
air defecation.
tuberculosis,
which are diseases sciences.
sis
of
public
health on establishing
associated
with enormous social
Fertility and mortality
and
providing
services is found
In the field of population we have stigma, the problem of drop-outs inadequate. With
many
such
Be­
several studies documenting socio­ is too common and acute.
services
in
operation
the
problem
cultural basis for fertility behaviour haviour research is of utmost im­ is becoming one of greater utili­
or mortality
behaviour.
Orent portance in tackling this problem. sation. The public must be moti­
(1975) found cultural factors as the In qn experiment at Gandhigram, vated to make use of such ser­
most important factors determining several approaches were used to vices.
The
services must now
tlie infant mortality levels of the reduce drop-outs from the leprosy . develop techniques of reaching
Kaba in South Eastern Ethiopia. and tuberculosis control program­ people based on sound principles
Finally, the family-centred
In some recent case studies in Tamil me.
approach,
where the spouse and of behavioural sciences and suc­
Nadu we have found female infan­
cessfully demonstrated techniques?
ticide is a major factor in deter­ children of the patient were educa­ Future prospects
mining fertility levels in some caste ted and requested to co-operate,
As the acute communicable disea­
groups.
The high cost of dowry proved most successful in reducing
ses have been brought under con­
tlie
rate
of
dropouts.
Behaviour
and subsequent economic support
trol, there has been a correspond-*
to be given to the girl’s family even Research which revealed the poten­
ing increase in importance of chro­
tial
of
love
ties
between
the
patient
after marriage seem to sustain this
Social
and his/her spouse and children nic degenerative diseases.
practice.
On the other hand we
factors are much more important
helped
persuade
the
patient
to
con
­
have also found that among the
for these latter diseases in etiology,
tinue taking treatment.
vellala
gounders, another caste
Speci­
In .one instance, antagonistic treatment and prevention.
group in Tamil Nadu,. there is a
fic
infectious
agents
are
being
re­
strong motivation for fewer children rumour? hampered the family plan­
placed
by*
social
and
psychological
largely, arising out of the motivation ning programme in a village. Im­
‘processes' as ‘causes* of disease,
to avoid further splitting of the mediately social scientists got busy
while changes in one’s way of life
studyingthe
rumours.
An
epide
­
landholding and economic competi­
have become a crucial factor in
miological
approach
to
rumour
tion for status among equals.
phenomena helped to identify the the treatment of these’’ chronic ill­
A number of studies done by the
host,, environmental and agent fac­ nesses. Also technological chan­
Gandhigram Institute of Rural
tors in the. origin and spread of ges have produced new public
Health and- Family Welfare have
rumours.
With this knowledge health, problems such as radiation,
shown that a large proportion of
..the social scientists evolved effec­ air pollution, occupational disea­
non-adopters report having- more
tive methods for .controlling the ses and even accidents in the conchildren than they desired.
Pro­ rumour epidemic and suggested
(Contd. on3rd cover)

Social hurdles
Sometimes the existing practices

March-April 1988

Si

Voluntary Associations
in Health Care
Alok Mukhopadhyay
n India, the health sector has a

I

long tradition, of voluntaryism.
For centuries, th3 traditional healer
family in a tribal society has taken
care of the health needs of their
community voluntarily. In modem
times, Christian missionaries pio­
neered the tradition of running chari­
table dispensaries and hospitals.
Gurudev Tagore went much further
in his effort by evolving health care
service for the Santhal villages
around Shantiniketan, which includ­
ed the refreshing concepts of cooperatisation, low-cost curative services,
etc. Gandhiji throughout his life
propagated naturopathy, better sani­
tation, simple and wholesome food
through the constructive organisa­
tions that his followers set up
throughout the country. Another
milestone in voluntaryism was Dr.
Kotnis and his team of health pro­
fessionals’ brave input in the Chinese
liberation struggle.
During the colonial period, a Wes­
tern curative-oriented health service,
primarily to meet the needs of the
colonisers, was set up. This service
completely overlooked the strong
foundation of the Indian systems of
health care as detailed in Charak
Samhita and supplemented by the
Susrut Samhita, which always looked
at health care holistically. Unfortu­
nately, even after Independence, this
trend was not radically altered in
the Government health plan.
From the mid-sixties onwards, the
Western curative model of health
care went through a lot of question­
ing in the development circles all
over the world. Out of this process
grew various models of community

102

health programmes in voluntary sec­
tor, which emphasised more on the
decentralised curative service in
which' the health workers played a
significant icle and more importance
was placed on preventive aspects
including health education. A lot of
more effort was made, to involve the
community in their own health care.
Unfortunately, this trend of thought
somehow missed the important role
of traditional systems of medicine,
particularly involvement of tradi­
tional health practitioners in health
care delivery. There were several
innovative experiments of this new
approach in many parts of the coun­
try. Organisations like Voluntary
Health Association of India played
an important role in promoting these
relevant ideas among health groups
in all parts of this country. They
also provided support in terms of
training, production of relevant
health education materials, etc. This
development significantly influenced
the Government’s approach to pri­
mary health care in the future years.

Existing voluntary health services
can be mainly dividea under follow­
ing categories:
Specialised
programmes

community

health

These groups are primarily run­
ning decentralised, low-cost, com­
munity health programmes. In these
efforts, stress is on training of local
level village health workers, doing
preventive work, health education
and on community involvement.
Many of them go a little beyond
health by running income generation
programmes for the poorer commu­
nity so that they can meet their
basic nutritional needs.

Good examples of this approach
are the health programmes run by
the Society for Comprehensive
Health Projects at Jamkhed. Maha­
rashtra, Ashish Gram Rachna Trust
at Pachod, Maharashtra. RUHSA
Campus and Child in Need Institute
in West Bengal. These programmes
have done innovative work in various
aspects of primary health work
which is worth replicating.

One of the main problems of
these programmes is that they are
run around charismatic individuals.
Also, the funding input involved in
these programmes sometimes may
not be replicable by others and es­
pecially the government. Scientific
assessment of the impact of some
of these programmes is also not
easy because thorough base-line
datas are not available.
Integrated development programmes

In these programmes, health is a
part of the overall development acti­
vity. Consequently, their trust in
health care may not be as systematic
or as effective as the previous group
but the overal long-term effect of
their work in health and develop­
ment is very significant.

The Self Employed Women’s
Association, Ahmedabad, Social
Work Research Centre, Tillonia,
Gram Vikas, Berhampur (Orissa)
and the Maharogi Sewa Samiti,
Maharashtra are some of the good
examples of programmes under this
category.
Health Care for special groups of
people

This includes education, rehabi­
litation, care of handicapped people
like spastics, mentally retarded and
treatment and care of leprosy pati­
ents etc. These specialised agencies
are doing pioneering services keep­
ing in view the fact that hardly
any government infrastructure exist
in this sector of health care.

Swasth Hind

Viklang Kendra in Allahabad,
Spastic Society Centres in New
Delhi, Calcutta and Bombay, Maharogi Sewa Samiti are some of the
good examples of health care for
special groups of people. Some
organisations like the Family Plan­
ning Association of India take on
specialised family planning activity.
Despite the remarkable voluntary
effort all. over the country and rea­
sonable National Health Policy for­
mulated at the government level
during the mid-seventies, the state
of India’s Health needs much im­
provement. There is an extraordi­
nary difference between the health
status of the people of States of
Kerala and F’unjab on the one hand
and the people of Uttar Pradesh
and Bihar on the other. (For
Health Statistics sec pages 66-72
& 82).
Obviously, there are some funda­
mental problems in the health care
delivery system. Tn a very general
way some of the basic causes of
this situation can be identified as
follows:

4. The
present
government
health plan model has not
been built on the existing
strengths of traditional health
care system.
5. There is a need for greater
effort for improving the sani­
tation and safe driaking water
supply situation, which is the
major cause of ailment in
this country.

6. Primary education is not
spread throughout the coun­
try adequately and even in
the areas where it has spread.
it has failed to build a ra­
tional and scientific attitude
among the people. The drug
companies and other vested
interests have propped up
“pill, injection and tonic”
oriented
health
attitude
among the majority of the
people.
7. There has not been any effec­
tive inter-sectoral coordina­
tion within and outside the
health sector. Consequently,
there have been too many
vital gaps, overlapping and
confusion.

1. There has been little or no
In the given situation, what can
participation of the people in
health care, particularly in the be the most relevant role of volun­
tary health organisations?
government sector.
2. Although there has been some
restructuring of the colonial
health system after Indepen­
dence, it has not been radi­
cally altered to meet the needs
of the rural communities.
3. The gross disparity of health
budget between big city-based
hospitals and the rural pri­
mary health care needs to be
reviewed. Also, for the last
few Five Year Plans, bud­
getary allocation to the health
sector has gone through sub­
stantial reduction.

March-April 1988

(a) It is of primary importance to
build up a health movement
in the country. Creating po­
pular pressure at the grass­
root level for better utilisa­
tion of existing government
health facilities and at the
policy level to restructure the
health plan and for reorienta­
tion of the health budget are
. vital.

interests by promoting a kind
of health care which gene­
rates most benefit for them.

(c) Remote areas where the gov­
ernment health system does
not exist can be reached by
voluntary agencies with pri­
mary health care. It is to be
noted that voluntary agencies
do not replace government
health centres. Very often
one finds a successful volun­
tary health effort almost next
door to government infra­
structure. After all. it is the
Government health system
which can eventually make a
significant impact through­
out the country, therefore,
the main thrust has to be to
create popular pressure so
that the government system
works and to supplement
where essential but not to
replace it.
(d) Voluntary agencies can play
an important part in trying
out pioneering ideas and to
bridge some of the gaps that
exist in the government health
system.
(e) The voluntary sector has to
play an important role for
helping the handicapped.

(f) The voluntary sector can take
initiative in strengthening
roots of traditional medicine.
In a country where almost half
the population live below the pover­
ty line, the goal of Health for All
by the year 2000 is a mirage. It
can only be achieved if social, eco­
nomic and political structure of this
society undergoes some drastic
change.

(b) To develop a rational and
What role voluntary organisations
scientific attitude for health
care among the people so that can play in this process of change
they do not succumb to the needs to be debated, discussed and
publicity campaign of vested resolved.
a

103

All- for health:
a must for
Health For All
—An experience
Dr Sanjiv Kumar
Dr G. V. S. Murthy
t has become very clear that
1 health personnel alone cannot
do much for the health of the peo­
ple and significant improvement in
health cannot be achieved unless
the community level organizations
and the individuals themselves are
actively involved. Because of this
realisation, more and more empha­
sis is being laid on community parti­
cipation at the national and inter­
national level. All the national
The author with a group of children tn the field practice area.
health programmes have thus in­
5. Harness the immense poten­ tify the health related activities and
cluded community participation as
tial of youth and womens
the role that they could play in
an essential component. However,
these
activities. The following acti­
organizations, especially in
the medical curriculum still does not
vities
were
held:
maternal and child health re­
include the topic of community par­
lated activities.
1. Well baby shows: Special well­
ticipation in any subject in any
6.
Identify
the
schools
in
the
baby
clinics: Four such special
major way. There is urgent need
area
and
discuss
with
the
shows
were held at Chhainsa
to give due importance to this
headmaster
and
other
school
and
ten
at
Dayalpur to promote im­
aspect in the curriculum of medical
teachers,
as
to
what
activities
munization
growth
monitoring,
students and to expose them to these
could
receive
their
support.
knowledge
of
mothers
about
preven­
activities during their field posting.
7.
Involve
all
the
groups
in
tion
and
home
treatment
of
diar­
This will enable them to effectively
whatever
help
they
can
render.
rhoea
and
other
common
ailments
utilise the knowledge gained about
of children and personal hygiene.
community participation when they Strategy in action
These were called ‘Bal melas’ by the
This
strategy
was
carried
out
at
work in the community as doctors.
villagers. The arrangements were
two
primary
health
centres
—
Day
al
The health related activities can
made by the youth and the local
pur
and
Chhainsa
in
Haryana.
This
be approached, using the following
leaders.
is
part
of
the
intensive
field
practice
steps, in a logical fashion:
2. Celebration of World Health
area
of
the
Centre
for
Community
1. Identify the formal and nonMedicine of the All India Institute Days, 1986 and 1987: At Chhainsa
formal leaders and groups
Primary Health Centre (PHC) ex­
of Medical Sciences, New Delhi.
in the community.
At Dayalpur, some, active nonhibitions were held on these days to
2. Assess the potential of these formal leaders and members of impart health education to the vil­
individuals and groups for the village panchayat, constituted a
lagers on maternal and child health,
health related activities.
group to carry put various health
personal hygiene and common health
3. Identify the main health pro­ related activities. At Chhainsa, the
ailments. The youth played an im­
blems of the community.
Youth
Service
Organization portant role in
raising finances
4. Discuss the problems with (Yuva Seva Sanghatan), a non-poliand explaining the exhibits to the
them and take their views on
tical, socially aware and-motivated
villagers.
how they can help in taking group of the educated youth of the
3. Training of the youth in first
appropriate action for these
village, was identified. Weekly meet­ aid and basic Community health :
problems.
ings?. tfere held with them-to iden- The course involved teaching of

•104

Swasth Hind

basics of commcaity. health to 19
volunteers from Chhainsa and 20
from Dayalpur.. Pre- and post eva­
luation of the course showed a
significant strengthening of their
knowledge. The youth managed the
exhibitions on health.
4. Training of women volunteers
in maternal and child health care
and first aid: At village Dayalpur,
12 mothers were given training
and it was expected that these
women would act as catalysts for
change in the community.
5. Activities at the schools: At
village Chhainsa, an essay competi­
tion and health exhibition were or­
ganised at two primary, two middle
and one high school. A basic course
in community health and first aid
’was conducted for the teachers. At
the Dayalpur girls high school, a
poster competition on personal hy­
giene and nutrition was arranged
and a declamation contest for the
boys and girls high schools was
organised with the nelp of school
teachers and panchayat members.
Routine health education, medical
check up and immunization at all
the 30 schools in die area, was.
organised with the help of local
organisations.

(courtesy CHEB) and a well baby
show were organised in 1986. The ex?
hi bits were manned and explained
by the youth and the mother volun­
teers, trained by the PHC health
staff.
These were some of the activities
in which the local population active­
ly contributed towards promotion
of health of the community. There
cannot be a standard or uniform
method for community involvement
on a national Scale; Local consi­
derations would determine rhe rule
that the communitv may have to
play in the health infrastructure.
However, the doctor as the Team
leader, has to play a positive role
in identifying the community re­
sources, and in involving the various
organizations existing in that place.
He has to initiate the process, which
would then culminate in a strong
bond between the health function­
aries and the community. With only
12
years
left in
reaching
2000 A.D., the WHO has once again
focussed attention on community
involvement, by deciding that
‘Health for Ail — All for Health’
would be the theme of 1988, with?
out which the goal of Health for
All by 2000 A.D. cannot be
@
6. Immunization : The
youth achieved.
volunteers and the local leaders
were actively involved in improving (Contd. from Page *101)
the immunization coverage of chil­ trol and prevention of which social
dren, which reached above 90 per factors are very important.
cent in both the PHC’s
REFERENCES
7. Tracing Tuberculosis defduller Clark, M. Health in the Mexican American
culture, University of California Prvss,
cases : Some members of the HariBerkelyar.d Los
Angeles, 1959, pp
jan mohalla at village Dayalpur,
162-217.
came forward to help in converting Foster M. Traditional culture and the impac
of technological change. Harper and
the
defaulters of tuberculosis,
Row, publishers, New York 1962, pp
undergoing treatment at the PHC.
64-149.
The names of the defaulters were Hassan K.A. The cultural Frontier of Health
in a village in India. Manak'talas Bombay,
given to them and a doctor accom­
1967, pp. 63-142.
panied the elders of the mohalla,
Iswaran K. Shivapur—A South Indian village.
and convinced the patients to resu­
RonUdgc and Kvgan Paul Lid, London
(1968) pp. 89-126.
me treatment. Thus out of seven
defaulters, five had restarted regular Mathews.C.M.E., Health and culture in a
S nth Indian village. Sterling Publishers,
treatment.
New Delhi, 1979, pp. 96-180.

Authors of ths Month

Kum. Saroj Khaparde
Union Minister el State for Health &.
Family Welfare
New Delhi.
Dr Harcharan Singh
Adviser (Health)
and
Dr A. K. Kundu
Dy. Adviser (Health)
Planning Commission
New Delhi-110001
Christiane Vied ma
C/o W.H.O.,
New Delhi-110002
Dr P. K. Rajagopalan
Director
Vector Control Research Centre
Medical Complex, Indira Nagar
Pondicherry-605006
Dr (Suit) D. Lahiri
Director
Central Bureau of Health intelligence
(DGHS), Nirman Bhawan
New Delhi-110011
Dr (Smt) V. K. Bhasin
Director
Central Health Education Bureau
Kotla Road,
New Delhi-110002.
Shri N. L. Kalra
Chief Coordinating Officer
and
Dr M.V.V.L. Narasimham
Director
National Malaria Eradication Programme
22 Snamnath Marg
Delhi-110054.
Shri C. R. Krisbnamurthy
Health For All Officer
Regional
Office tor South East Asia
World Health Organization,
New Delhi-110002
Prof. Sonina th Roy
Director
National Institute of Health & Family
Welfare
New Mehrauli Road, Muniika
New Delhi-110067.
Dr K. S- Sanjivi
Director
and
Dr K. Venkateswara Rao
Joint Director
Voluntary Health Sendees
M. A. Chidambaram Institute of Com­
munity Health
Madras-600113.
Dr K. R. Sastry
Chief
Population Research Centre
The Gandhigram
Institute
of Rural
Health & Family Welfare Trust,
P. O- Ambathurai R. S. Anna District624309 Tamil Nadu.
Shri Alok Mukhopadbyay
Executive Director
Voluntary Health Association of India
40 Institutional Area,
New Delhi-110016.
Dr Sanjiv Kumar
8. Health education day: At vil­ Paul D.B. Health. Culture and Community— Lecturer
Case Studies of Public Reactions to University College of Medical Sciences.
lage Dayalpur, on the birthday of late
Health
Programmes,’ Russ JI Sage New Delhi.
Foundation, NvW York, 1955.
prime minister of India, Mrs. Indira
Dr G.V^. Murthy
Resident
Gandhi (19 October), an exhi­ Suchman ,A.E. Sociology and the field ofPublic Senior
Health, Russell Sage Foundation, New Centre for Community Medicine
ATI MS, New Delhi 110029.
bition on maternal and child health
York. 1963
Media
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