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MALARIA CONTROL AND COMMUNITY INVOLVEMENT :
A FIELD EXPERIENCE,-
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The views expressed in this document are
only of study team members and do not
reflect the policies and views of the
organization they represent. This document
is not a formal publication and is for private
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FIELD STUDY TEAM
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Dr.G.Gururaj
Additional Professor and Head,
Department of Epidemiology,
NIMHANS, Bangalore.
Dr.B.S.Paresh Kumar
Senior Lecturer,
Department of Sociology,
Mysore University.
Dr.T.S.Sathyanarayan
Assistant Scientific Officer,
Malaria Research Centre,
Bangalore.
Smt.Neerajakshi
Promotional Secretary,
Voluntary Health Association of Karnataka,
Bangalore.
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Sri.Ananda N
Programme Coordinator,
Catholic Health Association of India,
Karnataka Region.
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CONTENTS
PREFACE
1.
INTRODUCTION
2.
PURPOSE OF THE STUDY
3.
OBJECTIVES OF THE STUDY
4.
SITUATION ANALYSIS
5.
METHODOLOGY
6.
FIELD OBSERVATIONS:
6.1 ONGOING ACTIVITIES AT PHC AREA
6.2 PROBLEMS OF MALARIA IN VILLAGES
6.3 AWARENESS ABOUT MALARIA
6.4 HELP SEEKING PATTERN FOR MALARIA
6.5 HEALTH WORKERS VISITS
6.6 INSECTICIDAL SPRAYING
6.7 SURVEILLANCE ACTIVITIES
6.8 BIO ENVIRONMENTAL CONTROL ACTIVITIES
6.9 ENVIRONMENTAL SANITATION
6.10 TREATMENT ISSUES
6.11 LOCAL METHODS FOR MALARIA CONTROL
6.12 HEALTH EDUCATION
6.13 INTERSECTORAL ISSUES
6.14 ADMINISTRATIVE ISSUES
6.15 COMMUNITY ISSUES
7 . ISSUES FOR FUTURE ACTION
PREFACE
Investment
development
and
ach i eve
nat ional
programmes
are not new
in
developing
has
not been easy
for
these
countries.
programmes
the stated objectives. Yet, such is the faith
programmes
that
massive resource commitments
to
related
heal th
it
Unfortunately
various
in
are
to
on
these
being
made,
largely without the benefits of hindsight and without analysis of
factors
the
1eadi ng
to
success
and
failure
previous
of
endeavours.
is
There
a school of thought which believes that
only
if
representative field data are collected, analysed and directed to
planners and decision makers. perhaps many of the programmes will
have a chance to reach their stated objectives.
In the last
few
months
the
a
study
group
process
and played a role in developing a number of
community health cell has initiated
ini t iat ives
by networking with people interested in Malaria Control Programme
and some activities have evolved focussing on Karnataka.
Perhaps
against
this background Dr.Ravi Narayan -Coordinator,
Hea1 th
Cell ,
Government
of
India,
Dr.Ghosh, Malaria Research Centre, Bangalore, decided
to
a
bring
Dr.Ravi Kumar, Regional
Director,
multi-disciplinary team to go into
Malar i a
Control
recent 1y
concluded
i ssues
Communi ty
related
Programme, particularly in the context
Bio-environmental control project
the
of
in
Kolar
district . Thats how we were brought together. We are indebted
all these people for having given us an opportunity to
this
field study. Their comments and assistance at
has
been
of
immense help. Fox' their unstinting
to
undertake
every
help
to
and
spirit with which it was extended to us , we remain indebted.
stage
the
We
other
express sincere thanks to Kamasamudra PHC
staff
for
their immense help. Our
thanks
doctors,
and
are
to
also
Sri.Premanand Thambi, SIBS, Bangarpet, and everyone at MYRADA who
helped us with workshop arrangements and field work respectively.
We
wish to express our gratitude to the respondents
for
having
given their time freely and shared their opinion with us.
30th May, 1996
BANGALORE
FIELD STUDY TEAM
Page
SUMMARY :
National Malaria Control Programme
The
envisages
reducing
ma 1 ar i a
as
a major public health problem and is
a 11 empting
to
bring
about major changes in implementation and
monitoring
of
the programme.
a
In Karnataka malaria has been a major problem for
of
per i od
long
Chickmagalur,
ident i f i ed
Bi japur
been
Several in i t iat ives
have
in Karnataka to control the problem
through
di f ferent
method
promoted by Malaria Research Center
methods.
these
Among
the
of
( MRC) at
primary health centre area from 1992 onwards.
Bangalore
K amma s amu d r am
The experience
in implementation of this programme has given the
stimulus
repli cate
to
In
Karnataka.
sustainabi1i ty
this programme
in
other
the
order
to
understand
the
1 evel
of
and
malaria
bi©environmental
is in its early stages. This method was adopted in
MRC
Hassan,
Kolar,
have
and
as malaria epidemic areas.
developed
been
Chi tradurga
Tumkur,
of
districts
time and the
communi ty
necessary
districts
programme,
by
undertaken
the
present
involvement
dynami c
communi ty
a multidisciplinary study group
of
feas ibi1i ty,
Bioenvironmental control strategies and other aspects of
control
of
malaria
study
in
in
w .s
Kama s amudr am
primary health centre area.
This
was
an
exploratory study with
understanding the process and.
communi ty
involvement
interactive
and
respondents
and
vi1lages
f rom
and
an
emphas i s
on
(i )
(ii) identifying various issues in
part i c ipatory
staff
of primary
di fferent
sect ions
in
nature
hea1 th
of
study
The
participation.
with
centre
was
an
communi ty
area.
Kamasamudram
Nine
PHC
were
selected for this study based on the incidence of malaria
during
1
Page
the
first four months of 1996. A total of 155
the
during
interviewed
members t
youth
school
teachers,
club
study
members,
were
respondents
which
included
panchayat
pharmac ist,
anganwadi
workers r
time
review
of
activities was also done with the primary health center staff
to
facets.
At
of
end
patients.
workers and
A
malaria control programme in its various
understand
the
heal th
study, a workshop
the
of f i cers
and various non governmental agencies in the
conducted
to
identify their role and
programme
local
the
wi th
2
area
was
in
the
responsibi1i t ies
control programme.
the
Among
surve illance,
causation.
in
practices
were
noticed
treatment.
collection
workers
noticed
nonex i stent,
team.
Considerable
t ime
A
especially
measures,
gap
by
prob 1em
major
between
elapsed
of blood smears and followup treatment.
visits
attributed
by the study
unethical
some
eventhough
interms of followup remedial
was
radical
treatment,
providing
popular
very
was
PHC
the respondents informed that the local
of
even
vi1 lagers
problem of malaria was known to many of the
though they could not attribute clear reasons for its
Most
regular
progress.
and, other preventive activities were in
chemotherapy
1 eve 1
PHC
the
at
ongoing activities
reporting, passive and active
periodical
The
various
The
heal th
number
of
reasons
were
the staff. Active surveillance
for
malar i a
was
and
only
were
not regular and
subseguent to the withdrawal of MRC team
i
pass i ve
surveillance was in progress.
The rapport developed
by
the health workers with the communities was not effective interms
of
initiating
commun i ty
action
for
control ling
malaria.
Page
Insecticidal
spraying was unsatisfactory and the cooperation
of
the villagers was nonexistent. Community respondents had
var i ous
reasons of their own for refusal of spraying operation. A
number
of problems were revealed by the PHC staff interms of
difficulty
in approach. nonavailability of vehicles. pressures from
var i ous
other health programme and priorities of workers themselves.
The
Bi oenvironmentai
control
of
method
introducing
larvivorous fishes in vector breeding areas was initiated
dur i ng
1993
by MRC team.
The technical team was very much accepted
by
the
commun i ty
enormous
the
and
visiting team.
communi ty
However,
was
amount of work
done
by
it was noticed that the awareness in the
was not there and number of misconceptions were
found
to be present.
Communities were not aware of their role in
method
and
had
thought
consumabi1i ty
and
not for vector control. A number
like
prone nature of the area, salinity
drought
i ntroduct ion
of
f i shes
this
was
of
of
for
factors
the
water
stagnating water around breeding areas. and unhygenic methods had
al so
contr i buted
Commun i t i es
help,
for
lack of continuation
the
in
were agreeing to come forward and
provide
programme.
adequate
only if clear and total information was available to
them
and if they were involved from planning stages.
Environmental sanitation was totally neglected in the entire
area
wi th
nobody
imp 1 ementat ion.
found
to
be
deve1 opmen tai
assuming
any
respons ibi1i ty
ma 1 ar i a
its
The process of decentralization of power was not
an answer to this particular
problem.
Even
the
work of local nongovernmental agencies was not
an
integrated approach in the villages which we visited.
for
for
was mainly presumptive and
rad i ca1
Treatment
treatment
was
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The injection mania of the villagers was predominantly
hapazard.
responsible for this state which was inadequately attended by the
medical officers at the PHC level. A major area where no activity
was
on, was in health education
going
solutions.
and
understand the problems
to
vi 1 lagers
than
helping
identify
loca 1
between
fish
rearing
the
and
1 ocal
commun i t i es.
The
communicating
was also not effective interms of
techno 1ogy
whenever
An 'information gap' was found to be present
staff
heal th
educat i on
was more of an academic exercise rather
attempted
the
and
the
messages to the people who were the final recipients. The lack of
adopt ing
coordination was a major problem for
intersectoral
integrated
approach
fac i1i t i es
were
nonavailabi1i ty
the
available at the PHC,
though
Even
to malaria control programme.
an
of
administrative support by the PHC team and the higher authorities
was a major detrimental factor.
willing
part icipate
to
The non utilisation
the technical people.
total
provided
programme
avallable
is given to them and appropriate guidance
information
through
the
in
were
they
community respondents admitted openly that
’’The
existing
of
resources at the community level was a significant observation."
The
the
programme
The
programme
essential '
information,
to
pass ive
understanding
role
the
communi ties
explaining
communit i es
their
role
issue
the
specially
of
control
malaria
was a significant observation.
involve
and
of
various dimensions
its
in
sustainabi1i ty.
contro1
interms
team.
study
for
experience
present study has been a good learning
of
in
malaria
It
is
very
tota 1
by
providing
and
respons ibi1i t i es
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along
wi th
providing appropriate guidance
and
programme.
this
The intervention developed needs integrated community
approach
from
the inception of the project
d ialogues
wi th
community respondents.
major
and
monitoring
supervision of the project for successful implementation of
5
through
The PHC has
initiative in successful implementation of the
monitoring must go beyond
Evaluation
and
pos i t ive
change from al 1 sides for longterm
programmes.
members
cont i nuous
to
take
a
programme.
and
examine
sustainabi1i ty
of
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’’The National Malaria Control Strategy (NMCS) is directed to
provide
freedom
has i c
right.
from malaria to the people of
NMCS
takes
cognizance
of
Ind i a
as
prevailing
the i r
malaria
situation and new epidemiological paradigms in the country. Thes
are Tribal malaria. Irrigation malaria. Urban
paradigms
and Peri-urban malaria, Project malaria. Marginal rural
malaria
malaria,
Migration malaria, and Border malaria. Malaria control under
primary
based
political
cornmi tmen t
coordination, legislative
support,
intervent ions
on epidemiological assessment, and flexibility in
approaches.
NMCS
care system requires :
hea1 th
intersectoral
br i ngs
the
control
In the background of new epidemiological
paradigms,
drug
policy,(i i)
out
insecticide policy.
the
need
to
review:
(i)
(iii)re-organization of NMEP in tune with the
NMCS,(iv) decentralization of malaria control,(v) epidemiological
reasoning in control approaches,(vi) health systems research. and
(vi i) training.”
(Source : National Malaria Control Strategy Document, 1994.)
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7
1. INTRODUCTION
it
malaria control operations at the community level
In
understood
that the local communities must be involved at
s t age
the
of
operat ions
field
the
under
every
plan
modi f i ed
is
of
This has given rise to increased expectations by the
operat ions.
people that their active role should be taken into account i n the
National Malaria Eradication Programme (NMEP). Since malaria is a
and
1 ocal
problem,
f oca 1
locally
addressed
with
decentralized planning.
measures
the control
total
to
needs
involvement
communi ty
At the same time, a number of
be
and
voluntary
agencies working in different developmental programmes as part of
While
the local communities needs to be involved at every stage.
many
voluntary agencies would be interested in
the required technical support and
activity,
malaria
control
coordinat ion
wi th
other governmental agencies has not been to the desired extent. A
of
bound
meet
to
communi ty
this nature designed to benefit the
programme
with problems and failures
wi thout
the
is
active
support and involvement of the communities.
In
Karnataka,
the problem of malaria has
over a period of time.
regional
ma1 a r i a
probl emat i c
Chi ckmagalur,
increasing
As per the statistics available from
office.
Karnataka
is
one
areas for malaria. The districts of
Tumkur,
been
Chi tradurga
and
the
the
highly
Kolar,
Hassan,
of
Bi japur
have
been
identified as Malaria endemic areas with high rates of Plasmodium
this.
the
problems
of
insecticide resistance and drug resistance has only added to
the
falciparum
infection.
existing problem.
Along
with
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2. PURPOSE OF THE STUDY
During the past few months. a group of people from Community
health cell. Malaria research centre. Regional office of
heal th,
Voluntary
heal th
hea1 th
associat ion
of
Karnataka,
Catholi c
association of India
Karnataka, researchers from other agenc i es
have
to
met
frequently
di scuss
the
problem
of
in
Malaria
Karnataka. Preliminary meetings helped in review of the available
statistics,
role of voluntary agencies, ways in which
voluntary
organizations can support malaria programmes in different places.
Recently, MRC team had done intense work in Kolar district
Kamasamudra
in
PHC area based on Bio-environmental control
control 1ing
feas ibi1i ty
and
ret iculatus)
the
the
project for transfer of
communi ty
entire
is
This
malaria.
i nvolvement
in
first
demonstration
technology.
Karnataka.
methods
sus tainabi1i ty
Guppies
(Lebi stes
were released at several water bodies covering
PHC area. This intervention
ongo i ng
survei1 lance
s imultaneous1y
ac t ivi ties.
drug
the
strengthened
di stribut ion
and
control measures in the PHC area.
The
declining
exper ience
of
this initial effort
not i ced
API has lead towards replication of the same in
districts of Karnataka. However,
to
as
make
this
intervent ion
by
a
other
it was felt that there is a need
and
other
control
strategies
sustainable in order to make it a "people’s programme".
Transforming
intervent ion
from
understanding
of
a technology driven programme
'Laboratory
the
programme
to
in
or
translating
Land'
requires
a
bas i c
its
entire
gamut
and
8
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communi ty's
measures.
percept ions
of the problem and
suggested
a change calls for "redefining
Such
the
remedial
roles’
and
involving everyone in the process.
W i t h t h i s in view, a need was felt to undertake a
dynamics
communi ty
study on malaria control with a special focus
environmental
control
Dr.G.Gururaj
(Addi t iona1
ep i demi o1ogy,
NIMHANS, Bangalore), Dr.B.S.Paresh
Lecturer,
Dr.T.S.Sathyanarayan
research
centre,
field
team
compr i s i ng
of
Professor
and
Head,
department
of
of
soc i ology,
(Ass i s tant
Kumar
Mysore
Research
Scientific,
Smt.Neerajakshi
Bangalore),
N
Sri.Ananda
of
assoc i at i on
(Programme
(Sen i or
Univers i ty),
Coordinator,
Malaria
(Promotional
Secretary, Voluntary health association of Karnataka,
and
Bio-
A
methods.
department
on
Bangalore)
Cat. ho lie
India, Karnataka) was constituted
to
hea1 th
undertake
this study in Kamasamudra PHC area.
The
points.
need for this present study was felt from several
view
While
new
s trategi es
the country is in the process of
and
techno logical
for
coi
rol
of
operat ions
methods
have
during
the
at grassroot levels.
Al so, a
been developed which would be
next
wi thout
few years. These
the
through
malaria
means, it is essential to observe the
these
sus ta i ned
techn i ques
developing
process
number
of
of
new
put
into
pract i ce
interventions
will
not
active involvement of
people
at
be
local
1 eve 1s.
In order to facilitate their participation. a
commun i ty
dynami c
study in this area was identified as a thrust
area
for
strengthening malaria control programmes, not only in Kamasamudra
PHC area but also in other districts of Karnataka and India.
9
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3.OBJECTIVES OF THE STUDY
Having identified PHC Kamasamudra as a problematic area
malaria,
group
the
decided to focus indepth
on
a
for
review
of
imp 1 ementat ion
of
ongoing malaria control activities to :
the
a) understand
current
status
of
malaria control activities at village level.
b) study
communi ty
knowledge,
perspect ives,
awareness,
and participatory process in malaria
pract i ces
and
i ts
and
control operations.
c) develop
an
involvement.
of
the
acceptance
sustainabiIi ty
of
Bi o-cnvi ronmenta1
understanding
in
control methods by the communities.
4. SITUATION ANALYSIS
district of Kolar is situated in the South East
The
region
of the state and has a population of over 20,51,729 million (1991
The district consists of 3,338 villages spread over
census).
11
taluks over a total area of 98,223 sq. kms. The district receives
1 ow
rain fall and is a plain terrain region with hilly and
area.
forested
The
district receives low
fall
rain
wi th
average of about 600 mm. Tanks provide the major source of
for
irrigat ion
(total number being 4,479) and the
less
an
water
district
is
known as land of tanks. The major occupation is agriculture. With
commun i t i es
cont i nue,
reali s ing
there
that
agriculture
has been a gradual shift
being
di ff icult
towards
sericulture.
This is progressing well as a cottage industry. About 80% of
state’s
silk is produced in this district. There are 45
heal th
centers
in
this district. Information
to
related
the
primary
to
the
10
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topographical
nature
of Kolar district has been
summarised
11
in
table 1.
Table 1. Salient characteristics of Kolar district.
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Area : 98,223 Sg.Kms.
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Population : 20,51,729
No. of villages :
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3,338
Taluks :
11
Tanks :
4,479
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Average rainfall : 600 mm.
Major occupation : Agriculture and sericulture.
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No. of PHCs : 45.
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I Major malaria vectors : Anopheles
Culcifacies
Culci facies
(breeding
I
primarily
in
in
tanks,
tanks,
irrigation
1
wells, and irrigation pits).
I
Fluviati1 is
Anopheles
(breeding
I
primarily
in
streams).
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Primary health centre Kamasamudra is one of the PHC’s, where
malaria
is
highly prevalent.
The major reason for
this PHC was that malaria was on the increase from 1991
An
epidemiological
shown in table 2 .
profile of malaria in
PHC
taking
up
onwards.
Kamasamudra
is
t.
Page - 12
Table 2. Epidemiological profile of PHC Kamasanvdra
/---------------------------/
I
I
I
I Total
I Bld. Smear I
Total IP1 a smod i urn IP1 a smod i um I
Year
I Population I Examined I Positives I
Vivax iFalciparwnl PF%
I-------- 1-------- 1-------- 1
I
1991
I 94710
I 27183
I
877
1
766
111
I 12.7
I
I-------- 1-------- 1-------- 1
|----I
1992
I 28620
I
2957
I
95232
1842
215
I 10.5
|-------- 1-------- 1
|----I
1993
I 24774
I
2080
I
1724
I 103357
225
I 10.8
|-------- 1-------- 1
I---1994
I 103869
I 22797
I
1038
I
888
150
I 14.6
I-----(-------- 1-------- 1
I---1995
i 106244
24159
666
366
300
I 45.1
I----I---I
I
I
1996 * I 111556
3928
82
63
19
I 23.2
I
\—
★
Provision upto March 1996.
** Annual Blood Examination Rate.
.Annual Parasite Index.
\
(Slide
(Slide
I
l+ve Rate IFal.RateI
aa
ABER
API
(
I
I
3.2
7.2
I
I
I
I
I
I
I
I
8.3
4.6
2.8
2.1
I
I
I
I
I
I
I
I
I
I
I
0.40
0.80
0.90
0.66
I
I
I
I
I
I
I
I
1.24
0.48
28.7
30.4
|-----
23.9
21.9
22.7
I
I
I 9.2
I
( 19.4
I
I
I
I
I
I
3.5
I 20.1
I
9.8
I
I 6.3
I
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Fig-1 • Malaria problem districts in Karnataka state
for implementationi of Bio-environmental Control
Strategy during VIII plan
Fi gPHC
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Page
the
Table 2 shows that the incidence of malaria has been on
increase since 1991 as shown by total positives and API. However,
onwards
1993
since
there
has
dec line
a
been
Falciparum
parameters. To our surprise, the number of Plasmodium
a
shows
cases
sudden and
analys i s
In tens ive
suf f iciently
of
i ncrease
s igni fleant
various
factors
could
during
1995.
exp lain
not
this increase. MKC team started
for
same
the
on
operat ing
in
Kamasamudra area from 1992 onwards. By 1993 June the geographical
maps
reconnaisance and fish release was completed. A copy of the
this purpose is shown in figure 1. The
prepared
for
moni tored
malaria
situation during
1994-95
also
team
(including
cross-
examination of smears).
and Anopheles Fluviatilis
are
the
important vectors in this area. These mosquitoes
breed
in
Anopheles
most
irrigation
are
Cuiici facies
sources
wells. tanks and streams. Few other breeding
irrigation channels. drinking water wells.
pits
i rr i gat i on
(also known as farm ponds). seepage water. etc.
Two rounds of DDT are sprayed every year with a coverage
official
20% household dwellings and 55% cattle sheds as per the
people
Due to high refusal rate of DDT spray by local
reports.
of
as it is known to damage sericultural activities, alternate methods
of
vector
environmental
has
were
thought
of ,
among
parti cular
control was one of them. This
wi th
introduction of DDT since
1950s.
intervention much importance was not given for
Due
methods
s i nee
of this century. However, these measures took
the
Bio
which
formed the backbone of malaiia control programme
beginning
seat
contro1
the
a
back
to
this
Bio-environmental
13
Page
control
bl ood
in the programme. Many felt that, if people
for
sprayed
that
smear
their
houses
it was enough to control the disease. Time has
this
wheel,
examination and allowed
to
be
revealed
was not to be the case. With the
comp1 eted
turn
current
the
for
Bio-
method along with the people's participation.
Due
the
environmental
strategies
emphasize
need
to innumerable number of water bodies, fish rearing as a
measure
their
gave
was
geographi ca1
given priority in controlling
reconnaissance
and
vector
malaria.
biology
of
control
Based
s tud i es,
on
the
locally available larvivorous fish "guppy" {Lebistes reticulatus)
was
re 1 eased
into
water
bodies
laying
special
emphas i s
irrigation and draw wells where prevalent vector mosquitoes
on
were
found in abundance.
PHC
Kamasamudra
has
a total population of 95,333
and
is
s i tuat ed
close to Andhra Pradesh and Tamil Nadu, It is s i tuated
o
o
between 12-19 latitude and between 74-78 longitude. The average
rain fall in PHC Kamasamudra was 748 mm.
There are 141
vi11 ages
in
this PHC area and malaria is a perennial problem.
Out of
MPW
sections in this area.
probl emat i c
from a malaria view point.
given in table 3.
6 are considered
highly
11
The API and the average API rates are
14
Page 15
Table 3. API Rates in PHC Kamasamudra area in different villages.
/----
\
A P I
/
I
MPW Section
-I---I 1991
1992
I 1. Balamanda
I
I--------------- -I
I 2. Kethaganahally I
-I
I 3. Kamasarnudra
-I
I 4. D.P..Hally
I
25.7
47.9
33.3
21.0
I 5. Thopphanahal1i
I
-I
I 6. Mustralalli
I
I--------------- - I
I 7. Velgamadi
8.2
36.3
4.6
21.1
1.2
10.7
I 8. S.G.Kote
0.3
0.9
0.2
1.0
19.3
128.8
17.1
69.0
-I
I 9. C.A. Hally
-I
I 10. Banqarpet
I----------i 11. Hudkula
-I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
0.1
0.4
I
I
0.2
0.2
I
1993 I
---- 1
72.9 I
----1
27.2 I
----1
10.6 I
---- 1
8.7 I
----1
11.5-I
---- 1
14.4 I
----1
16.6 I
4.8 I
----1
8.1 I
2.6 I
11.4 I
I
1994
12.2
72.6
17.4
1.3
11.2
10.4
I
I
I
I
I
I
I
I
I
I
I
I
I
I
16.0
1995
5.1
35.6
18.1
2.4
I
I
I
I
I
I
I
17.3*
4.5
1.6
I
I
I
I
I
I
I
0.3
1.7
I
0.2
15.7
0.9
1.7
\--------------
★ Problematic Sections
\
I Average API
I
66.3*
I
I
39.1*
I
I
35.1*
I
I
19.7*
I
I
I
I
12.1
12.1
I
I
I
1
I
I
I
I
|------------
11.2*
1.2
0.5
I
I
I
I
I
I
I
I
I
I
I
I
I
I
/
Source : PHC Kamasamudra
Page
5. METHODOLOGY
was
This
s t udy.
an exploratory,
Hardcore
techni ques
research
methods
threatening
adop ted
samp1e
part i c ipatory
size,
sampling
The
information in this area.
Hence,
a case study approach to study this problem in
Kamasamudra area. Out of the 11 villages in this area.
from
se1ect ion
during
of
these
were
selected
for
our
villages were based
on
malaria
useful
the
team
the
PHC
9 villages
study.
The
inci dence
1996 as shown in table 4. Among these villages. the
environmental
all
sect i ons
di f ferent
study
interactive, participatory and non
dialogue with the local communities would be
col 1ect ive
get
of
a
and questionnaires were not incorporated.
team felt. that an open ended,
to
interactive and
Control method of fish release was implemented
in
except
Bio-
Puram. The number of malaria
cases
dur i ng
in
the
months of January, February, March and April is shown in table 4.
The field work consisted of intense interactive
during
ear 1 y
t imings
were essential as all the villagers would
only
at
this
morning
and late evening
time. The study team also
hours.
di scuss ions
These
flexible
be
available
all
efforts
to
women,
youth
and
sections of villages in terms of
caste
and
also the accessibility of these villages to the Kamasamudra
PHC.
provide
adequate
elderly.
di f ferent
The
made
representation for men and
village interviews focussed on not only malaria but
various
ongoing control activities. The sample was opportunistic and each
member of the study group approached respondents independently. A
predecided
included
checklist was used to elicit information.
in the checklist were demographic data cf
The
areas
respondents,
16
Page
awareness
about
provided
by PHC and community perceptions about the
sus tainance
of
programme.
after
the
interview.
the
disease
and
its
transmission,
Information was documented
soon
services
the
17
Page - 13
Table 4. Distribution of Malaria cases in selected villages.
/-/----------------
I Village Name
I-------------I 1. C.Yelsamanda
I 2. D. Yelsamanda
I 3. Armanahalli
---------- 1___
1 Population I PV
348
I
I
I
I
I
I
I
I
358
I
1
510
I
I
I
I
I
I
417
I
4
I 8. Bodaqurki
650
I
I
1
I 9. Kamasamudra
2995
I 4. Thoppanahally
I-------------I 5. Bogalahally
I 6. D. Kalavanchi
620
271
|----------------
I 7. Puram
|-----------------
Total
I
I
I PF
I-—
I
|---
I
I
669
\
January
6
I
I
I
I
I
I
I
I
I
I
1
I
I
I
1
1
\
* Mass blood survey was done by MRC/PHC team.
Source : PHC Kanasamudra.
I
I
I
I
I
I
I
I
I
I
I
I
I
I
—I
T’ I
—I
I
—I
I
—I
1 I
—I
—I
— I
I
— I
—I
4 I
—I
1 I
I
I
I
1 I
—I
7 I
March
February
PV I PF
—I
5 I
—I
2 I
1
I
—I
I
—I
I
—I
I
—I
2 I
—I
I
—I
I
—I
10 I
I
I
I
I
I
I
I
I
I
I
I
I
1
1
I
I
I
I
I
I
I
—I
T’ I
—I
5 I
—I
2 I
—I
1 I
—I
—I
I
—I
I
3 I
—I
— I
—I
— I
11 I
PV I PF
I—
1 I
I—
I
I—
I 1
I—
I 1
I—
I
I—
I
I—
3 I
I—
1 I 2
I—
I
I—
5 I 4
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
April
I
—I—
I
T I PV I PF’ I T
—I
—I
I
—I
1 I
I
I
I
—|
I
—I
I
I
I
I
I
—I
—I
1 I 20 I 1 I 21 *1
— I-- — I
— I -- 1
3I
2 I
5 I
1 I
— I-- — I
— I -- 1
4I
0 I
4 I
— I
— I -- 1
— I-- — I
— I
I
-- 1
-- 1
3 I
6 I
6 I
I
1 -- 1
— I -- 1
3 I
3 I
3-I
-- 1
— I -- 1
3 I 1 I
4-I
I
-1
-1
I
—I
9 I 39 I 3 I 42 I
-- /
Page
this
In
a
wh i ch
interviewed
club
way
members,
total
number
of
155
included 4 local panchayat members,
pharmac i s t,
1
1
5
worker,
Anganwadi
were
respondents
youth
2
schoo1
teachers, 9 health workers and 35 patients. Remaining constituted
residents of different villages.
Apart from these community interactions, a review of activi
ties
was also done with the PHC staff consisting of two
off icers,
workers
peopl e
block
health education officer,
medical
mult ipurpose
(male and female), and other staff at PHC
working in the departments of education.
heal th
Al so,
level.
affairs,
youth
pharmacy, fisheries and others were also met during this time.
12,
May
On
agencies,
1996,
of
various
vo1un tary
(district
malaria
of f i cer,
representatives
governmental
agencies
assistant health officer), panchayat chairman and members.
along
wi th
the
d i scussed
study
team
participated in
of
problems
malaria,
a
workshop.
The
group
contro1
measures
along
wi th
reflect ions
and observations of study team. Later, a
number
areas
identified for mutual
strengthen
were
to
col laboration
of
programme at peripheral levels (detailed report in Appendix I).
6. FIELD OBSERVATIONS
6.1 ONGOING ACTIVITIES AT PHC AREA :
Even
though,
PHC Kamasamudra is a highly
malaria
area, no vigorous activities seems to be ongoing. The
endemi c
act i- i t ies
at the PHC level include periodical reporting. passive and active
surve illance,
spraying,
prevent ive
activities in
terms
of
insect i cidal
and regular chemotherapy. Even though introduction
of
19
Page
f i shes
on
a
large scale was undertaken in
this
area
by
lessened
i ts
vigour,
subsequent to the withdrawal of the team. As the Medical
Of f icer
Bangalore,
at
PHC
the
programme
seems to have
remarked ’’malaria is one among the
52
MRC
programmes
regular reporting as and when desired." The need for
with
information
by higher authorities seems to be very high as requests are
sent
every
sent t
as
now and then for malaria. Reports are generated and
and when required. The ongoing passive surveillance
for
treatment
rear i ng,
pat i ents
di stribut ion
and collection of
and maintenance along
blood
provides
smears.
wi th
Fish
survei1 lance
activities seems to be on the decline over a period of time.
6.2 PROBLEM OF MALARIA IN VILLAGES :
all
In
malaria
the villages, people knew about the
exi stence
and reported that it has been their for so
many
of
years.
But, they were not aware that the problem of malaria was so large
and its impact on day to day living of people. specially economic
loss
to the family. loss of work. loss of school days and
aspects. Many of them believe that poor environmental
was
other
san i tat ion
one of the major reasons for spread of malaria, but
at
the
same time they felt that they were totally helpless to do somethi ng
blood
about it. In one of the village (Armennahal1i),
survey
everyone
was
undertaken
in
the
previous
where
month.
mass
almost
knew who had suffered from malaria during the past
one
month and where they took treatment.
1 ack
Few
observed
of
resources,
respons i ble
that lack of interest by
lack of planning
and
panchayat
implementation
for the poor state of environmental
spread of malaria in their village.
members,
sani tat ion
were
and
20
Page
6.3 AWARENESS ABOUT MALARIA :
Major i ty
of
the community respondents seem to
the existence of malaria in their region. The
about
know!ng
be
respondents
equated chills and fever with malaria. However, majority of
them
were
not
aware that malaria is transmitted by
mosqui to
bites.
Some
even
believed that drinking water causes
malaria.
Other
sani tat ion,
aspects thought to be responsible were environmental
agricultural-irrigational development, rainfall or the spread
species in the region.
vector
that
knew
or
smear and examination will prove
blood
collect ing
Majority of them also
of
di sprove
malaria in their body.
6.4 HELP SEEKING PATTERN FOR MALARIA :
Many of the respondents and their family members knew
the
Kamasamudra and its effective role
existence of the PHC
malaria patients.
handling
Some were also obtaining
care
the local civil hospital at Kolar Gold Fields (KGF). The
of
migrat ion
topographical
was
quite
Nadu. People from these states
PHC
Kamasamudra
came
here
popular!ty
of
the
treatment
and
did not turn up later. The PHC
locate
was
no
problem
in
the
obtaining
not
could
The
also influenced by the availability
in the PHC. We noticed that drugs were adequate and
drugs
Andhra
vi11 ages.
their address during their next visit to
help seeking pattern was
the
to
due
staff
from
of
to
for
getting the
right
treatment
even
of
there
though
injections were a favourite among the communities.
f
in
problem
because
rampant
situation of PHC Kamasamudra adjoining
Tami 1
and
Pradesh
malaria
about
10**
21
Page
people
Though
treatment
access
of
to
had known and accepted Kamasaihudra
respondents
malaria. a segment of
the primary health centre, rapport
existing
class differences determined the
Some
them reported that due to lack of
of
PHC
for
observed
that
wi th
staff,
utilisat ion
fol low
and
pat tern.
up
remedial
measures, they were not willing to go to PHC and sought help from
KGF
hospital or private practitioners at
c i vi 1
which
KGF
was
nearly 20 kms away.
6.5 HEALTH WORKER VISITS :
Interactions with the PHC staff revealed that health workers
had
a
vi1lages
definite tour programme every month with
ident i f ied
for
visits on particular days. Since the
being
number
of
health workers were less (2 out of 10 posts of MPW Male and 3 out
of
14
posts of MPW Female were vacant). sudden
programmes
resulted
and
and
pressure
the
due
to
priority
in making their visits to villages
less
frequent.
nonavailability
of
Added
this,
to
new
of
fixing
of
programmes
somewhat
haphazard
the
was
vehicle to visit any of the
of
problem
vi1lages.
The
existing vehicle needs the manpower support of 6-8 people to push
it. as and when it stopped. Health workers during their visits to
villages could not meet people. leaders or families with
because
pat ients
the
time
of
their
visit
was
malaria
always
inappropriate and many would be working in agricultural field
at
that
survei1 lance
of
which was appreciated by many of
the
time.
In these situations, only
malaria was found to exist
passive
village respondents. They mentioned that for almost every patient
visiting
was
taken
PHC, tablets were given along with an injection.
and
they were informed that
the
results
smear
would
be
22
Page
communicated
to
them.
However, in majority
of
instances
of reports was not conveyed back to them. This
results
23
the
resulted
in patients seeking help from other sources or were provided half
treatment or did not radical treatment (to be given for malaria).
Some of the health workers were not found to enjoy
adequate
rapport
with the communities as their scheduled visits were
known,
irregular
and not at times when people
when they visited villages,
Even
were
avallable.
information on malaria was
provided
totally
except
treatment
being
given. Some of the
a smear being
taken
informed
respondents
had not visited theLr villages for more
workers
months
with reasons known to health workers rather than
Some
respondents in particular
not
presumpt ive
and
hea1th
respondents.
not
vi1lage
that
than
6
vi1 laqe
ment ioned
that their health workers were more involved in activities
other
than their stipulated work.
6.6 INSECTICIDAL SPRAYING :
DDT spray is one of the commonest methods of malaria control
adopted for a long period of time. The instructions to staff have
to
been
cover
human
dwe11ings,
and
rooms
NMEP,
1995,
PP112). To our surprise. even the PHC staff were not fully
aware
(Operational
of
the
manua1
structures
mixed
for malaria action programme.
to be sprayed. Our visits
revea1ed
that
entry
of
dates on the walls by the DDT
every
house
i ndi cated
with
dwel1ings
this was an ongoing activity as
to
the
vi11 ages
not i ced
by
the
spraying
team.
Almost
had this information written on their
wa Ils
wh i ch
that
the visits were quite regular.
Our
interact ion
the PHC and the District Malaria Officer revealed that
the
Page
aval lability
Even
DDT and supportive equipment
of
vi11agers
the
many
times
admi t ted
was
that
DDT
important,
helps in reducing mosquitoes, gets their
c 1 ean
felt
and
sorry
for
refus ing.
good.
quite
spray
envi ronment
the
However,
is
reasons
at tributed
for refusal of spraying was because of the fear
that
ser i culture
would suffer rather than for health reasons. We
did
not
observe or noticed larvicidal spraying carried out
area.
Few other issues related to spraying have not
into
account
over
sericultural
a
period of
time.
With
the
in
this
been
taken
increase
activities and knowing fully well that DDT
in
affects
silk worms, communities would not allow DDT spray anywhere in
or
near
to
their house. Their house, their
surrounding
nei ghbours
house
and
areas were not sprayed in any way. For a
number
of
spraying
was
fami lies
i nvolved
just
ritual of an operation. It was only the
a
cowsheds,
bathrooms,
uninhabi tated
respondents
and
in sericulture, the process of
open
dwelling.
which
space
were
in
the
sprayed.
outside
walls.
vi1lage,
some
Many
believed that DDT spray increased mosquito
of
breeding
also resulted in more bed bugs within the house. The use
pressure
tactics by spraying team was not helpful in any way
communities
spray,
did not have basic information on importance of
procedure of spraying, merits and demerits.
the
of
as
DDT
periodicity.
reducing the problem of malaria or the spraying techniques or any
other
some
issues. This cosmetic work had only increased vectors
reported
that
the total coverage was less
and
10%
for
villages and it could be totally stopped. Some of them also
felt
than
that DDT on animal fodder was injurious to health of the animals.
Women
did not approve of spraying within their dwelling area
as
24
25
Page
it was difficult for them to shift their belongings and tolerance
of
determi ne
DDT
whether
is
spraying
accepted
factors
these
"the pungent odour’ of DDT for long time. All
not
or
the
by
communi ties. These issues needs to be discussed at various levels
before a final decision about its continuity can be taken.
6.7 SURVEILLANCE ACTIVITIES :
There
the
number of reactions from
were
ongoing surveillance activities.
about
vi11agers
Our interactions with PHC staff
and
communities revealed that passive surveillance
was
ongoing
and
active
subsequent
to
partial
survei11ance
had
declined
blood
by MRC team. In one village. it seems that mass
withdrawl
smear
surveys
malaria
in
also conducted due to a
was
high
that village. We did not notice or
incidence
of
about
any
hear
shortage of laboratory equipments or reagents or other things for
survei1 lance.
continuing
However
the
Laboratory
of
post
Technician was vacant for a long time and some junior person
was
of
the
deputation to cover this activity.
placed
on
vi1lage
respondents
Major!ty
be
taken
whenever they have fever with chills and rigors and tablets
need
knew that blood smear needed
to
to be swallowed immediately.
However,
the
a number of problems were noticed with
survei1 lance
Accessibi1i ty
of
activity
which
needs
to
be
Migratory
malaria
strengthened.
the primary health centre and villages
major issue for both communities and the PHC staff
was more common in this area as
to
regard
was
a
respect ively.
people
from
neighboring states visited the PHC because of "its popularity for
treating malaria". At the same time many had not received radical
Page
treatment. They were also not informed about the results of blood
smear
examinat ion
Di scont inui ty
as
addresses
were
given
incorrect.
in the treatment between presumptive
due
to nonreporting of smear results was a major
can
give
and
radical
problem.
rise to increasing drug resistance among
This
new
malaria
this
pr imary
cases and lead to its spread to other regions.
was no active surveillance going on in
There
centre even though it is a malaria endemic area. Lack
heal th
staff
technical
interms
of
workers,
field
of
supervisors,
technicians was a major hindrance for malaria control activities.
programme,
Under
the
higher
author!ties
peop 1 e
every
the target approach
that
25 smears to be
recommended
collected
month by the health workers had only
the
by
1 f 000
per
resulted
in
or inaccurate reports of questionable nature. The
PHC
staff disclosed that they could only collect about 15 smears
per
incorrect
1,000
population. This once again indicates that a target
based
approach will not work while multiple programmes are going on
the PHC level. The pressure from various other health
ranging
at
programmes
from immunization to filaria control, had only
resulted
in relegating malaria as a peripheral activity. The entire nature
work
seems
to
programme
can
exert
of
be dependent
on
how
much
at the PHC level. The
pressure
priori ties
each
of
the
health workers themselves for malaria was found to be very low as
they did not know the gravity of the situation in their own area.
The
long period between smear collection, communicating
and
providing radical treatment was extremely high ranging
1-2
mon ths
in some instances. as noticed by
the
results
notat ions
from
on
26
Page
stencils of the
to
wall of houses by the health workers. This leads
problems of drug resistance, transmission of this
resi stance
and problems in longterm control of malaria.
6.8 BIO-ENVIRONMENTAL CONTROL ACTIVITIES :
Af ter
identifying malaria as one of the serious problem
in
this area, the Malaria Research Center in Bangalore undertook the
task
of
Two
types of larvivorous fishes were considered
testing out the Bio-environmental
(Gambus i a
af f ini s)
and Guppies
(Lebi stes
contro1
strategies.
viz. ,
Gambus ia
ret i culatus).
After
making geographical mapping of all the vector breeding areas, the
team introduced 'Guppies', which were readily available in
into
numbers
many of the water bodies.
Three
large
viz. ,
vi1lages
Puram (Kethaganahally section), Bodapathi (D.P.Hally section) and
Banganathu
(Toppenahally section) were used as control
vi 1 lages
as no BEC methods were Introduced in these villages. In 1996, the
incidence
malaria
shown
an
community
increase
in one of the control
and
this
was
vi1lages
therefore
(Puram)
included
has
in
our
dynamics study. The MRC team worked during 1993-95
in
this area and fishes were left in many of the potential points of
vector breeding (table 5).
27
Page - 2g
Table 5. Details of Guppy fish introduced in Kamasamudram PHC.
/---------------
I
I Section
I
I-----------IMustarahally
I-----------IThoppanahally
I-----------IBalamanda
ID.P.Hally
I------------IKamasamudra
j---------------
iK.G.Hally
I
TOTAL
I
\
-------------------------------------- \
iFish
I
llrrigationl
I introduced! Tank I
Well
I
Wei 1
Ivillage
I
I
I
I
I
13
18
182
I
I
I
I
I
I
16
22
248
I
I
I
I
I
I
I
14
10
190
I
I
I
I
I
I
I
I
10
4
125
I
I
I
I
I
I
I
18
13
244
I
I
I
I
I
I
I
I
I
16
18
183
I
I
I
I
I
I
I
87
85
1172
I
I
I
Draw
Well
26
23
21
17
42
28
157
llrrigationl Borrow iNumber of I
I pits
I pits
I fishes
I
I
I
I introduced I
------ I
_|------------j--------- |
122
199
1
18.500 I
--------j
I------- j
42.500 I
4
33
I
I
I
I
------|
-------|
I
29,000 I
22
2
I
I
I------- j
------ I
I
22
16.500 I
0
I
I
I
I------- |
43,000 I
66
12
I
I
I
-------|
I
------j
I
41.500 I
22
12
I
I
I
I------- |-----------|
I
I 24
I 1,91,000 I
32
I
------------ /
Page
Medical Officer of the PHC remarked that "it is a remarkably
effective method." As per the official statistics
cost
provided
in table 1 and figure 2 it was observed that there was a definite
in
decline
the problem of malaria in this region
due
to
thi s
in tervent ion. It needs to be examined whether fish breeding alone
has
contributed or a number of combined ongoing activities
have
resulted in this decline.
Many of the village respondents knew about this 'technology'
also added that this technology helps in
and
pur i f i cat ion
Some school children in PHC area were aware of
water also.
of
this
because of the exhibition arranged by MRC. People were willing to
this up as a continuous ongoing activity only if they
take
were
provided all details about this intervention earlier.
MRC
The
dur i ng
MRC
staff were very much accepted
their work.
team
the
by
The dedication, commitment and
were brought to light by the PHC team
and
the communities were not informed about the
However,
communi ty
interest
of
communi ty.
growth
of
fish, methods of survival, precautions they need to adopt, follow
up strategies, development of fish hatcheries and others.
di sclosed
It was
by the health worker attached to MRC team that 50
out
of
80 tanks (where fishes were left) had dried up during
summer
and
all fishes were dead. Since the district is a drought
prone
area, drying up of tanks is not unusual, but nobody knew what
Many of the community respondents expressed that
do next.
f i shes
were
left for consumption purpose and were
important
these
waiting
them to grow. so that they could catch and consume them.
point is that rearing of bigger fishes in areas
to
for
Another
where
29
Number of malaria cases
-a
o
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8 s: S
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8 5
«s
§to iIjn § O
° u
m
V
ft
V*
<•
0
n
5Zl
O
O
54
CO
O1
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£
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z
co
ft
§
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co
co
o
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g
o
r
o
z
s
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g
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g
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,
ro
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g
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T-
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o
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Page
reared leads to Guppies being eaten away
are
Guppies
programme.
local predators and thus eliminating the intervention
of garbage in the wells, salinity of the water and
Presence
the
determining
flow or stagnation pattern were other factors
water
other
by
this
the growth of fishes and subsequent reduction of malaria in
region.
i ssues
other
communities were totally unaware of many
The
the
related to fish breeding and were not aware of their role in
entire
process.
them.
1eavi ng
The entire process of getting
them
in water points, presence
fish.
of
rearing
hatcheries,
follow up, maintenance and sustainability were not known to
many
excellent opportunity
which
This only indicates that an
them.
was
avallable
for
educat ion,
community
to
long term control was lost due
1 ack
of
The
other
publi c
works,
involvement and participation.
sectors
like fisheries, agriculture, irrigation.
forestry
were in no way involved in the process and thus it
become more of a scientific/technology project being
had
transferred
by the MRC team rather than people's programme.
6.9 ENVIRONMENTAL SANITATION :
number
the
i ncrease
in
environmental
san i tat ion
during
With
of
this
activities
related
intervention
programme,
was
a general increase in the level of awareness
communi ties
and many were willing to cooperate in this
there
However, the exact problem was that
it?
in
to
the
process.
many did not know how to
Who will do it? Will it continue? Will it lead to long
do
term
change? Even though many agreed that this is an important area of
activity,
the
"modus operand! " was not known
nobody to guide then.
and
there
was
30
Page
the
After
decentralization of power and the
emergence
this
raj , the mandal panchayats were not effective in
panchayat
of
process
in any way. as many of them did not show any
interest
in
agencies
were
get ting
into environmental sanitation like making gutters
(open
this
area.
A number of
voluntary
part icular
drainage), removing water pools and others, but, however this was
an
fragmented
and
approach.
For example, gutters were constructed in
a piecemeal approach rather than
integrated
one
vi11 age
without any provision for eliminating stagnating water. Thus even
a beneficial work for growth of the community can be
detrimental
for the health of the same community. Open drainage systems
common
in almost every village with intense
breeding.
mosqui to
Negli gence
and
concerned
to enlist community participation in keeping
was
c 1 ean
non i nvo1vement
of
the
a major factor in a situation
or
author!ties
where
no
were
those
vi1lages
educational
activities were going on. Waste disposal was not a priority
in
the
stored
vi1lages,
near
but for many residents the waste
to their house. as it could be
shifted
had
area
to
be
later
for
their agricultural lands.
6.10 TREATMENT ISSUES :
The presumptive treatment given by health workers at village
level
was
Availability
found
to
of
drugs
be good as
community.
indicated
by
the
and distribution of
the
drugs
at
the
community and the effectiveness of the medicines were quite good.
Thus , PHC Kamasamudra had established itself as a major centre
for treatment for malaria during the last few years.
31
Page
When the active surveillance system slowed down, people
to
longer
travel
of
incompleteness
comp 1ete
distance to obtain
had
treatment.
radical treatment might prove to be
The
a
grave
threat for malaria during the years to come. Villagers were
also
going
t hrough
cannot
be
an 'injection mania’ as they
felt
that
treated without the injection by a doctor.
in
uneth i ca1
its own way. Communities were not
malaria
which
convinced
is
that
injections are not required for routine treatment of malaria.
6.11 LOCAL METHODS FOR MALARIA CONTROL :
practices
of
fumi gat ion
of
importance
the
household
such
as
dry or wet grass and burning cow dung
cakes
was
the
every
to
known
at
level
Communi ty
Some
people
beli eve
neem tree as an effective
measure
for
member.
household
mosqui to
control. Our observations revealed that houses having television.
and newspapers were aware of bednets. Good Knight,
rad i o
and
mosquito repellents. Question
other
bednets
of
using
Ban i sh
impregnated
raises the fundamental question of affordability by
There
commun i t i es.
was
no active programme going
level to promote local methods towards waste
commun i ty
at
on
the
the
di sposal
or mosquito control in any of these villages.
6.12 HEALTH EDUCATION :
Our
interactions
with the PHC
and
there is an immense scope
communi ty
for
heal th
education
the
effective
revealed
that
regarding
various aspects of malaria control. In
malaria
contro1
of
var i ous
aspects
of
expressed
that
they
people were
malar i a
must
be
interested
and
its
informed
in
about
knowing
control.
about
respondents
Individuals
these
Zhs 06388
onqo i ng
■
32
Page
which will enable them to participate at
activities.
their
own
and
the
were exposed to malaria control activities by
MRC
in these programmes. The children at Kamasamudra
1 eve 1
Thoppanaha11i
through various school exhibitions but had not internalised these
in their daily life.
i ssues
for
chi 1dren
run .
The
about malaria, but was not continued on
and knew about DDT spraying,
1onger
a
educated youth in these villages were also
problem
malar i a
informat ion
This had provided good
aware
surve illance
of
and
improvement of environmental sanitation. When asked how they were
utilising this information.
they quipped that " they did not care
about it ”.
However,
which
their appears to be an "information block and
resulted
had
communi cat ion
in
total
a
of
lack
or
gap "
ineffective
between health staff and the communities. Many
of
them opined that they could have done health education programmes
better,
but due to constraints of time.
local technology.
1 ack
of
literature and media support this activity was not done.
At
the
same
an
time,
examination
day
educat i on
level .
schools
remained
question or a topic of study and not
to day application.
pressure
in
as
more
for
pract i cal
due
to
the
PHC
A number of preconceived notions operated in a major
way
and
Health education also suffered
prioritization of various programmes
at
for systematic health education programmes. The question of
environmental
control and related health education was
top i c of discussion.
As fish rearing was a primary
a
impart
responsibi1ities
heal th
educat i on.
'* nobody
bothered
In
this
abou t
major
intervent ion
activity of MRC, a question arose as to whether MRC or PHC
should
Bio
staff
division
of
hea1 th
educat ion
job
33
Page
programmes”.
It
was felt that MRC's primary objective
was
transfer the technology to state health ministry. But both
have
local
PHC
culminated
the
The constraints on the part of the MRC was the
lack of personnel and
a
sides
not taken into consideration ” the community ” who are
final recipients.
to
familiarity in local languages even though
part of the
person was
team.
This
problem
had
in total absence of health education at the level
of
community resulting in lack of any follow up or ongoing activity.
6.13 INTERSECTORAL ISSUES :
Intersectoral
control
malar i a
act ivi ty
programme.
is a key area for
the
success
of
of
agenc i es
like
department,
MRC, Forestry, Agriculture,
Fi sheries,
Irrigation,
Educat ion,
Information
responsibi1i t ies
Number
and
Broadcas ting
have
make this programme a success.
to
Heal th
equal
There
was
ample evidence of participation by the people as they allowed MRC
to
their water spots and irrigation
use
for
pits
introducing
fishes and subsequent distribution without knowing the importance
A good cooperation was also noticed between
of the same.
staff
and the MRC unit at the policy and
formulation
The department of forestry had cooperated very
level.
distribution
usefulness
these
programme
of
sapling
tree
wi thout
even
well
informing
i t, to the community (at the working
of
health
in
the
level).
To
positive steps at the top level, complimentary efforts
at
imp 1 ementat ion
1 eve 1
was
totally
has
the
di ff i culty
of
level.
Fishery
1acking.
approach
always
reali t ies
at
the
involved
only
in Bethamangala area and
field
The
A
top
bottom
plans
to
department
was
converting
not
to
Kamasamudra
area.
34
Page
total lack of dialogues and consensus building
There
was
common
platform
between various departments.
on
to all those involved was essentially lacking.
the
health centre’s staff only one person was actively
Even
a
feed
Systematic
back
35
among
involved
in MRC activities and others did not show any concern or interest
Bi o-envi ronmenta1
in
control
agencies were totally ignorant
methods.
The
local
voluntary
about the entire malaria
contro1
(at grass
programme, while their priorities were different,
root
1 eve Is), even though they expressed willingness to participate.
6.14 ADMINISTRATIVE ISSUES :
The local administration of the PHC and the panchayats
a
predominant
role
in malaria control activities
at
play
the
PHC
1 eve1. There was no shortage of drugs, reagents, slides and other
basic supportive facilities except manpower and vehicle.
The PHC
developed a very good information system on malaria
control
had
as noted by the fact information was available even for the first
10 days in the month of May.
examination.
There was no backlog of slides
but feed back to the patients and
was totally lacking.
communi ties
the
The presence of a chief medical officer
the PHC with qualification and experience in Public Health and
sound commitment to improving health of the people is
sign
for
the success of the programme.
This
continuation of malaria control activities
despite
other
constraints.
The issue of
had
for
at
a
a positive
resulted
in
to the possible level
giving
priori ty
for
local health problems like malaria in this area was a signi fleant
positive development as the information system was excellent with
annual reports available on a regular basis.
Page
However,
considerable
amount of pressure was found
to
present on the PHC team due to a number of programmes and
up actions for each of them.
Hence, the priority each
received
was
programme
officers from the Directorate.
manpower
especial 1y
major
directly dependent
bus,
of
fol low
programme
senior
the
The essential 1 ack
of
techni cians,
was
a
made
certain
areas
as health workers had to travel only by the
local
hindrance.
nonaccess i ble
on the visits
MPWs, supervisors and
Absence
of
a
vehicle
which was inconvenient for a programme of
The government staff revealed that
this
magni tude.
the recent formation of zilla
parishad and decentralization of power had only resulted in
importance
for
author i tat ive
heal th
and
as the local
power
exert i ng
leaders
had
rather
nobody
sure who the end user was?, what happened
who
does
moni tor ing
and
supervision at the field level
what
with these
reports?,
present,
but
these
to
etc .
by
more
mutua1ly
than
Systematic reporting has always been
reports?,
1 ess
become
support ive.
was
be
Lack
the
of
medical
officer who was anchored to the PHC had only resulted in improper
programme operation and even if it was implemented, i t was
sans
quali ty’ .
The issue of recognizing "a worker’s work” at the grass root
1evels
was
will have a major impact.
One of the workers at the
PHC
actively involved in MRC activities at the beginning of
the
programme,
any
but was so disheartened later as he did
not
appreciation for his work from his superiors. His
receive
work
was
rather considered as a 'plush posting’ rather than committed work
at
till
the field area.
The incentive due to him were
not
re 1 eased
date which had made him less enthusiastic over a period
of
36
Page
t i me.
From
priority
Wh i 1 e
the administrative view point where
problem, these issues have to be
malaria
is
37
a
extens ively.
debated
number of reports and statistics revealed the
of
gravi ty
the situation. it was less of a priority area at field level
and
implementation levels.
6.15 COMMUNITY ISSUES :
Communities in villages are also going through a change with
the distant impact of urbanization on them.
dwelling
is
individual
very
slightly disappearing in villages, giving
units.
recept ive,
mosquito
open 1y
rise
Communities in the villages we surveyed
open
to suggestions. and were
well
admi t ted
the i r
refusal for
DDT
spraying
aware
of
They
because
reasons (effect on sericulture). The rearing of
a welcome idea in these communities from both the
malaria control and water purification.
to
were
menace, symptoms of malaria and treatment given.
economi ca1
was
The concept of mixed
of
fish
of
point
Even though many of them
admitted that keeping their environment clean was essential. they
did not know who should take this responsibility.
At the conununity level. nonutilization of existing resources
like schools, NGO’s, panchayats, cooperatives, youth clubs was
notable observation. Many of them did not know their
in
the
while
control programme. and thus had assumed a
keeping
their
conf idence
in
1evels
quite
was
expectat ions
very
high.
improper
radi ca1
detai 1,
wi th
i nvo1vement
passive
The
government related programmes at the
a
role
1 ack
of
grass
root
evident.
The issues of
res i stance
to
treatment
needs to
examined
greater
be
the communities assuming a passive
in
role
than
DDT,
an
Page
active
the
one. The sustainability of the committed
programme
one by MRC team, makes it less effective. if communities
like
do
not take on the responsibility for continuation of the same.
Developmental
not
have
activities by non governmental agencies
any positive impact towards spread of malaria
due
did
to
lack of integrated efforts.
7. ISSUES FOR FUTURE ACTION
The
control
presen t
study
process
of
malaria
programme at the level of primary health centre and
vi11 ages.
A
number of bottlenecks have been identified
existing activities.
in
has examined the
strengthening
in
its
the
These issues needs to be taken into account
existing
act ivi ties
before
repli eating
the
programme in different parts of the state and country.
(1)
Exchange
of
informat i on
at
di fferent
1evels.
Information networks, dialogue groups. consensus building
be
undertaken
through programme activities between
should
heal th
related staff from other departments at every level. Even
and
wi thin
the PHC, the need for exchange of information among the PHC staff
and with the communities is very vital.
(2)
team.
PHC
Local
team
coordinators need to be identified
by
the
and the
to
initiate.
government
departments
MRC
participate and sustain community programmes in the long run.
(3)
The
community dynamics needs to be understood
time of base line data collection and to be continued at
intervals
for
further
mod i f icat ions
in
the
at
regular
programme.
var i ous issues at community level needs to be clarified with
communities for the success of the programme.
the
The
the
38
Page
(4)
Once
success fu 1 ,
team
at
the
intervention
is
to
be
useful
it is always a common practice for
the
intervening
found
to withdraw from the field area.
the
of the
begi nning
programme
Steps need to be
about
various
strategies on a step by step approach, about gradual
over to the
communi ties.
and
p 1 armed
wi thdrawa1
and
phased
supervi sing
the
continuation of work by the communities and determining the
long
wi thdrawa1,
handing
term impact of the programme.
Importance
(5)
should
be
given
the
to
and
PHC
the
programme" .
communities and for making the programme a "people’s
This
is
or
any
other
prevention programme during long term activities. The
PHC
should
take
to
gain
a very crucial step for the success of malaria
keen interest from the beginning in order
enough expertise to sustain the programme in all areas of work.
(6)
Intersectoral planning does not work in isolation.
The
various sectors needs to be involved by mutual dialogues, sharing
respons ibi1i t ies
communi ty
the
an
integrated
local
schools,
educators,
voluntary
all the sectors and monitoring
by
to
and commitments, providing information
in
manner .
(7)
commun i ty
The
Anganwadi s,
agenc i es
and
trained
by
heal th
workers, block health
other grassroot level functionaries
MRC
sustainabi1i ty
collect ively
representat ives,
in
development,
operation,
needs
to
maintenance
and
must
move
of fish technology and the whole team
for the success of the programme and this needs
be planned in a collaborative way.
be
to
39
Page
to
Training methodology for these activities needs
(8)
be
planned at the inception of the programme. The training has to be
at
individual
local
and group levels. in
examples at a time convenient to the community.
1 ocal
using
by
1anguages
Des i gning
needs
educational materials in local languages and other aspects
to be planned in an integrated way.
part i cipat ion
aim
shou1d
1 eve 1
root
grass
at
the
to setup the programme and not on
peoples
of
1 evel
officially
the
quoted figures of malaria incidence. Evaluation strategies
to
be
entirely
di f ferent
from
the
the
at
and monitoring of these programmes
Evaluat ion
(9)
needs
methodologies
current
recommended by many of the agencies.
10)
The
success
of any of these
proven
technologies
is
determined by the sustainability of the programme in the long run
and whether it is possible to replicate the same in many
If the programme is to be sustainable it needs to be
to
peop1e
technical
for
staff.
managing the programme with
This
needs
to be
transferred
inputs
mini mum
planned
in
different way as compared to the ongoing techniques.
places.
an
by
ent irely
40
Page
/
\
At
the end of the study, the team
cont inues
to
too
many
I
ponder over
a few crucial questions.
"With
1
I
I
I
programmes to be implemented at village level, how
I
I
I
I
I
can
I
1
is
I
I
I
I
I
I
it possible to overcome the existing bottlenecks?. How
technologies and programmes developed at
premi er
laboratories could be transferred at grass root level?.
Wi 11
any
of
the
programmes
become
I
I
I
I
I
”peop1e's
programmeH in the long run?. At what stages communities
will realise prevention and control is a better option
I
I
I
I
I
I
I
questions like this will continue.
I
transformation
I
I
"by understanding. sharing and working with people."
\
41
for
their own socioeconomic development?.
Seri es
I
I
I
of
I
We
strongly
beli eve
that
this
process
of
can begin in only one way and that
is
I
I
I
I
I
I
I
/
Page
Appendix I
Malaria Workshop in Bangarpet (Kolar district) on 12th May, 1996.
The
was
workshop on Malaria Control and
jointly
sponsored
(i i )Department
of
Heal th,
Associ at ion
SIBS,
(vi )
by
(i)
Communi ty
Malaria
Research
of Hea1 th, Government of India,
Government
of
of Karnataka,
Bangarpet,
Karnataka,
(iv)
Involvement
(iii )
Department
Voluntary
Heal th
(v) Community Health Cell,
(vii) CHAI, Karnataka
Centre,
Bangalore,
(vi i i)
and
CMAI ,
South India office.
* The workshop was designed to bring about a three way
ning process between (a), programme authority,
lear-
(b) organiz
ation involved in implementation and (c) community.
* Informa 1
get
together
was
the
strategy.
No
were created on the dias, thereby much
pos it ions
formal
of
the
official colouring any workshop would get was removed.
*
Study team members co-ordinated the workshop.
*
The
programme started at 11.00 a.m. with a
fol 1 owed
by a very informal welcome by
smal 1
Sri .
prayer
Premananda,
Secretary VHAI-K and Coordinator SIBS.
*
The
August
house introduced themselves.
There
were
45
people present (inclusive of sponsoring groups) consisting
of
doctors
coordinators)
(5) ,
NGO' s
(Directors/Animators/Sector
(21), panchayat members (7), other
faculty
(3), hospital nurses/health workers (6) and others (3).
->
There were 21 women, 24 men.
42
Page
Dr.
Ravi Kumar, Regional Director, division of
family
the
welfare services, Government of India, briefly
problem
object ives
the
heal th
of
Malaria in
Indi a/Kama taka
and
d i scussed
outlined
of the workshop. He initiated the dialogue by
part icipants
to
have an
interactive
and
di scuss ion
the
asking
in
this
District Malaria Officer taking the reins
from
workshop rather than didactic lectures.
Dr.Vasudev,
Dr.Ravi
Kumar briefly explained the situation in
and
Karnataka
focussed his views to Kolar district as a whole. He not only gave
statistics
increase
about
in
pos i t ive
Kolar,
workers/techn ic i ans
time.
He
cases of
malaria
showing
a
steep
absence
of
field
whose posts have remained vacant for a
1 ong
but also explained
concluded that statistically.
the
prevalence
of
malaria
cases have gone unreported for various administrative short falls
and expressed fear that if the system was charged and information
was fully available the situation would have been worse than what
is today. He then explained the need for community involvement in
control ling
the
disease and highlighted various
methods
being
adopted by the health authorities. He requested Dr.Ghosh who
the
next
speaker
to explain
the
"Bio-envi ronmental
was
Control"
methods being adopted in and around Kamasamudra, which had showed
positive results.
Dr.Ghosh spoke at length on the disease/the carrier/and
control
methods.
B. E.C.
method
was
He supported his
explained by
arguments
showing
wi th
’’Guppies”
statistics.
whi ch
collected from Kamasamudra area. Their characteristics and
utility
the
was
their
were briefly explained. Every possible question which
a
43
Page
would have asked at the field level was raised by
commun i ty
participants,
Dr. Ghosh was able to provide
necessary
the
answers.
Dr.Ghosh
spoke in English which was translated by Dr.Vasudev
Kannada.
There
part icipants
in
to
as
the
to take a look at the exhibition set up by the
MRC
This experience of ’’seeing”
till now,
”listened
to”
st imulated
even questions.
exhibi t ion
the
so
brief interval
enable
same hall.
the
a
was
to
representative.
they
had
answers
and
’’Congratulations to the MRC team
for
gave the participants more
was an observation made by
MRC
what
entomo1ogi s t
who was
manda1
panchayat
present
was
asked
immediately by a participant to examine a nearby well and suggest
necessary remedies which was promptly attended to.
After
their
at
the short break the study team from Bangalore
shared
experiences about malaria and control activities.
the
villages from where some of the panchayats
ongoing
members
had
come.
The presentation was broadly divided into four sectors
Dr.
arose.
Paresh
He
si tuat ion
method
to
Kumar
explained how the need
emphasized the study was only
this
for
s tudy
of
the
at Kamasamudra PHC area where MRC had introduced
BEC
contain
interdisciplinary
team
malaria.
addressed
The
understanding
quest ion
itself was
i)
this
which
How
far
the
efforts of MRC had reached the community? ii) How effectively the
programme sustained itself with community participation? iii)
To
understand the Kamasamudra PHC and its work dynamics in terms
of
this
and
major disease in all its dimens ions.
elucidate
iv) To appreciate
the success and failures of Kamasamudra PHC
staff
in
44
Page
implementing the programme.
a) their very own problems.
b) PHC staff vis-a-vis community.
c) FHC and district administration.
Community and its reaction to the programme.
6. Identify areas of concern where corrective measures be
taken
and possible involvement of voluntary agencies.
The
understood that it was a
team
study,
action
based research and "not” an evaluation of the
wh i ch,
would
fix
responsibi1ities.
very
The
and
reflection
programme,
the
fact
team
comprised of an epidemiologist, entomologist, sociologist, social
worker,
and
examine
every aspect of Malaria as a disease, as a social
and
coordinator
of VHAK,
as a concern for the community.
Dr. Paresh quickly
the participants.
to enter the community.
adopted
elicit
informat ion
Demographic
intervention
data,
issue
to
The team was introduced
summed up the
methodology
He emphasized that there was
with total freedom to the team
member
to
on the four broad based
i ssues
namely
(i)
(ii) Awareness about the
disease
(iii)
MRC
nor
spec i f i c
samp 1e
size.
no
was
sample
opportun i s t i c
to
intent iona1ly
done
It
ques t ionnaire,
standard
was
(iv) service by PHC/Community participation.
Team members also spent time to educate the respondent about
The interviews were one to one and recording
the
programme.
the
information was done immediately
over .
after the interviews
"Free Association' methodology was adopted giving
freedom for the respondent to give his views.
only
of
were
maximum
The question
to guide, to clarify. to initiate the line
of
were
di scuss ion.
45
Page
Field interviews were conducted early in the morning and later in
the evening at their door steps. In all 155 interviews were made.
PHC
of
of the villages were made on the basis
choice
The
statistics of positive cases between January 1996 to March
1996 .
One control village of MRC was chosen as it had recorded
Malaria
cases in the recent past.
from
Sathyanarayana
Dr.
MRC
the
briefly
explained
bioenvironmental control method and how the same was experimented
in Kamasamudra PHC area.
He fielded questions pertaining to fish
and its utility other than malaria control.
Dr. G. Gururaj provided insights into working of PHC at
level, their problems. limitations and those
field
the
where
areas
cooperation from the people themselves were wanting. He explained
the
problem facing the field workers and how the
insensitive to them.
were
admini s trat ion
He placed before the participants the
lapses
that were noticed during active/passive
malaria
cases
and how people themselves could
survei11ance
of
have
to
he 1ped
resolve the issues.
Ms.
and
questions
communi ty
at
Neerajakashi elucidated various observations,
the
v i ew
She
dug
deep
dynamics and how they were reacting to this
gut level. Her respondents. a teacher,
representative,
soci ety
putforth by the community.
remarks,
respondents
from
the
weaker
a
how far the programme
of the community.
programme
Women
Mandal
of
the
point
of
sect ion
and even a ex-member of panchayat gave their
into
remained under wraps from the
point
46
Page
on the field observations provided
Based
were
part i c ipant s
two
into
divided
groups
by the
the
team
exp1ore
to
the
possibility of making the programme sustainable, at the community
During
1 eve 1.
last
4
years
of
MPC
intervent ion,
the
in
Kamasamudra area. an inventory of experience gained were made and
were
examined
as
to
how
far
they
could
meaningful
give
asked
to the lapses of the programme. The group was
explanat ion
explore the possibility of correcting the lapses through
the
experience gained and how far the entire programme could be
made
Kumar
were
and
their
to
programme.
peop1e’s
Dr.Pri thvi sh
and
Dr.Paresh
rapporteures to the two groups.
Future course
two groups came back after their discussion
The
recommendat ions
the
of consensus of both the groups
areas
are
were placed before the house. The following
on
immediate
which
action was suggested.
Voluntary organizations and their participation
Voluntary organizations present admitted that their priority
sector
part
in
to
take
control.
Two
developmental activities but were prepared
was
the
health sector, especially
representatives
malaria
to
offered
provide
voluntary
organizations
necessary
infrastructure so as to train the people at the
root level about the programme.
to
permi t
the
grass
They further asked the local PHC
MPW’s of the area to participate
in
the
above
training programme so that the trainees could interact with their
PHC
counterpart in the future.
programme
They proposed that the
training
should be done at Kamasamudra PHC and field visits
be
47
Page
importance.
given
a
was
There
consensus
total
the
by
part i cipants, should a new programme be started the people had to
the
be taken into confidence and told about the programme. Often
programme
got
explain
about
and then
underway
the
author i t i es
into
moved
approach
at
the
village level had never given required results and this needs
to
the
programme.
This top/down
be changed.
Mass Media
Avallable
pertain i ng
1i terature
and
other
means
of
communication
to malaria and related issues was not sufficient
comprehensive.
Further
they
workshop
suggested
that
available
pr inted
1i terature,
were
immediate
not
locali zed.
posters which are
durable material and they are localized.
Hence
the
to
make
taken
be
action
made
out
Hospitals came
to show video cassettes in their OPD's and inpatient
and
of
forward
dormi tori es
if they were made available. But they insisted that the
mater i al
provided should be in local language. They further suggested that
para-medi ca1
there
programme
team
will take
part
in
ongoing
training
and will carry the message back to the hospital
where
there contact with patients was more meaningful.
Voluntary Organizations present suggested that Mahila Mandal
in
these areas could be effectively used to spread
and
also
their
the
to identify health worker for this programme.
concerned
opinion
that the Mahila
Manda1s
under
message
It
was
their
guidance were active and therefore it was easy to get the message
across .
48
Page
Bio-environmental Control
this was a new area for the village
organizations
they
to
s tar t
suitable number of hatcheries at strategic point with the
active
As
needed
help and direction. They
f urther
They
further
supply
of
said these hatcheries could provide
f inger1ings
to any one who had
the
vi11 age.
a
cont inuous
of
local youth and other members
of
involvement
vo1unteered
point
and
present
were
They
were
water
a
volunteered to nurture fishes in them.
Members
the
of
the disease and its
about
concerned
village panchayat who
were
implicat ions.
certain that people’s participation was not an obstacle.
Instead
many of the government programmes hardly reached the villages and
impact.
made
its
1 east
concern.
support
them
mistakes,
Therefore,
"a
government
evoked
programme”
able
to
reasons
for
shortcomings they were prepared to go along with
them
They opined that if the government was
on a continuous basis without giving
local
voluntary
organizations.
and
also
seek the help of the
They
said
i t was their credibility which was at stake
not
and
that of the government. if the programme failed.
The meeting requested the authorities concerned to
such
action necessary to train people by the end of
July
These voluntary organizations informed that on a written
from
the
members
government they would initiate the
1996.
request
i dent i f i cat ion
of villages who could be eventually trained
the malaria control programme.
ini t iate
to
of
oversee
49
50
Page
The
formal
participants
affair,
instead
were happy that the workshop
it
was
informal
and
not
was
recogn i zed
a
the
participant as more important than the speakers and guests.
They
that if they were aware that the entire workshop was
being
said
conducted
in
Kannada some more members
of
their
organizat ion
would have preferred to participate. They requested that it would
be
necessary
conceived
be
and
important that the
workshop
that
on the same lines so that a villager may
home and put in his best to contain this disease.
The meeting ended with a vote of thanks.
is
being
feel
at
Page
Appendix II
Some
comments by the respondents in their own
words
highlight the reality of the situation and provide a
wh i ch
quali tat ive
overview of the problems and constraints at different levels
are
provided below. The respondents expression has been translated to
english to the possible extent.
ON HEALTH CAPE FUNCTIONARIES.
*
"He comes and signs on the wall and his duty is over"
*
’’When we go to PHC, the doctor won't even listen what is our
ai iment. First he will put a needle in my arm (the same
one
he
buy
has given to earlier patient) then write a slip
medicine
from
treatment
i rrespect ive
outside
and
charge
some
cash
of our economic status”.
to
this
for
(rate
is
Rs.3.50 for injection).
*
"Once
they
1eaving
take blood smear the
four tablets with me.
heal th
worker
Sometimes the
vanishes,
results
take
”If my contribution to the programme is not recognised.
why
one to two months time”.
should I work".
a
"Unless
people
at high places realise
problems
at
field
1evel, no programme will succeed".
"If we do not agree for DDT spraying. the doctor won’t allow
us inside PHC”.
★
’’Who
will
sit and teach us
like you did. People
do
the i r
routine work and go”.
*
’’Even though we are near to hospital, nobody cares for us"
”We do our work and get our salary ".
51
Page
*
"PHC
doctor does not give us free treatment. we go
to
KGF
private doctor".
★
wants to sit in one place and
"Health
vi s i tor
us
to
collect
people so that she can talk to them in a group.
it
ask
is not right".
*
important in field work. We
a
vehicle
doctors should have a primary degree in public
hea1th
"Mobility
is
have
which is more a nuisance than help".
*
"PHC
and not super speciality
★
"Programme fails not because of people or the implementation
but
author i ty
because
of the-- logistic
provided
by
the
planner".
"Intersectoral coordinator is never there. In Ashraya sc erne
houses,
is the ventilation?
where
heal th
Was
department
consulted on these grass root level programmes?
★
"Too
little
educational
no
training,
quali f icat ion
no
or
job satisfaction, we expect
responsive
them
to
create
smal 1
group
miracles at the grass root levels".
"Programmes
are present yet there is always a
which keeps working and maintain some semblance".
DDT
has
spraying
why
res i stant
been
refused
and
mosqui toes
are
then the programme is
being
continued
and
target.
How
funds put to wrong use".
★
"Anyway
we
get
blood
smears
to
the
meet
authentic are they".
V
06388
52
Page
ON COMMUNITIES ROLE.
*
’’We will do our house work, why should I do neighbours
work
and who will clean the gutters inbetween”.
■k
"We do not know Malaria, but we know fever and chills
*
"We
are
poor people.
other
all the way and explained
to
us
about
otherwise who talks to poor
people
like
because of getting malaria if we don't agree for
DDT
people
"You
al 1
Just have some pegs of alcohol and sleep over".
things.
*
Where to bring money for
came
problem,
malaria
us" .
*
"Just
sericulture
is
our
poor cannot afford bed nets and other things. We
cover
spraying,
we
cannot
starve
as
1ivelihood" .
★
"We
ourselves in bedsheets or drink arrack and sleep".
k
"You have the time and purpose hence you sit and explain not
the government health workers".
ON FISH TECHNOLOGY.
*
"After
Delhi team started working in this area the
the
wells
drinking
well
has
come down. The fishes they have released in
have
c1eaned
water.
We are not scared
of
malar i a
water now".
*
"They asked us to plant and look after it so I am doing just
that"
"They
came and released fishes in our well and they do
grow. I thought I could eat them".
not
53
Page
54
ON THE ROLE OF VILLAGE PANCHAYATS.
"The
panchayat
member
comes only for votes
and
not
for
cleaning the gutter".
★
"Panchayat must do all the work. Why should we do it".
*•
)
»
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